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Chronic obstructive pulmonary disease

About

What is covered

This pathway covers the management of COPD in adults (aged over 16 years) in primary and secondary care.
An estimated 3 million people have COPD in the UKHealthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission.. Most people are not diagnosed until they are in their fifties.
COPD is predominantly caused by smoking and is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months but is usually progressive in the long term. Exacerbations often occur, when there is a rapid and sustained worsening of the patient's symptoms beyond normal day-to-day variations.
There is no single diagnostic test for COPD. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.

Updates

Updates to this pathway

4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
9 November 2015 Pathway restructured and summarised recommendations replaced with full recommendations.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added to this pathway.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedure guidance 517) added to breathlessness and exacerbations.
11 March 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
24 February 2015 Minor maintenance update.
2 December 2014 Minor maintenance update.
1 October 2014 Minor maintenance update.
11 August 2014 Minor maintenance update.
20 March 2014 Minor maintenance updates.
24 September 2013 Insertion of endobronchial valves for lung volume reduction in emphysema (NICE interventional procedure guidance 465) added to breathlessness and exacerbations.
11 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
29 May 2012 Minor maintenance updates.
23 March 2012 Roflumilast for the management of severe chronic obstructive pulmonary disease (NICE technology appraisal guidance 244) added to the treating stable COPD path.
16 January 2012 Services for people with COPD (NICE commissioning guide) added to resources dropdown list.
25 October 2011 Minor maintenance updates.

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Short Text

Management of chronic obstructive pulmonary disease in adults (aged over 16 years) in primary and secondary care

What is covered

This pathway covers the management of COPD in adults (aged over 16 years) in primary and secondary care.
An estimated 3 million people have COPD in the UKHealthcare Commission (2006) Clearing the air: a national study of chronic obstructive pulmonary disease. London: Healthcare Commission.. Most people are not diagnosed until they are in their fifties.
COPD is predominantly caused by smoking and is characterised by airflow obstruction that is not fully reversible. The airflow obstruction does not change markedly over several months but is usually progressive in the long term. Exacerbations often occur, when there is a rapid and sustained worsening of the patient's symptoms beyond normal day-to-day variations.
There is no single diagnostic test for COPD. Diagnosis relies on a combination of history, physical examination and confirmation of airflow obstruction using spirometry.

Updates

Updates to this pathway

4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added.
15 December 2015 Link to care of dying adults in the last days of life (NICE guideline NG31) added.
9 November 2015 Pathway restructured and summarised recommendations replaced with full recommendations.
17 August 2015 Link to NICE pathway on antimicrobial stewardship added.
6 August 2015 Smoking cessation: supporting people to stop smoking (NICE quality standard 43) added to this pathway.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedure guidance 517) added to breathlessness and exacerbations.
11 March 2015 Minor maintenance update.
4 March 2015 Link to NICE pathway on excess winter deaths and illnesses associated with cold homes added.
24 February 2015 Minor maintenance update.
2 December 2014 Minor maintenance update.
1 October 2014 Minor maintenance update.
11 August 2014 Minor maintenance update.
20 March 2014 Minor maintenance updates.
24 September 2013 Insertion of endobronchial valves for lung volume reduction in emphysema (NICE interventional procedure guidance 465) added to breathlessness and exacerbations.
11 January 2013 Minor maintenance updates.
4 December 2012 Minor maintenance updates.
7 August 2012 Minor maintenance updates.
29 May 2012 Minor maintenance updates.
23 March 2012 Roflumilast for the management of severe chronic obstructive pulmonary disease (NICE technology appraisal guidance 244) added to the treating stable COPD path.
16 January 2012 Services for people with COPD (NICE commissioning guide) added to resources dropdown list.
25 October 2011 Minor maintenance updates.

Sources

NICE guidance

The NICE guidance that was used to create the pathway.
Chronic obstructive pulmonary disease (2010) NICE guideline CG101
Chronic obstructive pulmonary disease - roflumilast (2012) NICE technology appraisal guidance 244
Varenicline for smoking cessation (2007) NICE technology appraisal 123
Insertion of endobronchial valves for lung volume reduction in emphysema (2013) NICE interventional procedures guidance 465
Living-donor lung transplantation for end-stage lung disease (2006) NICE interventional procedures guidance 170
Lung volume reduction surgery for advanced emphysema (2005) NICE interventional procedures guidance 114
Chronic obstructive pulmonary disease (2011 updated 2016) NICE quality standard 10

Quality standards

Smoking cessation: supporting people to stop smoking

These quality statements are taken from the smoking cessation: supporting people to stop smoking quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statements

Diagnosis with spirometry

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People aged over 35 years who present with a risk factor and one or more symptoms of chronic obstructive pulmonary disease (COPD) have post-bronchodilator spirometry.

