The information on this page will help you to make a safe and accurate diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
This is not a substitute for completing an appropriate respiratory assessment module.
For advice and support on choosing the right course for you, please see our training and development page.
All about Chronic Obstructive Pulmonary Disease (COPD)
- COPD is a chronic, progressive lung condition characterised by symptoms such as breathlessness, cough and sputum production.
- These symptoms result from airway inflammation or alveolar damage that causes long term irreversible airflow obstruction.
- COPD develops over time and can be influenced by a combination mix of genetics and environmental exposures across a person’s lifetime (GETomics).
- Smoking is the leading risk factor for COPD, but environmental and occupational exposures also contribute to disease development.
- Many people with COPD experience exacerbations or ‘flare ups’, where symptoms can worsen, and they need additional treatment.
- Around 1.7 million people are living with COPD, and a further 600,000 are potentially living undiagnosed across the UK
- People from the poorest communities are five times more likely to die from COPD than those in the richest
Effective COPD management should focus on:
• Relieving symptoms
• Maintaining lung function
• Preventing exacerbations
• Reducing the risk of mortality
Preventing exacerbations is crucial
Even one moderate exacerbation increases the risk of future multiple exacerbation events, starting a spiral of excessive disease progression and an increased risk of death.
- Gold, 2024
COPD Guidelines
There are currently 3 COPD guidelines in use in the UK
Chronic Obstructive Pulmonary Disease in Over 16s: Diagnosis And Management (NICE 2018)
Global Initiative for Chronic Obstructive Pulmonary Disease (2026)
All Wales COPD Management and Prescribing Guideline (Updated 2025 )
Clinical assessment - what to ask
COPD is diagnosed using a combination of a thorough clinical history, clinical examination, and objective confirmation with post-bronchodilator spirometry. Additional investigations should be carried out where appropriate to identify comorbidities or alternative causes of symptoms.
Even when COPD is confirmed through history, examination, and spirometry, you should consider further testing if your patients symptoms suggest coexisting conditions such as asthma or other respiratory or cardiac disease.
Obtaining a comprehensive clinical history is key to understanding your patient’s risk factors for COPD. It will also help you to identify their symptoms, and how much they are affecting your patient’s quality of life.
Taking the time to do this will help you plan treatment that will be the most effective for them, and thereby reduce their risk of a flare up.
Use the guide below to structure your clinical history taking. Alongside each question is the rationale for why it is important, along with suggestions for additional actions you can take to support your diagnosis. The more detail you can gather at this stage, the easier your future management will be!
| Questions to ask your patient | Why this question matters |
|---|---|
| How long have you been breathless for? What brings it on? Is it all of the time, or some of the time? What makes it worse? |
Breathlessness in COPD is chronic and progressive over time, worse with exercise and persistent. Breathlessness that comes and goes and night waking with difficulty breathing, especially in younger patients, may be suggestive of asthma. See here for NICE's guide to clinical features differentiating COPD and asthma. |
|
Do you cough, wheeze or get chest tighness? Do you ever have chest pain? |
A cough in COPD may be continual or intermittent, productive or non-productive. Chest pain should always be investigated for a cardiac cause. |
| Do you have frequent chest infections? | Many patients will have had exacerbations before they are diagnosed, because they have normalised their symptoms or don’t realise that they are significant. Look through your patient’s notes for evidence of repeated chest infections or episodes of ‘winter’ bronchitis. They might have been prescribed antibiotics and/or steroids, or inhalers in the past. |
| Are you a past or current smoker? Do/did you smoke roll ups, cigars, a pipe, a water pipe, marijuana? How many years have you smoked/did you smoke for? What quantity of tobacco do/did you smoke? Have you been exposed to passive smoking in your lifetime? |
Tobacco smoking is the leading cause of COPD, responsible for about 90% of cases. Passive smoking can contribute to COPD. |
| Do you have acid reflux, or indigestion symptoms? | Gastro-oesophageal reflux disease (GORD) is common in people with COPD and has been associated with increased COPD exacerbation frequency. |
| Tell me about your work and hobbies (past and present) | Some occupations and activities are associated with a risk of developing COPD. |
| How do you heat your home? | Indoor pollutants from burning coal and wood can contribute to COPD. |
| Do you live/have you lived in an area of high outdoor pollution? | For people who have never smoked, air pollution is the leading known risk factor for COPD. |
| Has anyone in your family had COPD or another type of lung disease? | Smoking, and having a close relative with COPD, increases the risk of developing COPD. Genetic factors such as alpha-1-antitrypsin deficiency might make some people more susceptible. Always consider A1AT in younger patients with no smoking history. |
| Did you have any lung problems in your childhood? | Factors like maternal smoking and severe childhood respiratory infections can impair lung growth and increase the likelihood of developing COPD. |
Patients with COPD have a higher risk of co-morbidities such as heart failure and lung cancer, in addition to other differential diagnoses. Review your patient's notes for the notes for clues for other causes of their symptoms, like asthma, atopy, pulmonary embolism or anxiety.
