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Chronic obstructive pulmonary disease

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What is covered

This interactive flowchart covers diagnosing and managing COPD in people aged 16 and over. It also sets out an antimicrobial prescribing strategy for acute exacerbations of COPD in adults.

Updates

Updates to this interactive flowchart

11 June 2019 Bronchoscopic thermal vapour ablation for upper-lobe emphysema (NICE interventional procedures guidance 652) added to lung volume reduction procedures.
27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
4 December 2018 Update of chronic obstructive pulmonary disease in over 16s: diagnosis and management (NICE guideline NG115). Recommendations from chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing (NICE guideline NG114) added.
19 December 2017 Endobronchial valve insertion to reduce lung volume in emphysema (NICE interventional procedures guidance 600) added.
25 July 2017 Roflumilast for treating chronic obstructive pulmonary disease (NICE technology appraisal guidance 461) added to roflumilast.
4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added.
9 November 2015 Structure revised, and summarised recommendations replaced with full recommendations.
6 August 2015 Smoking: supporting people to stop (NICE quality standard 43) added.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedures guidance 517) added.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on diagnosing and managing chronic obstructive pulmonary disease in people aged 16 and over in an interactive flowchart

What is covered

This interactive flowchart covers diagnosing and managing COPD in people aged 16 and over. It also sets out an antimicrobial prescribing strategy for acute exacerbations of COPD in adults.

Updates

Updates to this interactive flowchart

11 June 2019 Bronchoscopic thermal vapour ablation for upper-lobe emphysema (NICE interventional procedures guidance 652) added to lung volume reduction procedures.
27 February 2019 Air pollution: outdoor air quality and health (NICE quality standard 181) added.
4 December 2018 Update of chronic obstructive pulmonary disease in over 16s: diagnosis and management (NICE guideline NG115). Recommendations from chronic obstructive pulmonary disease (acute exacerbation): antimicrobial prescribing (NICE guideline NG114) added.
19 December 2017 Endobronchial valve insertion to reduce lung volume in emphysema (NICE interventional procedures guidance 600) added.
25 July 2017 Roflumilast for treating chronic obstructive pulmonary disease (NICE technology appraisal guidance 461) added to roflumilast.
4 February 2016 Update of chronic obstructive pulmonary disease in adults (NICE quality standard 10) added.
9 November 2015 Structure revised, and summarised recommendations replaced with full recommendations.
6 August 2015 Smoking: supporting people to stop (NICE quality standard 43) added.
24 March 2015 Insertion of endobronchial nitinol coils to improve lung function in emphysema (NICE interventional procedures guidance 517) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Roflumilast for treating chronic obstructive pulmonary disease (2017) NICE technology appraisal guidance 461
Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123
Bronchoscopic thermal vapour ablation for upper-lobe emphysema (2019) NICE interventional procedures guidance 652
Endobronchial valve insertion to reduce lung volume in emphysema (2017) NICE interventional procedures guidance 600
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
Air pollution: outdoor air quality and health (2019) NICE quality standard 181
Smoking: supporting people to stop (2013) NICE quality standard 43
Chronic obstructive pulmonary disease in adults (2011 updated 2016) NICE quality standard 10
Chronic obstructive pulmonary disease: olodaterol (2015) NICE evidence summary ESNM54
OxyMask for delivering oxygen therapy (2018) NICE medtech innovation briefing 160
VIDAvision for lung volume analysis in emphysema (2018) NICE medtech innovation briefing 148
Smart One for measuring lung function (2017) NICE medtech innovation briefing 96
Needle-free arterial non-injectable connector (2016) NICE medtech innovation briefing 85

Quality standards

Smoking: supporting people to stop

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

Air pollution: outdoor air quality and health

These quality statements are taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health 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

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE guideline NG115, recommendations 1.1.1, 1.1.5, 1.1.8 and 1.1.10

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.
[NICE's guideline on chronic obstructive pulmonary disease and expert opinion]
Symptoms of COPD
Symptoms of COPD are:
  • exertional breathlessness
  • chronic cough
  • regular sputum production
  • frequent winter 'bronchitis'
  • wheeze.
[NICE's guideline on chronic obstructive pulmonary disease, 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 NICE's guideline on chronic obstructive pulmonary disease, recommendations 1.1.9 and 1.1.10]

