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Practice Nurse

Chronic Obstructive Pulmonary Disease

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This resource is designed to assess knowledge of the management of patients with Chronic Obstructive Airways Disease. The assessment is composed of 10 clinically-rich self-assessment questions, based upon the updated NICE guideline. Complete the questions and reflect on your answers to obtain a certificate for 1 hour of CPD, which you can include in your professional development portfolio.

On completion of this resource, the user should have:

Improved knowledge of the NICE algorithms for the diagnosis and treatment of patients with COPD.

Improved knowledge of the care pathways concerned with the management of patients with COPD.

A better understanding of the grading and assessment of patients' symptoms.

On completion of the resource, you can download your certificate for one hour of CPD.

NICE: Chronic obstructive pulmonary disease (update): 

Management of chronic obstructive pulmonary disease in adults in primary and secondary care (CG101)

Global Initiative for Chronic Obstructive Lung Disease. 

Global strategy for the diagnosis, management and prevention of COPD (2013 update)


(Access to up to three resources is free. Access to all the resources is open to members)

The assessment is composed of 4 clinically-rich assessment questions based upon the NICE guidance.

Knowledge on the NICE algorithms for the treatment of patients with COPD.

Knowledge of the care pathways concerned with the management of patients with COPD.

Knowledge on the grading and assessment of patients' symptoms.

A 65 year old male presents to clinic complaining of breathlessness on exertion. He is a long-term smoker, smoking approximately 20 cigarettes daily. Following full assessment, including spirometry, he is diagnosed with COPD. He has been aware of some breathlessness for a few years but feels that this has now become more pronounced and troublesome. He becomes breathless when playing with his grandchildren or whenever he encounters an incline. He informs you that he is able to walk approximately 100m on the flat before he has to stop because of breathlessness.

NICE recommends using the Medical Research Council (MRC) Dyspnoea Scale to assess disability in patients with COPD, at diagnosis and at regular intervals. Into which grade of dyspnoea would this man fall?

This man has MRC Grade 4 dyspnoea because breathlessness stops him after only 100m of exertion on the flat. It is important to grade any dyspnoea as this helps to target appropriate treatment and other therapeutic interventions, such as pulmonary rehabilitation, and is a marker of disease progression.

Assessment of dyspnoea, while important, is only part of a full assessment of a patient with COPD. COPD eventually affects every aspect of a patient's life, causing significant loss of quality of life. Depression is common. The COPD Assessment Test (CATest) is a patient-completed questionnaire that assesses these aspects. It is quick to complete, easy to score and was specifically developed for primary care use.


1. How sensitive is the MRC Dyspnoea SCale for identifying subtle changes in breathlesss in response to medical intervention, such as a change in inhaled bronchodilator therapy?

2. What arrangements are in place for recording the effect of COPD on a patient's quality of life? Are relevant questions included in the practice COPD template?

Question 1

A 72 year old woman with a long history of COPD was admitted to hospital with an acute exacerbation. It was her first admission, although she had a previous exacerbation of her COPD approximately 9 months ago that was managed at home. She was treated in hospital with oral steroids and antibiotics and has been discharged on a combination inhaler of long acting beta 2 agonist plus inhaled steroid, in addition to her usual short-acting beta agonist for rapid symptom relief as necessary.

She presents to the GP surgery after discharge for review. Her FEV1 is 50% predicted.

Which of the following would be the most appropriate intervention, following this woman's hospital admission?

Acute exacerbations of COPD are important events. Their frequency increases as the disease becomes more severe, and frequent exacerbations are associated with increased mortality. A retrospective survey of patients admitted to hospital found that 34% were readmitted and 14% had died within 3 months of that adminission.

Exacerbations are also known to accelerate lung function decline and to have a significantly adverse effect on the patient's quality of life. It can take up to 3 months for patients to recover back to their baseline function.

Although evidence for the effectiveness of self-management in COPD is not as strong as it is in asthma, the NICE guideline for COPD recommends the provision of an emergency course of steroids and antibiotics to those individuals with 1 or more exacerbations in 12 months.

