NICE 2018 Guideline on diagnosis of COPD

Written by Hina Zahid Published On 2019-01-04T19:00:36+05:30 | Updated On 4 Jan 2019 7:00 PM IST

NICE has released its updated 2018 guidelines on diagnosis of Chronic obstructive pulmonary disease in over 16s.COPD is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases.

Following are the major recommendations for Diagnosing COPD:

The diagnosis of chronic obstructive pulmonary disease (COPD) depends on thinking of it as a cause of breathlessness or cough. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry.

Spirometry

1. Perform spirometry:

at diagnosis

to reconsider the diagnosis, for people who show an exceptionally good response to treatment

to monitor disease progression.

Incidental findings on chest X‑rays or CT scans

2. Consider primary care respiratory review and spirometry for people with emphysema or signs of chronic airways disease on a chest X‑ray or CT scan.

3. If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:

offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services)

warn them that they are at higher risk of lung disease

advise them to return if they develop respiratory symptoms

be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer.

4. If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:

ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency

reassure them that their emphysema or chronic airways disease is unlikely to get worse

advise them to return if they develop respiratory symptoms

be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer.

Further investigations

5. Perform additional investigations when needed, as detailed in table 2.

Table 2 Additional investigations

Investigation	Role
Sputum culture	To identify organisms if sputum is persistently present and purulent
Serial home peak flow measurements	To exclude asthma if diagnostic doubt remains
Electrocardiogram (ECG) and serum natriuretic peptides*	To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of: • a history of cardiovascular disease, hypertension or hypoxia or • clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale
Echocardiogram	To assess cardiac status if cardiac disease or pulmonary hypertension are suspected
CT scan of the thorax	To investigate symptoms that seem disproportionate to the spirometric impairment To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis) To investigate abnormalities seen on a chest X‑ray To assess suitability for lung volume reduction procedures
Serum alpha‑1 antitrypsin	To assess for alpha‑1 antitrypsin deficiency if early onset, minimal smoking history or family history
Transfer factor for carbon monoxide (TLCO)	To investigate symptoms that seem disproportionate to the spirometric impairment To assess suitability for lung volume reduction procedures
* See the NICE guideline on chronic heart failure in adults for recommendations on using serum natriuretic peptides to diagnose heart failure

Reversibility testing

6. Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. For more information on diagnosing asthma, see the NICE guideline on asthma.

Table 3 Clinical features differentiating COPD and asthma

	COPD	Asthma
Smoker or ex-smoker	Nearly all	Possibly
Symptoms under age 35	Rare	Often
Chronic productive cough	Common	Uncommon
Breathlessness	Persistent and progressive	Variable
Night-time waking with breathlessness and/or wheeze	Uncommon	Commn
Significant diurnal or day-to-day variability of symptoms	Uncommon	Common

Assessing severity and using prognostic factors

COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis.

7. Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD.

8. From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis:

FEV1

smoking status

breathlessness (MRC scale)

chronic hypoxia and/or cor pulmonale

low BMI

severity and frequency of exacerbations

hospital admissions

symptom burden (for example, COPD Assessment Test [CAT] score)

exercise capacity (for example, 6‑minute walk test)

TLCO

whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation

multimorbidity

frailty.

Table 4 Gradation of the severity of airflow obstruction

		NICE guideline CG12	ATS/ERS	GOLD 2008	NICE guideline CG101
Post-bronchodilator FEV1/FVC	FEV1 % predicted	Severity of airflow obstruction
	-	-	Post-bronchodilator	Post-bronchodilator	Post-bronchodilator
<0.7	≥80%	-	Mild	Stage 1 – Mild	Stage 1 – Mild
<0.7	50–79%	Mild	Moderate	Stage 2 – Moderate	Stage 2 – Moderate
<0.7	30–49%	Moderate	Severe	Stage 3 – Severe	Stage 3 – Severe
<0.7	<30%	Severe	Very severe	Stage 4 – Very severe*	Stage 4 – Very severe*
* Or FEV1 below 50% with respiratory failure. ¹ Celli BR, MacNee W, Agusti A et al. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal 23(6): 932–46 ² Global Initiative for Chronic Obstructive Lung Disease (GOLD; 2008) Global strategy for the diagnosis, management and prevention of COPD

Table 5 Reasons for referral include

Reason	Purpose
There is diagnostic uncertainty	Confirm diagnosis and optimise therapy
Suspected severe COPD	Confirm diagnosis and optimise therapy
The person with COPD requests a second opinion	Confirm diagnosis and optimise therapy
Onset of cor pulmonale	Confirm diagnosis and optimise therapy
Assessment for oxygen therapy	Optimise therapy and measure blood gases
Assessment for long-term nebuliser therapy	Optimise therapy and exclude inappropriate prescriptions
Assessment for oral corticosteroid therapy	Justify need for continued treatment or supervise withdrawal
Bullous lung disease	Identify candidates for lung volume reduction procedures
A rapid decline in FEV1	Encourage early intervention

Assessment for pulmonary rehabilitation	Identify candidates for pulmonary rehabilitation
Assessment for a lung volume reduction procedure	Identify candidates for surgical or bronchoscopic lung volume reduction
Assessment for lung transplantation	Identify candidates for surgery
Dysfunctional breathing	Confirm diagnosis, optimise pharmacotherapy and access other therapists
Onset of symptoms under 40 years or a family history of alpha‑1 antitrypsin deficiency	Identify alpha‑1 antitrypsin deficiency, consider therapy and screen family
Symptoms disproportionate to lung function deficit	Look for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation
Frequent infections	Exclude bronchiectasis
Haemoptysis	Exclude carcinoma of the bronchus

For more details click on the link: www.nice.org

breathlessnessCATchronic obstructive pulmonary diseaseCOPDCOPD Assessment TestcoughDiagnosis and ManagementFEV1forced expiratory volume in 1 secondforced vital capacityFVCguidelineICSinhaled corticosteroidLABALAMAlong-acting beta agonistlong-acting muscarinic antagonistMedical Research CouncilMRC dyspnoea scaleNICENIPPVover 16sresting oxygen saturationSaO2spirometrywheeze

Source : With inputs from NICE

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Hina Zahid