A changing landscape: diagnosis

and management of COPD

Steve Holmes and Jane Scullion

cessation at all ages (Anthonisen et al, 2005)

and the value of pulmonary rehabilitation
Abstract (Puhan et al, 2009), as well as influenza and
Chronic obstructive pulmonary disease (COPD) is a common and often particularly
pneumococcal immunisation and aggressive
debilitating disease. Progressively worsening breathlessness can limit normal daily
management of disease exacerbations (Nichol
functioning, reduce quality of life (QoL) and increase the risk of premature death.
et al, 1999; Groenwold et al, 2009; Wedzicha
Importantly, early diagnosis, improving symptoms and QoL, along with minimising
and Donaldson, 2012)
exacerbations and hospital admissions, are primary goals of patient care. In recent
years, the assessment of COPD has moved away from equating disease severity
solely with the degree of obstructive lung impairment to include patient symptoms,
Diagnosis of COPD
History-taking is central to the diagnosis of
exacerbation history and comorbidities, as well as smoking status. There are now
COPD, with assessment of aetiological factors
more therapies that reduce symptoms and prevent exacerbations, thereby improving
that may have placed the patient at risk of
QoL. This review explores the diagnosis and management of COPD and positive
COPD, and a review of symptoms suggestive
clinical approaches to managing patients.
of the diagnosis. The diagnosis is confirmed
Key words: COPD ■ Breathlessness ■ Quality of life ■ Assessment ■ Primary care by post-bronchodilator spirometry. The FEV1
■ Management to FVC ratio (FEV1/FVC) represents the
proportion of the lung’s vital capacity that

C
hronic obstructive pulmonary
disease (COPD) is a common and
often particularly debilitating disease
with breathlessness as the primary
disabling symptom (Decramer et al, 2012).The
Global Initiative for Chronic Obstructive Lung
Disease (GOLD) guidelines define COPD
as a disease state characterised by airflow
limitation that is not fully reversible, is usually
progressive, and is associated with an abnormal
inflammatory response of the lungs to inhaled
noxious particles or gases (GOLD, 2014). In
addition, COPD is associated with systemic
effects and comorbidities, with systemic
inflammation a common factor (Decramer
et al, 2012). Patients can suffer unpleasant
symptoms that affect daily functioning and
quality of life (QoL) (National Institute for
Health and Care Excellence (NICE), 2011).
Ultimately, COPD increases the risk of
premature death (Decramer et al, 2012).
COPD patients typically have symptoms of
chronic bronchitis and emphysema, but broad
variations in clinical phenotype are apparent
Steve Holmes, General Practitioner, Park Medical
Practice, Shepton Mallet, Somerset; Jane Scullion,
(Decramer et al, 2012).The chronic productive
cough characteristic of bronchitis reflects
abnormal responses in the mucus glands in
the airways that normally operate to keep the
airways moist. The chronic inflammation of
these small airways causes the development of
thickened walls that exude an inflammatory-
affected mucus that blocks the airway (Hogg
et al, 2013). In emphysema, the tiny air sacs
(alveoli) in the lungs where gas exchange
takes place are gradually destroyed and it is
their narrowing and reduction in number
that lead to the severe airflow obstruction in
COPD (Hogg et al, 2013). These pathogenic
mechanisms that underlie COPD all contribute
to expiratory flow limitation, which in turn
inhibits complete lung emptying during the
breathing cycle, a physiological state called
‘dynamic hyperinflation’ (Thomas et al,
2013). This increases the work of breathing,
while decreasing the efficiency of respiratory
muscles, so increasing breathlessness and
reducing functional capacity.
Developing therapies that address the
underlying inflammatory mechanisms of
COPD and prevent the inexorable course of the
disease has proven challenging (Barnes, 2013).
can be forcibly expelled in the first second
of breathing out and allows the distinction
between a restricted lung volume and airflow
obstruction to be made. COPD airflow
obstruction is defined as a post-bronchodilator
FEV1 to FVC ratio (FEV1/FVC) of less
than 0.7. This value should be reviewed in
conjunction with a recent chest X-ray and
full blood count, in addition to a compatible
clinical history, to make the diagnosis of
COPD (NICE, 2010; Broekhuizen at al, 2012).
If airflow limitation is fully or substantially
reversible, shown by a marked increase in
FEV1 in response to a bronchodilator, the
alternative diagnosis of asthma should be
considered. Clinical symptoms are also useful
to differentiate between COPD and asthma
(Table 1) (NICE, 2010). Both asthma and
COPD involve narrowing of the airways
as a result of inflammation, but asthma
attacks are usually short-term and reversible,
whereas COPD is progressive and the damage
permanent, with the airflow obstruction only
partly reversible.
Assessing disease severity
There has been considerable change in recent
years in the assessment and management of
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Nurse Consultant, Glenfield Hospital, University
Hospitals Leicester
Accepted for publication: January 2015
Nonetheless, effective treatment strategies are COPD. A move away from equating disease
available that address the symptoms of COPD severity solely with the degree of obstructive
and improve patients’ QoL (NICE, 2011). lung impairment has led to the development of
Evidence shows the importance of smoking multidimensional indices predictive of health

