COPD - NICE guideline
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NICE guideline of Chronic Obstructive Pulmonary Disease
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COPD - NICE guideline
- 1. 0 Chronic obstructive pulmonary disease Implementing NICE guidance 2nd Edition July 2011 NICE clinical guideline 101
- 2. NICE Pathway The NICE COPD pathway covers the management of COPD in adults in primary care and secondary care and shows recommendations on: ā¢ When to consider referral ā¢ Diagnosis ā¢ Managing stable COPD ā¢ Managing exacerbations ā¢ Palliative Care Click here to go to NICE Pathways website
- 4. What this presentation covers Background Scope Definition Recommendations Costs and savings Discussion NICE COPD quality standard Find out more
- 5. Epidemiology ā¢ About 3 million people have chronic obstructive pulmonary disease (COPD) in the UK ā¢ Nearly 900,000 people in England and Wales are diagnosed as having COPD and an estimated 2 million people have COPD which remains undiagnosed ā¢ Symptoms usually develop insidiously making it difficult to determine the true prevalence of the disease ā¢ Most patients are not diagnosed until they are in their fifties
- 6. Background ā¢ COPD is predominantly caused by smoking and is characterised by airflow obstruction that: - is not fully reversible - does not change markedly over several months - is usually progressive in the long term ā¢ Exacerbations often occur, where there is a rapid and sustained worsening of symptoms beyond normal day- to-day variations requiring a change in treatment
- 7. Scope The scope for the guideline update was to examine: a) Diagnosis and severity classification: ā¢spirometry and post-bronchodilator values ā¢multidimensional severity assessment indices (for example, the BODE index) a) Management of stable COPD and prevention of disease progression ā¢long-acting bronchodilators: beta2 agonists and anticholinergics (tiotropium, formoterol fumarate, salmeterol) as monotherapy and in combination, both with and without inhaled corticosteroids ā¢mucolytic therapy (carbocisteine and mecysteine hydrochloride) BODE = body mass index, airflow obstruction, dyspnoea and exercise tolerance
- 8. Definition of COPD ā¢ Airflow obstruction is defined as reduced FEV1/FVC ratio (< 0.7) ā¢ It is no longer necessary to have an FEV1 < 80% predicted for definition of airflow obstruction ā¢ If FEV1 is ā„ 80% predicted, a diagnosis of COPD should only be made in the presence of respiratory symptoms, for example breathlessness or cough ā¢ COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction. FEV1 = forced expiratory volume in 1 second FVC = forced vital capacity
- 9. Natural History ā¢The Fletcher-Peto Diagram, illustrating the effects of smoking on rate of decline in FEV1
- 10. Diagnose COPD Consider a diagnosis of COPD for people who are: ā¢ over 35, and ā¢ smokers or ex-smokers, and ā¢ have any of these symptoms: - exertional breathlessness - chronic cough - regular sputum production, - frequent winter ābronchitisā - Wheeze ā¢ And no clinical features of asthma [2004]
- 11. Diagnose COPD: Spirometry ā¢ Perform spirometry if COPD seems likely [2004] ā¢ The presence of airflow obstruction should be confirmed by performing post-bronchodilator spirometry [new 2010] ā¢ Consider alternative diagnoses or investigations in: - older people without typical symptoms of COPD where the FEV1/FVC ratio is < 0.7 - younger people with symptoms of COPD where the FEV1/FVC ratio is ā„ 0.7 [new 2010] ā¢ All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results [2004]
- 12. Differentiating COPD from asthma Clinical features COPD Asthma Smoker or ex-smoker Nearly all Possibly Symptoms under age 35 Rare Often Chronic productive cough Common Uncommon Breathlessness Persistent and progressive Variable Night time waking with breathlessness and or wheeze Uncommon Common Significant diurnal or day to day variability of symptoms uncommon Common [2004]
- 13. Differentiating COPD from asthma: 2 ā¢ If diagnostic uncertainty remains, the following findings should be used to help identify asthma: - FEV1 and FEV1/FVC ratio return to normal with drug therapy - a very large (>400ml) FEV1 response to bronchodilators or to 30mg prednisolone daily for 2 weeks - serial peak flow measuremenst showing significant (20% or greater) diurnal or day-to-day variability - remaining diagnostic uncertainty may be resolved by referral for more detailed investigations [2004]
