About the Toolkit COPD-X Aid Spirometry Calculator Lung Age Estimator Resources


About the Respiratory Toolkit

Lung Foundation Australia Primary Care Respiratory Toolkit supports the promotion of lung health as well as the early diagnosis and best practice management of lung disease. Evidence shows that Chronic Obstructive Pulmonary Disease is under-recognised, under-diagnosed and under-managed. The Primary Care Respiratory Toolkit has been developed to redress this.

Use the Lung Health Checklist, a simple one minute questionnaire to identify those people who are at risk of lung disease, including Chronic Obstructive Pulmonary Disease. For those who are identified at risk based on the Lung Health Checklist, a simple lung function screening test using a COPD screening device can identify those who would benefit from full diagnostic testing. These two tools will help you identify those within your practice who would benefit from diagnostic testing for COPD using spirometry.

Spirometry is essential for confirming diagnosis of COPD. The Spirometry Calculator provides useful tools for understanding and interpreting spirometry results. Please note: the spirometry tools used in the Respiratory Toolkit are based on Australian data

The Lung Age Estimator has been developed to support clinicians to motivate current smokers to quit, by providing a graphic illustration of estimated lung age.

Once COPD is Confirmed by spirometry, the COPD-X Aid will guide the primary care practitioner in Optimising function, Preventing deterioration by Developing a management plan, and managing eXacerbations.


The dashboard button at the top right of this window, is a quick means to access a subset of the tools of this toolkit.


Lung Foundation Australia Primary Care Respiratory Toolkit is based on The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease

Lung Foundation Australia acknowledges the original contributors to the development of the Primary Care Respiratory Toolkit in 2011. Acknowledgements of original contributors were current at the time of publication.

  • Alan J. Crockett, PSM, MPH, PhD, FANZSRS
    Director, Primary Care Respiratory Research Unit, Discipline of General Practice, School of Population Health & Clinical Practice, University of Adelaide, Adelaide, SA (Chair)
  • Peter A. Frith, MB BS, FRACP
    Professor and Head, Southern Respiratory Services, Flinders Medical Centre and Repatriation General Hospital, Daw Park, SA and Chair, Lung Foundation Australia COPD Coordinating Committee
  • Kerry Hancock, BMBS
    Chair, Lung Foundation Australia GP Advisory Group
  • Heather Allan
    Director – COPD National Program, Lung Foundation Australia
  • Paul Ayward, BA, MA, PGCE, MA(Ed), PhD
    Discipline of General Practice, University of Adelaide
  • Members of the Lung Foundation Australia General Practice Advisory Group who reviewed and commented on iterations of the resource:

    A/Prof Amanda Barnard
    Dr David Batt
    Prof Ian Charlton
    A/Prof H John Fardy
    Dr Chris Hogan
    Dr Steven Rudolphy
    Dr Victoria Smith
    Dr Noela Whitby
    Dr Russell Wiseman
    Dr Sanjiva Wijesinha

  • Primary Care Respiratory Toolkit development and support provided by Andre Duszynski at Pardalo

The Primary Care Respiratory Toolkit was reviewed and updated in December 2014. The following people contributed to the review:

  • Alan J. Crockett, PSM, MPH, PhD, FANZSRS
    Professor of Clinical Respiratory Physiology at the School of a Health Sciences, University of South Australia, Adelaide
  • Kerry Hancock, BMBS
    Chair, Lung Foundation Australia GP Advisory Group
  • Elizabeth Harper, B. App. Sci. (App. Chem.)
    Director, COPD National Program, Lung Foundation Australia
  • Judy Powell, MPH, Grad. Dip. (Man.), B. App. Sci. (P.E.)
    Project Manager, Primary Care, COPD National Program, Lung Foundation Australia

Additional sources of information include:

National Prescribing Service (NPS) – Chronic Obstructive Pulmonary Disease
National Prescribing Service (NPS) - Inhaler Technique
International Primary Care Respiratory Group, Clinical Use of Pulse Oximetry, Pocket Reference 2010
Stepwise Management of Stable COPD
COPD-X Concise Guide for Primary Care

Special thanks to the University of Adelaide for their ongoing support of this program.

The COPD National Program receives unrestricted sponsorship towards the development of training and resources from the following:

Foundation Partners: Boehringer Ingelheim Pty Ltd; A Menarini Australia Pty Ltd

Boehringer Ingelheim Pty Ltd A Menarini Australia Pty Ltd

Principal Partners: Novartis Pharmaceuticals Australia Pty Ltd; Air Liquide Healthcare Pty Ltd

Novartis Pharmaceuticals Australia Pty Ltd Air Liquide Healthcare Pty Ltd

Supporting Partners: AstraZeneca; GlaxoSmithKline

Lung Foundation Australia supports and encourages the dissemination and exchange of information. However, the material in this resource is protected by copyright. Lung Foundation Australia has no objection to this material being reproduced provided that Lung Foundation Australia is recognised as the owner and that the material remains unaltered.

Copyright 2017, Lung Foundation Australia

Lung Foundation Australia

Lung Foundation Australia is a national not-for profit organisation whose mission is to promote lung health and reduce the impact of lung disease in Australia. The COPD National Program works across five strategic areas: clinical education and support, community awareness, patient support, advocacy and research.

Lung Foundation Australia offers a patient information and resource centre which provides members of the community with information on various aspects of lung disease and support available. It can be reached by toll-free number 1800 654 301 or by email. The Lung Foundation website also provides a range of information www.lungfoundation.com.au

Lung Foundation Australia

PO Box 1949
Milton QLD 4064


Level 2, 11 Finchley Street
Milton QLD 4064

Toll-free: 1800 654 301 (patient support)
Telephone: (07) 3251 3600
Fax: (07) 3368 3564


Lung Foundation Australia Primary Care Respiratory Toolkit has been developed to support those working in primary care to diagnose and manage Chronic Obstructive Pulmonary Disease.

While this new tool has been developed based on feedback from general practitioners and practice nurses, we are sure that there are still improvements that can be made to make it even more useful. We would appreciate hearing from you.

Please email us to provide your feedback.

Bug Reporting

As we continue the development of this resource, we expect that a bug or two may have escaped our notice. If you would like to report unexpected behaviour relating to this website, please feel free to email us.

Please describe the following if possible:

An overall description of the bug
Steps to reproduce
Expected result
Actual result
Additional information

Thank you!