432 British Journal of Nursing, 2015 Vol 24, No 8

status and prognosis such as DOSE (dyspnoea,
obstruction, smoking, exacerbations) (Jones
et al, 2009a) and BODE (body mass index
(BMI), obstruction, dyspnoea, exercise) (Celli
et al, 2004).
The guidelines of NICE and the GOLD
initiative—a collaboration between the
World Health Organization (WHO), the US
National Institutes of Health (NIH) and the
US National Heart, Lung, and Blood Institute
(NHLBI)—recommend that the assessment of
COPD include:
■■ Spirometric assessment of the severity of
airflow limitation
■■ Symptoms
■■ Exacerbation history
■■ Comorbidities. (NICE, 2010; GOLD, 2014)
This reflects a more holistic approach to
patient care in current clinical practice than
just the degree of obstruction. In practice,
holistic assessment should involve the patients’
ideas, concerns and expectations and other
issues, including their social and spiritual
situation. This approach is valuable, as COPD
is a heterogeneous condition and no single
measure gives an adequate assessment of
disease severity or prognosis.
Spirometric assessment of the
severity of airflow limitation
Evaluation of the severity of airflow limitation
is based on the FEV1 values relative to
those predicted for normal people and given
as a percentage (NICE, 2010). Classes of
airflow obstruction severity are presented
as percentage of post-bronchodilator FEV1
predicted (Table 2) (NICE, 2010).
COPD symptoms assessed using
patient-centred questionnaires
We know that FEV1 often has little correlation
with the symptoms experienced by patients
and other markers of disease severity. Patient-
centred questionnaires are valuable to gain
an accurate clinical picture of disease status,
symptom severity, activity limitation and QoL
(van der Molen et al, 2013), although they are
not widely used.
Dyspnoea (breathlessness) is the symptom
that most affects patients’ daily lives and is
often the reason for seeking medical help,
as in the case study presented. The Medical
Research Council (MRC) dyspnoea scale is
a simple-to-administer assessment that can
be used to grade the effect of dyspnoea on
daily activities and is recommended by NICE
(2010) (Table  3). Although a concern is that
patients can score differently on different
days, the scale provides acceptable test-retest
434
Table 1. Clinical symptoms used to differentiate between COPD and asthma
Symptom COPD Asthma
Smoker or ex-smoker Majority Possibly
Symptoms under age 35 Rare Common
Chronic productive cough Common Uncommon
Breathlessness Persistent and Variable
progressive
Night-time waking with breathlessness Uncommon Common
or wheeze
Significant diurnal or day-to-day symptom variability Uncommon Common
(NICE, 2010)
Table 2. Classes of airflow obstruction severity as post-bronchodilator FEV1% predicted
Stage of severity Post-bronchodilator FEV1% predicted
I – Mild ≥80%
II – Moderate 50−79%
III – Severe 30−49%
IV – Very severe <30%
(NICE, 2010)
Table 3. MRC dyspnoea scale
Grade Degree of breathlessness related to activities
1 Not troubled by breathlessness except on strenuous exercise
2 Short of breath when hurrying or walking up a slight hill
3 Walks slower than contemporaries on level ground because of breathlessness, or has to
stop for breath when walking at own pace
4 Stops for breath after walking about 100 metres or after a few minutes on level ground
5 Too breathless to leave the house, or breathless when dressing or undressing
(NICE, 2010)
reliability (Mahler et al, 2009). The scale COPD treatment strategies
correlates with other dyspnoea scales and The goals of COPD patient care are to improve
lung-function measurements, but there is functional status and QoL and minimise
limited evidence to show that functional exacerbations and hospital admissions. Good-
capacity can be measured with dyspnoea quality care plans take into account the
scales. Recent evidence suggests that dyspnoea patients’ needs and preferences, and allow the
scales should not be a substitute for actual opportunity for informed decisions about
functional capacity testing (Boer et al, 2012). care options and treatment (NICE, 2010).
The COPD assessment test (CAT) is a Recommended interventions include:
useful, self-administered patient questionnaire ■■ Smoking cessation (GOLD, 2014)
tool that can be used in the everyday clinical ■■ Vaccination (pneumococcal and annual
setting to assess the impact of COPD (Jones et influenza (NICE, 2010))
al, 2009b). Comparing consecutive CAT scores ■■ Strong encouragement for physical activity
provides valuable information for long-term (Vestbo et al, 2013)
follow up and can help improve management ■■ Suitable referral to pulmonary rehabilitation
(Zhao et al, 2014), although it is only validated (NICE, 2010)
for people who only suffer from COPD and ■■ Dealing with anxiety and depression (NICE,
do not have any other comorbidities. Other 2010)
assessments to estimate disease severity include ■■ Management of other comorbidities
exercise tolerance (e.g. 6-minute walking test (including coronary heart disease,
suggested in BODE), an assessment of oxygen osteoporosis, etc)
© 2015 MA Healthcare Ltd
saturation using pulse oximetry, history of ■■ Inhaled medications (GOLD, 2014).
exacerbations, BMI and the presence of cor
pulmonale (failure of the right side of the Smoking cessation
heart) (NICE, 2010). This should be encouraged at all times, including
British Journal of Nursing, 2015 Vol 24, No 8
 Box 1. A case history: Graham dyspnoea (MRC Grades 3−5) with functional
limitation (Bolton et al, 2013). However, it is
Graham, a 63 year-old accountant, is an avid golfer, but on a recent golfing holiday in Portugal, he
not suitable for people who cannot walk and