- 14. Diagnose COPD: assessment of severity ā¢ Assess severity of airflow obstruction using reduction in FEV1 NICE clinical guideline 12 (2004) ATS/ERS 2004 GOLD 2008 NICE clinical guideline 101 (2010) Post- bronchodilator FEV1/FVC FEV1 % predicted Post- bronchodilato r Post- bronchodilator Post- bronchodilator < 0.7 80% Mild Stage 1 (mild) Stage 1 (mild)* < 0.7 50ā79% Mild Moderate Stage 2 (moderate) Stage 2 (moderate) < 0.7 30ā49% Moderate Severe Stage 3 (severe) Stage 3 (severe) < 0.7 < 30% Severe Very severe Stage 4 (very severe)** Stage 4 (very severe)** * Symptoms should be present to diagnose COPD in people with mild airflow obstruction ** Or FEV1 < 50% with respiratory failure [new 2010]
- 15. Patient with COPD Palliative care Smoking Breathlessness & exercise limitation Frequent exacerbations Respiratory failure Cor pulmonale Abnormal BMI Chronic productive cough Anxiety & depression Managing stable COPD Assess symptoms/problems Manage those that are present as below Patients with COPD should have access to the wide range of skills available from a multidisciplinary team
- 16. Managing stable COPD: Stop smoking ā¢ Encouraging patients with COPD to stop smoking is one of the most important components of their management ā¢ All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity ā¢ Record a smoking history, including pack years smoked ā¢ Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [2010] [2004]
- 17. Managing stable COPD: Promote effective inhaled therapy In people with stable COPD who remain breathless or have exacerbations despite using short-acting bronchodilators as required, offer the following as maintenance therapy: ā¢if FEV1 ā„ 50% predicted: either LABA or LAMA ā¢if FEV1 < 50% predicted: either LABA+ICS in a combination inhaler, or LAMA Offer LAMA in addition to LABA+ICS to people with COPD who remain breathless or have exacerbations despite taking LABA+ICS, irrespective of their FEV1 ICS = inhaled corticosteroid LABA = long-acting beta2 agonist LAMA = long-acting muscarinic agonist[new 2010]
- 18. Managing stable COPD: inhaled therapies SABA or SAMA as required* Breathlessness and exercise limitation Exacerbations or persistent breathlessness Persistent exacerbations or breathlessness LABA LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA Discontinue SAMA ________ Offer LAMA in preference to regular SAMA four times a day FEV1 ā„ 50% FEV1 < 50% LABA + ICS in a combination inhaler ________ Consider LABA + LAMA if ICS declined or not tolerated LAMA + LABA + ICS in a combination inhaler Offer Consider * SABAs (as required) may continue at all stages
- 19. Managing stable COPD: Oral corticosteroids ā¢ Maintenance use of oral corticosteroid therapy in COPD is not recommended ā¢ Some patients with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation ā¢ The does of oral corticosteroids should be kept as low as possible ā¢ Any patient treated with long term corticosteroid therapy should be monitored for the development of osteoporosis and given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment without the need for monitoring
- 20. Managing stable COPD: Oxygen ā¢ Clinicians should be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression ā¢ Use appropriate oxygen therapy: ā¢ Long-term oxygen therapy ā¢ Ambulatory ā¢ Short burst
- 21. Managing stable COPD: Cor pulmonale ā¢ A diagnosis of cor pulmonale should be considered if patients have: - Peripheral odema, raised venous pressure, systolic parasternal heave, a loud pulmonary second heart sound. ā¢ Assess need for oxygen ā¢Use diuretics [2004]
- 22. Managing stable COPD: provide pulmonary rehabilitation Pulmonary rehabilitation An individually tailored multidisciplinary programme of care to optimise patientsā physical and social performance and autonomy Tailor multi-component, multidisciplinary interventions to individual patientās needs Hold at times that suit patients, and in buildings with good access Offer to all patients who consider themselves functionally disabled by COPD Make available to all appropriate people, including those recently hospitalised for an acute exacerbation [new 2010]
- 23. Multidisciplinary working ā¢ COPD care should be delivered by a multidisciplinary team that includes respiratory nurse specialists ā¢ Consider referral to specialist departments (not just respiratory physicians) [2004] Specialist department Who might benefit? Physiotherapy Advice about excessive sputum Dietetic advice People with BMI that is high, low or changing over time Occupational therapy People needing help with daily living activities Social services People disabled by COPD Multidisciplinary palliative care teams People with end-stage COPD (and their families and carers)