Health Professional Resources

The following lists resources that are useful for general practice:

COPD-X Concise Guide for Primary Care


The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease

Smoking cessation pharmacotherapy: an update for health professionals
Supporting smoking cessation: a guide for health professionals

COPD On-Line: An interactive training program for primary care nurses

MBS Item Flow Chart for COPD
MBS Flow Charts for COPD (PDF)

Stepwise Management of Stable COPD
Stepwise Management of Stable COPD

COPD Assessment Tool

MMRC Dyspnoea Scale

Resource Order form

Pulse oximetry
IPCRG Clinical Use of Pulse Oximetry, Pocket Reference 2010

Patient Resources

The following lists resources that are useful for patients:

Better Living with Chronic Obstructive Pulmonary Disease: A Patient Guide

Speaking with your GP: A guide for patients to make the most of their appointments
LFA Fact Sheet - Talking with your Doctor about COPD (PDF)
LFA Fact Sheet - Talking with your GP about COPD - Symptom Diary (PDF)

Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease Fact Sheet (PDF)

Home Oxygen Booklet

COPD The Basics


The COPD-X Aid has been developed to guide primary care practitioners in the recognition, diagnosis and management of Chronic Obstructive Pulmonary Disease. It is based on the evidence-based consensus document, the COPD-X Plan, Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2014.

This was an independent joint project of the Thoracic Society of Australia and New Zealand and Lung Foundation Australia, contributed to by physicians, general practitioners, nurses and allied health professionals – cf MJA 2003; 178(Suppl).

Stepwise COPD management summary

The Stepwise COPD management summary provides a pictorial summary of COPD management for clinicians.

COPD-X Concise Guide for Primary Care

The Concise Guide for Primary Care provides evidence-based practical recommendations for healthcare professionals on the diagnosis and management of COPD.

Confirm Diagnosis

Please select a topic below for more detail:

COPD should be considered in all smokers and ex-smokers aged over 35 years

Packyear Calculator

10-15 pack-years is a level at which the risk of COPD increases dramatically.

Cigarettes per day


Years as smoker


Confirm the presence and history of symptoms

The Lung Health Checklist is a quick way to identify those patients over 35 who are at risk of COPD.

  • Are you a smoker or ex-smoker?
  • Do you or have you worked in a job that exposed you to dust, gas, or fumes?
  • Do you cough several times most days?
  • Do you cough up phlegm or mucus most days?
  • Do you get out of breath more easily than others your age?
  • Do you experience frequent chest infections?

If the patient says yes to any of these and is 35 years of age or older, they could be at risk of having COPD and would benefit from further testing either by conducting full diagnostic spirometry or conducting a test with a COPD screening device.

The Checklist is also available at:

Screening using a COPD screening device can identify patients at risk of COPD who would benefit from diagnostic spirometry

  • Targeted Case Finding of COPD – Spirometry remains under-utilised in general practice. Simple COPD screening tools (such as the PiKo-6 and COPD 6) can be utilised to help identify your patients particularly at risk of COPD who would benefit from further diagnostic testing using spirometry.
  • For further information on the use of these devices in general practice go to:


    Here you will find:

    • Lung Foundation Australia Position Paper on the Use of COPD screening devices for Targeted Case-Finding in Community Settings
    • Targeted COPD Case-Finding in a Community Setting: A Training Video
    • COPD Screening Devices: An Instruction Sheet
    • Identifying those at Risk of COPD: COPD Screening Results Form
    • Conducting COPD Screening in General Practice

Assess airflow obstruction - spirometry is essential to confirm COPD diagnosis and to determine limitation of disease severity. The Spirometry Calculator will help determine the degree of severity based on FEV1.

  • Once COPD has been diagnosed, the following table helps classify the severity of COPD as outlined in the COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease (COPD-X).
  • It should be noted that different international guidelines e.g. GOLD, describe levels of severity differently. This Toolkit uses the stages described in COPD-X.

COPD severity FEV1
(% predicted)
Symptoms History of
Mild 60—80% predicted • Breathless on moderate exertion
• Recurrent chest infections/bronchitis
• Little or no effect on daily activities
Frequency may increase with severity of disease Present across all severity groups
Moderate 40—59% predicted • Increasing dyspnoea
• Breathlessness on level ground
• Increasing limitation of daily activities
• Cough and sputum production
• Exacerbations requiring corticosteroids and/or antibiotics
Severe < 40% predicted • Chronic cough
• Dyspnoea on minimal exertion
• Daily activities severely curtailed
• Experience regular sputum production

  • Referring for Spirometry – For those general practices who do not have the resources to conduct spirometry, referral should be made to a respiratory laboratory. A list of respiratory laboratories in Australia is maintained by Lung Foundation Australia. Contact 1 800 654 301.
  • Training in Spirometry – There are several spirometry training programs for general practitioners and practice nurses. Contact Lung Foundation Australia for further information 1 800 654 301.

The diagnosis of COPD rests on the demonstration of airflow limitation which is not fully or substantially reversible

Airflow limitation that is not fully reversible is defined as post-bronchodilator FEV1/FVC < 0.70 and FEV1 < 80% predicted.

If airflow limitation is fully or substantially reversible, treat as asthma

If the FEV1 response to bronchodilator is:

  • > 400ml, strongly consider asthma or asthma/COPD overlap
  • < 400ml (but ≥ 200ml and ≥ 12%), consider asthma/COPD overlap or an asthma component depending on history and pattern of symptoms.


COPD-X Guidelines - Confirm Diagnosis

Optimise Function

Please select a topic below for more detail:

Develop a General Practice Management Plan and Team Care Arrangement

Patients diagnosed with COPD qualify for a GP Management Plan (GPMP) or Item 721 and a Team Care Arrangement (TCA) or Item 723. A GPMP should be provided by the patient’s usual General Practitioner and can be reviewed three monthly (Item 732). The GPMP should be based on the agreed management goals of the patient and may include many of the actions listed below and in Prevent Deterioration. The GPMP may also include a COPD Exacerbation Action Plan to equip the patient to recognise the onset of an exacerbation and know how to manage it.

Team Care Arrangements are structured management plans for COPD patients that provide ongoing care from a GP and at least two other health care providers.

A flow chart outlining the available MBS items is available by clicking here.