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

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE guideline NG115, recommendations 1.2.20, 1.2.21 and 1.3.46

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 NICE's guideline on chronic obstructive pulmonary disease]
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.
[NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.54]
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.
[NICE's guideline on chronic obstructive pulmonary disease, section 1.3]
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

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE guideline NG115, recommendation 1.2.79

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’.
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 NICE’s guideline on chronic obstructive pulmonary disease, recommendation 1.2.80]
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 NICE's guideline on chronic obstructive pulmonary disease]
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's guideline on 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 NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.80]
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

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE guideline NG115, recommendation 1.3.31

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 NICE's guideline on chronic obstructive pulmonary disease]

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

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE guideline NG115, recommendations 1.3.34

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 NICE's guideline on chronic obstructive pulmonary disease]
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 NICE's guideline on chronic obstructive pulmonary disease 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.
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.

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: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop 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 and the quality and outcomes framework (QOF) indicator SMOK001.
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 and the QOF indicator SMOK004.

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
These include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Advice
This 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. 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: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop 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 and the quality and outcomes framework (QOF) indicator SMOK004.

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

Definitions of terms used in this quality statement

Healthcare practitioners
These include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.
Evidence-based smoking cessation services
These are local services providing accessible, evidence based and cost effective support to people who want to stop smoking.
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

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: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop 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. 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

Definitions of terms used in this quality statement

Behavioural support
This can be individual or group behavioural support.
NICE’s guideline on stop smoking interventions and services states that individual behavioural support involves scheduled face to face meetings between someone who smokes and a counsellor 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.
It also states that group behavioural support involves scheduled meetings in which 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’s guideline on stopping smoking in pregnancy and after childbirth 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.

Pharmacotherapy

This quality statement is taken from the smoking: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop 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. 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

Definitions of terms used in this quality statement

Pharmacotherapy
Pharmacotherapies for smoking cessation are nicotine replacement therapy (NRT), varenicline or bupropion.
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’s technology appraisal guidance on varenicline for smoking cessation states that varenicline should normally be prescribed only as part of a programme of behavioural support.
NICE’s guideline on stopping smoking in pregnancy and after childbirth 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.

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: supporting people to stop quality standard. The quality standard defines clinical best practice for smoking: supporting people to stop 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
Four-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’s guideline on stop smoking interventions and services states that success should be defined by a carbon monoxide monitor reading of less than 10 ppm at 4 weeks after the quit date. 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.

Strategic plans

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution.

Rationale

Local authorities should be strategic leaders of local initiatives to address air pollution, working in a coordinated way with key partners to ensure a consistent and planned approach. Identifying their approach to air pollution in the Local Plan, local transport plan and other key strategies will provide a clear framework for joined-up local action. The key components of their approach should include enabling zero- and low-emission travel (including active travel such as cycling or walking) and developing buildings and spaces to reduce exposure to air pollution.

Quality measures

Structure
a) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will address air pollution, including who is responsible for delivering key actions.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
b) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable active travel.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
c) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will encourage and enable travel by zero- and low-emission vehicles.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
d) Evidence that local authorities identify in the Local Plan, local transport plan and other key strategies how they will develop buildings and spaces to reduce exposure to air pollution.
Data source: Local data collection, for example, a review of actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
e) Evidence that local authorities identify key actions to address air pollution and monitor progress against them.
Data source: Local data collection, for example, progress on actions to improve air quality is included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local authorities work with partners to ensure the Local Plan, local transport plan, and other key strategies identify the approach to addressing air pollution, including enabling zero- and low-emission travel and developing buildings and spaces to reduce exposure to air pollution. Local authorities work together to prevent migration of traffic and emissions to other communities, which may result in areas of poor air quality.
People in the community know that their local authority and other local organisations are working together to protect them from the effects of air pollution.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.1.1, 1.1.2 and 1.1.3