Rationale

A diagnosis of COPD is confirmed by post-bronchodilator spirometry. To ensure early diagnosis, spirometry should be done in primary care when a person presents with a risk factor for COPD (which is usually smoking) and one or more symptoms of COPD.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people aged over 35 years presenting with a risk factor and one or more symptoms of COPD have post-bronchodilator spirometry.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Evidence of local arrangements and written clinical protocols to ensure that healthcare professionals in primary care using post-bronchodilator spirometry are trained and competent in its use.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
c) Evidence of local arrangements to ensure that primary care services providing post-bronchodilator spirometry are supported by quality control processes.
Data source: Local data collection.
Process
Proportion of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD who have post-bronchodilator spirometry.
Numerator – the number in the denominator who have post-bronchodilator spirometry.
Denominator – the number of people aged over 35 years presenting with a risk factor and one or more symptoms of COPD.
Data source: Local data collection. Quality and Outcomes Framework indicator COPD002: The percentage of patients with COPD in whom the diagnosis has been confirmed by post-bronchodilator spirometry between 3 months before and 12 months after entering on to the register.
Outcome
COPD incidence.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services) ensure that quality-assured post-bronchodilator spirometry is carried out in people aged 35 years and over who have a risk factor and one or more symptoms of COPD, to confirm diagnosis of COPD. Service providers ensure that healthcare professionals are trained and competent in performing and interpreting post-bronchodilator spirometry.
Healthcare professionals (in primary care services) ensure that they perform quality-assured post-bronchodilator spirometry in people aged 35 years and over who have a risk factor and one or more symptoms of COPD, to confirm diagnosis of COPD. Healthcare professionals ensure they remain up to date with training and competencies in performing and interpreting post-bronchodilator spirometry.
Commissioners (clinical commissioning groups) ensure that they commission services in which people aged 35 years and over who present with a risk factor and one or more symptoms of COPD receive quality-assured post-bronchodilator spirometry to confirm a diagnosis of COPD.

What the quality statement means for patients, service users and carers

People aged 35 or older who have an increased risk of COPD and who have one or more symptoms of COPD are offered a test to check how well their lungs work (called post-bronchodilator spirometry). This test is used to diagnose COPD. People are at an increased risk of COPD if they smoke or have smoked in the past, or if they have been exposed to harmful fumes, dust or chemicals, often at work. Symptoms of COPD include breathlessness, long-lasting cough, coughing up phlegm, frequent winter ‘bronchitis’ and wheezing.

Source guidance

Definitions of terms used in this quality statement

Risk factors
Risk factors for COPD include:
  • smoking history
  • occupational exposure to harmful fumes, dust or chemicals
  • exposure to fumes, such as biomass fuels.
[Chronic obstructive pulmonary disease (NICE guideline CG101) and expert opinion]
Symptoms of COPD
Symptoms of COPD are:
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter 'bronchitis'
  • wheeze.
[Chronic obstructive pulmonary disease (NICE guideline CG101) recommendation 1.1.1]
Post-bronchodilator spirometry
Post-bronchodilator spirometry is used to identify abnormalities in lung volumes and air flow. Spirometry should be performed by a healthcare professional who has had appropriate training and who has up-to-date skills. The use of post-bronchodilator spirometry should be supported by quality control processes.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101) recommendations 1.1.2.5 and 1.1.2.6]

Inhaler technique

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People with chronic obstructive pulmonary disease (COPD) who are prescribed an inhaler have their inhaler technique assessed when starting treatment and then regularly during treatment.

Rationale

Bronchodilator therapy is usually delivered using a hand-held inhaler device. People with COPD need to use their inhaler correctly to receive the optimal treatment dose. Assessing inhaler technique should happen at the first prescription once a person has been taught the correct technique, and then be reassessed regularly (for example, at their annual review, if their treatment changes or after an acute exacerbation) throughout the duration of a person’s treatment in primary, community and secondary care services.

Quality measures

Structure
a) Evidence of local arrangements and written clinical protocols to ensure that people with COPD who are prescribed an inhaler have their technique assessed at the start of treatment and then regularly during their treatment.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Evidence of local arrangements and written clinical protocols to ensure that healthcare professionals in primary, community and secondary care services are trained and competent in teaching inhaler technique.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
Process
a) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at the start of treatment.
Numerator – the number in the denominator who have their inhaler technique assessed at the start of treatment.
Denominator – the number of people with COPD prescribed an inhaler.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed at their annual review.
Numerator – the number in the denominator whose last inhaler annual review was no longer than 12 months since the previous one or since inhaler initiation.
Denominator – the number of people with COPD prescribed an inhaler for more than 12 months.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
c) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after a change in treatment.
Numerator – the number in the denominator who had their inhaler technique assessed after a change in treatment.
Denominator – the number of people with COPD prescribed an inhaler who have had their inhaler changed.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
d) Proportion of people with COPD prescribed an inhaler who have their inhaler technique assessed after an acute exacerbation.
Numerator – the number in the denominator who had their inhaler technique assessed after an acute exacerbation.
Denominator – the number of people with COPD prescribed an inhaler who have had an acute exacerbation.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
Outcome
a) Exacerbation rates.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Hospital admissions.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary care services, community services and secondary care services) ensure that systems are in place and healthcare professionals are trained and competent to teach people with COPD who are prescribed an inhaler the correct inhaler technique and to assess their inhaler technique when starting treatment and regularly during their treatment.
Healthcare professionals (nurses, GPs, secondary care doctors, physiotherapists, occupational therapists and pharmacists) ensure that they provide training in the correct inhaler technique to people with COPD when they have been prescribed an inhaler. Healthcare professionals ensure that they assess the person’s inhaler technique when starting treatment and regularly during their treatment.
Commissioners (clinical commissioning groups) ensure that they commission services in which people with COPD who are prescribed an inhaler are trained and assessed in the correct inhaler technique when they start treatment, and have their technique reassessed regularly during their treatment.

What the quality statement means for patients, service users and carers

People with COPD who are given an inhaler have a check to make sure that they can use it correctly when they start treatment and at least once a year at their annual review. They should also have a check if their treatment changes or after a sudden flare up of their symptoms (called an acute exacerbation).