A link to sample forms for TCA and GPMP plans are available through the Department of Health and Ageing: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement

Consider using assessment tools to measure level of functioning and symptoms

Assess level of functioning at home:

  • The COPD Assessment Tool is a simple and short (eight item) questionnaire for patients diagnosed with COPD. It is designed to form a foundation of understanding between clinician and patient and can help you achieve your aims in improving and maintaining your patient’s quality of life. http://www.catestonline.org/
  • The Modified Medical Research Council Dyspnoea Scale is useful for clinical assessment and can provide a baseline indication of the patient’s status:
0 "I only get breathless with strenuous exercise"
1 "I get short of breath when hurrying on the level or walking up a slight hill"
2 "I walk slower than people of the same age on the level because of breathlessness or have to stop for breath when walking at my own pace on the level"
3 "I stop for breath after walking about 100 yards or after a few minutes on the level"
4 "I am too breathless to leave the house” or “I am breathless when dressing"

Prescribe optimal drug therapy for level of severity and patient symptoms

  • A Stepwise Management Guide to Stable COPD will guide clinicians in COPD management
  • Inhaled bronchodilators provide symptom relief and may increase exercise capacity
  • If no improvement to bronchodilator after two months, check inhaler technique and adherence before changing therapy
  • Long-term use of oral corticosteroids is not recommended
  • Inhaled corticosteroids should be considered in patients with moderate to severe COPD and who have experienced frequent exacerbations
  • Inhaled combination therapy should be considered in patients with severe COPD to reduce symptoms and exacerbations and improve quality of life

For all symptomatic patients with COPD:

  • Follow a stepwise approach to pharmacological treatment to manage breathlessness, functional capacity, and exacerbation frequency is achieved
  • Use short-acting inhaled bronchodilator therapy for short-term relief of breathlessness

For patients receiving short-acting bronchodilators who have persistent troublesome dyspnoea, add a long-acting beta2agonist or a long-acting muscarinic antagonist (or both in combination if monotherapy is not adequate) for regular use.

For patients with FEV1 > 50% predicted and ≥ 2 exacerbations in 12 months:

  • Initiate a high-dose inhaled corticosteroid + long –acting beta₂agonist fixed dose combination and discontinue any long-acting beta2agonist monotherapy
  • For patients with moderate to severe COPD with frequent exacerbations who are not receiving a long-acting muscarinic antagonist, consider addition of long-acting muscarinic antagonist to the inhaled corticosteroid plus long-acting beta2agonist

For severe COPD (FEV1 < 40% predicted), consider adding low-dose theophylline (100mg twice daily).

Avoid long-term (> 2 weeks) use of oral corticosteroids.

Check adherence with pharmacotherapy

In developing the medicine regimen it is important that the patient is fully informed, and more specifically that they understand:

  • What the medicine is for
  • How the medicine works and the benefits for taking it as prescribed
  • How long before the medicine takes effect
  • How and when to administer the medicine (e.g. morning or night)
  • How long the effects of the medicine last and how often they must take the medicine
  • For how long they must take the medicine (e.g. a short course or lifelong treatment)
  • What the possible side effects of the medicine are and how to limit or avoid side effects. For example, long term use of oral steroids increases the risk of osteoporosis
  • If the medicine will interact with other medicines

Consider a home medicines review if adherence issues are more likely (e.g. multiple medicines, significant changes to medicines, confusion, visual impairment).

Check device technique

Significant rates of incorrect use have been reported for all types of inhalers, with up to 90% of patients using an incorrect technique in some clinical studies, resulting in inadequate drug delivery to the lungs.

Elderly patients may be more likely to have problems using inhaler devices due to deteriorating eyesight, poor hand strength, coordination difficulties and cognitive impairment.

Concurrent use of several different types of inhaler devices can also increase error rates.

The number of different types of inhalers used by a patient should be minimised wherever possible.

A useful video display of correct inhaler technique can be found on the National Prescribing Services (NPS) website:

Encourage physical activity

  • Why is fitness important?
    People who have COPD are often less active and can lose their fitness and muscle strength. Breathlessness leads to inactivity which causes further deconditioning which increases breathlessness, and so on. Ultimately, the patient becomes unable to carry out activities of daily living and becomes increasingly isolated.

    Benefits of exercise:
    • Reduce dyspnoea
    • Improve arm, body and leg muscle strength to help with daily activities
    • Assist with sputum clearance
    • Improve balance
    • Improve psychological wellbeing
    • Assist weight control
    • Improve bone density

  • Exercise guidelines:
    1. Exercise regularly – aim for 4 to 5 sessions per week
    2. Aim to exercise for at least 20 to 30 minutes per session (does not need to be continuous)
    3. Aim for moderate intensity
    4. An exercise program should include:
      - Aerobic – walking is ideal
      - Strength training
      - Stretching
    5. For more information, including sample exercise programs see Exercise and Physical Activity – Chapter 11, Better Living with COPD: A Patient Guide

Consider referral to pulmonary rehabilitation

Pulmonary rehabilitation is a six to eight week program combining education and exercise training. It has a high level of scientific evidence for multiple benefits, and few adverse effects. It should be considered for all people with symptomatic COPD (moderate to severe), and can even be commenced in early phases of recovery from exacerbations.

Pulmonary rehabilitation reduces dyspnoea, fatigue, anxiety and depression, improves exercise capacity, emotional function and health related quality of life and enhances a patient’s sense of control over their condition.

Pulmonary rehabilitation reduces hospitalisation and has been shown to be cost-effective.

Pulmonary rehabilitation should be considered for all people with symptomatic COPD (moderate to severe) and can even be commenced in the early phases of recovery from exacerbations

To find out about pulmonary rehabilitation programs near your patient, contact Lung Foundation Australia at 1 800 654 301.

Pulmonary rehabilitation fact sheet

Review nutrition

  • Frequent small meals can reduce dyspnoea.
  • Excessive weight-loss is a common problem in patients with end-stage COPD. Conversely, obesity in patients with COPD is associated with sleep apnoea, CO2 retention and cor pulmonale. Referral to a dietitian should be considered.
  • COPD increases the risk of poor nutrition, weight-loss and reduced muscle strength. Healthy Eating (Chapter 15 of Better Living with COPD: A Patient Handbook) provides advice for patients who are underweight, overweight and those who struggle with a lack of energy to shop, cook and eat proper meals.

Airway clearance techniques are indicated for those patients who have evidence of sputum

Airway clearance techniques are only indicated for patients with COPD who have evidence of sputum. This is likely to include individuals who have the clinical features of chronic bronchitis, those with co-existent bronchiectasis and some patients during an acute exacerbation.

A variety of techniques are available and advice can be sought from a respiratory physiotherapist.

