NICE NG115 (2019): COPD diagnosis and management in adults

Official guidelineChronic obstructive pulmonary disease in over 16s: diagnosis and management (NG115). NICE, 2019.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Adults over 16 years with suspected or confirmed COPD in primary and secondary care.

Key recommendations

Diagnose COPD based on a combination of history (breathlessness, chronic cough, sputum, risk factors such as smoking) and spirometry showing a post-bronchodilator FEV1/FVC ratio below 0.7, while recognising spirometry can overdiagnose or underdiagnose in older or younger adults respectively.
Offer smoking cessation advice and support at every opportunity, as this is the single most effective intervention to slow disease progression.
Offer pulmonary rehabilitation to all appropriate patients, including those recently hospitalised for an exacerbation, unless they are unable to exercise.
First-line pharmacological treatment is a short-acting bronchodilator (SABA or SAMA) used as needed.
For further treatment, use the presence or absence of asthmatic features or features suggesting steroid responsiveness to guide choice: those without such features should step up to a combination of a long-acting beta agonist (LABA) and long-acting muscarinic antagonist (LAMA); those with such features should receive LABA plus inhaled corticosteroid (ICS), stepping up to LABA/LAMA/ICS triple therapy if needed.
Reserve triple therapy (LABA/LAMA/ICS) for patients who remain symptomatic or continue to have exacerbations despite LABA/ICS or LABA/LAMA.
Consider oral theophylline only after trials of long-acting bronchodilators, or in patients unable to use inhaled therapy, due to its narrow therapeutic index and interaction potential.
Use long-term oxygen therapy only in patients meeting specific criteria based on arterial blood gas measurements, and assess suitability using formal protocols rather than oxygen saturation alone.
Offer prophylactic azithromycin to selected patients who continue to have frequent exacerbations despite optimised standard treatment, after excluding contraindications such as significant QT prolongation and ensuring baseline ECG and liver function testing.
Manage exacerbations with increased bronchodilator use, a short course of oral corticosteroids, and antibiotics only when sputum is purulent or there are signs of pneumonia or clinical signs of a bacterial infection.
Identify and manage comorbidities such as cardiovascular disease, anxiety, depression, and osteoporosis, as these are common and affect prognosis.

What is new in this edition

Moved away from basing initial dual or triple inhaled therapy escalation purely on FEV1 severity, instead emphasising asthmatic/steroid-responsive features to decide between LABA+LAMA and LABA+ICS pathways.
Strengthened criteria and caution around prophylactic azithromycin use, including need for cardiac and hepatic screening before starting.
Clarified that a diagnosis should not rely on spirometry alone given risks of over- and under-diagnosis across age groups.

Practice points for students

Remember the FEV1/FVC < 0.7 post-bronchodilator threshold defines airflow obstruction but must be interpreted alongside clinical picture, especially in the very old and young adults.
Think of the inhaled therapy pathway as splitting early at the 'asthmatic features/steroid responsiveness' decision point rather than progressing by severity.
Routine use of oral corticosteroids or antibiotics for every exacerbation is not recommended; antibiotics require evidence of bacterial infection.
MRC dyspnoea scale and exacerbation frequency are more central to treatment decisions than FEV1 percentage alone.
Pulmonary rehabilitation should be considered a core intervention, not an adjunct, particularly post-exacerbation.

Condition

Chronic obstructive pulmonary disease