Source guidance

Equality and diversity considerations

Elderly people, or people with learning disabilities, physical disabilities or cognitive impairment may experience difficulties learning and retaining the adequate inhaler technique to ensure that they get the optimal treatment dose. An individual patient assessment should be carried out before choosing the most appropriate device for delivery of inhaled therapy.

Assessment for long-term oxygen therapy

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People with stable chronic obstructive pulmonary disease (COPD) and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need long-term oxygen therapy (LTOT).

Rationale

LTOT is used to treat people with stable COPD who have developed daytime hypoxaemia. People with COPD and a persistent resting stable oxygen saturation of 92% or less should be assessed for their suitability for LTOT, which can improve survival, pulmonary haemodynamics, polycythaemia and neuropsychological health.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need LTOT.
Data source: Local data collection Royal College of Physicians’ National COPD Audit Programme.
Process
Proportion of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less who have their arterial blood gases measured to assess whether they need LTOT.
Numerator – the number in the denominator who have their arterial blood gases measured to assess whether they need LTOT.
Denominator – the number of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
Outcome
a) Hospital admission for acute exacerbation.
Data source: Local data collection.
b) Quality of life.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (primary and secondary care services) ensure that systems are in place for people with stable COPD and a persistent resting oxygen saturation level of 92% or less to have their arterial blood gases measured to assess whether they need LTOT.
Healthcare professionals ensure that they measure the arterial blood gases of people with stable COPD and a persisting resting oxygen saturation level of 92% or less to assess whether they need LTOT.
Commissioners (clinical commissioning groups) ensure that they commission services in which people with stable COPD and a persisting resting oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need LTOT.

What the quality statement means for patients, service users and carers

People with COPD that is stable and who have low levels of oxygen in their blood (when checked using a device that clips to their finger) have this confirmed by a blood test, to assess whether they need long-term oxygen therapy. Long-term oxygen therapy is treatment with oxygen breathed in through a tube (placed just inside the nose) or a mask connected to an oxygen supply. It is usually given for at least 15 hours during the day or night.

Source guidance

Definitions

Long-term oxygen therapy (LTOT)
The provision of oxygen therapy for continuous use at home, usually given for at least 15 hours during the day or night.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101)]
Assessment for LTOT
Assessing people for LTOT should comprise measuring arterial blood gases on 2 occasions at least 3 weeks apart in people who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable.
[Chronic obstructive pulmonary disease (NICE guideline CG101) recommendation 1.2.5.6]
Stable COPD
The absence of any of the features of a recent acute exacerbation, such as worsening breathlessness, cough, increased sputum production and change in colour of sputum.
[Chronic obstructive pulmonary disease (NICE guideline CG101) recommendation 1.3.1]
Persistent resting stable oxygen saturation
An oxygen saturation (measured with a pulse oximeter) that is persistently 92% or less when the person is in a chronic stable state and is at rest (is not, and has not recently, been exercising).
[Expert opinion]

Pulmonary rehabilitation for stable COPD and exercise limitation

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People with stable chronic obstructive pulmonary disease (COPD) and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Rationale

Pulmonary rehabilitation programmes improve a person’s exercise capacity, quality of life, symptoms and levels of anxiety and depression.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit and organisational audit.
Process
a) Proportion of people with stable COPD and exercise limitation due to breathlessness who are referred to a pulmonary rehabilitation programme.
Numerator – the number in the denominator who are referred to a pulmonary rehabilitation programme.
Denominator – the number of people with stable COPD and exercise limitation due to breathlessness.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit.
b) Proportion of referrals of people with stable COPD and exercise limitation due to breathlessness that result in the person attending a pulmonary rehabilitation programme.
Numerator – the number in the denominator that result in the person attending a pulmonary rehabilitation programme.
Denominator – the number of referrals of people with stable COPD and exercise limitation due to breathlessness to pulmonary rehabilitation programmes.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit.
c) Proportion of attendances of people with stable COPD and exercise limitation due to breathlessness that result in the person completing a pulmonary rehabilitation programme.
Numerator – the number in the denominator that result in the person completing a pulmonary rehabilitation programme.
Denominator – the number of attendances of people with stable COPD and exercise limitation due to breathlessness at pulmonary rehabilitation programmes.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit.
Outcome
a) Hospital admissions for acute exacerbation.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Quality of life.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
c) Exercise capacity.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: Pulmonary rehabilitation clinical audit.
d) GP attendances.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care and community services) ensure that systems are in place for people with stable COPD and exercise limitation due to breathlessness to be referred to a pulmonary rehabilitation programme.
Healthcare professionals refer people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.
Commissioners (clinical commissioning groups) ensure that they commission services in which people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

What the quality statement means for patients, service users and carers

People with COPD that is stable and who have difficulty walking and have to walk slowly and stop often or soon become breathless, are referred to a pulmonary rehabilitation programme. This includes exercises, information about COPD, diet advice and support depending on the person’s needs.

Source guidance

Definitions of terms used in this quality statement

Exercise limitation
Medical Research Council dyspnoea scale of breathlessness grade 3 and above. A breathlessness of grade 3 is defined as ‘walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace’.
[Chronic obstructive pulmonary disease (NICE guideline CG101)]
Pulmonary rehabilitation programme
A multidisciplinary programme of care for people with chronic respiratory impairment that is individually tailored and designed to optimise each person's physical and social performance and autonomy.
Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. Programmes should be available within a reasonable time from referral.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG 101) recommendation 1.2.8.3]
Programmes comprise individualised exercise programmes and education, and:
  • are at least 6 weeks in duration and include a minimum of twice-weekly supervised sessions
  • include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training
  • include a defined, structured education programme.