People who are at risk of an exacerbation - and this patient is an obvious example - should be encouraged to respond promptly to symptoms of an exacerbation by:

Commencing oral steroids (unless contraindicated) if increased breathless is interfering with their normal daily activity

Starting antibiotics if their sputum becomes purulent, and

Increasing their use of short acting bronchodilators to control thier symptoms.

1. What patient information for self-management of exacerbations of COPD is available in your place of work?

2. What strategies would need to be employed to ensure the safe and effective use of such plans?

3. Which factors would you need to take into consideration when giving self-management advice - e.g. the individual's willingness and ability to cope?

Question 2

A 50 year old woman presents with symptoms of exertional dyspnoea and a productive cough. She is a current smoker. Following full assessment she is diagnosed with COPD. Her spirometry shows moderate obstruction - FEV1 70% of predicted value and she has an MRC dyspnoea score of 2. What is the first line of approach to this patient's management?

Stopping smoking significantly slows down the relentless decline of lung function seen in smokers with COPD and can lead to improved life expectancy at every stage of the disease, but particularly in the mild and moderate stages.

NICE recommends that all COPD patients should have an up-to-date smoking history, in smoking pack years, recorded. Those who are still smoking, regardless of age or disease severity, should be advised and encouraged to stop and offered help to do so at every available opportunity. The message is 'It is NEVER too late to stop! 'The use of pharmacological aids to smoking cessation nicotine replacement therapy, bupropion, varenicline and referral to specialist smoking cessation services should be considered where appropriate.

NICE Brief interventions and referral for smoking cessation (PH1)

M Galloway. Smoking cessation: What works? Practice Nurse 12 October 2012;42(15):16-20

1. What are the possible barriers to giving smoking cessation advice to this patient and how might they be overcome?

2. How effective is advice from a healthcare professional in persuading smokers to stop?

Question 3

A 72 year old male presents with deteriorating shortness of breath and productive cough. He has had COPD for a number of years but continues to smoke 10 cigarettes a day. His latest spirometry, 3 months ago, showed an FEV1 40% of predicted. He is treated with a combination inhaler of salmeterol and fluticasone (Seretide), a long-acting muscarinic antagonist (Spiriva [tiotropium]), together with carbocisteine. He has had a number of acute exacerbations of COPD over the last 2 years. On examination he has a temperature of 37C, a blood pressure of 136/80 mmHg and has brought a sputum pot of a tenacious green mucous.

With regard to his antimicrobial treatment, which of the following is appropriate?

There is evidence for survival benefit when acute exacerbations of COPD characterised by an increase in sputum volume and purulence are treated with antibiotics. This is reflected in the NICE guideline.

Antibiotic choice should be guided by advice from the local microbiologist regarding the currently circulating pathogens, but the most appropriate antibiotics are generally an aminopenicillin, macrolides such as clarithromycin, and tetracyclines.

This man has had a number of exacerbations and may also benefit from having an emergency supply of antibiotics and steroids at home so that he is able to start treatment promptly.

Optimizing antibiotic selection in treating COPD exacerbations

 Int J Chron Obstruct Pulmon Dis 2008;3(1):31-44

1. How effective are first line antibiotics for the treatment of COPD in individuals with severe disease?

2. What other strategies might be helpful in reducing the frequency of acute exacerbations of COPD?

Question 4

A 72 year old male with a 5 year history of chronic cough presents to the practice with an acute exacerbation of his cough. The cough is typically worse during winter months. He smokes 10 cigarettes a day, and has difficulty stopping smoking. He uses a variety of inhalers and is prescribed antibiotics. His post-bronchodilator FEV1 is 60% of predicted. At which stage of severity of airway obstruction would you categorise this patient?

This patient has moderate airflow obstruction, characterised by an FEV1 of between 50-79% of predicted. The brief clinical history here is suggestive of COPD although a more detailed history would be needed to rule out alternative diagnoses.

