COPD (Chronic obstructive pulmonary disease) (Guidelines)

Consider a diagnosis of COPD in patients who are smokers or ex-smokers with:

• Breathlessness on exertion
• Chronic cough
• Regular sputum production
• Frequent winter bronchitis or chest infections
• Wheeze

Patients with COPD will have airflow obstruction which does not significantly improve with bronchodilator therapy. Post-bronchodilator FEV1/FVC < 0.7 confirms airflow obstruction and would be considered diagnostic.

It is possible to have emphysema on radiological imaging of the lungs in the absence of airflow obstruction, these patients are not generally considered to have COPD, however, sometimes these patients may still benefit from bronchodilator therapy.

Differential diagnoses

Consider these alternative diagnoses prior to diagnosing COPD:

Lung cancer

• May present with new persistent cough, look for red flags such as:
  • Haemoptysis
  • Unexplained weight loss
  • Hoarseness
  • Finger clubbing
• See the Urgent Suspected Cancer guidelines for further details: Urgent suspected Lung Cancer (Guidelines) | Right Decisions

Asthma

• Variable symptoms, look for diurnal variability, as well as variation from day-to-day
• May co-exist with COPD (COPD / asthma overlap syndrome)
• May have increased symptoms with allergen exposure and a background of atopy and / or eczema
• May have family history of asthma and or eczema
• Reversible airflow obstruction (but may have normal spirometry)
• Look for raised eosinophils ≥0.3 x 10⁹/L, elevated FeNO (≥ 50 for diagnosis), bronchodilator reversibility testing or consider PEFR monitoring if suspect this

Bronchiectasis

• Increased sputum production
• Frequent chest infections
• May have a past medical history of childhood pneumonia, pertussis, TB or IBD
• Coarse lung crepitations
• Commonly exists alongside COPD

Interstitial lung disease

• Dry cough
• Fine respiratory crackles
• Restrictive breathing pattern on spirometry
• Finger clubbing

Heart failure

• Orthopnoea and paroxysmal nocturnal dyspnoea
• Coarse bibasal crackles
• Peripheral oedema (although can be present in COPD if cor pulmonale)
• Spirometry may be normal or show a restrictive breathing pattern

Anaemia

Alpha-1 antitrypsin disease

• Early-onset emphysema (<40 years)
• Family history of lung / liver disease

At an initial COPD review, a thorough and structured assessment should take place to confirm diagnosis, establish baseline health, and create a personalised management plan. This should be reviewed subsequently at routine annual reviews.

History and symptom assessment

Detailed history

• Focus on respiratory symptoms (breathlessness, cough, sputum, wheeze), frequency of exacerbations, and impact on daily living.

Smoking status

• Document current and past smoking history, and offer cessation support and nicotine replacement if needed. 

Comorbidities

• Ask about other conditions (e.g., heart failure, diabetes, osteoporosis, anxiety, depression)

Assess cardiovascular risk

• Using QRISK or equivalent.
• Statin treatment (atorvastatin 20mg daily) should be offered for the primary prevention of CVD to people with an estimated 10-year CVD risk of 10% or more if lifestyle interventions have not proved to be effective. 
• Further information on cardiovascular risk assessment: CVD risk assessment and management | Health topics A to Z | CKS | NICE

Assess for hypertension

• And manage according to guidelines

Medication review,

• Check all current medications, adherence, and side effects.
• Assess inhaler technique.
• Consider how many courses of steroid the patient has taken and whether there is need to review and optimise chronic management.

Symptom severity scores

The MRC Dyspnoea scale

• This is used to grade breathlessness to assess severity
• This aids decision making for management.

COPD Assessment Test (CAT)

• Used to measure health status and symptom burden
• This aids decision making for management.

Physical examination

General exam

• Check for finger clubbing (which is not in keeping with COPD and may raise concern for lung cancer amongst other diagnoses), cyanosis, peripheral oedema, and signs of respiratory distress

Vital signs

• Record heart rate, blood pressure, respiratory rate, and oxygen saturation (pulse oximetry)

Nutritional status

• Measure BMI and assess for weight loss or malnutrition.