Equality and diversity considerations

Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment.

Pulmonary rehabilitation after an acute exacerbation

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (COPD) start a pulmonary rehabilitation programme within 4 weeks of discharge.

Rationale

Starting a pulmonary rehabilitation programme within 4 weeks of hospital discharge after an acute exacerbation reduces the short-term risk of hospital readmission, and improves the quality of life and the short-term exercise capacity of people with COPD.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people with COPD admitted to hospital for an acute exacerbation start a pulmonary rehabilitation programme within 4 weeks of discharge.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit and organisational audit.
Process
Proportion of people discharged from hospital after an acute exacerbation of COPD who start a pulmonary rehabilitation programme within 4 weeks of discharge.
Numerator – the number in the denominator who start a pulmonary rehabilitation programme within 4 weeks of discharge.
Denominator – the number of people discharged from hospital after an acute exacerbation of COPD.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit.
Outcome
a) Hospital admissions for acute exacerbations.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Quality of life.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
c) Exercise capacity.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme: pulmonary rehabilitation clinical audit.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care and community services) ensure that systems are in place for people admitted to hospital for an acute exacerbation of COPD to start a pulmonary rehabilitation programme within 4 weeks of discharge.
Healthcare professionals ensure that people admitted to hospital for an acute exacerbation of COPD are referred for and receive a pulmonary rehabilitation programme within 4 weeks of discharge.
Commissioners (clinical commissioning groups) ensure that they commission services in which people who are admitted to hospital for an acute exacerbation of COPD are referred for and receive a pulmonary rehabilitation programme within 4 weeks of discharge.

What the quality statement means for patients, service users and carers

People with COPD who have had a hospital stay because of a sudden flare up of their symptoms (called an acute exacerbation) start a pulmonary rehabilitation programme within 4 weeks of leaving hospital. This includes exercises, information about COPD, diet advice and support depending on the person’s needs.

Source guidance

Definitions of terms used in this quality statement

Acute exacerbation
An exacerbation is a sustained worsening of a person’s symptoms from their usual stable state and which is beyond usual day-to-day variations and acute in onset. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in sputum colour.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101)]
Exercise capacity and physical activity levels are impaired during and after an exacerbation, contributing to skeletal muscle dysfunction, particularly of the lower limbs.
[Adapted from British Thoracic Society Guideline for pulmonary rehabilitation in adults]
Pulmonary rehabilitation programme
A multidisciplinary programme of care for people with chronic respiratory impairment that is individually tailored and designed to optimise each person's physical and social performance and autonomy.
Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. Programmes should be available within a reasonable time from referral.
[Adapted from Chronic obstructive pulmonary disease NICE guideline CG 101 recommendation 1.2.8.3]
Programmes comprise individualised exercise programmes and education, and:
  • are at least 6 weeks in duration and include a minimum of twice-weekly supervised sessions
  • include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training
  • include a defined, structured education programme.

Equality and diversity considerations

Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment.
Some people with COPD may not be well enough to attend a pulmonary rehabilitation programme within 4 weeks of an acute exacerbation, may not have attended hospital after an acute exacerbation of COPD or may not have been admitted to hospital after their exacerbation of COPD.

Emergency oxygen during an exacerbation

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People receiving emergency oxygen for an acute exacerbation of chronic obstructive pulmonary disease (COPD) have their oxygen saturation levels maintained between 88% and 92%.

Rationale

During an exacerbation, people with COPD may experience a worsening of gas exchange in the lungs, which can lead to low blood oxygen levels. Emergency oxygen is often given during the treatment of an exacerbation, either in the community, during transfer to hospital in an ambulance or while being assessed at hospital.
In some people, uncontrolled oxygen therapy may reduce the depth and frequency of breathing, leading to a rise in blood carbon dioxide levels and a fall in the blood pH (acidosis). Controlled oxygen therapy must therefore be administered by a delivery device and at a flow rate that helps the oxygen saturation to be maintained between 88% and 92%.

Quality measures

Structure
Evidence of local arrangements and written clinical protocols to ensure that people receiving emergency oxygen for an acute exacerbation of COPD have their oxygen saturation levels maintained between 88% and 92%.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
Process
Proportion of people receiving emergency oxygen for an acute exacerbation of COPD who have their oxygen saturation levels maintained between 88% and 92%.
Numerator – the number in the denominator whose oxygen saturation levels are maintained between 88% and 92%.
Denominator – the number of people with an acute exacerbation of COPD receiving emergency oxygen.
Outcome
a) Frequency of non-invasive ventilation due to oxygen toxicity.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
b) Morbidity rates.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (community and secondary care services, ambulance trusts, A&E departments) ensure that devices and flow rates are used to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.
Healthcare professionals ensure that devices and flow rates are used to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.
Commissioners ensure that they commission services that use devices and flow rates to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.

What the quality statement means for patients, service users and carers

People with COPD who need emergency oxygen because of a sudden flare up of their symptoms (called an acute exacerbation) receive the correct amount of oxygen to keep the oxygen levels in their blood at a safe level.