The FEV1 as a percentage of predicted is a good prognostic indicator in COPD. However, it is important to remember that FEV1 alone is a poor predictor of disabilty. Not all patients with the same degree of airflow obstruction will experience the same degree of disability and breathlessness. A comprehensive assessment of disease severity should also include:

- The degree of breathlessness (using the Medical Research Council [MRC] Dyspnoea Scale)

Symptomatic management should be based on the individual's perception of symptoms and not solely on the degree of airflow obstruction. The NICE and the PCRS-UK treatment algorithms reflect this approach.

Earlier diagnosis and earlier treatment of COPD in primary care

 Primary Care Respiratory Journal 2011;20(1):15-22

1. What methods can be used objectively to assess the effectiveness of symptom management in COPD?

2. How practical are these methods for primary care use?

Question 5

A 55 year old female comes to clinic complaining of some breathlessness on exertion particularly when hurrying or climbing a flight of stairs. She is a little worried because her brother has been diagnosed with COPD, and she has smoked approximately 10 cigarettes daily for at least 30 years, although she stopped completely a year ago. There is little to note on examination, her symptoms are non-variable and she has no personal or family history of asthma, atopic or cardiovascular disease. Her blood pressure is normal, she has a BMI of 24.8 kg/m

 and her chest-X-ray is unremarkable. Spirometry shows moderate obstruction (FEV1 64% of predicted value). What is the most appropriate next step with this patient?

Short-acting bronchodilators, beta 2 agonist or muscarinic antagonist (anticholinergic), are the initial treatments recommended by NICE for the relief of breathlessness and exercise limitation. A therapeutic trial of regular treatment with these agents, separately and in combination, will help determine which treatment is most effective in each individual case. Response to therapy should be measured in terms of symptomatic response - 'Which therapy makes you feel better/able to do more/less breathless?' - rather than in terms of improved lung function.

The COPD CATest is designed for use in primary care settings and is more sensitive to change with bronchodilator therapy than the MRC Dyspnoea score and can be used to assess response to therapy in this case.

Spirometric reversibility testing, with bronchodilators or steroids, is not routinely recommended by NICE. COPD can usually be diagnosed on the basis of the history and spirometry. Reversibility testing can sometimes be helpful in differentiating between asthma and COPD, where this is suspected. In this woman's case, there is nothing in the history to suggest that she may have asthma, she has a significant smoking history and a first-degree relative with COPD. Reversibility testing would not therefore be indicatied.

NICE: Chronic obstructive pulmonary disease (update): Management of chronic obstructive pulmonary disease in adults in primary and secondary care (CG101)

Booth A. Reversibility testing. Practice Nurse 23 November 2012;42(18):36-41

1. When might reversibility testing be helpful?

2. How is the issue of reversibility testing covered in your practice protocol? Would further, definitive guidance be helpful?

Question 6

A 65 year old male with stage 2 (moderate) COPD attends for routine review. He has had several exacerbations recently, but has managed to stop smoking and is keen to do whatever he can to help himself. His FEV1 is 56% of predicted and his MRC Dyspnoea score has worsened in the last year, from 2 to 3. He finds his breathlessness troublesome and limiting. He is currently taking a long acting muscarinic antagonist (Spiriva [tiotropium]) and a combination inhaler of salmeterol and fluticasone (Seretide). What might be beneficial for this man?

Pulmonary rehabilitation is a multidisciplinary programme of care, individually tailored and designed to optimise each patient's physical and social performance and autonomy. It is both effective and cost effective and is becoming more widely available, both in community and secondary care settings. NICE recommends that it is offered to all patients who consider themselves functionally disabled by their breathlessness (MRC Dyspnoea score 3 or more) and who are physically able and willing to undertake the course. Patients who are unable to walk or who have unstable cardiovascular disease may not be suitable, but oxygen use and severity of COPD are not barriers to patients completing and benefitting from a programme. Indeed, those who are most disabled may stand to gain the most.

Patients who are being referred should be informed of the benefits they are likely to gain, and the commitment they need to make to receive those benefits. The patient in this scenario is already on optimal pharmacological management. Because he is keen to help himself he would be an ideal candidate for pulmonary rehabilitation.

Lacasse Y, Goldstein R, Lasseron TJ, et al. 