Identify and manage co-morbidities

Common co-existing conditions include:

  • Cardiovascular disease
  • Heart failure
  • Sleep-related breathing disorders
  • Aspiration
  • Diabetes mellitus
  • Anxiety and depression
  • Gastro-oesophageal reflux disease (GORD)

Prevent or treat osteoporosis - Patients with COPD are at increased risk of fracture due to:

  • The disease itself
  • The use of high dose inhaled corticosteroids and courses of systemic steroids
  • Co-existing risk factors such as lack of physical activity, reduced muscle mass, immobilisation and aged related hypogonadism

Other co-existing conditions include:

  • Pneumonia
  • Skeletal muscle loss or dysfunction
  • Lung cancer
  • Obesity or malnutrition
  • Pulmonary hypertension

Assess and manage psychosocial needs

Depression, anxiety, panic disorder, and social isolation are common in patients with COPD and often increase the risk of hospitalisation. In addition to usual clinical assessment, the presence and impact of anxiety and depression may be reliably predicted with several validated questionnaires. Three commonly used assessment tools in primary care are:

  • Kessler Psychological Distress Scale (K10)
  • Depression Anxiety Stress Scale 21 (DASS 21)
  • Hospital Anxiety and Depression Scale (HADS)

One of the most effective means of improving the patient’s functional and psychological state is pulmonary rehabilitation. Call Lung Foundation Australia for information on local programs (1800 654 301)

Refer patient to Lung Foundation Australia support group network: 1800 654 301

Consider referral to respiratory physician

  • To establish diagnosis or exclude other pathology
  • If patient is not responding to treatment
  • To consider other therapies
  • To assess for long-term oxygen therapy
  • To assess suitability for surgical therapy

Encourage patient to contact Lung Foundation Australia for information

Lung Foundation Australia has a range of educational resources for patients and can be contacted toll-free on 1800 654 301. Feel free to also email us.


COPD-X Guidelines - Optimise Function

Better Living with COPD - A Patient Guide

Prevent Deterioration

Please select a topic below for more detail:

Assess smoking status at each visit

Ensure the smoking status of each patient is recorded and up-to-date.

Flag current smokers for brief smoking cessation advice or referral to local programs.

Support smoking cessation

  • The single most important intervention to prevent or slow the progression of COPD is smoking cessation; it preserves residual lung function at any stage of the disease and delays the onset of disability and death. There is evidence to show that personalising smoking cessation advice based on lung age and the lung age calculator may increase cessation rates. The Lung Age Estimator is a visually effective tool developed to support clinicians motivate current smokers to quit by providing a graphic illustration of estimated lung age.
  • The Royal Australian College of General Practitioners has developed an excellent resource to support smoking cessation in general practice: Supporting smoking cessation: a guide for health professionals
  • For all smokers, offer brief counselling and details of Quitline (13 78 48) as a minimum intervention at every visit. Best practice is summarised in the 5-A strategy:

    Ask and identify smokers at every visit

    Advise about the risks of smoking and benefits of quitting

    Assess the motivation to quit

    Assist cessation

    Arrange follow-up within a week of the quit date and one month after

    For smokers who continue to smoke, offer both counselling and nicotine dependence treatment provided there are no contraindications.

  • Pharmacotherapy:
    • Nicotine Replacement Therapy (NRT) - All forms of NRT are useful in aiding smoking cessation. Higher dose forms of NRT (4mg) are more effective than lower dose forms (2mg) for more addicted smokers and can be used while patients are still smoking. More than one form of NRT can be used concurrently with increased success rates and no safety risks. Refer to RACGP Supporting Smoking Cessation Guide for dosing guidelines using NRT.
    • Varenicline - Varenicline was developed to counteract the effects of nicotine on the nAChR (brain receptors). It is more effective than bupropion, more effective than NRT monotherapy and similar in effect to combination NRT. A 12-week course of treatment is recommended. In the first 4 weeks smokers should start varenicline and then set a quit date 1-2 weeks after starting, but a later date is sometimes appropriate. The dose is as follows: 1-3 days: 0.5mg daily; days 4-7: increase to 0.5 mg twice daily; and continue with 1 mg twice daily from day 8 to the end of a 12 week treatment course. To reduce relapse, patients who successfully quit at 12 weeks can be prescribed another 12 weeks of varenicline.
    • Bupropion - Bupropion increases quit rates compared to placebo and is effective for smokers with depression, cardiac disease and respiratory disease, including COPD. The recommended dose is 150 mg orally once daily for three days, then 150 mg twice daily. Bupropion is available as a starter pack of 30 tablets and a continuation pack of 90 tablets. The patient should stop smoking in the second week of treatment.

  • The following interventions have been shown to be effective in supporting people to stop smoking, including:

    Level I: Evidence obtained from systematic review of relevant randomised controlled trials

    • Smoking cessation advice from health professionals is effective in increasing quit rates. The major effect is to help motivate a quit attempt.
    • All health professionals can be effective in providing smoking cessation advice.
    • Brief smoking cessation advice from health professionals delivered opportunistically during routine consultations has a modest effect size, but substantial potential public health benefit.
    • Follow-up is effective in increasing quit rates.
    • Pharmacotherapy with nicotine replacement therapy, bupropion or varenicline is an effective aid to assisting motivated smokers to quit.
    • There is no significant effect of acupuncture or hypnotherapy in smoking cessation.

    Level II: Evidence obtained from one or more well-designed, randomised controlled trials

    • Instituting a system designed to identify and document tobacco use almost doubles the rate of health professional intervention and results in higher rates of cessation.
    • Telephone callback counselling services are effective in assisting cessation for smokers who are ready to quit.

    Level III: Evidence obtained from well designed, non-randomised controlled trials, or from well-designed cohort or case control studies

    • Factors consistently associated with higher abstinence rates are high motivation, readiness to quit, moderate to high self-efficacy and supportive social networks.

    Level IV: Evidence obtained from case series, either post-test or pre-test and post test

    • Introducing smoking restrictions in the home environment can assist quitting smoking successfully.