Definitions of terms used in this quality statement

Local authorities
All tiers of local government including county, district and unitary authorities, as well as regional bodies and transport authorities.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1]
Other key strategies
Relevant local strategies, such as the air quality action plan, commissioning and procurement strategy, core strategy, environment strategy, and health and wellbeing strategy.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and expert opinion]
Zero- and low-emission travel
Includes cycling and walking; travel by zero- and low-emission vehicles such as electric cars, buses, bikes and pedal cycles; and car sharing schemes or clubs.
[Adapted from NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.1 and terms used in this guideline]
Developing buildings and spaces to reduce exposure to air pollution
This could include:
  • siting and designing new buildings, facilities and estates to reduce the need for motorised travel
  • minimising the exposure of vulnerable groups to air pollution by not siting buildings (such as schools, nurseries and care homes) in areas where pollution levels will be high
  • siting living accommodation away from roadsides
  • avoiding the creation of street and building configurations (such as deep street canyons) that encourage pollution to build up where people spend time
  • including landscape features such as appropriate species of trees and vegetation in open spaces or as 'green' walls or roofs where this does not restrict ventilation
  • considering how structures such as buildings and other physical barriers will affect the distribution of air pollutants.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.1.2]

Equality and diversity considerations

Local authorities should ensure that strategic plans identify areas where air pollution is highest and, in particular, locations where people who are vulnerable to air pollution may be exposed to high levels of air pollution, such as schools, nurseries, hospitals and care homes, so that targeted approaches can be put in place.
Local authorities should ensure that they assess the impact on vulnerable groups if local charges on certain classes of vehicle in clean air zones are proposed. If necessary, actions to mitigate the impact of charges on specific groups should be identified.

Planning applications

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Rationale

The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Addressing air pollution at the planning stage for major developments may reduce the need for more expensive remedial action at a later stage. It can also help to maintain people’s health and wellbeing during and after construction. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based.

Quality measures

Structure
a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution.
Data source: Local data collection, for example, review of supplementary planning guidance.
b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.
Data source: Local data collection, for example, review of supplementary planning guidance.
Process
Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Numerator – the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Denominator – the number of planning applications for major developments granted permission.
Data source: Local data collection, for example, local planning application system.
Outcome
a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.
Data source: Local data collection, for example, survey of residents. Data for local authorities from the Department for Transport National Travel Survey are available under special licence.
b) Annual and hourly mean concentrations for nitrogen dioxide (NO2).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM10).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.
d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM2.5).
Data source: Local data collection, for example, monitoring results are included in the Department for Environment, Food and Rural Affairs’ Local Air Quality Management annual status report. Modelled data from the Automatic Urban and Rural Network are available from the Department of Environment Food and Rural Affairs’ UK Air Information Resource.

What the quality statement means for different audiences

Local planning authorities ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution during and after construction. Local planning authorities provide guidance for applicants and have a clear framework for assessing proposals in line with the Local Plan, local transport plan and other key strategies. Local guidance should make it clear that proposals to minimise or mitigate road-traffic-related air pollution must be evidence based. Local planning authorities monitor compliance with planning conditions or obligations to minimise and mitigate road-traffic-related air pollution.
Local authority planning officers assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments using an agreed local framework to ensure they are evidence based. Local authority planning officers encourage applicants to modify their planning applications if necessary, to include evidence-based approaches to minimise or mitigate road-traffic-related air pollution.
Planning applicants for major developments know that the local planning authority will assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications to ensure they are evidence based. Planning applicants can get information on what the local planning authority is looking for and how the proposals will be assessed. Planning applicants for major developments modify their application to improve the approach to minimising or mitigating road-traffic-related air pollution if required by the local authority.
People in the community know that their local planning authorities require developers to show how they will minimise road-traffic-related air pollution and improve local air quality around big building projects when they apply for planning permission. This is to help protect local people from the effects of air pollution on their health.

Source guidance

Definitions of terms used in this quality statement

Major developments
Development involving any one or more of the following:
  • the winning and working of minerals or the use of land for mineral-working deposits
  • waste development
  • the provision of dwelling houses where:
    • the number of dwelling houses to be provided is 10 or more or
    • the development is to be carried out on a site having an area of 0.5 hectares or more and the number of dwelling houses is not known
  • the provision of a building or buildings where the floor space to be created by the development is 1,000 square metres or more or
  • development carried out on a site having an area of 1 hectare or more.