- 24. Follow-up of patients with COPD ā¢ Follow-up of patients should include: -Highlighting the diagnosis in the case record -Recording the values of spirometric tests -Offering stop smoking advice -Recording the opportunistic measurement of spirometric parameters ā¢ Patients should be reviewed at least once per year ā¢ For most patients with stable severe disease regular hospital review is not necessary [2004]
- 25. Managing exacerbations ā¢ Minimise impact of exacerbations by: - giving self-management advice on responding promptly to symptoms of exacerbation - starting appropriate treatment with oral steroids and/or antibiotics - use of non-invasive ventilation when indicated - use of hospital-at-home or assisted-discharge schemes ā¢ The frequency of exacerbations should be reduced by appropriate use of inhaled corticosteroids and bronchodilators, and vaccinations [2004]
- 26. Use non-invasive ventilation (NIV) ā¢ Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations not responding to medical therapy ā¢ NIV should be delivered by staff trained in its application, experienced in its use and aware of its limitations ā¢ When starting NIV, make a clear plan covering what to do in the event of deterioration and agree ceilings of therapy [2004]
- 27. Palliative care ā¢ Palliative care depends on good understanding of patientsā: - Perception of their quality of life - Satisfaction with current functioning - Expectations ā¢ Opioids, benzodiazepines, tricyclic antidepressants, major tranquilisers and oxygen can be used for the palliation of breathlessness in patients with end stage COPD unresponsive to other medical therapy ā¢ Providers of care should adopt an effective and equitable standardised approach to palliative care such as that provided by the Liverpool care pathway or equivalent [2004]
- 28. Costs per 100,000 population Costs are based on recommendations which have the most significant resource impact: 1.2.2.5 - 1.2.2.9 Costs per annum Ā£ Current cost of prescribing 524,291 Future cost of prescribing 624,812 Incremental cost of prescribing 100,521 Estimated 5% reductions in hospital admissions 30,302 Estimated cost of implementation 70,219
- 29. Discussion ā¢ How can we improve identification and diagnosis of people over 35 who have a risk factor? ā¢ How does our use of spirometry compare with the recommendations? ā¢ How will our prescribing practice need to change? ā¢ What pulmonary rehabilitation services are available? ā¢ How do we minimise the risk of exacerbations for our patients?
- 30. NHS Lung Improvement Visit the NHS Lung Improvement Programme webpages (www.improvement.nhs.uk/lung) for further practical support consistent with implementing the recommendations in this guideline
- 31. NHS Evidence Visit NHS Evidence for the best available evidence on all aspects of respiratory diseases, including COPD Click here to go to the NHS Evidence website
- 32. Find out more Visit www.nice.org.uk/CG101 for: ā¢the guideline ā¢the quick reference guide ā¢āUnderstanding NICE guidanceā ā¢costing report ā¢audit support ā¢baseline assessment tool
- 33. NICE quality standard COPD July 2011
- 34. Quality standards A quality standard is a set of specific, concise statements that: ā¢act as markers of high-quality, cost-effective patient care across a pathway or clinical area, covering treatment and prevention ā¢are derived from the best available evidence such as NICE guidance or other NHS evidence accredited sources ā¢are produced collaboratively with the NHS and social care, along with their partners and service users
- 35. COPD quality standard ā¢ This quality standard covers Assessment, diagnosis and clinical management of chronic obstructive pulmonary disease (COPD) in adults. ā¢ It does not include prevention, screening or case finding. ā¢ The quality standard consists of 13 quality statements.
- 36. Quality statement 1 People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by post bronchodilator spirometry carried out onā calibrated equipment by healthcare professionals competent in its performance and interpretation. Quality measure Process: a)Proportion of people with COPD who have one or more indicative symptoms recorded. b) Proportion of people with COPD who have the diagnosis confirmed by post bronchodilatorā spirometry
- 37. Quality statement 2 People with COPD have a current individualised comprehensive management plan, which includes high- quality information and educational material about the condition and its management, relevant to the stage of disease. Quality measure Process: Proportion of people with COPD who have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease.