Investigations

Spirometry

• Spirometry should be performed at time of diagnosis and to monitor disease progression.
• Confirm diagnosis with post-bronchodilator spirometry (FEV1 / FVC ratio <0.7) 

Chest X-ray

• This should be performed in newly diagnosed patients to exclude other pathologies 

Full blood count

• To check for anaemia, polycythaemia and eosinophilia 

Self-management and education

• Provide information on COPD, inhaler use, and lifestyle modifications 
• Develop or review a self-management action plan for exacerbations and daily management 
• Below is a list of different resources to aid with this:
  • MyLungsMyLife
    
  • British Lung Foundation
    
  • Chest Heart and Stroke Scotland
    
  • Self-management plans 'Traffic Lights for COPD' are free to order or can be printed
  • Use self-management checklist as an aide-memoire
    
  • NHS Highland Respiratory Resource Hub
    
  • MySelf-Management | Highland, Scotland

Pulmonary rehabilitation

• Discuss and refer if appropriate, especially if MRC 3 or above:
• See section within Prevention of Exacerbations and Pulmonary Rehabilitation.

Vaccinations

• Check and offer influenza and pneumococcal vaccines as per The Green Book

Psychosocial and practical support:

• Mental health: Screen for anxiety and depression 
• Social needs: Assess ability to manage at home, and refer to social services if needed
• Financial advice: Discuss benefits and financial support available, especially for those requiring home oxygen 

Follow-up

Frequency:

• Plan regular reviews (annually, or more frequent if unstable)

Consider referral to respiratory specialist, physiotherapy, occupational therapy, dietician, or mental health services, as needed

Possible reasons for referral to Secondary Care include:

• Diagnostic uncertainty
• Suspected severe COPD at diagnosis
• The individual requests a second opinion
• Onset of cor pulmonale
• Bullous lung disease (eg Giant bulla)
• Rapid decline in FEV1
• Assessment for lung volume reduction surgery or lung transplantation
• Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency
• Symptoms disproportionate to lung function deficit
• Haemoptysis

Referral to the community respiratory team may be appropriate if the patient would benefit from general support and advice for management of their condition or for specific issues such as:

• Assessment for oxygen therapy or long-term nebuliser therapy
• Management of dyspnoea
• Recurrent exacerbations

How to refer

• Respiratory consultant via SCI Gateway
• Community Respiratory Team via SCI Gateway or nhsh.communityrespiratoryteam@nhs.scot

Non pharmacological prevention

Vaccination

Ensure appropriate vaccinations are offered as appropriate, currently:

• Annual flu vaccination
• Annual covid vaccination (for those aged >75 years, or those with a weakened immune system)
• Single dose of pneumococcal vaccine as per The Green Book Green Book Chapter 25 - pneumococcal

Smoking cessation

• Discuss this with the patient and offer referral to smoking cessation service Contact Us – Smoke Free Highland
• Nicotine replacement products can be prescribed as per Highland Formulary Nicotine dependence (Formulary: CNS) | Right Decisions

Pulmonary Rehabilitation

There is a strong evidence base for pulmonary rehabilitation (PR) and it is one of the most cost-effective interventions we have to offer to patients with COPD.

• Consider referral to pulmonary rehabilitation if:
  • MRC dyspnoea score of grade 3 and above
  • Frequent exacerbations
  • Any patient where breathlessness is impacting on their quality of life
  • Following recent hospitalisation for an exacerbation
  • Those who consider themselves functionally disabled by COPD
• Before referral, outline the commitment required for pulmonary rehabilitation and the consequent benefits to people with COPD, and ensure patients are receiving optimal medical management prior to referral.
• Refer as per routine physiotherapy referral or though SCI gateway

• Pulmonary rehabilitation: Aim
  • Individually tailored pulmonary rehabilitation programmes aim to stabilise or improve both the physical and mental wellbeing of the patient by attempting to return the patient to highest possible level of functional capacity given their respiratory handicap and general medical status.
• Objectives
  • To achieve maximal functional independence in activities of daily living
  • To improve the psychological wellbeing of the patient
  • To improve appropriate prophylactic advice and education on lifestyle modification for patients, relatives and carers
  • To minimise the need for and dependency on Health and Social Services, and other agencies
  • To prevent downward spiral into disability
• More information
  • Pulmonary Rehabilitation
• Patient information
  • Pulmonary Rehabilitation | Doctor
    
  • Journey with the NHS | Right Decisions

Pharmacological prevention of exacerbations

• Inhaled therapy is known to reduce the exacerbation rate in COPD. Sometimes it is also appropriate to consider oral therapies.