Equality and diversity considerations

Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities.

Reducing emissions from public sector vehicle fleets

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Public sector organisations reduce emissions from their vehicle fleets to address air pollution.

Rationale

The public sector fleet is substantial and includes various vehicle types, some of which are highly polluting. Reducing emissions from public sector vehicle fleets will help to reduce road-traffic-related air pollution. Public sector organisations can extend their impact by commissioning transport or fleet services from organisations that reduce emissions from their vehicle fleets to address air pollution. By publicising their approach, public sector organisations can encourage organisations in other sectors to take action to reduce emissions from their vehicle fleets.

Quality measures

Structure
a) Evidence that public sector organisations identify how they will reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, a plan to reduce fleet emissions. Organisations could use the Sustainable Development Unit’s Health Outcomes of Travel Tool (HOTT) to develop a plan.
b) Evidence that public sector organisations require commissioned transport or fleet services to reduce emissions from their vehicle fleets to address air pollution.
Data source: Local data collection, for example, commissioning specifications. Commissioning specifications could require adherence to the Department for Environment, Food and Rural Affairs’ Government Buying Standards for transport.
Outcome
a) Proportion of zero- or ultra-low-emission vehicles in public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.
b) Overall fuel consumption for public sector vehicle fleets.
Data source: Local data collection, for example, fleet statistics.

What the quality statement means for different audiences

Service providers (such as local authorities, NHS trusts, police and fire and rescue services) develop a plan for how they will reduce emissions from their vehicle fleet to address air pollution and monitor the impact of the plan on vehicle type and total fleet CO2 emissions. Providers consider a range of approaches including:
  • replacing vehicles with zero- or ultra-low-emission vehicles over time
  • incentives to lease zero- or ultra-low-emission vehicles
  • training drivers to change their driving style
  • consolidating and sharing vehicles to ensure efficient use
  • action to minimise congestion caused by delivery schedules
  • specifying emission standards for private hire and other licensed vehicles.
Public sector fleet managers support the development and monitoring of a plan to reduce emissions from the vehicle fleet to address air pollution. Public sector fleet managers ensure that staff are aware of the plan and take action in line with the priorities identified.
Commissioners (such as local authorities, clinical commissioning groups, NHS England, and police and crime commissioners) ensure that commissioned transport or fleet services have a plan for how they will reduce emissions from their vehicle fleet to address air pollution and ensure providers monitor the impact of their plan on vehicle type and total fleet CO2 emissions.
People in the community know that public sector organisations are working to reduce pollution from their vehicles. This will help to reduce local air pollution and protect people from the effects on their health.

Source guidance

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendations 1.4.1, 1.4.2, 1.4.3 and 1.4.6

Advice for people with chronic respiratory or cardiovascular conditions

This quality statement is taken from the air pollution: outdoor air quality and health quality standard. The quality standard defines clinical best practice for air pollution: outdoor air quality and health and should be read in full.

Quality statement

Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor.

Rationale

Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating.

Quality measures

Structure
a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, training records.
b) Evidence of local processes to ensure that children, young people and adults with chronic respiratory or cardiovascular conditions attending routine health appointments are given advice on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, service protocols.
Process
Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor.
Numerator – the number in the denominator that were given advice on what to do when outdoor air quality is poor.
Denominator – the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment.
Data source: Local data collection, for example, audit of patient records.
Outcome
a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor.
Data source: Local data collection, for example, survey of children, young people and adults with chronic respiratory or cardiovascular conditions.
b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations.
Data source: NHS Digital’s Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attacks, acute chronic obstructive pulmonary disease exacerbations, heart attacks, strokes, heart failure and angina attacks.

