Diagnosing COPD

A NICE pathway brings together all NICE guidance, quality

standards and materials to support implementation on a specific
topic area. The pathways are interactive and designed to be used
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uses numbering to link the boxes in the diagram to the associated
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To view the online version of this pathway visit:
http://pathways.nice.org.uk/pathways/chronic-obstructivepulmonary-disease
Pathway last updated: 24 September 2013
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Pathways

Diagnosing COPD

Chronic obstructive pulmonary disease pathway

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NICE Pathways

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Diagnosing COPD

NICE Pathways

Person with possible COPD

No additional information

When to consider a diagnosis of COPD

Consider a diagnosis of COPD for people who are:

over 35, and
smokers or ex-smokers, and
have any of these symptoms:
exertional breathlessness
chronic cough
regular sputum production
frequent winter 'bronchitis'
wheeze
and do not have clinical features of asthma:
chronic unproductive cough
significantly variable breathlessness
night-time wakening with breathlessness and/or wheeze
significant diurnal or day-to-day variability of symptoms.
Ask about the following factors where COPD is suspected:
weight loss
effort intolerance
waking at night
ankle swelling
fatigue
occupational hazards
chest pain
haemoptysis.

Quality standards
The following quality statement is relevant to this part of the pathway.

Chronic obstructive pulmonary disease pathway

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Diagnosing COPD
1.

NICE Pathways

Diagnosis

Initial diagnostic evaluation

Perform initial diagnostic evaluation if COPD seems likely:

Post-bronchodilator spirometry (record absolute and percentage of predicted values).
Consider spirometry in people with chronic bronchitis.
All health professionals involved in the care of people with COPD should have
access to spirometry and be able to interpret the results.
Any healthcare worker with up-to-date training may perform spirometry.
Spirometry services should be supported by quality control processes.
Use ERS 1993 reference values1 but be aware these may lead to underdiagnosis
in older people and are not applicable in black and Asian populations2.
Chest X-ray to exclude other diagnoses (investigate abnormalities using a CT scan).
Full blood count to identify anaemia or polycythaemia.
BMI calculation.
Determining disease severity
Disability in COPD can be poorly reflected in the FEV1. A more comprehensive assessment
also includes:
degree of airflow obstruction and disability
frequency of exacerbations
prognostic factors such as breathlessness (assessed using the MRC scale), TLCO, health
status, exercise capacity, BMI, PaO2 and cor pulmonale.
Investigate symptoms that seem disproportionate to the spirometric impairment using a CT scan
or TLCO testing.
Calculate the BODE index to assess prognosis (where the component information is currently
available).
Assess severity of airflow obstruction using the table below.

Quanjer PH, Tammeling GJ, Cotes JE et al. (1993) Lung volumes and forced ventilatory flows. Report Working
Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the
European Respiratory Society. European Respiratory Journal (Suppl) 16: 5-40.

Chronic obstructive pulmonary disease pathway

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Definitive spirometry reference values are not currently available for all ethnic populations. The GDG was aware
of ongoing research in this area.

Chronic obstructive pulmonary disease pathway

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NICE Pathways

Diagnosing COPD

Consider alternative diagnoses in older people without typical symptoms of COPD and FEV1/
FVC ratio < 0.7, and younger people with symptoms of COPD and FEV1/ FVC ratio 0.7.
Spirometric reversibility testing is not usually necessary as part of the diagnostic process or to
plan initial therapy.
Severity of airflow obstruction
NICE clinical
guideline
12(2004)
Postbronchodilator FEV1

ATS/ERS
GOLD 20082
20041

NICE clinical
guideline
101(2010)

%predicted

PostPostPostbronchodilator bronchodilator bronchodilator

< 0.7

80%

Mild

Stage 1
Mild

Stage 1 Mild3

< 0.7

5079%

Mild

Moderate

Stage 2
Moderate

Stage 2
Moderate

< 0.7

3049%

Moderate

Severe

Stage 3
Severe

Stage 3
Severe

< 0.7

< 30%

Severe

Very severe

Stage 4
Very severe4

Stage 4 Very
severe

FEV1/FVC

Quality standards
The following quality statement is relevant to this part of the pathway.
1.

Diagnosis

Chronic obstructive pulmonary disease pathway

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Celli BR, MacNee W (2004) 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 chronic obstructive pulmonary disease.

3

Symptoms should be present to diagnose COPD in people with mild airflow obstruction.

Or FEV1 < 50% with respiratory failure.

Chronic obstructive pulmonary disease pathway

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Diagnosing COPD

NICE Pathways

Doubt over diagnosis?

No additional information

Diagnose COPD and start treatment

See Chronic obstructive pulmonary disease / Treating stable COPD

Make provisional diagnosis and start empirical treatment

See Chronic obstructive pulmonary disease / Treating stable COPD

Reassessing diagnosis

Reassess diagnosis in view of response to treatment:

Clinically significant COPD is not present if FEV1 and FEV1/ FVC ratio return to normal with
drug therapy.
Asthma may be present if:
there is a > 400 ml response to bronchodilators
serial peak flow measurements show significant ( 20%) diurnal or day-to-day
variability
there is a > 400 ml response to 30 mg prednisolone daily for 2 weeks.
Refer for more detailed investigations if needed.

Confirming and recording diagnosis

For all people with diagnosed COPD:

highlight the diagnosis of COPD in the notes and computer database (using Read codes)
record the results of spirometric tests at diagnosis absolute and percentage of predicted.

Managing stable COPD

See Chronic obstructive pulmonary disease / Managing stable COPD

Chronic obstructive pulmonary disease pathway

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Diagnosing COPD

NICE Pathways

Glossary
Source guidance
Chronic obstructive pulmonary disease. NICE clinical guideline 101 (2010)

Patient-centred care
Patients and healthcare professionals have rights and responsibilities as set out in the NHS
Constitution for England all NICE guidance is written to reflect these. Treatment and care
should take into account individual needs and preferences. People should have the opportunity
to make informed decisions about their care and treatment, in partnership with their healthcare
professionals. If someone does not have the capacity to make decisions, healthcare
professionals should follow the Department of Health's advice on consent, the code of practice
that accompanies the Mental Capacity Act and the supplementary code of practice on
deprivation of liberty safeguards. In Wales, healthcare professionals should follow advice on
consent from the Welsh Government.
If the person is under 16, healthcare professionals should follow the guidelines in Seeking
consent: working with children. If a young person is moving between paediatric and adult
services their care should be planned and managed according to the best practice guidance
described in the Department of Health's Transition: getting it right for young people.

Your responsibility
The guidance in this pathway represents the view of NICE, which was arrived at after careful
consideration of the evidence available. Those working in the NHS, local authorities, the wider
public, voluntary and community sectors and the private sector should take it into account when
carrying out their professional, managerial or voluntary duties. Implementation of this guidance
is the responsibility of local commissioners and/or providers. Commissioners and providers are
reminded that it is their responsibility to implement the guidance, in their local context, in light of
their duties to avoid unlawful discrimination and to have regard to promoting equality of
opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent
with compliance with those duties.

Chronic obstructive pulmonary disease pathway

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Diagnosing COPD

NICE Pathways

Copyright
Copyright National Institute for Health and Care Excellence 2013. All rights reserved. NICE
copyright material can be downloaded for private research and study, and may be reproduced
for educational and not-for-profit purposes. No reproduction by or for commercial organisations,
or for commercial purposes, is allowed without the written permission of NICE.

Contact NICE
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www.nice.org.uk
nice@nice.org.uk
0845 003 7781

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