Medication has been shown to reduce risk and/or frequency of exacerbations

  • Long-acting beta2agonists (salmeterol, eformoterol, indacaterol) or long-acting muscarinic antagonists (tiotropium, glycopyrronium bromide or aclidinium bromide) improve lung function, symptoms, quality of life, and reduce exacerbation frequency.
  • Inhaled corticosteroids combined with long-acting beta2agonists (fluticasone propionate/salmeterol, budesonide/eformoterol) will reduce exacerbation frequency and improve quality of life.
  • Exacerbations tend to cluster. Therefore, a recent history of an exacerbation (within the last 12 months) is the greatest risk factor for a further exacerbation.
  • Current evidence does not support long-term antibiotic use to prevent exacerbations in patients with COPD. However, they should be used in exacerbations with an increase in cough, dyspnoea, sputum volume or purulence (see Manage Exacerbations).
  • Stepwise Management Guide to Stable COPD
  • For patients with FEV1 < 50% predicted and ≥ 2 exacerbations in 12 months:
    • Initiate a high-dose inhaled corticosteroid and long acting beta₂agonist fixed dose combination and discontinue any long acting beta₂agonist monotherapy.
    • For patients with moderate-to-severe COPD with frequent exacerbations who are not receiving a LAMA, consider addition of a LAMA to the ICS/LABA.
  • Preventing exacerbations has a key role in preventing deterioration.
  • Optimise pharmacotherapy to reduce the risk of exacerbations.
  • Identify and treat patients with exacerbation symptoms early using increased doses of bronchodilators, antibiotics if infection is evident, and oral corticosteroids for moderate to severe exacerbations.
  • Implement written action plans to treat exacerbations early.

Recommend annual influenza immunisation

Influenza immunisation reduces the risk of exacerbations, hospitalisation and death in patients with COPD.

Ensure all patients with COPD receive influenza vaccine immunisation. This is strongly recommended and should be actively promoted in patients with COPD.

Recommend regular pneumococcal immunisation with a "booster" after age 65

Pneumococcal polysaccharide vaccine, 23-valent (23vPPV); Pneumovax 23), produces significant immune responses in immunocompetent adults but there is no direct evidence supporting its efficacy in preventing exacerbations.

Pneumococcal vaccine (23vPPV) is recommended for those with:

  • Newly diagnosed COPD who have never received pneumococcal immunisation; a first dose of 23vPPV is recommended at diagnosis followed by up to two additional doses. For older adults who have already received an aged-based first dose of 23vPPV at aged 65 years (non-Indigenous) or 50 years (Indigenous), a single revaccination dose of 23vPPV is recommended a minimum of 5 years after the previous dose.
  • Pre-existing COPD: the first revaccination dose of 23vPPV is recommended at a minimum of 5 years after the most recent dose of 23vPPV, followed by a third dose at 65 years of age or five years after the previous dose, whichever is the later.

Guide to pneumococcal immunisations for patients with COPD

Please refer to this link to The Australian Immunisation Handbook (10th Edition, 2013) on the Department of Health website for further details:

Mucolytics may benefit certain patients with COPD

A Cochrane review could only find two randomised trials and based on this suggest that mucolytics reduce the frequency of exacerbations in patients with COPD who are not receiving inhaled corticosteroids.

Some patients with severe COPD and persistent sputum production who are receiving inhaled corticosteroids may also derive some benefit from mucolytics.

Currently in Australia, the available mucolytics for COPD are bromhexine (Bisolvon®) and acetylcysteine (Omegapharm Acetylcysteine Solution for inhalation via nebuliser).

A placebo controlled trial of N-Acetylcysteine in patients with stable COPD found significant improvement in small airway function and reduction in the frequency of exacerbations.

Advocate active lifestyle

The benefits of physical activity are well documented and patients should be encouraged to maintain an active lifestyle. Support patients to set physical activity goals that are specific and attainable.

For further information see Optimise Function.

Initiate regular review

Patients with COPD should be reviewed at least once per year or more frequently if indicated.

The review should cover the following:

  • Smoking status and desire to quit
  • Level of physical activity
  • Referral for pulmonary rehabilitation
  • Assess coping ability and strategies
  • FEV1 performance status
  • Medicine adherence and ability to use inhalation devices
  • Review for optimal inhaled bronchodilator therapy as per ‘Stepwise Management of Stable COPD’
  • Consider inhaled corticosteroid therapy if the patient has had >2 exacerbations in the last 12 months
  • Influenza and pneumococcal vaccination status
  • Any persistent chest x-ray abnormality should be reviewed 4-6 weeks post-discharge
  • Review possession, use and appropriateness of COPD Action Plan to manage exacerbations
  • Need for long term oxygen therapy – should be reviewed 4-6 weeks post discharge
  • Assessment of co-morbidities that are associated with COPD and/or impact on its management (e.g. IHD, CCF, osteoporosis risk and management, diabetes)
  • Need for referral to specialist

Assess functional status and impact of COPD either via traditional history taking/symptom checklists or using validated assessment tools such as the COPD Assessment Test (CAT) and the Modified Medical Research Council (mMRC) Dyspnoea scale.

The decision to alter pharmacotherapy should consider:

  • Exertional dyspnoea
  • Functional status
  • History of exacerbations
  • Complexity of medicines or devices
  • Patient preference
  • Occurrence of adverse effects

MBS Item 732 "Review GPMP or Coordinate Review TCA" is available to General Practitioners.

Long-term oxygen therapy has survival benefits for COPD patients with hypoxaemia

  • Long-term oxygen therapy prolongs life in hypoxaemic patients (PaO2 < 55-60 mmHg). PaO2 refers to the arterial carbon dioxide pressure in the blood, where high levels indicate an excess of carbon dioxide, as measured by an arterial blood gas (ABG) test, usually done by a physician.
  • Hypoxaemia is defined as PaO2 ≤ 55mmHg or by PaO2 ≤ 59 mmHg plus evidence of polycythaemia, pulmonary hypertension or right heart failure.
  • Pulse oximetry is a useful screening test to determine if further assessment i.e. ABG, is required. It measures oxygen saturation of haemoglobin in arterial blood. It can rapidly detect changes in oxygen saturation, thus providing an early warning of dangerous hypoxaemia.

    Evaluation of SpO2 measurements

    An SpO2 of greater than 95% is generally considered to be normal.

    An SpO2 of 92% or less (at sea level) suggests hypoxaemia.