was walking slower than his colleagues and struggled to carry his clubs. He had been diagnosed
with COPD 3 years before after two winter ‘chest infections’, following spirometry, chest X-ray, full those who have suffered recent acute coronary
blood count and clinical assessment. His smoking history of 32 pack years and spirometry (FEV1/ syndrome (ACS) or recent major surgery. In
FVC ratio=0.62; FEV1% predicted=57%) confirmed the diagnosis of COPD. Graham was given the case of Graham (Box 2), who has started
separate salbutamol and ipratropium inhalers and, with smoking-cessation support, finally stopped to smoke again and has ongoing anxiety,
smoking. At his last visit, his four-time daily use of ipratropium had been changed to a long-acting pulmonary rehabilitation appears particularly
muscarinic antagonist. Since then, he has begun smoking again, is anxious about his symptoms, and suitable. Pulmonary rehabilitation has been
is increasingly breathless shown to have a number of benefits, which
have been assessed and graded in terms
Box 2. A case history: Graham (continued) of strength of evidence within the BTS
guidelines (Table 4) (Bolton et al, 2013).
In his review, Graham scores 4 on the MRC dyspnoea scale. Spirometry shows his FEV1 has fallen
Outstanding questions include whether or
a little since his previous reading and his CAT score has increased to 26. The nurse is concerned
about Graham’s smoking and high anxiety levels. She does not consider that the deterioration
not the benefits of pulmonary rehabilitation
in FEV1 and symptoms are linked to other medical causes of increased breathlessness. She decrease over time in the disease course of
checks his inhaler technique; ensures he is happy with his inhaler devices and can use them; COPD. Recent evidence suggests that they do
books an influenza vaccination; and arranges the pneumococcal vaccination that he has not had not. Van Ranst et al (2014) have shown that
previously. He is referred for a pulmonary rehabilitation course; breathing techniques to cope with those severely impaired by COPD with high
breathlessness are also discussed. Stepping up Graham’s medication from a single long-acting exacerbation rates can experience reductions
bronchodilator to either a combination inhaler or an additional inhaler is discussed too in both exacerbation and hospitalisation
frequency after participation in comprehensive
Table 4. Benefits of pulmonary rehabilitation and strength of evidence
pulmonary rehabilitation.
Strength of Degree of breathlessness related to activities
evidence
Anxiety and depression
Depression and anxiety are significant and
A Improves exercise capacity
common comorbidities in people with
Reduces the perceived intensity of breathlessness
COPD, but can be difficult to identify and
Improves health status
Reduces number of hospitalisations and days treat because their symptoms often overlap
Reduces anxiety and depression associated with COPD with those of the disease and often remain
B Upper-arm strength/endurance training improves arm function
unrecognised and under-treated (Yohannes
Benefits persist beyond training period and Alexopoulos, 2014). Recent evidence
Improves survival points to a biological link, suggesting that
Improves recovery after hospitalisation for exacerbation low-grade chronic inflammation mediates in
Enhances the effect of long-acting bronchodilators part the association of depressive symptoms
C Respiratory muscle training can be beneficial (dyspnoea, health status, exercise and pulmonary function (Yohannes and
capacity), especially when combined with general exercise training Alexopoulos, 2014).
(Bolton et al, 2013) Once recognised, treatment of depression
is important. Several approaches are used and
in Graham’s case (Box 1). Smoking cessation is seen as a failure on the part of the clinician or have shown promising results. These include
the most important intervention and the one patient (GOLD, 2014). smoking cessation, pulmonary rehabilitation,
with the greatest capacity to influence the Calculating the value of interventions, psychological therapy, and pharmacotherapy
natural history of COPD in those sufferers IMPRESS (the joint initiative between the with antidepressants. It is important to consider
who smoke (GOLD, 2014). Even in severe British Thoracic Society (BTS) and the an integrated approach to tackling depression
COPD, smoking cessation slows progression Primary Care Respiratory Society UK) that involves patients, care givers and the
of the disease and improves survival (Qureshi, formed a ‘value pyramid’ that shows that even necessary health professionals in order to
2014). Intensive smoking cessation programmes with the costs of pharmacotherapy, intense optimise the treatment approach to anxiety and
with pharmacotherapy are warranted. Brief efforts for smoking cessation are more cost- depression (Yohannes and Alexopoulos, 2014).
intervention counselling should be a routine effective and are ‘good value’ compared with
part of all clinicians’ skills, and signposting other interventions (IMPRESS, 2012). Inhaled medications
patients to appropriate services can help them Inhaled therapies are the main pharmacological
to stop smoking. Pharmacotherapies such Pulmonary rehabilitation treatments for COPD, with bronchodilation the
as nicotine-replacement products and other The benefit of pulmonary rehabilitation primary goal. Bronchodilators help symptoms
products including varenicline, bupropion and compared with usual care is strongly by addressing the pathophysiological features
nortriptyline have been shown to be of benefit. supported by clinical evidence for those of dyspnoea, reversing dynamic hyperinflation
© 2015 MA Healthcare Ltd