If you think COPD may be causing all or some of your patient's symptoms, you can perform or refer your patient for spirometry testing.
Spirometry
Spirometry is an objective diagnostic test which should be quality assured. It should only be performed and technically reported by an HCP who has received appropriate training.
The Association for Respiratory Technology and Physiology (ARTP) Spirometry National Register is a list of HCPs who have completed the ARTP Spirometry Certification. Joining the National Register is not mandatory, but it ensures that all HCPs have their skills assessed and are certified as competent.
For advice and support on choosing the right training for you, please see our training and development page.
You can access the Performing and Interpreting Spirometry 6 part course on the NHS Learning Hub.
Spirometry testing in COPD
Spirometry is essential when diagnosing COPD, as it confirms the presence of persistent airflow obstruction.
A post bronchodilator FEV1/FVC ratio of less than 0.70 is traditionally used to indicate airflow obstruction and remains the conventional diagnostic threshold for COPD.
However, relying on the fixed 0.70 ratio alone can be misleading in some individuals. Lung function changes with age, and the FEV1/FVC ratio is influenced by age, height, sex and ethnicity. As a result, using a fixed cut off can:
• overdiagnose COPD in older adults
• underdiagnose COPD in younger adults
To improve diagnostic accuracy, spirometry should also be interpreted using the Lower Limit of Normal (LLN) and Z-scores.
Lower Limit of Normal
The LLN represents the lowest value expected in healthy people of the same age, height, sex and ethnicity. Values below this threshold are statistically unlikely to be normal.
Z-score
A Z-score indicates how many standard deviations a person’s result is above or below the predicted average for a healthy reference population matched for age, height, sex and ethnicity.
• A Z-score of 0 means the result is exactly average
• A Z-score of −1.645 defines the Lower Limit of Normal
• Results below −1.645 fall outside the normal range and are considered clinically significant
Using LLN and Z-scores alongside the fixed ratio reduces the risk of misdiagnosis and supports a more individualised and accurate interpretation of spirometry.
If post bronchodilator spirometry demonstrates airflow obstruction, and this is supported by the clinical history and symptoms, a diagnosis of COPD is likely.
For a clear practical guide, see: How to interpret GLI 2012 lung function tests using Z scores and LLN.
Reversibility testing
Reversibility testing is another type of spirometry test but is not used for COPD diagnosis unless your clinical assessment has identified that your patient has features of asthma. You can also use peak flow monitoring to identify airflow variability. Learn more about peak flow monitoring in COPD with this guide from PCRS.
Additional tests
Complete your assessment using the relevant tests below. These results will help you identify and treat any co morbidities and provide baseline information that you can use for reviewing your patient in the future.
| Test | Rationale |
|---|---|
| Blood pressure | To establish baseline and identify hypertension. |
| Heart rate | To establish baseline and exclude arrythmia such as atrial fibrillation. |
| Peripheral oxygen saturations | To establish baseline and identify hypoxaemia. |
| Body mass index | Being overweight or underweight is prevalent in COPD and associated with increased mortality. |
| Chest x ray | A chest X-ray isn't used to diagnose COPD but is helpful to rule out other conditions like lung cancer, pulmonary fibrosis, bronchiectasis, skeletal issues, and cardiac diseases. It can show signs of COPD such as lung hyperinflation. |
|
Blood tests:
|
Identify anaemia or polycythaemia. Identify high eosinophils which might respond to an inhaled corticosteroid. or suggest asthma To identify cardiac failure as a cause of breathlessness. Identifying this deficiency allows for specific treatments, such as alpha-1 antitrypsin augmentation therapy (currently only available in clinical trial). Testing can help identify at-risk family members who may also benefit from early intervention and lifestyle modifications to prevent or manage COPD. |
| ECG | To identify a cardiac condition as a cause of breathlessness. |
| CT thorax - if indicated | To investigate symptoms that seem disproportionate to the spirometry results, explore signs suggesting other lung conditions like fibrosis or bronchiectasis, assess abnormalities found on chest X-rays, and determine suitability for lung volume reduction procedures. |
| Sputum culture – if sputum is purulent and persistent | To identify organisms which can be treated with antibiotics. |
Resources for your patient
A diagnosis of COPD can be distressing. Offer your patient our First steps to living with COPD booklet and signpost them to our Helpline, where our specialist nurse and healthcare advisors are available to talk things through with your patient, and explore any social and practical difficulties they might have.
Don’t forget our Helpline is here to support HCPs as well. Call and speak with our supportive respiratory nurse specialists if you have questions or worries about diagnosing, treating or supporting your patients with a lung condition.
Follow this link to find out how to assess your patient with COPD so that you can decide what treatment is right for them.