Chronic Obstructive Pulmonary Disease (COPD) is characterised by airflow obstruction that is not fully reversible, with a reduced FEV1/FVC ratio of less than 0.7

NICE recommends that a diagnosis of COPD is considered in patients older than 35 with a risk factor (generally smoking) who present with one or more of the following: 
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter ‘bronchitis’ 
  • wheeze 

  • Spirometry - obstructive pattern; done post bronchodilator
    • Severity of COPD
      • Mild – FEV1 ≥ 80% predicted
      • Moderate – FEV1 50 – 79% predicted
      • Severe – FEV1 30 – 49% predicted 
      • Very severe – FEV1 <30% predicted or < 50% predicted with respiratory failure 
  • CXR
  • FBC - looking for polycythaemia/anaemia
  • BMI calculation 


  • General management 
    • Stop smoking 
      •  Offer NRT, varenicline or bupropion
    • Medications
      • Inhaled therapy
        • Short-acting beta 2 agonists (SABA) for symptomatic relief
        • Preventative therapy:
          • FEV1 ≥ 50% predicted: long-acting beta 2 agonist (LABA) or long-acting muscarinic antagonist (LAMA) 
          • FEV1< 50% predicted: either LABA with inhaled corticosteroid or LAMA 
      • Oral theophylline if patient unable to use inhalers or in addition to if adequate control not achieved with inhalers
        • Plasma levels must be monitored 
        •  Dose must be reduced if macrolide or fluroquinolone antibiotics prescribed
      • Mucolytic drugs
  • Long term oxygen therapy
    • Indications:
      • PaO2 less than 7.3kPa in stable COPD
      • PaO2 less than 8kPa if stable and one of:
        • secondary polycythaemia
        • nocturnal hypoxaemia (=sats <90% for more than 30% of the time)
        • peripheral oedeam
        • pulmonary hypertension
      • Need at least 2 ABGs done at least 3 weeks apart
      • Need O2 for 15 hours per day, greatest benefits if used for 20 hours per day
  • Consider lung volume reduction surgery 
    • If single large bulla on CT and FEV1 <50% predicted or
    • breathless and marked restriction in daily living and all of the following criteria met:
      • FEV1 more than 20% predicted
      • PaCO2 less than 7.2 kPa
      • upper lobe predominant emphysema
      • TLCO more than 20% predicted

  • Management of an exacerbation
    • Oral corticosteroids – prednisolone 30mg od for 7 to 14 days 
    • Nebulised salbutamol and ipratropium bromide
    • If infective, antibiotics – empirically a macrolide or tetracycline
    • IV theophylline if inadequate response to nebulisers
    • NIV for persistent hypercapnic ventilatory failure
      • Consider if ongoing acidosis after one hour of standard medical treatment
      • If pH <7.26 higher risk of NIV failure so should be managed in high dependency setting 
      • Initial IPAP 10cm H20, titrated in increments of around 5cm H20 each 10 minutes to usual target IPAP of 20cm H20
      • EPAP 4-5cms H2O 
      • ABGs at 1 hour, 4 hours and 12 hours as a minimum 
Last updated: April 2013

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Secret collector of interesting anonymised ECGs. Fan of the Bath Photomarathon. Lover of cream teas. [Sarah Hudson] (Your Picture)