Counselling by physicians and other health patients functionally limited by dyspnoea of the lungs, and emptying the trapped
professionals is also effective. However, ultimately, (Bolton et al, 2013). The BTS guidelines air through dilatation of the distal airways
tobacco dependence can be considered a chronic give a ‘Grade A’ recommendation to offer (Thomas et al, 2013).
disease and relapse is common; it should not be pulmonary rehabilitation to patients with For patients with mild airflow obstruction

436 British Journal of Nursing, 2015 Vol 24, No 8


and symptoms, short-acting ß2-agonists
(SABAs) and/or short-acting muscarinic
antagonists (SAMAs) are the recommended
initial bronchodilator treatment, on an ‘as
required’ basis for relief of breathlessness or
exercise limitation (NICE, 2010). Commonly
prescribed short-acting bronchodilators
include salbutamol (a SABA) and ipratropium
bromide (a SAMA). For those with more
significant symptoms, treatments include
long-acting ß2-agonists (LABAs) and long-
acting muscarinic antagonists (LAMAs);
and for recurrent exacerbations, inhaled
corticosteroids (ICSs) co-prescribed with a
LABA. In patients with mild-to-moderate
COPD (FEV1≥50% predicted) who remain
symptomatic or experience exacerbations, a
LABA (e.g. salmeterol or formoterol twice-
daily or indacaterol once-daily) or a LAMA
(e.g. tiotropium or glycopyrronium once-
daily or aclidinium twice-daily) are treatment
options (NICE, 2010).
COPD treatment in moderate to
severe disease
Combining inhaled medications
The traditional treatment approach for
moderate to severe COPD recommended by
NICE is to start maintenance therapy either
with the LAMA tiotropium (once-daily and
until recently the only LAMA available),
or less frequently a LABA (e.g. salmeterol
or formoterol twice-daily or more recently
indacaterol once-daily), then to escalate
treatment with the addition of a combination
inhaler comprising an ICS plus a LABA.
This standard approach of therapy escalation
is now being challenged, with a consensus
view from GOLD (2014) recommending
that clinicians rethink this algorithm and
consider a broader range of treatment
options (Han et al, 2013). The principle
of the GOLD consensus is based on a
combined assessment of air flow obstruction,
symptoms and exacerbation risk on three
axes, stratifying patients into four categories
(A, B, C and D). These include LAMA/
LABA dual therapy, which is recommended
as a treatment alternative for group B patients
(high symptoms/low risk), group C patients
(low symptoms/high risk) and group D
patients (high symptom/high risk). Although
the GOLD view on these categories is
somewhat controversial, with an inherent
conflict between how to interpret FEV1
© 2015 MA Healthcare Ltd
and exacerbations and how to interpret
symptoms when CAT and the MRC score
(or adapted ‘mMRC’ score) do not correlate,
they do point to a broader consideration
British Journal of Nursing, 2015, Vol 24, No 8
Box 3. A case history: Graham (continued)
Graham is reassured about his breathlessness and coping mechanisms are discussed. After
discussion of the inhaler options (either an ICS/LABA combination inhaler, or both a LAMA and
LABA), Graham decides he would prefer to avoid using steroids and is prescribed a once-daily
LABA to be taken with his once-daily LAMA. Graham feels much happier to attend the pulmonary
rehabilitation programme and is hopeful that his breathlessness will ease
of the merits of different combinations of
inhaled medications in the management of
stable COPD.
Optimising the choice of
intervention
ICS/LABA combinations reduce the rate
of exacerbations and improve lung function
in COPD (Calverley et al, 2007). Summary
evidence of the effect of ICS on COPD
exacerbations is provided by recent Cochrane
meta-analyses (Yang et al, 2012; Nannini et al,