Pulmonary rehabilitation for chronic obstructive pulmonary disease

. Cochrane Database Systematic Review 2009;3


1. How accessible is pulmonary rehabilitation in your area?

2. How would you go about assessing an individual's willingness and commitment to completing a rehabilitation programme?

Question 7

A 72 year old male with known stage 3 (severe) COPD attends your chronic disease management clinic. He smoked 20 cigarettes per day for many years, but has now managed to stop. He has a productive cough which has been particularly troublesome for at least 2 years. He currently takes a long-acting muscarinic antagonist (Spiriva [tiotropium]), and combined budesonide and formoterol (Symbicort). He also has a salbutamol inhaler, which he uses once or twice a day for symptom relief and he has had a few courses of oral steroids with acute exacerbations. Which of the following therapies might be useful for this patient?

Carbocisteine (Mucodyne) is a useful mucolytic therapy that should be trialled in patients with chronic productive cough. Carbocysteine can reduce the viscosity of sputum, making it easier to clear and less troublesome, so improving symptoms. The drug should be trialled for 1 month and if no benefit is seen, discontinued. It is not suitable for the treatment of acute exacerbations.

Erdosteine is a mucolytic that is only licensed for short term use in exacerbations. A course of treatment is for 10 days.

 for exacerbations of chronic obstructive pulmonary disease: systematic review. BMJ 2001;322:1271

Best evidence review: mucolytics - an update on their use in COPD

1. What criteria would you use to assess the effectiveness of a therapeutic trial of a mucolytic agent?

Question 8

A 66 year old male with severe (Stage 3) COPD attends for review. He has had the disease for many years and continues to smoke 10-15 cigarettes a day. He is breathless on mild exertion (MRC Grade 4), but does not suffer from frequent exacerbations. He currently takes the short acting muscarinic antagonist, ipratropium, four times a day and uses a salbutamol inhaler as much as four or five times a day in addition. What therapy would it be appropriate to try in order to give him better symptom relief?

This man has poorly controlled symptoms and is not currently taking optimal bronchodilator therapy. Although he does not suffer from frequent exacerbations he has severe disease and is therefore likely to benefit from a combination inhaler of inhaled steroid and long acting beta 2 agonist, or a long acting muscarinic antagonist. If a long acting muscarinic antagonist is introduced, the short ancting muscarinic antagonist inhaler should be stopped.

The choice of therapy should take into account the individual patient's response to therapy and their preferences. If these therapies fail to control his symptoms adequately, a referral for pulmonary rehabilitation may also be appropriate, although some centres do not accept current smokers onto programmes.

Patients with an FEV1 of more than 50% of predicted should be offered inhaled steroid and long acting beta 2 agonist inhalers only if they experience 2 or more exacerbations a year.

Primary Care Respiratory Society UK COPD treatment algorithm

Warren E. When to use steroids in COPD. Practice Nurse 7 September 2012;42(13):12-16


1. Apart from improved symptomatic relief, what are the other potential advantages of long acting agents?

2. Before increasing therapy, what other aspect of this man's treatment would be worth checking?

Question 9

A 55 year old patient with COPD attends your clinic as he has had problems with worsening symptoms over the last couple of months. He is short of breath on moderate exertion, and has a FEV1 of 72% predicted. He is on optimal therapy with good inhaler technique but is short of breath on moderate exertion, and uses a salbutamol inhaler 4 -5 times a day.

Which of the following is a criterion for referral of this patient for a secondary care opinion?

In this man's case, referral for a second opinion is merited. His FEV1 suggests moderate disease and his symptoms appear disproportionate to his lung function. This disproportionate symptomatology may reflect an alternative disease process requiring further investigation, such as cor pulmonale, pulmonary hypertension, or an alternative diagnosis. Other reasons for referral include doubt relating to the diagnosis, consideration for oxygen therapy or a request for a second opinion from the patient.

Table of Referral criteria in the NICE guideline

Referral criteria from primary care - COPD

1. What referral pathways are stipulated in your practice protocol for situations like this?

Chronic Obstructive Pulmonary Disease

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