Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore 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under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – 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Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – 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Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Acute Kidney Injury – Introduction Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired 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Home | Articles | Respiratory | Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease

Last updated 3rd December 2020

Page Created on 21st August 2019 by Chris Isles.  Due for review 21st August 2020.


  1. Consider in anyone with breathlessness, cough, or chronic sputum production.
  2. Risk factors include smoking or occupational exposure to dust, fumes, or chemicals.
  3. Diagnosis depends on the presence of fixed airflow obstruction using spirometry with FEV1/FVC ratio of <70%.
  4. NB this fixed level may overdiagnose older people and underdiagnose younger people.

Ten Factors Associated with Poor Prognosis

  1. FEV
  2. Breathlessness using MRC scale
  3. Chronic hypoxia and/or cor pulmonale
  4. Low BMI
  5. Severity and frequency of exacerbations
  6. Hospital admissions
  7. Exercise capacity eg 6 minute walk test
  8. Carbon monoxide gas transfer
  9. Meets criteria for long term oxygen therapy and/or home non-invasive ventilation
  10. Comorbidity and/or frailty

The Five Fundamentals of COPD Care

  1. Treatment and support to stop smoking
  2. Pneumococcal and flu vaccinations
  3. Pulmonary rehabilitation if indicated
  4. Personalised self management plan
  5. Optimised treatment for comorbidities

Exacerbation Action Plans

  1. Offer a 5 day course of oral prednisolone 30mg and oral antibiotic to keep at home if
  2. They have had an exacerbation within the last year, and remain at risk of exacerbations and
  3. They understand and are confident about when and how to take these medicines, and the associated benefits and harms and
  4. They know to tell their healthcare professional when they have used the medicines, and to ask for replacements.

When to Give Antibiotic

  1. Many exacerbations including some severe exacerbations are not caused by bacterial infections so will not respond to antibiotic
  2. Antibiotic recommended for exacerbation with history of more purulent sputum
  3. Should also give if clinical or radiological signs of pneumonia
  4. Oral therapy nearly always adequate
  5. If no previous antibiotic, Rx Amoxicillin 500mg PO for 5 days
  6. If previous antibiotic OR penicillin allergy, Doxycycline 200mg stat followed by 100mg daily for 5 days BUT NOT BOTH

Inhaled Therapies

  1. Only prescribe inhalers after patients have been trained to use them and can demonstrate satisfactory technique.
  2. Consider spacer or breath activated device if has difficulty using an MDI
  3. If using a spacer, patient should either breathe in and out 5 times for each puff OR breathe one puff in and hold for 10 seconds.
  4. Use short acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation.
  5. Long acting inhalers are intended to improve day-to-day symptoms and reduce exacerbation risk. Before starting, consider whether the five fundamentals of COPD therapy have been addressed.
  6. In particular consider whether the patient’s symptoms could be caused by another physical or mental health condition eg heart failure which is common and often underdiagnosed and undertreated in patients with COPD.
  7. Advice on when to use long acting beta agonists (LABA), long acting muscarinic antagonists (LAMA) and inhaled corticosteroid (ICS) is shown in the flow chart
  8. There are a bewildering number of inhalers out there.  The respiratory nurses will use a patient’s inspiratory flow rate to choose the one that is most suitable.
  9. Dumfries Respiratory Team suggest discharging patient on SABA as sole inhaler if COPD (or presumed COPD) is a new diagnosis for review and follow up in primary care.
  10. The following inhalers are commonly prescribed in D&G:-
    • LAMA/LABA – Anoro Ellipta 52/55 one inhalation daily
    • LABA/ICS – Fostair 100/6 one inhalation twice daily either as MDI or as a NEXThaler
    • LABA/LAMA/ICS – Trimbow 87/5/9 two inhalations twice daily as MDI

Features Suggesting Asthma/Steroid Responsiveness

  1. Any previous, secure diagnosis of asthma or of atopy
  2. A higher blood eosinophil count*
  3. Variation in FEV1 over time of at least 400 mL or
  4. Diurnal variation in peak expiratory flow of at least 20%.
  5. If asthmatic features or features suggesting steroid responsiveness are present, consider a LABA/ICS inhaler instead of LAMA/LABA as initial long acting inhaled therapy

*’Higher’ eosinophil count has been chosen deliberately, rather than specifying a particular value. Evidence suggests a link between eosinophil count and steroid responsiveness though it is not yet clear what the precise threshold should be or on how many occasions or over what time period it should be elevated. It is likely that the threshold will lie within the upper part of the normal range.

Prophylactic Azithromycin in People with Frequent Exacerbations

  1. Regular azithromycin can be beneficial in COPD but should only be considered after several criteria have been met.
  2. Offer the five fundamentals of COPD care and treatment with inhaled therapies first.
  3. Before starting azithromycin ensure that the person has had

    • sputum and TB culture to identify antibiotic resistant organisms, atypical mycobacteria, or pseudomonas that may need specific treatment
    • training in airway clearance techniques to optimise sputum clearance
    • CT chest to rule out bronchiectasis and other lung pathologies.
  4. Subject to the above, consider prophylactic azithromycin 250 mg three times a week for people with COPD if they do not smoke (as it is ineffective in continuing smokers) who continue to have frequent or prolonged exacerbations with sputum production or exacerbations resulting in hospitalisation.
  5. Before starting azithromycin, do an ECG to rule out prolonged QT interval and baseline LFTs.
  6. When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs.

Stepped Care for COPD