2013). In an analysis of patients (n=5601) with
predominantly poorly reversible severe COPD,
exacerbation rates with ICS/LABA twice-daily
combinations were significantly reduced (rate
ratio 0.87, 95% CI 0.80–0.94) compared with
ICS alone (Nannini et al, 2013).
A clear issue with ICS/LABA is concern
over adverse side effects, in particular an
increased risk of pneumonia with higher doses
of inhaled corticosteroid. Moderate-quality
evidence from the Cochrane analysis shows an
increased risk of pneumonia with ICS/LABA
combinations (Nannini et al, 2013). This
supports the view that patients and clinicians
together should carefully assess the benefit/risk
of ICS/LABA prescribing in severe COPD,
given the high level of prescribing of these
combinations, often outside the guidelines.
NICE recommends considering a LAMA in
addition to LABA where ICS is declined or
not tolerated (as in Graham’s case, Box 3).
More than 12% of patients with COPD in the
UK are prescribed ‘triple’ therapy (NICE, 2011),
a particularly costly intervention. The ‘value
pyramid’ (IMPRESS, 2012) shows the relative
position of interventions in terms of cost per
quality-adjusted life years (QALY) and shows
the very high cost of triple therapy (£35 000–
187  000/QALY) (IMPRESS, 2012). Value
is an important consideration in optimising
treatment and management of COPD. For
clinicians, the value paradigm is fundamental in
achieving high value for patients. These costings
highlight the need to focus on appropriate
prescribing of inhaled medications to reduce
overuse (IMPRESS, 2012).
New options in bronchodilation
Currently, a number of new treatments that
combine bronchodilators with different
CLINICAL FOCUS
mechanisms of action are just becoming
available for prescribing (Bateman et al,
2014). Targeting two different mechanisms of
bronchodilation by combining a muscarinic
antagonist and a ß2-agonist has the potential to
maximise bronchodilation without increasing
the dose of the individual bronchodilator,
while minimising the variability in response
to individual agents (Tashkin and Ferguson,
2013). Recently, Ultibro® (formerly QVA149),
a new fixed-dose combination of indacaterol
(LABA) and glycopyrronium (LAMA) as
a once-daily dual bronchodilator delivered
through a single device was approved.
More recently, a second LABA/LAMA single
inhaler of umeclidinium and vilanterol was
approved, also indicated for the long-term,
once-daily maintenance treatment of airflow
obstruction in patients with COPD. Data from
large phase-III clinical trials showed that LABA/
LAMA combinations improve lung function
more than the individual LABA and LAMA
components, and were superior to tiotropium
in patients with moderate to severe COPD,
improving FEV1 and dyspnoea (Decramer et
al, 2014; Rodrigo and Plaza, 2014). Indacaterol/
glycopyrronium combination was also shown to
be superior to twice-daily salmeterol/fluticasone
propionate, improving trough FEV1, dyspnoea
and use of rescue medication (Vogelmeier et al,
2013). These new combination inhalers with
once-daily administration may also increase
patient compliance.
Managing COPD towards
the end of life
Long-term oxygen therapy (LTOT)
There is strong evidence for the long-term
administration of oxygen (>15 hours per day)
to COPD patients with respiratory failure
resulting in increased survival in patients with
severe resting hypoxemia (GOLD 2014;Turner
et al, 2014). NICE guidelines recommend that
LTOT be targeted at patients who have a PaO2
(blood gas tension) of less than 7.3 kilopascals
(kPa) when stable or a PaO2 greater than
7.3 kPA and less than 8 kPa when stable, and
one of: secondary polycythaemia, nocturnal
hypoxaemia, peripheral oedema or pulmonary
hypertension (NICE, 2010). Oxygen is often
prescribed inappropriately for intermittent
use with the intention of preventing hospital
437

