Questionnaire/history: Suspicion: > 35 years? + Smoking (pack years smoked (no. of cigarettes smoked per day: 20 x no. of year smoked)? Occupational or environmental exposure? + One or more of the following: - Breathlessness (typically persistent, progressive over time and worse on exertion)? - Chronic/recurrent cough? - Regular sputum production? - Frequent lower respiratory tract infections? - Wheeze? Onset, variability and progression of symptoms? Degree of breathlessness (Medical Research Council (MRC) dyspnoea scale)? - Grade 1: not troubled by dyspnoea except on strenuous exercise - Grade 2: shortness of breath when hurrying or walking up a slight hill - Grade 3: walks slower than contemporaries on the level ground due to shortness of breath or has to stop for breath when walking at own pace - Grade 4: stops for breath after approx. 100 meters or a few mutes on level ground - Grade 5: too breathless to leave the house or shortness of breath when dressing/undressing COPD Assessment test (CAT)? Previous exacerbation or hospitalisation? Past medical history? Family history? Current medication? Drug allergies? Examination: BMI? BP? HR? Temperature? SpO2? Chest? Peripheral oedema? Cor pulmonale (pulmonary hypertension)? - Raised jugular venous pressure (JVP)? - Systolic parasternal heave? - Loud pulmonary second heart sound (over the 2nd left intercostal space)?

- Hepatomegaly? - Peripheral oedema (to consider other causes)? Investigations: Post-bronchodilator spirometry: airflow obstruction if FEV1/FVC < 0.7 (FEV1 can be >= 80%) (routine reversibility testing not recommended)? Stage (FEV1% predicted)? Stage 1 (mild): >= 80 Stage 2 (moderate): 50 – 79 Stage 3 (severe): 30 – 49 Stage 4 (very severe): < 30 Full blood cell count (?anaemia or polycythaemia)? Alpha-1-antitrypsin deficiency (if < 40 years, minimal smoking history or FH)? Chest x-ray? Management: Smoking cessation (where applicable) Pneumococcal and annual influenza vaccinations Pulmonary rehabilitation if functionally disabled by COPD (usually MRC grade 3 and above) or recent hospitalization for an acute exacerbation Personalised self-management plan Optimised treatment for co-morbidities Inhalers SABA or SAMA as required If still limited by symptoms or exacerbations: No asthma or steroid responsiveness features: LAMA + LABA If still day-to-day symptoms adversely affecting quality of life: LAMA + LABA + ICS for 3 months, stop ICS if no improvement, otherwise continuation with at least annual review Asthma or steroid responsiveness features (including the below listed): - Previous 'secure' diagnosis of asthma or of atopy? - Higher blood eosinophil count? - Substantial variation in FEV1 over time (at least 400 ml) or diurnal variation in peak expiratory flow (at least 20%) LABA + ICS Still day-to-day symptoms continue to adversely impact quality of life or severe exacerbation (requiring hospitalisation) or 2 moderate exacerbations within a year: LAMA + LABA + ICS

Acute exacerbation

Bronchodilators: SABA with or without SAMA

Salbutamol 1-2 puffs every hour for 2-3 hours and then every 2-4 hours based on patient response Oral corticosteroids: Prednisolone 30-40 mg daily for 5 days

Antibiotics: Severe exacerbation: antibiotic

Non-severe exacerbation: antibiotic if 3 cardinal symptoms or 2 cardinal symptoms and increased purulence of sputum is one of them - Increase in dyspnoea - Increase in sputum volume - Increase in sputum purulence - Supporting symptoms include cough, wheeze, fever, URTI in last 5/7, RR/HR >20% above baseline Sputum culture if symptoms fail to resolve

Amoxicillin 500 mg TDS, doxycycline 200 mg stat then 100 mg OD, clarithromycin 500 mg bd or erythromycin for 5 days

If no improvement after 2-3 days switch to an alternative 1st line antibiotic from a different class

Alternative choice if severely unwell or high risk of treatment failure (guided by susceptibilities when available):

Co-amoxiclav 625 mg TDS, co-trimazole 960 mg BD, levofloxacin (under specialist advice) od for 5 days

Prescribing information Resource(s): Clinical Effectiveness (CE) Southwark: Chronic Obstructive Pulmonary Disease (COPD) Global Initiative for Chronic Obstructive Lung Disease (GOLD): Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2020 Report)

NICE CKS: Chronic Obstructive Pulmonary Disease NICE CKS: Chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing