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Practice Guidelines

Management of stable chronic obstructive pulmonary disease in primary and secondary care: summary of updated NICE guidance

BMJ 2010; 340 doi: (Published 25 June 2010) Cite this as: BMJ 2010;340:c3134

This article has a correction. Please see:

  1. John O’Reilly, consultant physician 1,
  2. Melvyn M Jones, senior lecturer2, general practitioner3,
  3. Jill Parnham, operations director4,
  4. Kate Lovibond, senior health economist4,
  5. Michael Rudolf, consultant physician5
  6. on behalf of the Guideline Development Group
  1. 1Aintree University Hospital, Liverpool L9 7AL
  2. 2University College London Medical School Department of Primary Care and Population Health, London N19 5LW
  3. 3Warden Lodge Surgery, Cheshunt EN8 8NW
  4. 4National Clinical Guideline Centre, Royal College of Physicians of London, London NW1 4LE
  5. 5Ealing Hospital NHS Trust, Ealing UB1 3HW
  1. Correspondence to: john.oreilly{at}

    Over three million people in the United Kingdom are estimated to have chronic obstructive pulmonary disease (COPD), of whom more than two million remain undiagnosed, representing the so called “missing millions” alluded to in the draft national strategy for COPD.1 2 3 This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on the management of stable chronic obstructive pulmonary disease in primary and secondary care,4 which update the COPD guidelines first published by NICE in 2004.5 The summary contains the most important recommendations relating to new diagnostic criteria for COPD, changes to the classification of severity of airflow obstruction, the need for multidimensional severity assessment, a new algorithm for inhaled drug treatments (figure), and the value of early pulmonary rehabilitation.

    Algorithm for use of inhaled therapies


    NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the updated recommendations are given in italic in square brackets.

    Diagnosing COPD

    • Consider a diagnosis of COPD in patients aged over 35 years who have a risk factor (generally smoking) and present with exertional breathlessness, chronic cough, regular sputum production, frequent winter “bronchitis” or wheeze.

    • Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. (Updated recommendation.) [Based on observational studies and the experience and opinion of the Guideline Development Group (GDG)]

    • Consider alternative diagnoses or investigations in:

      • -Older people without typical symptoms of COPD where the ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7

      • -Younger people with symptoms of COPD where the FEV1/FVC ratio is ≥0.7.

      • (Updated recommendation.) [ …

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