- 38. Quality statement 3 People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan. Quality measure Process: a) Proportion of people with COPD who are offered inhaled and oral therapies in accordance with NICE guidance. b) Proportion of people with COPD who receive their inhaled and oral therapies as part of an individualised comprehensive management plan.
- 39. Quality statement 4 People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Quality measure Process: Proportion of people with COPD who had a comprehensive clinical and psychosocial assessment in the previous 12 months which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities.
- 40. Quality statement 5 People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. Quality measure Process: Proportion of people with COPD who smoke who are offered the full range of evidence-based smoking cessation support.
- 41. Quality statement 6 People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme. Quality measure Process: Proportion of people with COPD meeting appropriate criteria who receive an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme.
- 42. Quality statement 7 People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Quality measure Process: Proportion of people who have had an exacerbation of COPD who are given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact.
- 43. Quality statement 8 People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service. Quality measure Process: Proportion of people with COPD with oxygen saturation less than or equal to 92% when stable, who are assessed for LTOT in accordance with NICE guidance by a specialist oxygen service.
- 44. Quality statement 9 People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD. Quality measure Process: Proportion of people with COPD receiving LTOT, who have had a review in the previous 12 months by a specialist oxygen service in accordance with NICE guidance, as part of the integrated clinical management of their COPD.
- 45. Quality statement 10 People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support.
- 46. Quality statement 10 continued Quality measure Process: a) Proportion of people with COPD admitted to hospital with an exacerbation who are cared for by a respiratory team b) Proportion of people with COPD admitted to hospital with an exacerbation, and who meet the criteria for early supported discharge, who are placed on a specialist early supported discharge scheme with appropriate community support.
- 47. Quality statement 11 People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, non invasiveā ventilation delivered by appropriately trained staff in a dedicated setting.
- 48. Quality statement 11 continued Quality measure Process: a)Proportion of people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure, who are promptly assessed for NIV, and for whom any subsequent delivery is promptly undertaken. b) Proportion of people admitted to hospital and receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure, who have it delivered by appropriately trained staff in a dedicated setting.
- 49. Quality statement 12 People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. Quality measure Process: Proportion of people discharged from hospital following an admission with an exacerbation of COPD, who are reviewed within 2 weeks of discharge.
- 50. Quality statement 13 People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs. Quality measure Process: Proportion of people with advanced COPD, and their carers, who receive palliative care that addresses physical, social and emotional needs.
- 51. What do you think? Did the implementation tool you accessed today meet your requirements, and will it help you to put the NICE guidance into practice? We value your opinion and are looking for ways to improve our tools. Please complete this short evaluation form. If you are experiencing problems accessing or using this tool, please email implementation@nice.org.uk To open the links in this slide set right click over the link and choose āopen linkā
Editor's Notes
- This slide set was amended in July 2011 and now includes information about the NICE quality standard on COPD ABOUT THIS PRESENTATION: This presentation has been written to help you raise awareness of the NICE clinical guideline on āChronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary careā (partial update). This guideline has been written for all healthcare professionals, people with COPD and their carers, patient support groups, commissioning organisations and service providers. The development of this guideline has updated sections of NICE clinical guideline 12 (published February 2004). Other recommendations from 2004 remain appropriate and form part of the new comprehensive guideline. New or updated recommendations have been made for spirometry, assessment of prognostic factors, and to the section on inhaled therapy (which now incorporates the previously separate sections on inhaled bronchodilators, inhaled corticosteroids and inhaled combination therapy). In this presentation and in the NICE guideline, recommendations are marked as following: [2004] indicates the evidence has not been updated and reviewed since the original guideline. [2007] applies to two specific recommendations that were developed as part of a technology appraisal in 2007. [2010] indicates that the evidence has been reviewed but no change has been made to the recommendation. [new 2010] indicates that the evidence has been reviewed and the recommendation has been updated or added. The guideline is available in a number of formats, including a quick reference guide. You should have copies of the quick reference guide available at your presentation so that your audience can refer to it. See the end of the presentation for ordering details. You can add your own organisationās logo alongside the NICE logo. We have included notes for presenters, broken down into ākey points to raiseā, which you can highlight in your presentation, and āadditional informationā that you may want to draw on, such as a rationale or an explanation of the evidence for a recommendation. Where necessary, the recommendation will be given in full. DISCLAIMER This slide set is an implementation tool and should be used alongside the published guidance. This information does not supersede or replace the guidance itself. PROMOTING EQUALITY Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity. Nothing in this guidance should be interpreted in a way which would be inconsistent with compliance with those duties.
