Introduction
Mastering the copd management nice guidelines (NG115) is a cornerstone of the UKMLA, as Chronic Obstructive Pulmonary Disease (COPD) is one of the most common respiratory presentations in both General Practice and Emergency Medicine. Unlike asthma, which is reversible, COPD is characterised by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities.
For the exam candidate, the challenge lies in navigating the specific 2018/2019 updates regarding inhaler therapy—specifically the “fork in the road” decision based on asthmatic features—and the strict protocols for managing acute exacerbations. This guide will dismantle the NICE NG115 guideline into a clear, memorisable pathway, ensuring you can differentiate between a “Pink Puffer” and a “Blue Bloater” and manage them safely.
For a broader foundation of respiratory pathology before diving deep, you may wish to review our Respiratory Essentials for UKMLA.
Key Takeaways
The Diagnostic Ratio: COPD is confirmed by a post-bronchodilator FEV1/FVC ratio < 0.7.
The “Fork in the Road”: Management depends on Asthmatic Features. If present = LABA + ICS. If absent = LABA + LAMA.
Acute Exacerbations: The “5-Day Rule.” Give Prednisolone 30mg for 5 days. Only give antibiotics if purulent sputum is present.
Oxygen Rules: Long-Term Oxygen Therapy (LTOT) is for non-smokers with pO2 < 7.3 kPa (or < 8.0 kPa with cor pulmonale).
Referral Criteria: Urgent referral (2-week wait) is required if there is haemoptysis (cancer risk) or rapid decline.
Diagnosis: The Spirometry Rules
The diagnosis of COPD should be considered in patients over 35 who are smokers (or ex-smokers) and present with exertional breathlessness, chronic cough, or regular sputum production. However, clinical suspicion is not enough; you need objective evidence.
The Gold Standard: Post-Bronchodilator Spirometry
NICE NG115 is explicit: COPD is confirmed by a post-bronchodilator FEV1/FVC ratio < 0.7.
Unlike asthma, which shows significant reversibility (>400ml improvement in FEV1), COPD shows minimal or no reversibility. If the ratio remains < 0.7 after giving Salbutamol, the obstruction is “fixed,” confirming the diagnosis.
Grading Severity
Once diagnosed, the severity of airflow obstruction is graded based on the FEV1 % predicted.
Table 1: COPD Severity Grading (NICE NG115)
| GOLD Stage | Severity | FEV1 % Predicted |
|---|---|---|
| Stage 1 | Mild | ≥ 80% |
| Stage 2 | Moderate | 50% – 79% |
| Stage 3 | Severe | 30% – 49% |
| Stage 4 | Very Severe | < 30% |
Exam Tip: Do not confuse the Diagnostic Ratio (< 0.7) with the Severity Grade (FEV1 %). The ratio diagnoses the disease; the FEV1 grades it.
Chronic COPD Management NICE Protocols: The Inhaler Ladder
The 2019 update to NICE NG115 introduced a critical decision point early in management: assessing for Asthmatic Features. This prevents the inappropriate overuse of Inhaled Corticosteroids (ICS), which increase the risk of pneumonia.
Step 1: The Foundation
All patients should be offered:
Smoking Cessation: The single most effective intervention to slow decline.
Pneumococcal & Influenza Vaccines: To prevent exacerbations.
SABA or SAMA: Short-acting Bronchodilator (e.g., Salbutamol or Ipratropium) to use PRN for breathlessness.
Step 2: The “Fork in the Road” (If symptoms persist)
If the patient remains breathless or has exacerbations despite SABA/SAMA, you must decide the next step based on the presence of Asthmatic Features.
What are Asthmatic Features?
✓ Previous diagnosis of asthma or atopy.
✓ High blood eosinophil count.
✓ Substantial variation in FEV1 over time (diurnal variation).
✓ Significant diurnal variation in Peak Flow.
Table 2: COPD Inhaler Therapy (The “Fork in the Road”)
| Clinical Picture | Recommended Therapy | Rationale |
|---|---|---|
| NO Asthmatic Features | LABA + LAMA (e.g., Anoro, Ultibro) |
Dual bronchodilation is superior to monotherapy. Avoids steroid side effects. |
| HAS Asthmatic Features | LABA + ICS (e.g., Fostair, Symbicort) |
Steroid targets the eosinophilic inflammation. |
Step 3: Triple Therapy (LAMA + LABA + ICS)
If the patient is still symptomatic despite Step 2, or if they are having ≥ 1 severe exacerbation requiring hospitalisation per year (or 2 moderate exacerbations), escalate to Triple Therapy.
Note: Before escalating, check inhaler technique and adherence!
Managing Acute Exacerbations (The 5-Day Rule)
An acute exacerbation of COPD (AECOPD) is defined as a sustained worsening of symptoms (cough, breathlessness, sputum volume/purulence) beyond normal variation.
The “Treatment Bundle”
For patients managing exacerbations in the community or hospital, NICE recommends a specific bundle.
