General management

• smoking cessation advice: including offering nicotine replacement therapy, varenicline or bupropion

• annual influenza vaccination
• one-off pneumococcal vaccination
• pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above)

Bronchodilator therapy

• a short-acting beta2-agonist (SABA) or short-acting muscarinic antagonist (SAMA) is first-line treatment
• for patients who remain breathless or have exacerbations despite using short-acting bronchodilators the next step is determined by whether the patient has 'asthmatic features/features suggesting steroid responsiveness'

There are a number of criteria NICE suggest to determine whether a patient has asthmatic/steroid responsive features:

• any previous, secure diagnosis of asthma or of atopy
• a higher blood eosinophil count - note that NICE recommend a full blood count for all patients as part of the work-up
• substantial variation in FEV1 over time (at least 400 ml)
• substantial diurnal variation in peak expiratory flow (at least 20%)

Interestingly NICE do not recommend formal reversibility testing as one of the criteria. In the guidelines they state that 'routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading...'. They then go on to discuss why they have reached this conclusion. Please see the guidelines for more details.

No asthmatic features/features suggesting steroid responsiveness

• add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
  • if already taking a SAMA, discontinue and switch to a SABA

Asthmatic features/features suggesting steroid responsiveness

• LABA + inhaled corticosteroid (ICS)
• if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
  • if already taking a SAMA, discontinue and switch to a SABA