Source guidance

Definitions of terms used in this quality statement

Acute exacerbation
An exacerbation is a sustained worsening of a person’s symptoms from their stable state beyond usual day-to-day variations and is acute in onset. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in the colour of the sputum.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101)]

Non-invasive ventilation

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

Quality statement

People with an acute exacerbation of chronic obstructive pulmonary disease (COPD) and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy have non-invasive ventilation.

Rationale

Non-invasive ventilation is used to treat persistent hypercapnic ventilatory failure and acidosis during an exacerbation of COPD, when a person’s arterial blood gases (especially the pH and carbon dioxide levels) are not responding (or worsening) despite optimal medical management. Non-invasive ventilation should be delivered in a dedicated setting by staff trained and experienced in its use because of safety concerns with using the equipment.

Quality measures

Structure
Evidence of local arrangements to ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non-invasive ventilation.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.
Process
Proportion of people with an exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment who have non-invasive ventilation.
Numerator – the number in the denominator who have non-invasive ventilation.
Denominator – the number of people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy.
Outcome
Mortality rates.
Data source: Local data collection. Royal College of Physicians’ National COPD Audit Programme.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (secondary care services and A&E departments) ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non-invasive ventilation.
Healthcare professionals ensure that people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non-invasive ventilation. Healthcare professionals are trained and experienced in using non-invasive ventilation.
Commissioners (clinical commissioning groups) ensure that they commission services in which people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical treatment have non-invasive ventilation.

What the quality statement means for patients, service users and carers.

People with COPD who have ‘ventilatory failure’ during a sudden flare up of their symptoms (called an acute exacerbation) are given an emergency treatment called non-invasive ventilation if they do not improve after 1 hour of treatment with medicine and oxygen. Ventilatory failure happens when a person can’t breathe deeply enough and waste carbon dioxide builds up in the blood causing acid to form. Non-invasive ventilation involves wearing a mask connected to a machine that pumps oxygen into the lungs.

Source guidance

Definitions of terms used in this quality statement

Acute exacerbation
An acute exacerbation is a sustained worsening of a person's symptoms from their stable state, and which is beyond usual day-to-day variations and acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101)]
Persistent acidotic hypercapnic ventilatory failure
Acute acidotic hypercapnic respiratory failure results from an inability of the respiratory system to provide sufficient alveolar ventilation to maintain a normal arterial PCO2 and blood pH level. Co-existent hypoxaemia is usually mild and easily corrected. Conventionally, a pH <7.35 and a PCO2 >6.5 kPa, persisting after initial medical therapy, define acute respiratory acidosis and have been used as threshold values for considering the use of non-invasive ventilation. More severe degrees of acidosis, such as pH <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation.
[Adapted from Chronic obstructive pulmonary disease (NICE guideline CG101) and expert consensus]
Non-invasive ventilation
Non-invasive ventilation is a method of providing ventilatory support that does not require an endotracheal tube. It is usually delivered through a mask that covers the nose or a mask covering the nose and the mouth.
[Chronic obstructive pulmonary disease (NICE guideline CG101)]
Non-invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy.
[Expert consensus]
Optimal medical treatment
Controlled oxygen therapy, nebulised bronchodilator therapy, systemic corticosteroids and antibiotics if indicated, in line with the NICE guideline on chronic obstructive pulmonary disease.
[Chronic obstructive pulmonary disease (NICE guideline CG101)]

Hospital discharge care bundle (placeholder)

This quality statement is taken from the chronic obstructive pulmonary disease in adults quality standard. The quality standard defines clinical best practice in chronic obstructive pulmonary disease in adults and should be read in full.

What is a placeholder statement?

A placeholder statement is an area of care that has been prioritised by the Quality Standards Advisory Committee but for which no source guidance is currently available. A placeholder statement indicates the need for evidence-based guidance to be developed in this area.

Rationale

Hospital discharge care bundles are designed to ensure that every person leaving hospital receives the best care. They emphasise the key interventions in the management pathway, including details of settings for care and treatment. There are several elements of ongoing care that an adult with COPD should start before discharge from hospital, which can improve their outcome. There is currently a lack of evidence-based guidance about the details that should be included in these care bundles.

Identifying people who smoke

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.

Rationale

There is evidence that people who smoke are receptive to smoking cessation advice in all healthcare settings. It is therefore important that healthcare practitioners proactively ask people if they smoke, and offer advice on how to stop.

Quality measures

Structure
Evidence of local arrangements to ensure that people are asked if they smoke by their healthcare practitioner, and those who smoke are offered advice on how to stop.
Data source: Local data collection.
Process
a) Proportion of people who are asked if they smoke by their healthcare practitioner.
Numerator – the number of people in the denominator who are asked if they smoke by their healthcare practitioner.
Denominator – the number of people who have face-to-face contact with a healthcare practitioner.
Data source: a) Local data collection. The quality and outcomes framework (QOF) contains indicators related to identifying and supporting people who smoke in primary care.
b) Proportion of people who smoke who receive advice on how to stop.
Numerator – the number of people in the denominator who receive advice on how to stop.
Denominator – the number of people who report that they smoke during face-to-face contact with a healthcare practitioner.
Data source: b) Local data collection. NICE public health guidance 10: audit support – criterion 3i. The QOF contains indicators related to identifying and supporting people who smoke in primary care.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people to be asked if they smoke by their healthcare practitioner, and for those who smoke to be offered advice on how to stop.
Healthcare practitioners ask their patients if they smoke, and offer those who smoke advice on how to stop.
Commissioners ensure that they commission services where healthcare practitioners ask their patients if they smoke, and that they offer those who smoke advice on how to stop.