    • In a patient with acute respiratory illness (e.g. influenza) or breathing difficulty (e.g. an asthma attack), an SpO2 of 92% or less may indicate a need for oxygen supplementation.
    • In a patient with stable chronic disease (e.g. COPD), an SpO2 of 92% or less should prompt referral for further investigation of the need for long-term oxygen therapy

    Clinical Use of Pulse Oximetry, Pocket Reference 2010

  • There are some important limitations of oximetry as outlined in the following table:

    Conditions Problem
    SpO2 values < 80% Pulse oximeters can over-estimate oxygen saturation, particularly in those with darkly pigmented skin.
    Poor perfusion (cold digits) due to hypotension, hypovolemic shock, cold environment, or cardiac failure May result in the machine not providing a reading
    Anaemia Oxygen delivery to tissues is inadequate but SpO2 is normal.
    Carbon monoxide poisoning Carbon monoxide binds to haemoglobin, resulting in inadequate oxygen transport despite normal pulse oximeter readings.
    Certain antiretroviral medications Affect oxygen’s affinity for haemoglobin.
    Movement, shivering patient, heart arrhythmias Oximeter may not be able to identify an adequate pulse signal.
    Nail polish, dirt, artificial nails Can cause false low readings or no readings.
    Bright artificial light (as in operating room) Can cause false low readings.
    Older patients Normal oxygen saturation levels may be slightly lower than in younger people.
    Sickle cell disease Does not confound SpO2 results in adults, but may in children.

  • Specialist referral is required to initiate subsidised Long-term Oxygen Therapy
  • For patients newly diagnosed with LTOT, Lung Foundation Australia has developed a user-friendly guide to living with LTOT - Home Oxygen Booklet. This guide includes information on nocturnal oxygen therapy.

Assess fitness to fly

Commercial aircraft operate at altitudes of up to 12 500 metres, with the plane’s interior pressurised to 2100–2400 metres. At this “altitude” the alveolar PaO2 for healthy individuals decreases from 103 mmHg (13.7 kPa) to 64 mmHg (8.5 kPa) and oxygen saturation declines from 97% to 93%.

As a general rule, supplemental oxygen is unlikely to be required if the resting oxygen saturation is 95% or higher, and likely to be required if oxygen saturation is 88% or lower. Patients with oxygen saturation values between these levels might require specialist assessment.

Before flying, patients should ideally be clinically stable. Patients recovering from an acute exacerbation are particularly at risk. Those already on long-term oxygen therapy need an increase in flow rate of 1–2 L per minute during flight. Careful consideration should be given to any comorbidity that may impair delivery of oxygen to the tissues (e.g. cardiac impairment, anaemia). Exertion during flight will exacerbate hypoxaemia.

The American Thoracic Society currently recommends that PaO2 during air travel should be maintained at more than 50 mmHg (6.7 kPa). At altitude, PaO2 can be estimated from PaO2 at sea level by means of published nomograms. If the PaO2 at sea level is less than 70 mmHg (9.3 kPa), PaO2 at 2300 metres is less than 50 mmHg (6.7 kPa). The natural conclusion is that all patients with a PaO2 less than 70 mmHg (9.3 kPa) at rest at ground level should receive supplemental oxygen.

Many lung function laboratories perform assessments for fitness to fly. These may include measurement of arterial blood gas levels or transcutaneous oxygen saturation while breathing a mixture of 15% oxygen and 85% nitrogen, which mimics conditions at 2800 metres.


COPD-X Guidelines - Prevent Deterioration

Better Living with COPD - A Patient Guide

Home Oxygen Booklet

Develop Support Network and Self-Management

Please select a topic below for more detail:

Provide self-management support to patients

  • 'Self-management support' is described as the healthcare and social-care services provided to individuals to enable them to take better care of themselves.
  • Patient self-management support includes a range of initiatives (e.g. education, awareness programs, support groups) involving patients and health professionals and delivered via different modalities (e.g. face-to-face consultation, internet, TV, telephone) aimed at enabling patients to enhance the management of their health.

Encourage patients to self-manage where appropriate

  • Assist patient to set realistic goals and strategies to achieve them
  • Assist patient to self-monitor, review progress with patient and reinforce achievements
  • Consider developing a GPMP (item 721) /TCA (item 723) which also reflects the patients goals and needs and actions to achieve them. This should also include a COPD Exacerbation Action Plan which will assist your patient to recognise and self-manage exacerbations where appropriate.

COPD imposes handicaps which affect both patients and carers

COPD imposes burdens for both patients and carers.

For patients, disability increases with COPD severity and is worsened by numerous complications and comorbid conditions.

Caring for a person with COPD, particularly in the severe stages can be physically, socially and emotionally demanding. Services are available to provide support for carers and can be accessed through the Commonwealth Respite and Carelink Centre (phone: 1800 059 059). These services include:

  • Respite care in emergency and short term planned care situations.
  • Assistance in locating and booking residential respite.
  • Access to an emergency respite service 24 hours a day.

An individualised chronic disease care plan anticipates the wide range of episodic and long-term care needs of people with chronic diseases.

  • COPD multidisciplinary care incorporating elements such as exercise, self-management education and exacerbation management can improve exercise capacity and health-related quality of life, and reduce hospitalisation.
  • Developing a practice register of patients with COPD and ensuring it is updated assists the practice in providing systematic care.

Good chronic disease care involves considering if the person is near the end of life, and planning accordingly.

Clinical support teams can help enhance quality of life and reduce disability for patients with COPD.

In addition to the GP and/or respiratory physician, and depending on access, the clinical support team for the patient with COPD may include a range of health professionals, including:

  • Practice Nurse
  • Pharmacist
  • Physiotherapists
  • Exercise physiologist
  • Respiratory Educator
  • Respiratory Nurse
  • Clinical psychologist/psychiatrist
  • Social Worker
  • Dietitian/Nutritionist
  • Occupational therapists
  • Speech pathologist

A GP Management Plan (GPMP) and Team Care Arrangement (TCA) based on the agreed management goals of the patient and that includes a written COPD Action Plan is a practical method of enlisting this clinical support team.

Patients, carers, and other family or friends should be engaged in the activities of the clinical support team.

Consider benefits of patient support groups and other community support services

Patients who receive education and psychosocial support show greater improvements in more aspects of health-related quality of life than those who receive education with no ongoing support. Some people may prefer individualised self-management training, but another proven way to provide such education and support is through patient support groups.

The Lung Foundation’s Information and Support Centre can be contacted, free call on 1800 654 301 or via enquiries@lungfoundation.com.au for:

  • Support group locations
  • Pulmonary rehabilitation program locations
  • Lungs in Action program locations
  • Links to other relevant services
  • Clinical and patient resources

For further information on community support services can be found in the Lung Foundation’s Better Living with COPD: A Patient Guide available at lungfoundation.com.au/patient-support/copd/better-living-with-copd-a-patient-guide

Patients who take appropriate responsibility for their own management may have improved outcomes – support the development of a self-management plan and a COPD Exacerbation Action Plan

In COPD, patient self-management support incorporating education and psychosocial support can improve health outcomes and reduce healthcare costs.