- NOTES FOR PRESENTERS: Key points to raise - If you are showing this presentation when connected to the internet, click on the orange button to go straight to the NICE Pathways website. The front page includes a two minute video giving an overview of the features and content within the site, as well as the list of topics covered. NICE Pathways: guidance at your fingertips Our new online tool provides quick and easy access, topic by topic, to the range of guidance from NICE, including quality standards, technology appraisals, clinical and public health guidance and NICE implementation tools. Simple to navigate, NICE Pathways allows you to explore in increasing detail NICE recommendations and advice, giving you confidence that you are up to date with everything we have recommended.
- NOTES FOR PRESENTERS: The NICE pathway can be found at http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease ā n.b. no āwwwā
- NOTES FOR PRESENTERS: In this presentation we will start by providing some background to the guideline and why it is important. We will then go through the guideline recommendations and highlight the key priorities for implementation. The NICE guideline contains 7 key priorities for implementation, which you can find on page 4ā5 of your quick reference guide. The key priorities for implementation cover the following areas: Diagnose COPD Stop smoking Promote effective inhaled therapy Provide pulmonary rehabilitation for all who need it. Use non-invasive ventilation Manage exacerbations Ensure multidisciplinary working Next, we will summarise the costs and savings that are likely to be incurred in implementing the guideline. Then we will open the meeting up with a list of questions to help prompt a discussion on local issues for incorporating the guidance into practice. Following this we will view the COPD quality standards. Finally, we will end the presentation with further information about the support provided by NICE. Some images and text in this slide set were provided by the British Thoracic Society
- NOTES FOR PRESENTERS: An estimated 3 million people have chronic obstructive pulmonary disease (COPD) in the UK. About 900,000 have diagnosed COPD and an estimated 2 million people have COPD which remains undiagnosed. Most patients are not diagnosed until they are in their fifties.
- NOTES FOR PRESENTER: The airflow obstruction is present because of a combination of airway and parenchymal damage. The damage is the result of chronic inflammation that differs from that seen in asthma and which is usually the result of tobacco smoke. Significant airflow obstruction may be present before the person is aware of it. COPD produces symptoms, disability and impaired quality of life which may respond to pharmacological and other therapies that have limited or no impact on the airflow obstruction. COPD is now the preferred term for the conditions in patients with airflow obstruction who were previously diagnosed as having chronic bronchitis or emphysema.
- NOTES FOR PRESENTERS: The complete guideline covers adults (16 years and older) with stable COPD including: chronic bronchitis, emphysema, chronic airflow limitation/obstruction. It does not cover people with asthma, bronchopulmonary dysplasia, bronchiectasis or acute exacerbations. These issues and associated recommendations from the 2004 guideline were not updated Diagnosing COPD Symptoms SpirometryFurther investigations Reversibility testingAssessment of severity and prognostic factors Identification of early diseaseReferral for specialist advice Assessment and classification of severity of airflow obstruction Managing stable COPD Smoking cessationFollow-up of patients with COPD Inhaled therapy (including delivery systems) Oral therapyCombined oral and inhaled therapy OxygenNon-invasive ventilation Pulmonary rehabilitationVaccination and anti-viral therapy Lung surgeryAlpha-1 antitrypsin replacement therapy Multidisciplinary managementFitness for general surgery Management of pulmonary hypertension and cor pulmonale Management of exacerbations of COPD Definition of an exacerbationAssessment of need for hospital treatment Investigation of an exacerbationHospital-at-home and assisted-discharge schemes Pharmacological managementOxygen therapy during exacerbations of COPD Invasive ventilation and intensive careRespiratory physiotherapy and exacerbations Monitoring recovery from an exacerbationDischarge planning Non-invasive ventilation (NIV) and COPD exacerbations
- NOTES FOR PRESENTER There is no single diagnostic test for COPD. Making a diagnosis relies on clinical judgement based on a combination of history, physical examination and confirmation of the presence of airflow obstruction using spirometry.
- NOTES FOR PRESENTERS: Reference: Fletcher C, Peto R, The natural history of chronic airflow obstruction, British Medical Journal, 1:1645-1648, 1977.