KEY POINTS
n COPD is a symptomatic, prevalent and costly disease
n Improving symptoms, quality of life (QoL) and minimising hospital admissions are the
primary goals of patient care
n Breathlessness is the prevailing symptom of COPD. Non-pharmacological and pharmacological
treatments can significantly improve QoL care, reduce exacerbations and breathlessness
n Smoking cessation and pulmonary rehabilitation are key cost-effective interventions, as are
influenza immunisations
n Bronchodilation is the main focus of pharmacological COPD treatment
n Early integration of palliative care can benefit patients with COPD and should be based on a
patient’s needs rather than prognosis
admissions. Recent evidence does not support
this practice, showing that admission to hospital
is more likely in LTOT users, whatever their
COPD severity. Therefore, oxygen use outside
the NICE recommendations does not appear
to prevent admissions (Turner et al, 2014).
Non-invasive positive pressure
ventilation (NPPV)
During the advanced stages of COPD, patients
experience severe bronchial obstruction,
pulmonary hyperinflation and chronic
ventilatory failure, resulting in hypercapnia and
respiratory acidosis. In patients with chronic
hypercapnic respiratory failure, NPPV results
in improvements in blood gases and lung
hyperinflation. Patients with COPD also report
improvements in exercise capacity, health-
related QoL and survival with long-term NPPV
(Köhnlein et al, 2014). Home NPPV is an
option for those with advanced disease.
Palliation and end-of-life care
Palliative care is an important component of
the comprehensive care of COPD and should
form part of the stepwise management of
COPD. A misunderstanding of the role of
palliative care can be a barrier to optimal
patient management. It is often mistakenly
assumed that palliative care is only appropriate
for the end of life, when all other options
have been exhausted. However, patients with
COPD will experience some level of recovery
from all except their last exacerbation
(Bourke and Peel, 2014). Therefore, modern
palliative care, based on patients’ needs rather
than prognoses, should apply in those who
suffer from COPD. In COPD patients, a
palliative assessment may be offered when
the patient has had an episode of non-
invasive ventilation for respiratory failure.
For these patients, palliative care should focus
on how their situation can be improved
438
while also fostering an understanding of
what cannot be achieved (Bourke and
Peel, 2014). A recent study investigated the
impact of early palliative integrated care
within respiratory services for patients with
breathlessness, including COPD patients.
This study found that early integration of
palliative care through breathlessness support
services improved breathlessness mastery and
survival in patients with COPD (Higginson
et al, 2014). BJN
Conflict of interest: Steve Holmes has received
sponsorship to attend educational meetings, advisory
boards or funding to speak (on speaker-chosen
slides) over the past 3  years for Primary Care
Respiratory Society UK (PCRS-UK), Royal
College of General Practitioners (RCGP),
Respiratory Education UK, Somerset GP Education
Trust, British Lung Foundation, several clinical
commissioning groups (CCGs), NHS England,
Health Education England, Almirall, AstraZeneca,
Beximco, Boehringer Ingelheim, Chiesi, Group  H,
GlaxoSmithKline (GSK), Orion, Mediconf,
Novartis, Pfizer, Pulse, Sandoz, University of Bath,
University of Cardiff.
Jane Scullion has received sponsorship to attend
educational meetings, advisory boards or funding to
speak (on speaker-chosen slides) over the past 3 years
for PCRS-UK, RCGP, Respiratory Education
UK, British Lung Foundation, several CCGs,
NHS England, Almirall, AstraZeneca, Boehringer
Ingelheim, Chiesi, GSK, Orion, Novartis, Pfizer,
Sandoz, Teva.
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