Increased Bronchodilators: Increase the frequency of SABA (Salbutamol) via a spacer or nebuliser.
Oral Corticosteroids:
The Rule: Give Prednisolone 30mg daily for 5 days.
Update: NICE reduced this from the old 7-14 day course. Longer courses do not improve outcomes and increase side effects (hyperglycaemia, osteoporosis).
Resource: Check contraindications in our guide to Prescribing Safety.
Antibiotics:
Do not give antibiotics automatically.
Criteria: Give only if there is purulent sputum (change in colour to green/yellow) or clinical signs of pneumonia/consolidation.
First Line: Amoxicillin 500mg TDS or Doxycycline 200mg stat then 100mg OD or Clarithromycin 500mg BD.
Duration: 5 days.
Oxygen Therapy in Exacerbations
In an acute setting, COPD patients are at risk of Type 2 Respiratory Failure (Hypercapnia) if given too much oxygen.
Target Saturation: 88% – 92%.
Delivery: Use a Venturi mask (e.g., 24% or 28%) rather than a non-rebreathe mask, unless in cardiac arrest.
Analysis: Learn to identify decompensation with Arterial Blood Gas Interpretation.
Long-Term Oxygen Therapy (LTOT)
LTOT is one of the few interventions (along with smoking cessation) that actually prolongs life in severe COPD. However, strict criteria apply because oxygen is a fire hazard.
Assessment: Assess patients with an FEV1 < 30% or those with cyanosis/polycythaemia. Measurement requires two Arterial Blood Gases (ABGs) taken at least 3 weeks apart in a stable patient.
NICE Criteria for LTOT:
PaO2 < 7.3 kPa on air.
PaO2 7.3 – 8.0 kPa on air PLUS one of the following:
Secondary Polycythaemia.
Peripheral Oedema (Cor Pulmonale).
Nocturnal Hypoxaemia.
Critical Safety Rule: The patient MUST be a non-smoker. Do not prescribe LTOT to a current smoker due to the risk of facial burns and house fires.
Clinical Scenarios: Putting it into Practice
Scenario A: The “Asthmatic” COPD Patient
Patient: 62-year-old male, ex-smoker (40 pack-years). Diagnosed with COPD (FEV1/FVC 0.65). Currently on Salbutamol PRN but still breathless. Blood tests show Eosinophils of 0.4 (High). History of hay fever.
Management: He is at the “Fork in the Road.”
Because he has Asthmatic Features (High eosinophils + Atopy), the correct next step is LABA + ICS.
Exam Trap: Starting him on LABA + LAMA would be incorrect as it ignores the eosinophilic inflammation.
Scenario B: The Acute Retainer
Patient: 75-year-old female brought in by ambulance with AECOPD. EMTs put her on 15L Oxygen via Non-Rebreathe mask. On arrival, she is drowsy. ABG shows pH 7.25, pCO2 9.5 kPa, pO2 15 kPa.
Analysis: She has developed CO2 Narcosis due to over-oxygenation (Hypoxic Drive removed).
Action: Stop high-flow oxygen immediately. Switch to a Venturi mask (24% or 28%) aiming for sats 88-92%. Repeat ABG in 20 mins. If acidosis persists despite controlled oxygen, consider Non-Invasive Ventilation (BiPAP).
CPSA Corner: Inhaler Technique & Counselling
In the CPSA, you may be asked to explain a new diagnosis or check inhaler technique.
Script: Explaining “Lung Age” (Smoking Cessation)
“Mr Smith, the best thing you can do for your lungs isn’t a medicine, it’s stopping smoking. Think of it this way: your lungs are ageing faster than you are. If we stop smoking now, we can’t ‘fix’ the damage already done, but we can slow down the ageing process so it matches a normal person’s again. This will preserve the breath you have left. For more support, I can refer you to our local stop smoking service or recommend resources from Asthma + Lung UK.“
Inhaler Technique Tips:
pMDI (Spray): “Slow and deep breath in.” Use with a spacer if coordination is poor.
DPI (Powder): “Fast and hard breath in” (to de-aggregate the powder).
Resource: If pneumonia is suspected during counselling, verify with Pneumonia Management NICE Guidelines.
Driving & Employment
Questions about fitness to drive are common in the UKMLA.
Group 1 (Car): No need to notify DVLA unless symptoms (like cough syncope) affect driving ability.
Group 2 (Lorry/Bus): Must notify DVLA.
Cough Syncope: If a patient faints after coughing, they must stop driving immediately and notify the DVLA (Group 1 and 2).
Practice Exercise: Test Your Knowledge
Question 1: A 68-year-old man with stable COPD is reviewed. He is currently taking a SABA PRN. He reports increasing breathlessness walking up hills. He has no history of asthma, his eosinophils are normal, and he has had no exacerbations in the last year. What is the most appropriate next step in management?
A) Add an Inhaled Corticosteroid (ICS)
B) Add a Long-Acting Beta-Agonist (LABA) only
C) Start a LABA + LAMA combination inhaler
D) Start a LABA + ICS combination inhaler
E) Refer for LTOT
Correct Answer: C) Start a LABA + LAMA combination inhaler.
