COPD

This guideline covers the management of chronic obstructive pulmonary disease (COPD) and is intended for use by healthcare professionals in both primary and secondary care. This guideline details the fundamentals of COPD care, the inhaler treatment pathway for adults, and selecting the most appropriate inhaler device. The guideline is also available as a visual summary.

Disclaimer: The recommendations in these guidelines do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Fundamentals of COPD care

The below fundamentals of care should be offered before commencing pharmacological treatment, revisited at every review and before any treatment escalation.

  • All patients should have a diagnosis of COPD, confirmed by post-bronchodilator spirometry.
  • Treat in line with South West London (SWL) asthma guideline if the patient has:
    • An active diagnosis of asthma, or
    • A past diagnosis of asthma (even with a significant smoking history), or
    • Fixed airflow obstruction likely secondary to chronically under-treated asthma.
  • Smoking
    • Smoking cessation is an important intervention which slows disease progression.
    • All COPD patients still smoking should be offered help to stop smoking (including medication and behavioural support) at every opportunity.
    • See Smoking Cessation section below for further information regarding local South West London Stop Smoking Services.
  • Vaccinations
    • Offer pneumococcal, influenza, respiratory syncytial virus and COVID-19 vaccinations in line with national guidance.
  • Pulmonary rehabilitation (PR)
    • PR improves symptoms and quality of life and physical and emotional participation in everyday activities.
    • See Pulmonary Rehabilitation section below for further information regarding local  South West London PR Services.
  • Personalised self-management plans
    • Develop a self-management plan together with patients that encourages them to respond promptly to the symptoms of an exacerbation.
  • Optimise treatment for co-morbidities.

The inhaler treatment pathway below is also available as a visual summary, is intended to be advisory rather than mandatory. Its purpose is to support consistency and equity in care for people with COPD in SWL. The pathway has been adapted from the London COPD Inhaler Pathway (developed by the London Respiratory Clinical Network) and the 2024 GOLD Report: Global Strategy for the Diagnosis, Management and Prevention of COPD. It is aligned to the South West London formulary.

Start inhaled therapies only if all the above interventions have been offered (if appropriate) and inhaled therapies are needed to relieve breathlessness or exercise limitation. Choose the device most appropriate to patient capability and preference, ideally within a single device type e.g., dry powder inhaler (DPI). Combination inhaler devices may improve adherence.

Initial therapy is chosen based on frequency and severity of COPD exacerbations in the last year, and the highest recorded eosinophil count. The index blood test should have been taken at a time when the patient is not exposed to oral corticosteroids or unwell with an exacerbation. A moderate exacerbation is one that required a course of systemic steroids and/or antibiotics, and a severe exacerbation requires hospitalisation.

  • For patients who have had no more than one moderate exacerbation in the last year and are experiencing exertional breathlessness:
    • Offer a long-acting beta-2 agonist (LABA) and along-acting muscarinic antagonist (LAMA) in one combination inhaler device (or as monotherapy if dual is not tolerated or contraindicated).
  • For patients who have had two or more moderate exacerbations or one or more severe exacerbations in the last year and have eosinophils less than 0.3×109/L3:
    • Offer a LABA and a LAMA in one combination inhaler device.
  • For patients who have had two or more moderate exacerbations or one or more severe exacerbations in the last year and have eosinophils 0.3×109/L3 or greater:
    • Offer a LABA, an inhaled corticosteroid (ICS) and a LAMA. A combination device may improve adherence.
  • Offer all patients a short-acting beta-2 agonist (SABA) inhaler to use as required. Offer a short-acting muscarinic agonist (SAMA) if a SABA is not tolerated.

Before stepping up inhaler treatment check the patient’s inhaler technique and adherence and consider a different device if necessary. Discuss referral to PR and treating tobacco dependence with the patient.

