Pulmonology · NICE

Chronic obstructive pulmonary disease

NICE

Source:NICE NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2019, with updates)GOLD 2024 Report

Verified Apr 2026

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Red Flags

Acute COPD exacerbation with severe respiratory acidosis (pH <7.35) — non-invasive ventilation; ICU if pH <7.25 or contraindicated^[1]
Eosinophilic exacerbation phenotype (blood eosinophils ≥0.3) — ICS-containing therapy reduces exacerbations^[1]
Pneumothorax in COPD — emergency intervention; tension pneumothorax suspected on low SpO₂ + tracheal deviation^[1]
Cor pulmonale or pulmonary hypertension features — echocardiography; consider long-term oxygen therapy if PaO₂ <7.3 kPa^[1]

First-line treatment

Interventions

Smoking cessation^[1]
Single most effective intervention; behavioural support plus pharmacotherapy (NRT, varenicline, bupropion); reduces lung-function decline rate
Pulmonary rehabilitation^[1]
Structured supervised exercise + education + nutrition; reduces dyspnoea, improves exercise tolerance and QoL; offer at MRC ≥2 dyspnoea
Long-term oxygen therapy (LTOT)^[1]
PaO₂ ≤7.3 kPa OR ≤8 kPa with cor pulmonale, polycythaemia, or peripheral oedema; ≥15 hours/day
Vaccination^[1]
Annual influenza, pneumococcal (PCV13/PPSV23), COVID-19; pertussis booster

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tiotropium (LAMA)^[1]	Long-acting muscarinic antagonist (LAMA)	18 mcg DPI once daily OR 2.5 mcg respimat 2 puffs daily	—	First-line maintenance for symptomatic COPD; reduces exacerbations and improves lung function
Indacaterol/glycopyrronium (LABA/LAMA)^[1]	Combination LABA/LAMA	85/43 mcg DPI once daily OR umeclidinium/vilanterol 62.5/25 mcg DPI once daily	—	Step up from monotherapy when symptomatic on LAMA alone or with frequent exacerbations
Beclomethasone/formoterol/glycopyrronium (LABA/LAMA/ICS)^[1]	Triple combination inhaler	Per device — 2 puffs BD typical	—	Add ICS to LABA/LAMA if blood eosinophils ≥0.3 OR ≥1 severe exacerbation/year despite dual therapy
Salbutamol^[1]	Short-acting beta-agonist (SABA)	100 mcg pMDI 2 puffs PRN	—	Rescue inhaler for breakthrough symptoms; combine with ipratropium during exacerbations
Prednisolone (exacerbation)^[1]	Oral glucocorticoid	30 mg PO once daily × 5 days	—	Acute exacerbation; reduces relapse and accelerates recovery
Amoxicillin or doxycycline (exacerbation)^[1]	Oral antibiotic	Amoxicillin 500 mg PO TID OR doxycycline 200 mg load then 100 mg PO BD × 5 days	—	Acute exacerbation with sputum purulence increase + sputum volume increase or breathlessness; choose per local resistance

Tiotropium (LAMA)^[1]

Long-acting muscarinic antagonist (LAMA)

Adult: 18 mcg DPI once daily OR 2.5 mcg respimat 2 puffs daily
Paediatric: —

First-line maintenance for symptomatic COPD; reduces exacerbations and improves lung function

Indacaterol/glycopyrronium (LABA/LAMA)^[1]

Combination LABA/LAMA

Adult: 85/43 mcg DPI once daily OR umeclidinium/vilanterol 62.5/25 mcg DPI once daily
Paediatric: —

Step up from monotherapy when symptomatic on LAMA alone or with frequent exacerbations

Beclomethasone/formoterol/glycopyrronium (LABA/LAMA/ICS)^[1]

Triple combination inhaler

Adult: Per device — 2 puffs BD typical
Paediatric: —

Add ICS to LABA/LAMA if blood eosinophils ≥0.3 OR ≥1 severe exacerbation/year despite dual therapy

Salbutamol^[1]

Short-acting beta-agonist (SABA)

Adult: 100 mcg pMDI 2 puffs PRN
Paediatric: —

Rescue inhaler for breakthrough symptoms; combine with ipratropium during exacerbations

Prednisolone (exacerbation)^[1]

Oral glucocorticoid

Adult: 30 mg PO once daily × 5 days
Paediatric: —

Acute exacerbation; reduces relapse and accelerates recovery

Amoxicillin or doxycycline (exacerbation)^[1]

Oral antibiotic

Adult: Amoxicillin 500 mg PO TID OR doxycycline 200 mg load then 100 mg PO BD × 5 days
Paediatric: —

Acute exacerbation with sputum purulence increase + sputum volume increase or breathlessness; choose per local resistance

Safety-net

Take maintenance inhalers every day even when breathing well — they prevent flares; rescue inhaler is for breakthrough symptoms only^[1]
Increased breathlessness, change in sputum colour or volume, fever — start your rescue plan and contact your clinician same day^[1]
Sudden severe breathlessness with chest pain — call emergency services (could be pneumothorax, PE, MI, or severe exacerbation)^[1]

Referral criteria

Severe acute exacerbation requiring NIV or invasive ventilationEmergency department / respiratory or ICU^[1]
Frequent exacerbations (≥2/year) despite optimal triple therapyRespiratory medicine for phenotype-driven add-ons (azithromycin, roflumilast, dupilumab in eosinophilic)^[1]
Suspected alpha-1 antitrypsin deficiency, lung volume reduction candidacy, or transplant assessmentRespiratory medicine specialist centre^[1]

Clinical summary

Diagnosis, inhaler therapy, and exacerbation management of COPD per NICE guidance, with bronchodilator-anchored stepped therapy.

References

1.NICE NG115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2019, with updates); GOLD 2024 Report (2019)

Drug

Class

Adult

Paediatric

Notes