The patient has no asthmatic features (no atopy, normal eosinophils). Therefore, the NICE guidelines recommend dual bronchodilation (LABA + LAMA). Monotherapy (LABA only) is no longer a standard step, and ICS is inappropriate without asthmatic features.
Question 2: A 55-year-old woman with COPD presents with an acute exacerbation. She has green sputum and increased breathlessness. She is prescribed Amoxicillin and Salbutamol nebulisers. Which steroid regimen is correct according to NICE NG115?
A) Prednisolone 40mg for 7 days
B) Prednisolone 30mg for 5 days
C) Prednisolone 30mg for 14 days
D) IV Hydrocortisone 100mg QDS
E) No steroids are indicated
Correct Answer: B) Prednisolone 30mg for 5 days.
Current NICE guidelines specifically recommend a short course of oral corticosteroids (30mg for 5 days) for exacerbations. Longer courses provide no additional benefit and increase risks.
Frequently Asked Questions (FAQ) about COPD Management NICE
Carbocisteine is a mucolytic agent that breaks down disulfide bonds in mucus, reducing its viscosity. NICE recommends considering it for patients with a chronic productive cough (sputum producers). It does not act as a bronchodilator but helps clear secretions and may reduce the frequency of exacerbations. It should be trialled for 4 weeks; if symptoms improve, it can be continued.
Roflumilast is a phosphodiesterase-4 (PDE-4) inhibitor used as an add-on therapy in severe COPD. It is generally reserved for specialists to prescribe for patients with severe COPD (FEV1 < 50%) and chronic bronchitis who are still having frequent exacerbations despite maximum inhaled triple therapy. It targets chronic inflammation but has significant gastrointestinal side effects.
Theophylline (a methylxanthine) has a very narrow therapeutic window and interacts with many drugs (e.g., Ciprofloxacin, Erythromycin). Toxicity causes arrhythmias and seizures. NICE recommends it only as a third or fourth-line option after trials of short and long-acting bronchodilators, or for patients who cannot use inhaled therapy. Plasma levels must be monitored closely.
Commercial aircraft cabins are pressurised to an altitude of roughly 8,000 feet, which drops the partial pressure of oxygen. Patients with severe COPD (FEV1 < 30%) or those already on LTOT should undergo a Hypoxic Challenge Test (Fitness to Fly test) before travelling. They may require in-flight oxygen if their pO2 drops significantly during the simulation.
These are classic clinical phenotypes. “Pink Puffers” (Emphysema dominant) tend to be thin, breathless, and maintain normal blood gases by hyperventilating (hence “Pink”). “Blue Bloaters” (Chronic Bronchitis dominant) tend to be overweight, cyanotic, and hypoventilate, leading to hypercapnia and cor pulmonale. In reality, most patients have a mix of both.
No, a Chest X-Ray cannot diagnose COPD; spirometry is required. However, a CXR is essential during the initial workup to exclude other pathologies like lung cancer, bronchiectasis, or fibrosis. In advanced COPD, a CXR may show hyperinflation (flattened diaphragms) and bullae, but a normal CXR does not rule out mild/moderate COPD.
Referral for Lung Volume Reduction Surgery (LVRS) is considered for patients with severe emphysema who have completed pulmonary rehabilitation but remain breathless. The surgery removes the worst-affected (bullous) parts of the lung, allowing the remaining healthier lung tissue to expand and function more efficiently.
NICE guidelines emphasize antimicrobial stewardship. Many exacerbations are viral or environmental (pollution). Antibiotics are only indicated if there is evidence of bacterial infection, specifically purulent (green/yellow) sputum or clinical signs of pneumonia/consolidation. Giving them for clear sputum contributes to antibiotic resistance without improving recovery.
This is a genetic cause of COPD. You should suspect it in younger patients (< 40 years old) who develop emphysema, especially if they are non-smokers. It causes pan-acinar emphysema (lower lobes) compared to the centri-acinar emphysema (upper lobes) caused by smoking. Diagnosis is by measuring serum Alpha-1 Antitrypsin levels.
Pulmonary Rehab is a structured programme of exercise and education. It is one of the most effective interventions for improving Quality of Life and exercise tolerance. NICE recommends it for any patient who considers themselves “functionally disabled” by their COPD (usually MRC Dyspnoea Scale ≥ 3), including those who have recently been hospitalised for an exacerbation.
Conclusion
Mastering copd management nice guidelines requires a structured approach. Remember the core pillars: Confirm the diagnosis with the < 0.7 ratio, Stratify treatment based on asthmatic features (LABA+LAMA vs LABA+ICS), and Manage exacerbations with the 5-day Prednisolone rule.
For the UKMLA, safety is paramount. Always check oxygen saturations, avoid over-oxygenating retainers, and ensure strict criteria are met before prescribing antibiotics or Long-Term Oxygen Therapy.