If a patient has further exacerbations following initial inhaled treatment consider the following options:

  • If the patient has a further exacerbation or has a suboptimal response despite LABA and LAMA treatment and eosinophils are less than 0.1×109/L3 consider seeking advice from, or referral to, a specialist.
  • If the patient has a further exacerbation or has a suboptimal response despite LABA and LAMA treatment and eosinophils are greater than 0.1×109/L3 consider a three-month trial of LABA, ICS and LAMA. If no improvement is seen, treatment should be stepped back down to LABA and LAMA and consideration given to seeking advice from, or referral to, a specialist.
  • If the patient has a further exacerbation or has a suboptimal response despite LABA, ICS and LAMA treatment consider seeking advice from, or referral to, a specialist.

If a patient is prescribed maximal optimum therapy and is still limited by breathlessness or has frequent exacerbations, seek specialist advice for review and potential escalation to adjunctive therapies where indicated.

The above inhaler treatment pathway is available as a visual summary.

Prescribers should be aware of an increased risk of side effects (including pneumonia) in patients who take ICS. Consider de-escalation of ICS if a patient has pneumonia or other considerable side effects. Seek specialist advice for patients who have recently had an episode of, or recurrent episodes of pneumonia. ICS therapy in this patient cohort may not be appropriate despite having features suggesting steroid responsiveness.

  • Inhalers should always be prescribed by brand.
  • The choice of medication(s) should consider the patient’s response to a trial of the medication, the medication’s side effects, potential to reduce exacerbations and cost. The selected device should be licensed for use in COPD.
  • The device selected should always be based on the patient’s ability to use the device(s) and their preference. Ensure consistency in prescribing and choose a similar device across all short and long-acting medicines.
  • Ensure patients receive training in the use of their device and have shown satisfactory technique. Send patients a video link via Accurx (GP Practices only) on how to use their inhalers.
  • Consider the environmental impact of inhalers and prescribe inhalers with a lower carbon footprint e.g. DPIs where possible and where clinically appropriate, most patients can use dry powder inhalers when trained. Remind patients to return their inhalers to a pharmacy for appropriate disposal and recycling.
  • Single inhaler therapy e.g. triple therapy may be more convenient and effective than multiple inhalers and may improve adherence.
  • If pressurised metered dose inhalers (pMDI) are prescribed, this should always be with a compatible spacer device. Spacers should be replaced after 6 to 12 months.
  • Stable patients on existing treatment should not be switched, unless clinically indicated.
  • When initiating a new inhaler device consider referring patients to their local community pharmacist for a New Medicines Service review to support with adherence and inhaler technique.

The following websites provide useful information:

  • RightBreathe: Inhaler prescribing information, including compatible spacer devices.
  • Asthma + Lung UK: ‘How to use your inhaler’ videos for patients.

Inhaler options within each class of medication

The inhalers below are the preferred options in SWL, refer to the SWL Formulary if these options are not clinically appropriate. Refer to the visual summary for a pictorial representation of the preferred inhaler options.

SABA Inhalers

  • Salbutamol Easyhaler® 100 micrograms DPI, one or two doses when required (low carbon footprint).
  • Ventolin Accuhaler® (Salbutamol) 200 micrograms DPI, one dose when required (low carbon footprint).
  • Salamol® (Salbutamol) 100 micrograms pMDI, one or two doses when required (high carbon footprint).

LABA + LAMA Inhalers

  • Anoro Ellipta® 55/22 micrograms▼ (umeclidinium and vilanterol) DPI, one dose once a day (low carbon footprint).
  • Duaklir Genuair® 340/12 micrograms▼ (aclidinium and formoterol) DPI, one dose twice a day (low carbon footprint).
  • Spiolto Respimat® 2.5/2.5 micrograms (tiotropium and olodaterol) soft mist inhaler (SMI), two doses once a day (low carbon footprint).
  • Ultibro Breezhaler® 85/43 micrograms (glycopyrronium and indacaterol) DPI, one dose once a day (low carbon footprint).
  • Bevespi Aerosphere® 7.2/5 micrograms (glycopyrronium and formoterol) pMDI, two doses twice a day (high carbon footprint).