- NOTES FOR PRESENTERS: Key points to raise: Please refer your audience to page 6 of the QRG which shows the algorithm to support the diagnosis recommendation. Recommendation in full: A diagnosis of COPD should be considered in patients over the age of 35 who have a risk factor (generally smoking) and who present with one or more of the following symptoms: exertional breathlessness chronic cough regular sputum production frequent winter ābronchitisā wheeze. [1.1.1.1] Related recommendations: COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients presenting for the first time. Features from the history and examination (see page 6 of the QRG) should be used to differentiate COPD from asthma whenever possible. [1.1.4.2]
- NOTES FOR PRESENTERS: Recommendations in full: Spirometry should be performed: - at the time of diagnosis,- to reconsider the diagnosis if patients show an exceptionally good response to treatment. [1.1.2.1] Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [1.1.2.2] Consider alternative diagnoses or investigations in:- older people without typical symptoms of COPD where the FEV1/FVC ratio is &lt; 0.7, - younger people with symptoms of COPD where the FEV1/FVC ratio is ā„ 0.7. [1.1.2.3] All health professionals involved in the care of people with COPD should have access to spirometry and be competent in the interpretation of the results. [1.1.2.4] Related recommendations: Spirometry services should be supported by quality control processes. [1.1.2.6] Use ERS 1993 reference values but be aware these may lead to under diagnosis in older people and are not applicable in black and Asian populations. [1.1.2.7] At the time of their initial diagnostic evaluation in addition to spirometry all patients should have: a chest radiograph to exclude other pathologies a full blood count to identify anaemia or polycythaemia body mass index (BMI) calculated. [1.1.3.1] Additional investigations should be performed to aid management in some circumstances (see page 6 of the QRG) [1.1.3.2] Reversibility testing is not usually necessary as part of the diagnostic process or to plan initial therapy [1.1.4.1]
- NOTES FOR PRESENTERS: Recommendations in full: COPD and asthma are frequently distinguishable on the basis of history (and examination) in untreated patients presenting for the first time. Features from the history and examination (such as those listed in table 3) should be used to differentiate COPD from asthma whenever possible. [1.1.4.2] Longitudinal observation of patients (whether using spirometry, peak flow or symptoms) should also be used to help differentiate COPD from asthma. [1.1.4.3]
- NOTES FOR PRESENTERS: Recommendations in full: Longitudinal observation of patients (whether using spirometry, peak flow or symptoms) should also be used to help differentiate COPD from asthma. [1.1.4.3] To help resolve cases where diagnostic doubt remains, or both COPD and asthma are present, the following findings should beused to help identify asthma: - a large (&gt; 400 ml) response to bronchodilators - a large (&gt; 400 ml) response to 30 mg oral prednisolone daily for 2 weeks - serial peak flow measurements showing 20% or greater diurnal or day-to-day variability. Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. [1.1.4.4] If diagnostic uncertainty remains, referral for more detailed investigations, including imaging and measurement of TLCO, should be considered. [1.1.4.5] Related recommendation: If patients report a marked improvement in symptoms in response to inhaled therapy, the diagnosis of COPD should be reconsidered. [1.1.4.6]
- NOTES FOR PRESENTERS: Key points to raise: Disability in COPD can be poorly reflected in the FEV1. A more comprehensive assessment also includes: - degree of airflow obstruction and disability - frequency of exacerbations - prognostic factors such as breathlessness (assessed using the Medical Research Council [MRC] scale), carbon monoxide lung transfer factor [TLCO], health status, exercise capacity, BMI, partial pressure of oxygen in arterial blood [PaO2] and cor pulmonale. [adapted from 1.1.5.1] Investigate symptoms that seem disproportionate to the spirometric impairment using a CT scan or TLCO testing. Calculate the BODE index (BMI, airflow obstruction, dyspnoea and exercise capacity) to assess prognosis (where the component information is currently available). Assess severity of airflow using the table on the slide. Recommendation in full: The severity of airflow obstruction should be assessed according to the reduction in FEV1 as shown in table on the slide [1.1.6.1] Abbreviations: ATS, American Thoracic Society; ERS, European Respiratory Society; FVC, forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease References : Quanjer PH, Tammeling GJ, Cotes et al. (1993) Lung Volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. European Respiratory Journal (Suppl) 16:5-40. Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position Paper. European Respiratory Journal 23(6): 932-46. Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