Commencing therapy

For patients that are treatment naïve:

Reviewing therapy

What to consider before escalating therapy: see section on prevention of exacerbations

For patients that have ongoing symptoms of dyspnoea despite being established on treatment, prior to escalating inhaled therapy you should consider non-pharmacological measures such as: checking inhaler technique; smoking cessation and pulmonary rehabilitation. If patients have ongoing dyspnoea despite optimising inhaled therapy and use of non-pharmacological measure please consider alternative causes to symptoms. 

Escalating inhaled therapy

For patients that have one or more moderate or severe exacerbations of COPD then this should prompt a review of inhaled therapy (see figure below). Non-pharmacological measures should also be considered including: checking inhaler technique, pulmonary rehabilitation, smoking cessation and annual vaccinations. If bronchiectasis is known to be present alongside COPD it may also be appropriate to consider physiotherapy input for chest clearance.

In addition,

Factors to consider when using ICS:

Definition

• An exacerbation of COPD is defined as an acute, sustained, worsening of a patient's symptoms, which may include of worsening dyspnoea and/or cough and sputum production. It is important to exclude other potential causes of symptoms, e.g. pneumonia, heart failure, pulmonary embolism.

Classification of severity of COPD exacerbations:

Assessment and management in Primary Care

• Check temperature, oxygen saturations, blood pressure and heart rate
• Assess for confusion or impaired consciousness
• Examine the chest
• Check ability to cope at home
• Consider if hospital admission is required
  • Severe symptoms such as sudden worsening of resting dyspnoea, high respiratory rate, decreased oxygen saturations, confusion, drowsiness
  • Acute respiratory failure
  • Cyanosis
  • Oedema
  • Failure to respond to initial medical management
  • Significant co-morbidities
  • Inability to cope/ insufficient home support
• Sputum cultures are NOT routinely required unless there is a change in sputum or systemic signs of infection

Antibiotics

• Most exacerbations of COPD are NOT infective (bacterial). Assess the effectiveness of recent antibiotic courses BEFORE prescribing subsequent therapy.
• Consider prescribing antibiotics if patients report a change in sputum colour and an increase in volume or thickness.
• Send sputum for culture BEFORE starting antibiotics to guide treatment for current and future management
• Consider any previous sputum cultures to guide likely pathogens and susceptibility.
• Dual antibiotic therapy, e.g. amoxicillin PLUS doxycycline, is NOT indicated for an infective exacerbation of COPD unless the patient is diagnosed with community-acquired pneumonia.
• Note the significant adverse drug reaction risks with macrolides and fluoroquinolones and the increased risk of C. difficile with co-amoxiclav and fluoroquinolones.
• COPD - acute infective exacerbation (Antimicrobial)

Bronchodilators

• Optimise the use of inhaled short acting bronchodilators (SABA) +/- inhaled short acting muscarinic antagonists (SAMA)
• Ensure patients have inhaler devices they are able to use
• In acute exacerbations patients may need to switch to metered dose inhalers (pMDI) + spacer

Corticosteroids

• Corticosteroids can be given in acute exacerbations of COPD to shorten recovery time, improve lung function, and improve oxygenation
• Corticosteroids are usually given to those in the community whose breathlessness is interfering with daily activities
• Prednisolone 30mg once daily for 5 days
  Consider gastroprotection and bone protection (particularly for patients requiring multiple courses per annum)
• Doses of up to 40mg daily for 3 weeks do NOT usually require a weaning dose reduction, however this may be considered for patients with recurrent, recent steroid exposure
• Maintenance low dose steroids are NOT recommended.
• Avoid prescribing fluoroquinolones to patients on oral corticosteroids due to the risk of acute tendonitis. See MHRA safety advice on fluoroquinolones.

Rescue medication

Following an acute exacerbation of COPD consider offering a patient a prescription for a rescue pack to keep at home if they meet the following criteria:

1. They have a definite diagnosis of COPD
2. They have a self management plan, agreed with a healthcare professional that includes the use of rescue medications.

NOTE: If they have used more than 2 supplies in any 3-month period or 3 supplies in 12 months, there MUST be a healthcare professional review BEFORE prescribing a further rescue pack. 

Patient can be instructed to use rescue antibiotics and steroids if they believe they have an infective exacerbation characterised by development or increase in sputum purulence and one or more of the following:

• Increase in shortness of breath
• Increase or change in sputum volume, thickness or colour

This can be reviewed at their annual COPD review, and if they have low exacerbation frequency and medications are going out of date before being used, it may be appropriate to stop supplying rescue packs.