LABA + ICS + LAMA Inhalers

  • Trelegy Ellipta® 92/55/22 micrograms (fluticasone furoate and umeclidinium and vilanterol) DPI, one dose once a day (low carbon footprint).
  • Trimbow Nexthaler® 88/5/9 micrograms (beclometasone and formoterol and glycopyrronium) DPI, two doses twice a day (low carbon footprint).
  • Trimbow® 87/5/9 micrograms (beclometasone and formoterol and glycopyrronium) pMDI, two doses twice a day (high carbon footprint).

All black triangle medications are subject to additional monitoring. Healthcare professionals should report any suspected adverse reactions on an MHRA Yellow Card. For further information on any medication, see British National Formulary or Summary of Product Characteristics. 

Environmental impact of inhalers

Pressurised metered dose inhalers use a propellant, which is a greenhouse gas that contributes to global warming. Dry powder inhalers, which use no propellant, are less harmful to the environment. Prescribers and patients are encouraged to consider using dry powder inhalers and soft mist inhalers whenever they meet the needs of the patient following a shared decision making discussion.

For more information and for supporting resources on the environmental impact of inhalers refer to the SWL IMO Respiratory webpage.

Use of the In-Check™ DIAL as a measure of inhaler technique

The In-Check™ DIAL may be used as part of an inhaler technique check during a patient’s annual COPD review.

Other tools or device features can also be used to assess a patient’s ability to use an inhaler. For example: Turbohaler® – inspiratory flow training whistles are available, Genuair® – the window changes colour when dose has been delivered and Nexthaler® – makes a clicking sound.

It is important to consider clinical outcomes when assessing the suitability of a particular device for a patient. The Handihaler® is the highest resistance inhaler currently available on the market and many patients use this device successfully with good clinical outcomes.

An exacerbation is a sustained worsening of the patient’s symptoms from their usual stable state which is beyond normal day-to-day variations and is acute in onset.

Commonly reported symptoms, increased relative to normal are:

  • worsening breathlessness
  • cough
  • increased volume or purulence of sputum production and change in sputum colour.

The change in these symptoms often necessitates a review. A range of factors (including viral infections, smoking and air pollution) can trigger an exacerbation, and many exacerbations (including some severe exacerbations) are not caused by bacterial infections so will not respond to antibiotics.

Acute exacerbation management:

  • short term increased use of short-acting bronchodilators
  • Oral corticosteroids
  • Oral antibiotics

Short Acting Bronchodilators

  • Increase dose or frequency of SABA use from baseline (not exceeding maximum licensed dose). Ensure patients always use a spacer with their pMDI.
  • Consider using nebulised treatment if a patient is not responding to inhaled SABA.
    • Salbutamol 2.5 to 5 milligrams when required, up to four times a day.
    • Ipratropium 250 to 500 micrograms three to four times a day.
  • If a patient is not responding to increased SABA doses, refer to the specialist community respiratory team for assessment.

Oral Corticosteroids

  • Prednisolone 30 milligrams daily for 5 days only. Prescribe as standard prednisolone tablets, reserve soluble tablets and oral solutions for people with swallowing difficulties. Consider issuing a steroid card if appropriate when prescribing oral or inhaled corticosteroids.
  • For all patients with a significant increase in breathlessness, sputum or cough and all patients admitted to hospital, unless contraindicated.
  • Patients should be made aware of the adverse effects of prolonged steroid therapy.
  • Osteoporosis prophylaxis should be considered for patients requiring frequent courses of oral corticosteroids.
  • Routine use of oral steroids in stable COPD is NOT recommended.

Oral Antibiotics

  • Treat with antibiotics if purulent sputum and increased shortness of breath and/or increased sputum volume. Refer to NICE guideline NG114 – Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing for full prescribing recommendations.
  • See local antimicrobial guidelines for recommended antibiotic choices and duration.
  • Change antibiotic if there is no improvement in symptoms on first choice taken for at least 2 to 3 days. Choice should be guided by sensitivities when available.
  • If a patient is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class. It is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD.

