Dr Raj Nair highlights the importance of ensuring that people with chronic obstructive pulmonary disease have access to smoking cessation services and pulmonary rehabilitation
Chronic obstructive pulmonary disease (COPD) is well recognised as a multisystem condition. It is currently the fourth leading cause of death from chronic disease worldwide1 and is predicted to be the third leading cause of death, behind ischaemic heart disease and cerebrovascular disease by 2030.2 Chronic obstructive pulmonary disease affects over 3 million people in England alone3 and accounts for 27,500 deaths annually; this equates to three people dying every hour.4,5 This preventable disease has a significant health and economic impact—nearly £500 million is spent annually in the NHS on direct costs as a result of COPD.6
NICE Clinical Guideline (CG) 101 on the Management of chronic obstructive pulmonary disease in adults in primary and secondary care, 7 which was published in 2010, was a partial update of the original guidance published in 2004 (CG12).8 It covers diagnosis, spirometry, assessment of disease severity, and management.7
This article explores the impact of the NICE guideline for COPD on primary care, its limitations, areas of deficiency, and the potential for future development.
NICE recommendations
It is recommended that a diagnosis of COPD is made on the basis of the presence of characteristic symptoms and signs and demonstration of airflow obstruction using spirometry.7 Assessment of the severity of airway obstruction is based on predicted forced expiratory volume in 1 second (FEV1); this will also help to guide pharmacological inhaler therapy (see Figure 1). The reclassification of disease severity (based on predicted FEV1) is a significant change from the previous version of the guideline, and was made so that the NICE advice was in line with other international guidelines on COPD.9,10 Disease severity should be assessed using the Medical Research Council (MRC) dyspnoea score.11
Both the NICE guideline and the Primary Care Respiratory Society UK have highlighted smoking cessation and pulmonary rehabilitation as key interventions for people with COPD (see Figure 2).7,12 Pulmonary rehabilitation is a personalised multidisciplinary approach that not only assists patients with their mobility, breathing, and confidence, but also helps them gain more of an understanding of their disease as well as independence from their breathlessness. Statistically significant and clinically meaningful improvements in exercise capacity and quality of life have been demonstrated in a meta-analysis of pulmonary rehabilitation.13 Pulmonary rehabilitation should be offered to all individuals with symptomatic COPD (i.e. functionally breathless, MRC dyspnoea score ≥3).7
Since publication of the updated NICE guideline on COPD, newer pharmacological interventions (both inhalers and oral phosphodiesterase-4 [PDE4] inhibitors) have been licensed, with further products in development. The exact impact of these drugs on disease trajectory and FEV1 has yet to be fully determined by NICE within a guideline or technology appraisal.
www.eguidelines.co.uk