• Rescue pack:
  • 5 day supply of 30mg of prednisolone daily
  • 5 day supply of antibiotics as per the current antimicrobial guideline for acute exacerbation of COPD.

Initial assessment

All patients should have:

• NEWS
• ECG
• CXR
• FBC, U+Es, LFTs and CRP
• Blood gas
• Viral throat swab
• MC+S (if producing sputum) 
• Blood cultures (if pyrexical)
• Theophylline level (if on theophylline)

Immediate treatment

Oxygen therapy

• Oxygen therapy should be delivered to all patients aiming SpO₂ >94% (Scale 1), unless they have an arterial blood gas demonstrating evidence of chronic CO₂ retention or previous documentation of CO₂ retention.
• If patient has evidence of chronic CO₂ retention, aim SpO₂ 88 to 92% (Scale 2) and this should be delivered via a venturi mask.

Bronchodilators

Nebulised bronchodilators should be driven via air with supplementary oxygen via nasal cannula. A tight-fitting mask should be worn when giving ipratropium to reduce risk of acute angle-closure glaucoma:

• Salbutamol 2.5mg nebules four times per day (can be given 2 hourly if required, can try increased dose of 5mg if severe symptoms and poor response to 2.5mg)
• Ipratropium bromide 500 microgram nebules four times per day (add if poor response to salbutamol alone and suspend usual inhaler if contains LAMA, such as Anoro Ellipta^®, Trelegy Ellipta^®, Trimbow^® or Trixeo^®)

Corticosteroids

• Oral prednisolone 30mg, once daily for 5 days
• If patient is unable to swallow oral medication, give IV hydrocortisone 100mg STAT. If they have an ongoing need for IV therapy continue IV hydrocortisone 50mg, 6 hourly, otherwise switch to oral prednisolone 30mg.

Antibiotics

• Antibiotics should ONLY be given if evidence of bacterial infection, such as increased purulent sputum production, raised inflammatory markers or focal radiological evidence of pneumonia.
• For antibiotic choice please refer to TAM guidance: Respiratory tract (Lower) (Antimicrobial) | Right Decisions
• Note: dual antibiotic therapy, e.g. amoxicillin PLUS doxycycline, is NOT indicated for an infective exacerbation of COPD unless the patient is diagnosed with community-acquired pneumonia.

Non-invasive ventilation

• If patients have evidence of hypercapnia and acidosis on an arterial blood gas they should receive a prompt senior medical review for consideration of NIV.
• If the decision is to give NIV it should be commenced within 1 hour of the ABG which has led to the decision to start it.
• All patients starting on NIV should have a discussion about escalation if therapy were to fail.

VTE prophylaxis

• Patients with an exacerbation of COPD are at high risk of developing DVT/PE in hospital and should receive prophylactic enoxaparin, unless contraindicated.
• Please complete VTE risk assessment on HEPMA and prescribe as per assessment.

Discharge

Patients should be off oxygen and nebulisers for 24 hours prior to discharge. Other considerations prior to discharge:

1. Review patients regular inhaled therapy and inhaler technique. If they are having recurrent exacerbations, consider escalating their inhaled therapy (see Inhaled Therapy).
2. Does the patient require follow up? All discharges should be referred to community respiratory specialist team nhsh.communityrespiratoryteam@nhs.scot for follow up. Consider if there is a need for follow up imaging (for example if there has been a chest x-ray abnormality).
3. If patient is a current smoker, they should be offered NRT and referred to the Smoking Cessation Service: Smoking cessation
4. Consider if pulmonary rehabilitation would be of benefit to the patient. More information via this link: Pulmonary Rehabilitation
5. For patient education and self-management, please direct them to Respiratory Resource Hub | NHS Highland

Macrolide antibiotics

Patients should be offered pulmonary rehabilitation and community respiratory team input PRIOR to this therapy being initiated.

For antibiotics for the acute management of COPD exacerbation please refer to: COPD - acute infective exacerbation (Antimicrobial)

• Some studies have shown that regular macrolide antibiotic use may reduce exacerbation rate.
• For patients with recurrent exacerbations whose inhaled therapy has been optimised azithromycin is an option (250 mg/day or 500 mg three times a week) for 1 year, then review. 
• However, azithromycin use is associated with an increased incidence of bacterial resistance, prolonged QTc and can affect hearing.
• Non-smokers are more likely to benefit from azithromcyin than current smokers.
• An ECG should be checked prior to starting azithromycin and then again after 1 month to review the QTc. Check for drug interactions with azithromycin BEFORE initiating.
• Patients on azithromycin should withhold it if receiving a course of an alternative antibiotic that prolongs the QTc interval. Avoid clarithromycin for infective exacerbations due to concerns about macrolide resistance.