Self-management plans involving written action plans for exacerbation management and education and counselling strategies that incorporate disease and symptom management, emotional support, problem solving and decision making have been shown to improve health outcomes.

Whilst self-management is effective, the types of patients for whom it is beneficial and the essential component of the intervention remain unclear.

Caution is advised when considering patient suitability for self-management support.

Evidence suggests that only patients who adhere to self-management plans receive benefits such as decreased exacerbation recovery time. One study of US veterans found worse outcomes for patients who were randomly allocated to a comprehensive care program involving self-monitoring compared with those who received usual care.


COPD-X Guidelines - Develop support network and self-management plan

Manage eXacerbations

Please select a topic below for more detail:

Detecting and managing exacerbations early can prevent deterioration and hospital admission

A COPD exacerbation is characterised by a change in the patient’s baseline dyspnoea, cough, and/or sputum that is beyond normal day-to-day variations, is acute in onset, and may warrant a change in regular medication or hospital admission.

The greatest predictor of an exacerbation is a history of exacerbations as these events cluster in time and become more frequent as the severity of COPD worsens.

A delay (≥ 24 hours) in presentation for and initiation of treatment of an exacerbation doubles the chance of hospital admission.

In contrast, early diagnosis and prompt management of exacerbations improve recovery/quality of life, reduce hospitalisation, and may prevent progressive functional deterioration.

Preventing COPD exacerbations is important as mortality increases with the frequency of exacerbations, especially if these require hospitalisation.

About 10% of patients with a primary diagnosis of COPD died either during admission or within the same year. Median survival from first admission was five years in men and eight years in women.(COPDX)

Complete an action plan for patients and/or carer to facilitate early treatment at home

Education of patient, carers and significant others may aid in the early recognition of exacerbations and avoid the need for hospitalisation.

An action plan can aid the recognition of, and response to, an exacerbation but needs to be combined with comprehensive self-management support and integrated care based on shared care to reduce hospitalisation.

Complete an agreed Action Plan with your patient so that they can recognise any change in symptoms that might indicate a possible exacerbation and know how to act:

Managing acute exacerbations of COPD workflow

Assist early treatment with increased bronchodilator, antibiotics and corticosteroids

  • In patients with exacerbations, prescribe increased doses of inhaled bronchodilator, such as:
    • Salbutamol (400-800 mcg), 4-8 puffs via metered dose inhalers (MDI) and spacer every 3-4 hours, titrated to response.
  • Adequate doses of bronchodilator delivered by MDI with a spacer are as effective as nebulisers.
  • In patients with exacerbations, prescribe oral corticosteroids (prednisolone 30-50 mg or equivalent, taken in the morning) for 5 days and then stop; tapering the dose should not be necessary.
  • In patients with exacerbations and clinical features of infection, prescribe oral amoxicillin (500 mg every 8 hours), or doxycycline (100 mg every 12 hours) for 5 days.
  • Treatment does not aim to eradicate colonising bacteria.

Reassess within 24 hours

Reassess symptoms 24 hours after starting treatment for an exacerbation (whether self or doctor initiated).

Consider hospital admission

Most patients with an exacerbation of COPD can be managed at home, but some need hospital treatment.

The decision about referral to hospital involves an assessment of:

  • The severity of symptoms (particularly the degree of breathlessness, the presence of cyanosis or peripheral oedema and the level of consciousness)
  • The presence of comorbidities
  • Whether or not the patient is already receiving long term oxygen therapy
  • The level of physical functioning, and
  • The patient’s ability to cope at home

Hospital or home treatment for exacerbation of COPD

Factor Treat at Home Treat in Hospital
Able to cope at home Yes No
Breathlessness Mild Severe
General condition Good Poor/deteriorating
Level of activity Good Poor/confined to bed
Cyanosis No Yes
Worsening peripheral oedema No Yes
Level of consciousness Normal Impaired
Already receiving long-term oxygen therapy No Yes
Social circumstances Good Living alone/not coping
Acute confusion No Yes
Rapid rate of onset No Yes
Significant comorbidity (particularly cardiac disease and insulin dependent diabetes) No Yes
SpO2 < 92% No Yes
Changes on chest X-ray No Present
Arterial pH level ≥ 7.35 < 7.35
Arterial PaO2 (mmHg) ≥ 7 kPa < 7 kPa

Adapted from National Institute of Health and Care Excellence (NICE) 2014, Managing exacerbations of COPD, NICE Pathways

Follow-up and further help after an exacerbation

Hospital discharge plans should be shared with the primary care team in a timely manner (preferably within 24 hours of discharge).

Patients with COPD discharged from hospital should be reviewed by a member of the primary healthcare team within 7 days of discharge.

Patients discharged with chronic cough and ongoing sputum production should be monitored closely and taught airway clearance techniques if they have difficulties clearing secretions.

Post discharge review items:

  • Level of physical activity
  • Referral for pulmonary rehabilitation
  • Assess coping ability and strategies
  • FEV1 and performance status
  • Medicine adherence and ability to use inhalation devices
  • Review for optimal inhaled bronchodilator therapy as per ‘Stepwise Management of Stable COPD’
  • Consider inhaled corticosteroid therapy if the patient has had >2 exacerbations in the last 12 months
  • Influenza and pneumococcal vaccination status
  • Any persistent chest x-ray abnormality should be reviewed 4-6 weeks post-discharge
  • Osteoporosis risk and management
  • Assess future risk and prompt management of exacerbations
  • Review COPD Action Plan
  • Need for long-term oxygen therapy should be reviewed 4-6 weeks post discharge

Asking about smoking and offer cessation advice.


COPD-X Guidelines - Manage eXacerbations

Stepwise Management of Stable COPD

One page, stepwise guide to pharmacological and non-pharmacological interventions according to level of severity of disease.

The Stepwise Management of Stable COPD summarises these key management elements.

Stepwise Management of COPD Front

The guide to addition of therapies advises on medicines that can be used together and medicines that should not be used together.