What the quality statement means for patients, service users and carers

People are asked if they smoke by their healthcare practitioners, and those who smoke are offered advice on how to stop.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Advice can vary by healthcare setting. In the context of primary care settings, this would involve evidence-based, opportunistic advice offered to people who smoke about the options and support available to help them stop smoking. In the context of secondary care settings, advice may involve the practitioner providing people who smoke with information and referring them to an evidence-based smoking cessation service.
The National Centre for Smoking Cessation and Training offers a training module on the delivery of evidence-based smoking cessation interventions, to ensure that this is done in a sensitive way within the brief time available with the patient.
This statement is linked to statement 2, because advice on how to stop may include a referral to an evidence-based smoking cessation service.

Equality and diversity considerations

Advice should be culturally appropriate and accessible to people with additional needs such as physical, sensory or learning disabilities, and to people who do not speak or read English.
Advice may include referral to an evidence-based smoking cessation service. NICE public health guidance 10 states that such services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use local evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Referral to smoking cessation services

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered a referral to an evidence-based smoking cessation service.

Rationale

Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care sets out the high-quality requirements for ensuring that pregnant women who smoke are referred to an evidence-based smoking cessation service.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who smoke who are referred to an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who are referred to an evidence-based smoking cessation service.
Denominator – the number of people identified as smokers in any healthcare setting.
Data source: Local data collection. The quality and outcomes framework (QOF) contains indicators related to support in primary care for people who smoke.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered a referral to an evidence-based smoking cessation service.
Healthcare practitioners offer people who smoke a referral to an evidence-based smoking cessation service.
Commissioners ensure that they commission services that offer people who smoke a referral to an evidence-based smoking cessation service.

What the quality statement means for patients, service users and carers

People who smoke are offered a referral to an evidence-based smoking cessation service to help them stop smoking.

Source guidance

Definition of terms used in this quality statement

Healthcare practitioners include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Evidence-based smoking cessation services are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.
The National Centre for Smoking Cessation and Training offers training modules for people delivering smoking cessation interventions.
This statement is linked to statement 1, because advice on how to stop may include a referral to an evidence-based smoking cessation service.
Quality statement 5 in the NICE quality standard on antenatal care states that 'Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment' and the appropriate referral criteria are defined. The supporting information also states that the midwife may provide the pregnant woman with information (in a variety of formats, for example, a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.

Equality and diversity considerations

NICE public health guidance 10 states that evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.
Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.
Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12–17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use evidence-based smoking cessation services.
Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Behavioural support with pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.

Rationale

People who smoke are more likely to stop smoking if they are offered a combination of interventions, with combined behavioural support and pharmacotherapy the most likely to be successful.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke are offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Data source: Local data collection.
Process
Proportion of people who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Numerator – the number of people in the denominator who receive behavioural support with pharmacotherapy from an evidence-based smoking cessation service.
Denominator – the number of people referred to an evidence-based smoking cessation service.
Data source: Local data collection. Contained in NICE public health guidance 10: audit support – criterion 7; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered behavioural support with pharmacotherapy by an evidence-based smoking cessation service.
Healthcare practitioners offer behavioural support with pharmacotherapy to people who have been referred to an evidence-based smoking cessation service.
Commissioners ensure that they commission evidence-based smoking cessation services that offer people who smoke behavioural support with pharmacotherapy.

What the quality statement means for patients, service users and carers

People who have been referred to an evidence-based smoking cessation service are offered behavioural support (which may be either individual or group counselling) together with drug treatment.

Source guidance

Definition of terms used in this quality statement

Behavioural support
This can be individual behavioural therapy or group behaviour therapy.
NICE public health guidance 10 states that individual behavioural therapy involves scheduled face-to-face meetings between someone who smokes and a practitioner from the smoking cessation service trained in smoking cessation. Typically, it involves weekly sessions over a period of at least 4 weeks after the quit date and is normally combined with pharmacotherapy.
NICE public health guidance 10 states that group behaviour therapy involves scheduled meetings where people who smoke receive information, advice and encouragement and some form of behavioural intervention (for example, cognitive behavioural therapy). This therapy is offered weekly for at least the first 4 weeks of a quit attempt (that is, for 4 weeks following the quit date). It is normally combined with pharmacotherapy.
Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
A summary of further considerations relating to pharmacotherapy is provided in quality statement 4.
Evidence-based stop smoking services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Pharmacotherapy

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.

Rationale

Pharmacotherapy interventions act as an aid to help people to stop smoking, and it is important that people who seek support to stop smoking receive the full course of their chosen pharmacotherapy to increase the chances of success.

Quality measures

Structure
Evidence of local arrangements to ensure that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Data source: Local data collection.
Process
Proportion of people who seek support to stop smoking and who agree to take pharmacotherapy who receive a full course.
Numerator – the number of people in the denominator who receive a full course of pharmacotherapy.
Denominator – the number of people who seek support to stop smoking and who agree to take pharmacotherapy.
Data source: Local data collection. Contained in NICE public health guidance 1: audit – criterion 5 and NICE public health guidance 10: audit support – criteria 5–8; Statistics on NHS Stop Smoking Services: England, April 2011 – March 2012 from the Health and Social Care Information Centre reports on smoking cessation interventions.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course.
Healthcare practitioners offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.
Commissioners ensure that they commission services that offer a full course of pharmacotherapy to people who seek support to stop smoking and who agree to take pharmacotherapy.