Mucolytics

These should be considered AFTER patient has been taught chest clearance techniques by a physiotherapist if symptoms are persistent.

• It can be suitable to consider mucolytics in some patients who frequently exacerbate who are not on inhaled corticosteroids, we generally advise discussing this with the community respiratory team (or the secondary care respiratory team).
• The options include carbocisteine and N-acetylcysteine.
  • There is evidence they can reduce exacerbation rate and may modestly improve health status.
  • These should be started on a trial basis and stopped if no benefit after 4 weeks.
  • N-acetylcysteine can be started at 600mg once a day.
  • Carbocisteine can be started at 750mg three times a day and if beneficial can be continued but consider reducing to 375mg[MH1.1] three times a day.

Phosphodiesterase type-4 inhibitors

• Roflumilast is NOT currently recommended by the Scottish Medicines Consortium for those with recurrent COPD exacerbations, and therefore we do NOT recommend starting it in new patients.
• We do have a small minority of respiratory patients already on this medication.

Theophylline

• Very occasionally secondary care specialists may prescribe theophylline in COPD patients, we do NOT recommend starting this in primary care.

COPD is a chronic and often progressive, obstructive lung disease and access to excellent ongoing care via a multidisciplinary integrated approach is essential.

Consider a proactive and palliative approach for patients with:

• Persistent symptoms despite optimal therapy
• an acute exacerbation which has required non invasive ventilation (NIV)
• cor pulmonale
• multiple acute exacerbations
• significant co-morbidity
• increasing frailty
• requirement for long term (at home) oxygen therapy (LTOT)

Have meaningful conversations with patients and families when they are well regarding their wants, needs and enable them to make informed decisions regarding their preference of care either in hospital or at home.

• This should be considered as part of the review process at annual reviews, as well as opportunistically when appropriate.

End of life care should include discussions with patients, and their families, about resuscitation status, and appropriate treatment escalation plans, including preferred place of care at the end of life.

• These decisions should be clearly documented on eKIS, making it accessible for SAS, and others via Care Portal.
• Regularly update discussions and decisions as required.
• Secondary care clinicians cannot update eKIS and so will need to update Primary care when these decisions are made.

Useful information can include:

• Baseline oxygen saturations
• Smoking status and suitability for home oxygen (in case of acute need)
• Any personalised plans with information that may prevent avoidable admission e.g.
  
  • Escalation of treatment plans (if in place)
  • Rescue pack and written self management action plan
  • Breathlessness management plan

ACP may also lead into conversations of DNACPR: Future care planning | Right Decisions

Management of dyspnoea

Dyspnoea (breathlessness) is a common and potentially distressing symptom affecting patients with COPD, regardless of severity, and may worsen as patients approach end of life. It is different for each individual and often unrelated to level of lung function. It can be distressing for families as they often feel helpless and so education and support should always include them. If all reversible causes have been treated, then consider firstly non pharmacological management of dyspnoea.

Breathing thinking functioning approach

Breathlessness is safe and normal, however it can be distressing and lead to anxiety and therefore it is important that patient education is considered as a key part of the management for this symptom.

The Breathing, Thinking, Functioning clinical model:
a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease.

• For further information, see: Welcome to the Breathing Thinking Functioning Website - Breathing Thinking Functioning
• In addition, we recommend reviewing the associated Cambridge Breathless Intervention Service leaflets: BIS patient information leaflets | CUH.
  • These are an excellent patient-focussed resource covering a range of topics including the BTF approach, managing exercise and physical activity and how to manage energy levels

Handheld fan

One simple and easy intervention to suggest is trialling a handheld fan as there is good evidence for cooling air passing over the face decreasing the symptoms of breathlessness.

Activity

It is important to advise patients that physical activity is helpful at any stage and is safe, although it may require modification compared to their pre-morbid activities. Sometimes equipment, such as walking aids, can be useful as they can be something to lean against or rest on when out of breath and can allow a patient to do more activities overall.

Pulmonary rehabilitation

This is a key part of the management of COPD and if not already considered it should be offered as an evidence based intervention which may improve the patient’s symptoms and exercise tolerance.

Pharmacological management of dyspnoea

Full details are in the Scottish Palliative Care Guidelines see section: Breathlessness | Right Decisions.

