Print Print
CKS is no longer commissioned by the National Institute for Health and Clinical Excellence (NICE). NICE remains committed to providing a replacement service for CKS and is currently reviewing its options. In the meantime, although CKS content is now not being maintained, it still remains relevant and will continue to be made available. CKS content was generated under a programme of topic creation and update. To check if the topic you are viewing is current or out of date, please refer to the topic publication details by clicking on the 'How up-to-date is this topic?' link in the left hand menu on individual topic pages.

Chronic obstructive pulmonary disease - Management
Basis for recommendation

These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].

  • NICE states that severity assessment is important because it has implications for treatment and relates to prognosis, but no single measure can adequately assess the true severity of COPD in an individual. Although spirometry alone may underestimate the impact of the disease in some people and overestimate it in others, spirometry can be used to assess the severity of airflow obstruction and to guide treatment and predict prognosis.
  • Different definitions of severity of airflow obstruction are recommended in the updated 2010 NICE guideline compared with the previous 2004 NICE guideline. Definitions of severity are now in line with other national and international guidelines.
  • Body mass index (BMI) reflects the impact of the disease in an individual and predicts prognosis. Evidence from cohort studies reviewed by NICE found that being underweight (BMI less than 20 kg/m2) was associated with increased mortality.
  • Features of cor pulmonale are based on observational studies and the opinion of the NICE guideline development group.
  • Several additional investigations recommended by NICE to assess severity are not feasible in primary care, and so are not recommended by CKS. These include transfer factor for carbon monoxide (TLCO), partial pressure of oxygen in arterial blood (PaO2), BODE index (a multidimensional index incorporating BMI, airflow obstruction, dyspnoea, and exercise capacity), and exercise capacity.
    • Specialist equipment is required to measure TLCO and PaO2.
    • A calculator or score sheet for the BODE index does not seem to be available online without subscription.
    • Substantial resources, including resuscitation equipment, are required to undertake a formal assessment of exercise capacity (that is, the 6-minute walk test) [American Thoracic Society Committee, 2002].
  • The DOSE index was recommended by two CKS reviewers. It is a composite index of severity of COPD for use in primary care that has four components: dyspnoea (D), measured using the MRC dyspnoea scale; airflow obstruction (O) according to FEV1; smoking status (S); and exacerbation frequency (E). Although the DOSE index is valid and feasible for use in primary care, it has not been included in CKS recommendations because it is unclear how it should be used to guide management. NICE recommends that a multidimensional assessment should be developed for use in primary care settings, but also states that 'any multidimensional assessment index would need to be subjected to health economic evaluation'.
  • NICE also recommends an assessment of health status; however, CKS could find no specific details of what measures this should include or how they would affect management.

© NHS Institute for Innovation and Improvement