COPD
A clinical reference for UK primary care
Last reviewed 24 September 2026 · Next review December 2026
In England, around 4.9% of adults aged 40 and over had a recorded diagnosis of chronic obstructive pulmonary disease (COPD) in 2019, which is approximately 1.4 million people. A further 1.9% (around 500,000 people) have symptoms, an inhaler prescription, and a smoking history but no formal diagnosis. Prevalence rises sharply with age, reaching 10.2% in those aged 70 to 79.1
Asthma + Lung UK reports that as many as 750,000 people in England are misdiagnosed with asthma, at an estimated cost of £132 million each year. The charity also highlights long waits for spirometry, and that two in five people referred to respiratory services were not starting treatment within the 18-week benchmark.2
NICE NG115 is the cornerstone clinical guideline for diagnosis and management. Diagnosis depends on suspecting COPD in people over 35 with a risk factor (typically smoking) and one or more respiratory symptoms, supported by post-bronchodilator spirometry showing an FEV1/FVC ratio below 0.7.3
Most COPD is managed in primary care. Severity is graded using post-bronchodilator FEV1 % predicted, but NG115 emphasises that single measures are insufficient and a range of prognostic factors should be considered alongside.3
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Diagnostic criteria
NG115 sets out a symptom-led approach supported by post-bronchodilator spirometry. The diagnosis is suspected on symptoms and signs, and supported by spirometry.3
NG115 recommendation 1.1.1. Suspect COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and present with one or more: exertional breathlessness, chronic cough, regular sputum production, frequent winter bronchitis, or wheeze.3
NG115 recommendation 1.1.5. Post-bronchodilator spirometry is required to confirm the diagnosis. Consider alternative diagnoses in older people with FEV1/FVC <0.7 but no typical symptoms (1.1.6).3
NG115 recommendation 1.1.3. Grade 1 = not troubled except on strenuous exercise; grade 5 = too breathless to leave the house, or breathless when dressing.3
NG115 recommendation 1.1.15. All patients should have a chest radiograph (to exclude other pathologies), full blood count (to identify anaemia or polycythaemia), and BMI calculated at the time of initial diagnostic evaluation.3
NG115 recommendation 1.1.18. Routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy.3
NG115 recommendation 1.1.19 (Table 3) lists features that help differentiate. COPD: nearly always smoker or ex-smoker, symptoms rare under age 35, chronic productive cough common, persistent and progressive breathlessness, night-time waking with breathlessness uncommon, diurnal variability uncommon. Where both conditions are present or diagnostic uncertainty remains, a large (over 400 ml) bronchodilator response or 20% or greater peak flow variability points to asthma (1.1.21).3
Severity of airflow obstruction
Mild airflow obstruction. NG115 recommendation 1.1.27 specifies that COPD should only be diagnosed at this stage if the person also has one or more of the symptoms in 1.1.1.3
Moderate airflow obstruction. All stages require post-bronchodilator FEV1/FVC <0.7 to confirm COPD.3
Severe airflow obstruction. Consider assessment for long-term oxygen therapy in addition to optimised inhaled therapy (1.2.57).3
Very severe airflow obstruction (or FEV1 below 50% with respiratory failure). Twice-yearly primary care review per NG115 Table 6.3
NG115 (1.2.3) says every person with COPD who is still smoking should be advised and encouraged to stop at every opportunity, regardless of age, and offered help to do so.3 NG209 recommendation 1.23.2 sets the expectation that all frontline staff are trained to offer very brief advice and refer to local stop-smoking support.4
NG209 recommendation 1.12.2 lists the medicinally licensed options. Cytisinicline was added in February 2025. Combination short-acting and long-acting NRT is more effective than either alone (1.12.8). Behavioural support should be offered alongside any pharmacotherapy.4
NG115 recommendation 1.2.18 bases inhaler choice on symptom improvement, the person's preferences and ability to use the device, potential to reduce exacerbations, side effects and cost, and asks prescribers to minimise the number of inhalers and inhaler types per person.3 The BTS, NICE and SIGN patient decision aid on asthma inhalers and climate change gives a typical preventer MDI a footprint of around 19 kg CO2e, and a typical DPI or soft mist inhaler under 1 kg CO2e. The decision aid is written for asthma, but the device data apply to the same products. It advises patients not to change inhalers without talking to their healthcare professional, and to return all used inhalers to a pharmacy for safe disposal.5