What the quality statement means for different audiences

Service providers (such as general practices, community health services, hospitals and community pharmacies) ensure that healthcare professionals are aware that information on air quality is available, what it means and what actions are recommended. Service providers ensure that processes are in place to provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments. Providers ensure that advice includes how to find out when outdoor air quality is expected to be poor such as from the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions who are attending a routine health appointment (and their families and carers, if appropriate). They also provide information on how to find out when outdoor air quality is expected to be poor, for example using the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index.
Commissioners (such as clinical commissioning groups and NHS England) commission services that provide advice on what to do when outdoor air quality is poor to children, young people and adults (and their families and carers, if appropriate) at routine health appointments.
People with long-term breathing or heart conditions (and their family and carers, if appropriate) are given advice at routine health appointments on what to do when outdoor air quality is poor and how to find out when it is likely to be poor.

Source guidance

Definitions of terms used in this quality statement

Routine health appointments
Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions.
[Expert opinion]
Advice on what to do when outdoor air quality is poor
Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as:
  • Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat.
  • Using an asthma reliever inhaler more often, as needed.
  • Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in.
[NICE’s guideline on air pollution: outdoor air quality and health, recommendation 1.7.7 and the Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]
Poor outdoor air quality
The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10).
[The Department for Environment, Food and Rural Affairs’ Daily Air Quality Index]

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Gradation of severity of airflow obstruction

NICE guideline CG12 (2004)
20041
GOLD 20082
NICE guideline CG101 (2010)
Post-bronchodilator FEV1/FVC
FEV1 % predicted
Severity of airflow obstruction
Post-bronchodilator
Post-bronchodilator
Post-bronchodilator
<0.7
≥80%
Mild
Stage 1 – Mild
Stage 1 – Mild
<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 severe3
Stage 4 – Very severe3
1. Celli BR, MacNee W, Agusti A et al. (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.
2. GOLD (2008) Global strategy for the diagnosis, management and prevention of COPD.
3. Or FEV1 below 50% with respiratory failure.

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
Sputum culture
To identify organisms if sputum is persistently present and purulent
Serial home peak flow measurements
To exclude asthma if diagnostic doubt remains
ECG and serum natriuretic peptides*
To assess cardiac status if cardiac disease or pulmonary hypertension are suspected because of:
  • a history of cardiovascular disease, hypertension or hypoxia or
  • clinical signs such as tachycardia, oedema, cyanosis or features of cor pulmonale
Echocardiogram
To assess cardiac status if cardiac disease or pulmonary hypertension are suspected
CT scan of the thorax
To investigate symptoms that seem disproportionate to the spirometric impairment
To investigate signs that may suggest another lung diagnosis (such as fibrosis or bronchiectasis
To investigate abnormalities seen on a chest X-ray
To assess suitability for lung volume reduction procedures
Serum alpha-1 antitrypsin
To assess for alpha-1 antitrypsin deficiency if early onset, minimal smoking history or family history
To investigate symptoms that seem disproportionate to the spirometric impairment
To assess suitability for lung volume reduction procedures

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 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 person with COPD 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 continued treatment or supervise withdrawal
Bullous lung disease
Identify candidates for lung volume reduction procedures
A rapid decline in FEV1
Encourage early intervention
Assessment for pulmonary rehabilitation
Identify candidates for pulmonary rehabilitation
Assessment for lung volume reduction procedures
Identify candidates for surgical or bronchoscopic lung volume reduction
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
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 people 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 motivation to quit
  • Adequacy of symptom control:
    • breathlessness
    • exercise tolerance
    • estimated exacerbation frequency
  • Need for pulmonary rehabilitation
  • Presence of complications
  • Effects of each drug treatment
  • Inhaler technique
  • Need for referral to specialist and therapy services
  • Smoking status and motivation to quit
  • Adequacy of symptom control:
    • breathlessness
    • exercise tolerance
    • estimated exacerbation frequency
  • Presence of cor pulmonale
  • Need for LTOT
  • Person with COPD's nutritional state
  • 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 treat the person
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 radiograph
No
Present
Arterial pH level
≥7.35
<7.35
Arterial PaO2
≥7 kPa
<7 kPa