What the quality statement means for patients, service users and carers

People who seek support to stop smoking and who agree to take pharmacotherapy are offered a full course of drug treatment.

Source guidance

Definition of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
NICE public health guidance 10 states that healthcare professionals who prescribe nicotine replacement therapy (NRT), varenicline or bupropion should offer advice, encouragement and support including referral to an evidence-based smoking cessation service. Pharmacotherapy should normally be prescribed as part of an abstinent contingent treatment, in which the smoker makes a commitment to stop smoking on or before a particular date. NICE technology appraisal guidance 123 states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE public health guidance 10 states that neither varenicline nor bupropion should be offered to young people under 18. Professional judgement should be used to decide whether or not to offer NRT to young people over 12 years who show clear evidence of nicotine dependence. If NRT is prescribed, offer it as part of a supervised regime. Varenicline or bupropion may be offered to people with unstable cardiovascular disorders who smoke, subject to clinical judgement.
NICE public health guidance 26 states that there should be a discussion about the risks and benefits of NRT with pregnant women who smoke. Nicotine replacement therapy should be offered if smoking cessation without NRT fails, or practitioner judgement should be used if women express a clear preference for NRT. Neither varenicline nor bupropion should be offered to pregnant or breastfeeding women.
It is important that people who smoke who receive pharmacotherapy receive a full course, which will vary depending on the individual smoker. A full course for NRT is at least 8 weeks, for varenicline it is at least 12 weeks and for bupropion it is at least 8 weeks. NICE public health guidance 10 outlines that the prescription of NRT, varenicline or bupropion should be sufficient to last only until 2 weeks after the target stop date with subsequent prescriptions given only to people who have demonstrated, on re-assessment, that their quit attempt is continuing.
Drugs with a metabolism that is affected by smoking (or stopping smoking) should be monitored, and the dosage adjusted if appropriate.

Equality and diversity considerations

There should be a discussion about risks and benefits of using NRT with young people aged 12–17 and pregnant or breastfeeding women.

Outcome measurement

This quality statement is taken from the smoking cessation quality standard. The quality standard defines clinical best practice for smoking cessation and should be read in full.

Quality statement

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Rationale

Recording smoking status using carbon monoxide testing after 4 weeks provides an incentive for people who are attempting to stop, and is an objective way to measure individual and service level outcomes.

Quality measures

Structure
Evidence of local arrangements to ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Data source: Local data collection.
Process
Proportion of people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Numerator – the number of people in the denominator who are assessed for carbon monoxide levels 4 weeks after the quit date.
Denominator – the number of people who smoke who have set a quit date with an evidence-based smoking cessation service.
Data source: Local data collection. The Health and Social Care Information Centre's Indicator Portal collects data on the number of people who smoke who successfully quit at the 4-week follow-up per 100,000 population.
Outcome
4-week quit rates.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place so that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Healthcare practitioners ensure that people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.
Commissioners ensure that they commission services for people who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

What the quality statement means for patients, service users and carers

People who smoke who have set a quit date with an evidence-based smoking cessation service are assessed for carbon monoxide levels 4 weeks after the quit date.

Source guidance

Definition of terms used in this quality statement

NICE public health guidance 10 states that success should be validated by a carbon monoxide monitor reading of less than 10 ppm at the 4-week point. This does not imply that treatment should stop at 4 weeks.
Evidence-based smoking cessation services
These are local services providing accessible, evidence-based and cost-effective support to people who want to stop smoking. NICE public health guidance 10 describes key characteristics of an evidence-based smoking cessation service. These include addressing the needs of minority communities in the local population, maintaining adequate staffing levels and benchmarking and reporting service outcomes.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Commissioning

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.

Education and learning

NICE produces resources for individual practitioners, teams and those with a role in education to help improve and assess users' knowledge of relevant NICE guidance and its application in practice.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Patient-centred care

Patients and healthcare professionals have rights and responsibilities as set out in the NHS Constitution for England – all NICE guidance is written to reflect these. Treatment and care should take into account individual needs and preferences. People should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals. If the person is under 16, their family or carers should also be given information and support to help the child or young person to make decisions about their treatment. Healthcare professionals should follow the Department of Health's advice on consent. If someone does not have capacity to make decisions, healthcare professionals should follow the code of practice that accompanies the Mental Capacity Act and the supplementary code of practice on deprivation of liberty safeguards.
For young people moving between paediatric and adult services, care should be planned and managed according to the best practice guidance described in the Department of Health’s Transition: getting it right for young people.
Adult and paediatric healthcare teams should work jointly to provide assessment and services to young people. Diagnosis and management should be reviewed throughout the transition process, and there should be clarity about who is the lead clinician to ensure continuity of care.

Supporting information

Severity of airflow obstruction

Severity of airflow obstruction
NICE clinical guideline 12(2004)
2004Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal 23(6): 932-46.
GOLD 2008GOLD (2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
NICE clinical guideline 101(2010)
Post-bronchodilator
FEV1 % predicted
Post-bronchodilator
Post-bronchodilator
Post-bronchodilator
< 0.7
≥ 80%
Mild
Stage 1 – Mild
Stage 1 – MildSymptoms should be present to diagnose COPD in people with mild airflow obstruction.
< 0.7
50–79%
Mild
Moderate
Stage 2 – Moderate
Stage 2 – Moderate
< 0.7
30–49%
Moderate
Severe
Stage 3 – Severe
Stage 3 – Severe
< 0.7
< 30%
Severe
Very severe
Stage 4 – Very severeOr FEV1 < 50% with respiratory failure.
Stage 4 – Very severe

Medical Research Council 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
Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. British Medical Journal 2: 257-66.

