Executive summary
- Diagnosis: Post-bronchodilator FEV1/FVC < 0.7. (Symptoms alone = insufficient).
- Fundamentals: Smoking cessation (Ask, Advise, Act), Pneumococcal/Flu/COVID vaccines, Pulmonary Rehab (if MRC ≥3).
- The Fork in the Road: Treatment choice depends on "Asthmatic Features" (History of asthma, Eosinophils >0.3, or FEV1 variation).
Stepwise Management
- Step 1: SABA or SAMA
- Short-acting bronchodilator for symptom relief (e.g., Salbutamol or Ipratropium).
- Step 2: The Main Choice (Persistent symptoms/exacerbations)
- No Asthmatic Features: Start LABA + LAMA (e.g., Anoro, Ultibro, Duaklir). Do not use ICS routinely.
- Asthmatic Features (or Eos >0.3): Start LABA + ICS (e.g., Fostair, Symbicort, Relvar).
- Step 3: Triple Therapy
- If remaining breathless or exacerbating on Step 2: Escalation to LAMA + LABA + ICS (e.g., Trimbow, Trelegy).
- Review: If no benefit after 3 months, step back to dual therapy to reduce pneumonia risk.
Exacerbation Management
- Antibiotics: Only if purulent sputum or clinical signs of pneumonia (e.g., Amoxicillin 500mg tds 5/7 or Doxycycline 200mg stat then 100mg od 5/7).
- Steroids: Prednisolone 30mg od for 5 days.
- Rescue Packs: Provide for self-management only if patient can distinguish exacerbation symptoms and is educated on use.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.