Options include: opioids and anxiolytics.

Opioids

• May reduce breathlessness both at rest and on exertion (taken 15 to 30 minutes prior to expected exertion)
• Robust evidence is lacking, so patients should be given a trial, and monitored for response and adverse effects
• Consider prescribing laxatives and anti-emetics proactively when prescribing opiates
• It is unlikely that doses above 30mg oral morphine, or equivalent, in 24 hours, will add benefit in the management of breathlessness. If small dose shows some benefit, there is almost never a need to increase that dose and it should always remain small.
• Usually suggest trialling 5mg MST twice a day, or alternatively can use 2.5mg oromorph up to 4 times a day if a short acting form preferred
• There is some evidence of benefit in allowing more physical activity
• Patient information: see HIS leaflet Opioids for breathlessness

Anxiolytics

• E.g. Lorazepam 500 micrograms may be useful in breaking the anxiety cycle, but longer term use should be avoided.

Oxygen therapy and NIV

Patients with resting hypoxia may benefit from Long term Oxygen Therapy (LTOT). Patients with resting SO₂ ≤ 92% may benefit from an oxygen assessment.

• These patients can be assessed in the first instance by the community respiratory team who can organise ABGs.
• Patients with a PO₂ <7.3kPa or PO₂ <8kPa with evidence of peripheral oedema, polycythaemia (HCT >55%) or pulmonary hypertension should have an oxygen assessment.
• Some patients who have had an episode of acute hypercapnic respiratory failure requiring NIV as an inpatient may have further assessment and be started on domiciliary nocturnal NIV.

Patients should be off oxygen and nebulisers for 24 hours prior to discharge. Other considerations prior to discharge:

1. Review patients regular inhaled therapy and inhaler technique. If they are having recurrent exacerbations, consider escalating their inhaled therapy (see Inhaled Therapy).
2. Does the patient require follow up? All discharges should be referred to community respiratory specialist team nhsh.communityrespiratoryteam@nhs.scot for follow up. Consider if there is a need for follow up imaging (for example if there has been a chest x-ray abnormality).
3. If patient is a current smoker, they should be offered NRT and referred to the Smoking Cessation Service: Smoking cessation
4. Consider if pulmonary rehabilitation would be of benefit to the patient. More information via this link: Pulmonary Rehabilitation
5. For patient education and self-management, please direct them to Respiratory Resource Hub | NHS Highland

• ABG: Arterial Blood Gas
• ACP: Anticipatory Care Planning
• BMI: Body Mass Index
• BTF: Breathing Thinking Functioning
• CAT: COPD Assessment Test
• COPD: Chronic Obstructive Pulmonary Disease
• CRP: C-Reactive Protein
• CVD: Cardiovascular Disease
• CXR: Chest X-ray
• DNACPR: Do Not Attempt Cardiopulmonary Resuscitation
• DPI: Dry Powder Inhaler
• ECG: Electrocardiogram
• eKIS: Electronic Key Information Summary
• FBC: Full Blood Count
• FEV1: Forced Expiratory Volume in 1 second
• FeNO: Fractional exhaled Nitric Oxide
• FVC: Forced Vital Capacity
• HCT: Haematocrit
• HR: Heart Rate
• IBD: Inflammatory Bowel Disease
• ICS: Inhaled Corticosteroid
• IV: Intravenous
• LABA: Long Acting Beta Agonist
• LAMA: Long Acting Muscarinic Antagonist
• LFTs: Liver Function Tests
• LTOT: Long-Term Oxygen Therapy
• MC+S: Microscopy, Culture and Sensitivity
• MI: Myocardial Infarction
• MRC: Medical Research Council
• MST: Modified Release Morphine Sulphate
• NEWS: National Early Warning Score
• NIV: Non-Invasive Ventilation
• NRT: Nicotine Replacement Therapy
• PE: Pulmonary Embolism
• PEFR: Peak Expiratory Flow Rate
• PO₂: Partial Pressure of Oxygen
• PR: Pulmonary Rehabilitation
• pMDI: Pressurised Metered Dose Inhaler
• QTc: Corrected QT Interval
• RR: Respiratory Rate
• SABA: Short Acting Beta Agonist
• SAMA: Short Acting Muscarinic Antagonist
• SPO₂: Peripheral oxygen saturation
• TB: Tuberculosis
• U+Es: Urea and Electrolytes
• VTE: Venous Thromboembolism