Rescue antibiotics and steroids

  • Consider offering patients a short course of oral corticosteroids and a short course of oral antibiotics to keep at home as part of their exacerbation plan if they:
    • Have had an exacerbation within the last year and remain at risk of exacerbation,
    • Understand and are confident about when and how to take these medicines,
    • Know to tell their healthcare professional as soon as they start taking their medicines and to ask for replacements,
    • Know to seek medical help if symptoms worsen rapidly or significantly, or do not improve within 2 to 3 days.
  • Refer to local antimicrobial guidelines for antibiotic choice and duration.
  • Prednisolone 5 milligrams tablets: Dose 30 milligrams daily for five days.
  • The decision to prescribe should be at the prescriber’s discretion in appropriate patients. Rescue medication should only be issued as an acute prescription and should NOT be added to the repeat medication list.
  • Provide patient with a COPD action plan.
  • Follow up with a review.
  • For patients who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this.

For patients who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation plan. Recommendations can be found in NICE guideline NG114 – Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing

Nebulised therapy is not appropriate for all patients and the majority can be taught to use handheld inhaler devices. However, the few patients with distressing or disabling breathlessness despite maximal therapy with inhalers should be referred to the Respiratory Specialist Team for formal assessment and provision of a compressor if appropriate.

  • Patients and their families or carers are advised not to purchase a nebuliser.
  • Only patients under the care of a Respiratory Specialist team should be using nebulisers for long term management of COPD.

Nebulised therapy should be reviewed two weeks after initiation. Refer to NICE guideline NG115 – Chronic obstructive pulmonary disease in over 16s: diagnosis and management section 1.2.30 for information on when to continue nebulised therapy. Note: If long term ipratropium nebules are required, consider stopping the LAMA component of the patient’s regular inhaled therapy.

Oral corticosteroids

  • In line with NICE guideline NG115 – Chronic obstructive pulmonary disease in over 16s: diagnosis and management sections 1.2.34 – 1.2.35 the maintenance use of oral corticosteroids is not normally recommended.
  • When prescribing oral corticosteroids, consider the person’s individual risk factors for adverse effects.
  • For information relating to frequency of prescriptions and when to seek specialist advice refer to NICE guideline NG115 – Chronic obstructive pulmonary disease in over 16s: diagnosis and management sections 1.2.126 – 1.2.129 and 1.3.13 – 1.3.20. For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the BNF.
  • Osteoporosis prophylaxis – Calcium and Vitamin D supplementation should be considered for patients requiring frequent courses or a maintenance dose of oral corticosteroids. Consider bone scans and bisphosphonates, if indicated and appropriate.
  • Consider prescribing a proton pump inhibitor (PPI) for gastrointestinal protection in people at high risk of gastrointestinal bleeding or dyspepsia. PPIs are not routinely indicated for prophylaxis of peptic ulceration in people using oral corticosteroids.
  • For information on the acute use of oral corticosteroids please refer to ‘Management of Acute Exacerbations of COPD’ section above.

Mucolytics

  • Use in patients with chronic cough productive of sputum.
  • Oral mucolytics make sputum less sticky and easier to expectorate.
  • Consider a 6 to 8 week trial of carbocisteine 750 milligrams three times daily. Review and reduce to 750 milligrams twice daily after 6 to 8 weeks if a positive response is seen.
  • Treatment should only be continued if there is symptomatic improvement. Stop if there is no reduction in cough frequency or sputum quantity.

Oral long term prophylactic antibiotic therapy

  • Prophylactic antibiotics e.g. azithromycin (usually 250 milligrams 3 times a week) should only be started following respiratory consultant assessment and advice. Therapy may be continued in primary care following specialist advice on duration.
  • Before starting azithromycin refer to NICE guideline NG115 – Chronic obstructive pulmonary disease in over 16s: diagnosis and management sections 1.2.45 – 1.2.53 for detailed information on baseline tests and monitoring. Please note, baseline tests should be completed by secondary care and results communicated to the GP, where relevant.
  • A review is advised after the first 3 months and then at least every 6 months. Only continue treatment if the continued benefits outweigh the risks. If required, seek specialist advice.