Stepwise Management of COPD Back

COPD-X Concise Guide for Primary Care

This new COPD-X Concise Guide for Primary Care has been written to assist GPs, nurses and the general practice team in the management of patients with COPD. It is available as a fully searchable PDF document with internal hyperlinks to assist navigation. Recommendations are easily identified by accent boxes and the recommendations are graded according to the strength and the quality of the evidence. Additional practice tips are included and designed to aid clinical care

COPD-X Concise Guide for Primary Care

Height in metres

Age in years







Predicted   Actual %   Actual %   % Change

FEV1 (l)


FVC (l)


FEV1/FVC (%)


PEFR (l/sec)


FEF25-75% (l/sec)


Spirometry Interpretation

The current interpretation is based on pre-bronchodilator measures and is to be used as a guide only to the possible presence of airways obstruction.

Ideally the correct interpretation should be made on post-bronchodilator results. This feature will be included as soon as trialling has been completed.

Type of ventilatory defect if applicable (pre-bronchodilator)

Degree of airways obstruction (pre-bronchodilator)

Preliminary diagnosis of asthma or COPD


FEV1 (l)

Forced Expiratory Volume in one second is the volume of air expired in the first second of a maximal expiration following a maximal inspiration. FEV1 is used to measure how quickly air can be expelled from the lungs. Most people can expire at least 70% of their air out within the first second.

FVC (l)

Forced Vital Capacity is the maximum volume of air that can be expired forcefully after a maximal inspiration. Most adults are able to empty their lungs to residual volume in 6 seconds.

FEV1/FVC (%)

The ratio is the FEV1 expressed as a percentage of the FVC and gives a clinically useful indicator of airflow obstruction.

PEFR (l/sec)

The fastest speed at which you can blow air out. This is expressed in litres per second to be consistent with most spirometres. To calculate Peak Expiratory Flow Rate (PEFR), multiply FEFR (l/sec) by 60.


FEF25-75% is the forced expiratory flow between 25% and 75% of the FVC. It used to be called MMEFR, MEFR. Mean Mid Expiratory Flow rate or Mean Expiratory Flow rate.

The Lung Age Estimator has been developed to support clinicians to motivate current smokers to quit, by providing a graphic illustration of estimated lung age.

Height in metres

Age in years




FEV1 (l)

Estimated lung age if smoker

Lung Age Estimator Interpretation

The green diagonal line on the chart is the estimated rate of decline of FEV1 in lifetime non-smokers.

The red line depicts the rate of decline for the susceptible smoker whose details have been entered above.

The orange line indicates the potential slowing of the rate of decline if the smoker quits.


Telling smokers their "lung age" significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear (1). However, it is likely that "lung age" may provide the necessary motivation for a smoker to recognise the need for change and to seek treatment.

The definition of "lung age" is the age of an average non-smoking person who has a Forced Expiratory Volume at 1 second (FEV1) the same as the individual you are preparing to counsel to quit smoking.

It has been well documented that smoking cessation reduces the rate of decline of FEV1 to the level of lifetime non-smokers (2,3,4). An increased emphasis on smoking cessation and more effective utilization of spirometry are needed to improve the management of COPD (5).

The "Lung Age Estimator" has been developed to facilitate a rapid and simple method of estimating the "lung age" of a smoker. The algorithms used in this estimation are based on previously published Australian predicted normal equations (6,7).


The "Lung Age Estimator" is simple to use requiring the smoker's chronological age, height in metres, gender and pre-bronchodilator FEV1 to be entered via the sliders on the screen.

The smoker's predicted FEV1 and estimated "lung age" will be displayed in blue. The green diagonal line on the chart is the estimated rate of decline of FEV1 in lifetime non-smokers. The red line depicts the rate of decline for the susceptible smoker whose details have been entered into the Estimator. The orange line indicates the potential slowing of the rate of decline if the smoker quits.

Maximum FEV1 is considered to be achieved at about 25 years of age and then decreases with age. The values on the y-axis of the graph equate to percentage of that maximum achieved FEV1. Age is shown on the x-axis. It is believed that people will experience dyspnoea and exercise intolerance when their FEV1 reduces to about 80% of their maximum achieved FEV1, with exacerbations and hospitalisations occurring when FEV1 reduces to 50% of maximum achieved FEV1 and systemic effects, respiratory failure and pulmonary hypertension at 30%.

An Example

If we use an example of a 1.7m 55 year old smoker patient with an FEV1 of 3.2 litres currently has the lung mechanics of someone who is 72 years old! If they continued to smoke (and are susceptible to the deleterious effects of cigarette smoke) by the time they were 65 years old their lung function potentially would have deteriorated to the extent that it is likely that they would be suffering from exacerbations of respiratory illness and possibly requiring hospital admission from time to time. Then with continued smoking to 75 years of age they would have severe COPD with respiratory failure, pulmonary hypertension and systemic effects, If they stopped smoking now at 55 years of age then lung function deterioration would be slowed and progression to the level where exacerbations and hospitalisations occur would be delayed to past 75 years of age.

1. Parkes G, Greenhalgh T, Griffin M, Dent R. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial. Brit Med J. 2008 Mar 15;336(7644):598-600B.

2. Humerfelt S, Gulsvik A, Skjaerven R, Nilssen S, Kvale G, Sulheim O, et al. Decline in Fev(1) and Air-Flow Limitation Related to Occupational Exposures in Men of an Urban-Community. European Respiratory Journal. 1993 Sep;6(8):1095-103.

3. Burchfiel CM, Marcus EB, Curb JD, Maclean CJ, Vollmer WM, Johnson LR, et al. Effects of Smoking and Smoking Cessation on Longitudinal Decline in Pulmonary-Function. Am J Resp Crit Care. 1995 Jun;151(6):1778-85.

4. Scanlon PD, Connett JE, Waller LA, Altose MD, Bailey WC, Buist AS, et al. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease - The Lung Health Study. Am J Resp Crit Care. 2000 Feb;161(2):381-90.

5. Mapel DW, Picchi MA, Hurley JS, Frost FJ, Petersen HV, Mapel VM, et al. Utilization in COPD - Patient characteristics and diagnostic evaluation. Chest. 2000 May;117(5):346s-53s.

6. Newbury W, Crockett A, Newbury J. A pilot study to evaluate Australian predictive equations for the impulse oscillometry system. Respirology. 2008 Nov;13(7):1070-5.

7. Gore CJ, Crockett AJ, Pederson DG, Booth ML, Bauman A, Owen N. Spirometric standards for healthy adult lifetime nonsmokers in Australia. Eur Respir J. 1995 May;8(5):773-82.

8. Newbury W, Newbury J, Briggs N, Crockett A. Exploring the need to update lung age equations. Primary Care Respiratory Journal 2010; 19(3): 242-247.