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Implementing the change in National Institute for Health and Clinical Excellence guidance on airflow obstruction grading in chronic obstructive pulmonary disease
  1. Rupert C M Jones1,
  2. Kevin Gruffydd-Jones2,
  3. David B Price3
  1. 1Peninsula Medical School, Respiratory Research Unit, Plymouth, UK
  2. 2Box Surgery, London Road, Corsham, UK
  3. 3University of Aberdeen, Department of General Practice and Primary Care, Aberdeen, UK
  1. Correspondence to Dr Rupert C M Jones, Peninsula Medical School, Room N21, 1 Davy Road, Plymouth PL6 8BX, UK; rupert.jones{at}

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The updated National Institute for Health and Clinical Excellence (NICE) chronic obstructive pulmonary disease (COPD) guidelines1 and the draft national strategy for COPD2 have recommended a change in the classification of airflow obstruction severity to align them with international classifications. NICE's 2004 guidelines recognised that disease severity is not the same as the severity of airflow obstruction and has recommended using other measures such as the Medical Research Council (MRC) dyspnoea scale, exacerbation frequency and multicomponent indices.3 However, UK primary care has been encouraged to code disease severity into mild, moderate and severe COPD based on lung function alone in line with NICE's 2004 guidance on airflow obstruction.

The code for COPD is thus H3; H36 is mild COPD; H37 is moderate COPD and H38 is severe COPD.

A person with COPD and an forced expiratory volume in 1 s of 42% of predicted has until now been coded as having moderate COPD; according to NICE 2010 they should now be coded as severe airflow obstruction. However, codes do not exist for mild, moderate, severe and very severe airflow obstruction. Therefore, for both patients and primary clinicians we have a communication problem and a coding problem. Clear guidance is needed on how the disease/airflow obstruction severity should be coded on primary care records without any conflicting or confusing advice.

Perhaps the answer is to abolish the codes for mild moderate and severe COPD and for new codes for airflow obstruction based on GOLD stages 1–4 to be generated. For practical purposes of classifying COPD severity, for example, for deciding the frequency of reviews, the MRC dyspnoea scale could replace H36–8 as markers of disease severity. The MRC scale is already being recorded in primary care. In future, COPD severity codes should be based on multicomponent indices, at present a suitable index for primary care has not been chosen. The NICE guidelines recommend the use of the BODE index when its component items are available, the need for the six minute walking test will make this impractical for routine use in primary care and there is insufficient evidence to approve newer indices such as the ADO4 and DOSE.5

Action is required now to address both the coding and communication issues so that the sensible advice from NICE can be implemented without causing confusion in primary care and distress to patients.



  • Competing interests None to declare.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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