NG115 was reviewed by NICE in July 2026 and now includes a biological therapy section (1.2.54).3 For add-on maintenance treatment of uncontrolled COPD with raised blood eosinophils, NICE technology appraisals recommend dupilumab (TA1142, March 2026) for people on triple therapy, or on LABA plus LAMA where an inhaled corticosteroid is not appropriate,6 and mepolizumab (TA1166, June 2026) for people on triple therapy. Uncontrolled COPD means one or more severe exacerbations or two or more moderate exacerbations in the previous 12 months; raised eosinophils means 0.3 x 109 cells per litre or more. Response is assessed at 12 months and the medicine stopped if severe exacerbations are higher than the year before starting, or the same with more moderate exacerbations (1.2.55). Treatment is specialist-initiated.7
The annual care processes
The primary care review set out in NG115 Table 6. At least annually for mild, moderate and severe COPD; at least twice a year for very severe COPD (1.2.142).3
Smoking status
Ask at every contact and offer very brief advice plus referral to local stop-smoking support per NG209 (1.23.2)
Symptom control
Breathlessness, exercise tolerance, estimated exacerbation frequency
Pulmonary rehabilitation
Assess need; consider for those at MRC grade 3 or above
Inhaler technique
And effects of each drug treatment
Spirometry
FEV1 and FVC; calculate BMI; MRC dyspnoea score
Self-management plan
Review the individualised plan and exacerbation action plan (1.2.126 to 1.2.133)
Referral pathways
Per NG115 Table 5: refer when there is diagnostic uncertainty or when both COPD and asthma are present. Where a person reports a marked improvement in symptoms with inhaled therapy, reconsider the diagnosis (1.1.23). Also refer if symptoms are disproportionate to the lung function deficit.3
Per NG115 Table 5: refer to confirm diagnosis and optimise therapy in suspected severe COPD, or where there is a rapid decline in FEV1, to encourage early intervention.3
Per NG115 Table 5: refer for assessment for long-term oxygen therapy, long-term nebuliser therapy, oral corticosteroid therapy, pulmonary rehabilitation, lung volume reduction procedures, or lung transplantation.3
Per NG115 Table 5: refer if symptoms begin under 40 years, or if there is a family history of alpha-1 antitrypsin deficiency, to identify the condition, consider therapy and screen family members. Bullous lung disease identified on imaging also warrants referral.3
Per NG115 Table 5: refer on the onset of cor pulmonale to confirm diagnosis and optimise therapy. Haemoptysis warrants referral to exclude carcinoma of the bronchus. Frequent infections warrant referral to exclude bronchiectasis.3
Find all NICE updates relevant to primary care
View NICE GuidelinesThis disease hub is intended for UK Healthcare Professionals only. Content reports established clinical knowledge and current NICE guidance. It is not a substitute for clinical judgment or for the original guidelines. Last reviewed 24 September 2026.
References
All sources verified at last review. Where primary literature is cited, original peer-reviewed publications are linked.
- 1.Stone PW, Osen M, Ellis A, Coaker R, Quint JK. Prevalence of chronic obstructive pulmonary disease in England from 2000 to 2019. Int J Chron Obstruct Pulmon Dis. 2023;18:1565–1574.
- 2.Asthma + Lung UK. Incurable lung conditions undiagnosed in thousands of people experiencing coughs and chest infections. Press release, 24 July 2024.
- 3.National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE guideline NG115. Published 5 December 2018, last updated 26 July 2019, reviewed 29 July 2026.
- 4.National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. NICE guideline NG209. Published 30 November 2021, last updated 4 February 2025.
- 5.British Thoracic Society, National Institute for Health and Care Excellence, Scottish Intercollegiate Guidelines Network. Patient decision aid on asthma inhalers and climate change. Last updated November 2024.
- 6.National Institute for Health and Care Excellence. Dupilumab for maintenance treatment of uncontrolled chronic obstructive pulmonary disease with raised blood eosinophils. Technology appraisal TA1142. Published 26 March 2026.
- 7.National Institute for Health and Care Excellence. Mepolizumab for maintenance treatment of uncontrolled chronic obstructive pulmonary disease with raised blood eosinophils. Technology appraisal TA1166. Published 17 June 2026.