Antibiotic treatment for adults aged 18 years and over

Antibiotic1,2
Dosage and course length
First-choice oral antibiotics (empirical treatment or guided by most recent sputum culture and susceptibilities)
Amoxicillin
500 mg three times a day for 5 days (see BNF for dosage in severe infections)
Doxycycline
200 mg on first day, then 100 mg once a day for 5-day course in total (see BNF for dosage in severe infections)
Clarithromycin
500 mg twice a day for 5 days
Second-choice oral antibiotics (no improvement in symptoms on first choice taken for at least 2 to 3 days; guided by susceptibilities when available)
Use alternative first choice (from a different class)
as above
Alternative choice oral antibiotics (if person at higher risk of treatment failure3; guided by susceptibilities when available)
Co-amoxiclav
500/125 mg three times a day for 5 days
Levofloxacin4
500 mg once a day for 5 days
Co-trimoxazole5
960 mg twice a day for 5 days
First-choice intravenous antibiotic (if unable to take oral antibiotics or severely unwell; guided by susceptibilities when available)6
Amoxicillin
500 mg three times a day (see BNF for dosage in severe infections)
Co-amoxiclav
1.2 g three times a day
Clarithromycin
500 mg twice a day
Co-trimoxazole5
960 mg twice a day (see BNF for dosage in severe infections)
Piperacillin with tazobactam
4.5 g three times a day (see BNF for dosage in severe infections)
Second-choice intravenous antibiotic
Consult local microbiologist; guided by susceptibilities
1 See the BNF for appropriate use and dosing in specific populations, for example, hepatic impairment, renal impairment, and administering intravenous antibiotics.
2 If a person is receiving antibiotic prophylaxis, treatment should be with an antibiotic from a different class.
3 People who may be at a higher risk of treatment failure include people who have had repeated courses of antibiotics, a previous or current sputum culture with resistant bacteria, or people at higher risk of developing complications.
4 The European Medicines Agency's Pharmacovigilance Risk Assessment Committee has recommended restricting the use of fluoroquinolone antibiotics following a review of disabling and potentially long-lasting side effects mainly involving muscles, tendons, bones and the nervous system. This includes a recommendation not to use them for mild or moderately severe infections unless other antibiotics cannot be used (press release October 2018).
5 Co-trimoxazole should only be considered for use in acute exacerbations of COPD when there is bacteriological evidence of sensitivity and good reason to prefer this combination to a single antibiotic (see BNF).
6 Review intravenous antibiotics by 48 hours and consider stepping down to oral antibiotics where possible.

Severity of exacerbation

A general classification of the severity of an acute exacerbation (Oba Y et al. 2017) is:
  • mild exacerbation: the person has an increased need for medication, which they can manage in their own normal environment
  • moderate exacerbation: the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics
  • severe exacerbation: the person experiences a rapid deterioration in respiratory status that requires hospitalisation.
Anthonisen et al. 1987 classified the type of an acute exacerbation based on 3 cardinal exacerbation symptoms:
  • increased breathlessness
  • increased sputum volume
  • sputum purulence.
The presence all 3 symptoms was defined as type 1 exacerbation; 2 of the 3 symptoms was defined as type 2 exacerbation; and 1 of the 3 symptoms with the presence of 1 or more supporting symptoms and signs was defined as type 3 exacerbation. This classification has been widely used to determine the severity of exacerbation in research studies, with more symptoms indicating a more severe exacerbation.
Supporting symptoms were:
  • cough
  • wheezing
  • fever without an obvious source
  • upper respiratory tract infection in the past 5 days
  • respiratory rate increase or heart rate increase 20% above baseline.

Glossary

(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(a sustained worsening of the person's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset: commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour)
(this includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time [at least 400 ml] or substantial diurnal variation in peak expiratory flow [at least 20%])
American Society of Anesthesiologists
American Thoracic Society
body mass index, airflow obstruction, dyspnoea and exercise capacity
British Thoracic Society
COPD assessment test
Comité Européen de Normalisation (European Committee for Standardisation)
chronic obstructive pulmonary disease
(in the context of this guidance, 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
(people who are not taking long-term oxygen therapy and who have a mean PaO2 greater than 7.3 kPa)
non-invasive ventilation
nicotine replacement therapy
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
(here, the term theophylline refers to slow-release formulations of the drug)
carbon monoxide lung transfer factor

Paths in this pathway

Pathway created: May 2011 Last updated: June 2019

© NICE 2019. All rights reserved. Subject to Notice of rights.

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