Additional investigations

Investigation
Role
Serial domiciliary peak flow measurements
To exclude asthma if diagnostic doubt remains
Alpha-1 antitrypsin
If early onset, minimal smoking history or family history
To investigate symptoms that seem disproportionate to the spirometric impairment
CT scan of the thorax
To investigate symptoms that seem disproportionate to the spirometric impairment
To investigate abnormalities seen on a chest radiograph
To assess suitability for surgery
ECG
To assess cardiac status if features of cor pulmonale
Echocardiogram
To assess cardiac status if features of cor pulmonale
Pulse oximetry
To assess need for oxygen therapy if cyanosis or cor pulmonale present, or if FEV1 <50% predicted
Sputum culture
To identify organisms if sputum is persistently present and purulent

Clinical features differentiating COPD and asthma

COPD
Asthma
Smoker or ex-smoker
Nearly all
Possibly
Symptoms under age 35
Rare
Often
Chronic productive cough
Common
Uncommon
Breathlessness
Persistent and progressive
Variable
Night time waking with breathlessness and/or wheeze
Uncommon
Common
Significant diurnal or day-to-day variability to day-to-day variability of symptoms
Uncommon
Common

Reasons for referral

Reason
Purpose
There is diagnostic uncertainty
Confirm diagnosis and optimise therapy
Suspected severe COPD
Confirm diagnosis and optimise therapy
The patient requests a second opinion
Confirm diagnosis and optimise therapy
Onset of cor pulmonale
Confirm diagnosis and optimise therapy
Assessment for oxygen therapy
Optimise therapy and measure blood gases
Assessment for long-term nebuliser therapy
Optimise therapy and exclude inappropriate prescriptions
Assessment for oral corticosteroid therapy
Justify need for long-term treatment or supervise withdrawal
Bullous lung disease
Identify candidates for surgery
A rapid decline in FEV1
Encourage early intervention
Assessment for pulmonary rehabilitation
Identify candidates for pulmonary rehabilitation
Assessment for lung volume reduction surgery
Identify candidates for surgery
Assessment for lung transplantation
Identify candidates for surgery
Dysfunctional breathing
Confirm diagnosis, optimise pharmacotherapy and access other therapists
Onset of symptoms under 40 years or a family history of alpha-1 antitrypsin deficiency
Identify alpha-1 antitrypsin deficiency, consider therapy and screen family
Uncertain diagnosis
Make a diagnosis
Symptoms disproportionate to lung function deficit
Look for other explanations including cardiac impairment, pulmonary hypertension, depression and hyperventilation
Frequent infections
Exclude bronchiectasis
Haemoptysis
Exclude carcinoma of the bronchus

Summary of follow-up of patients with COPD in primary care

Mild/moderate/severe (stages 1 to 3)
Very severe (stage 4)
Frequency
At least annual
At least twice per year
Clinical assessment
  • Smoking status and desire to quit
  • Adequacy of symptom control:
– breathlessness
– exercise tolerance
– estimated exacerbation frequency
  • Presence of complications
  • Effects of each drug treatment
  • Inhaler technique
  • Need for referral to specialist and therapy services
  • Need for pulmonary rehabilitation
  • Smoking status and desire to quit
  • Adequacy of symptom control:
– breathlessness
– exercise tolerance
– estimated exacerbation frequency
  • Presence of cor pulmonale
  • Need for LTOT
  • Patient's nutritional status
  • Presence of depression
  • Effects of each drug treatment
  • Inhaler technique
  • Need for social services and occupational therapy input
  • Need for referral to specialist and therapy services
  • Need for pulmonary rehabilitation
Measurements to make
  • FEV1 and FVC
  • Calculate BMI
  • MRC dyspnoea score
  • SaO2
Factors to consider when deciding where to manage exacerbations
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 LTOT
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
SaO2 < 90%
No
Yes
Changes on chest X-ray
No
Present
Arterial pH level
≥ 7.35
< 7.35
Arterial PaO2
≥ 7 kPa
< 7 kPa

Glossary

American Society of Anesthesiologists
American Thoracic Society
body mass index, airflow obstruction, dyspnoea and exercise capacity
British Thoracic Society
Comité European de Normalisation (European Committee for Standardisation)
chronic obstructive pulmonary disease
in the context of this pathway, the term 'cor pulmonale' has been adopted to define a clinical condition that is identified and managed on the basis of clinical features. This clinical syndrome of cor pulmonale includes patients who have right heart failure secondary to lung disease and those in whom the primary pathology is retention of salt and water, leading to the development of peripheral oedema
electrocardiogram
European Respiratory Society
forced expiratory volume in 1 second
forced vital capacity
global initiative for chronic obstructive lung disease
inhaled corticosteroid
long-acting beta2 agonist
long-acting muscarinic antagonist
long-term oxygen therapy
Medical Research Council
non-invasive ventilation
partial pressure of oxygen in arterial blood
partial pressure of carbon dioxide in arterial blood
peak expiratory flow
short-acting beta2 agonist
short-acting muscarinic antagonist
oxygen saturation of arterial blood
carbon monoxide lung transfer factor

Paths in this pathway

Pathway created: May 2011 Last updated: February 2016

© NICE 2016

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