Oral theophylline

Oral phosphodiesterase-4 inhibitors

  • Smoking cessation is an important intervention which slows disease progression, improves daily symptoms, and decreases frequency of exacerbations.
  • All COPD patients still smoking should be offered advice and help to stop smoking (including medication and behavioural support) at every opportunity. Patients can be sent information on smoking cessation services via Accurx (GP practices only).
  • Document an up-to-date smoking history, including pack years smoked for everyone with COPD. Pack years can be calculated using an online pack years calculator.
  • Very Brief Advice on Smoking (VBA+) training is available via the National Centre for Smoking Cessation and Training. VBA is a 30-second intervention that can be delivered by all healthcare professionals in almost every consultation with patients who smoke.
  • For more guidance on helping people to quit smoking, see NICE guideline NG209 – Tobacco: preventing uptake, promoting quitting and treating dependence

South West London Stop Smoking Services

NHS Croydon place

NHS Kingston place

NHS Merton place

NHS Richmond place

NHS Sutton place

  • Face to face support: please advise patients to drop into one of the pharmacies listed on the Sutton map
  • Pan-London Helpline: Phone 0300 123 1044 for telephone support to quit smoking or visit the stop smoking London portal 

NHS Wandsworth place

Secondary care Smoking Cessation Service

The  Smoking Cessation Service (SCS) discharge service, is a 12 week programme, commissioned by NHSE.  It allows NHS Trusts to offer NHS-funded tobacco treatment to people admitted to hospital who smoke. At discharge, the Trust can transfer people (who consent) to a community pharmacy of their choice, registered to deliver this service, to continue their smoking cessation treatment. This includes the provision of medication and support as required.

Pulmonary rehabilitation (PR) is an effective and cost-effective intervention for stable and post exacerbation COPD patients. Many services offer face to face, group sessions and online video classes.

Importantly it should be considered and presented to patients as a fundamental part of COPD management and not seen as an add-on to medical management.

  • Offer PR to all people who view themselves as functionally disabled by COPD.
  • Consider referring all patients with MRC Dyspnoea Scale score of >3 (2 or more for Wandsworth & Croydon patients) for PR.

PR can be adapted to suit the needs of most existing comorbidities although the patient must be able and willing to join in an exercise class. Those with recent cardiac events, uncontrolled cardiac conditions, those who will not be safe in a group environment or with comorbidities that prevent exercising to breathlessness e.g. severe osteoarthritis of the knee or severe back pain should be excluded at the point of referral.

South West London Pulmonary Rehabilitation Services

NHS Croydon place

  • Referral form available via DXS
  • Tel: 020 8401 3974 option 2 option 2
  • Email: [email protected]

NHS Kingston place

NHS Merton place

NHS Richmond place

NHS Sutton place

NHS Wandsworth place

  • Oxygen is a treatment for hypoxia not breathlessness and is a medication which requires a corresponding prescription.
  • Be aware that inappropriate oxygen therapy in patients with COPD may cause respiratory depression.
  • For advice on when to consider oxygen therapy and the criterion that needs to be met prior to prescribing, see NICE guideline NG115 – Chronic obstructive pulmonary disease in over 16s: diagnosis and management section 1.2.56.
  • Refer patients to their local Community Respiratory Specialist team or Home Oxygen Service and Review (HOSAR) for assessment and appropriate initiation of oxygen therapy. See below or contact details.

South West London Home Oxygen Services

NHS Croydon Place

  • Referral form available via DXS
  • Tel: 020 8401 3974 option 2 option 2
  • Email: [email protected]

NHS Kingston Place

NHS Merton Place

NHS Richmond Place

NHS Sutton Place

NHS Wandsworth Place

References

Document History 

Version: V 1.1 

Author: South West London Respiratory Medicines Optimisation Group

Approved by: Integrated Medicines Optimisation Committee (IMOC) 

Approval date: November 2024 

Review Date: November 2026 or sooner where appropriate.