- NOTES FOR PRESENTERS: Recommendations in full: An up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked), should be documented for everyone with COPD. [1.2.1.1] All COPD patents still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity. [1.2.1.2] Unless contraindicated, offer NRT, varenicline or bupropion, as appropriate, to people who are planning to stop smoking combined with an appropriate support programme to optimise smoking quit rates for people with COPD. [1.2.2.3] Additional information: See āVarenicline for smoking cessationā (NICE technology appraisal guidance 123) See āSmoking cessation services in primary care, pharmacies, local authorities and workplaces, particularly for manual working groups, pregnant women and hard to reach communitiesā (NICE public health guidance 10) A NICE/BMJ Learning on-line educational module (free to all users) is available through the NICE website http://www.nice.org.uk/usingguidance/education/educational_tools.jsp
- NOTES FOR PRESENTERS: Please refer your audience to page 10 of the QRG which focuses on delivery systems (inhalers, spacers and nebulisers). Key points to raise: In people with stable COPD and an FEV1 ā„ 50% who remain breathless or have exacerbations despite maintenance therapy with a LABA: - consider LABA + ICS in a combination inhaler consider LAMA in addition to LABA where ICS is declined or not tolerated. [1.2.2.7] Consider LABA+ ICS in a combination inhaler in addition to LAMA for people with stable COPD who remain breathless or have exacerbations despite maintenance therapy with LAMA irrespective of their FEV1. [1.2.2.8] The choice of drug(s) should take into account the personās symptomatic response and preference, and the drugās potential to reduce exacerbations, its side effects and cost. [1.2.2.10] Be aware of the potential risk of developing side effects (including non-fatal pneumonia) in people with COPD treated with inhaled corticosteroids and be prepared to discuss with patients [1.2.2.3]
- NOTES FOR PRESENTERS: This slide shows the treatment algorithm included within the full guideline (Algorithm 2a) and is reproduced on page 9 of your QRG. On pages 12 and 13 of your QRG you will also find a useful table which summarises the recommendations for managing symptoms and conditions in stable COPD.
- NOTES FOR PRESENTERS: Recommendations in full: Maintenance use of oral corticosteroid therapy in COPD is not normally recommended. Some patients with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible. [1.2.3.1] Patients treated with long-term oral corticosteroid therapy should be monitored for the development of osteoporosis and given appropriate prophylaxis. Patients over the age of 65 should be started on prophylactic treatment, without monitoring. [1.2.3.2]
- NOTES FOR PRESENTERS: Recommendation 1.2.5.1 in full on slide. Additional information: Please refer to page 11 of the QRG which summarise recomendations 1.2.5.1- 1.2.5.18
- NOTES FOR PRESENTERS: Recommendation 1.2.7.1 in full on slide. Recommendations in full: Patients presenting with cor pulmonale should be assessed for the need for long-term oxygen therapy. [1.2.7.3] Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. [1.2.7.4] The following are not recommended for the treatment of cor pulmonale: angiotensin-converting enzyme inhibitors calcium channel blockers alpha-blockers digoxin (unless there is atrial fibrillation). [1.2.7.5]
- NOTES FOR PRESENTERS: Recommendation in full: Pulmonary rehabilitation should be made available to all appropriate people with COPD including those who have had a recent hospitalisation for an acute exacerbation. [1.2.8.1] Pulmonary rehabilitation should be offered to all patients who consider themselves functionally disabled by COPD (usually MRC grade 3 and above). Pulmonary rehabilitation is not suitable for patients who are unable to walk, have unstable angina or who have had a recent myocardial infarction. [1.2.8.2] For pulmonary rehabilitation programmes to be effective, and to improve concordance, they should be held at times that suit patients, and in buildings that are easy for patients to get to and have good access for people with disabilities. Places should be available within a reasonable time of referral. [1.2.8.3] Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions, which are tailored to the individual patientās needs. The rehabilitation process should incorporate a programme of physical training, disease education, nutritional, psychological and behavioural intervention. [1.2.8.4] Patients should be made aware of the benefits of pulmonary rehabilitation and the commitment required to gain these. [1.2.8.5]
- NOTES FOR PRESENTERS: Please refer your audience page 14 of the QRG for more information on Referral for specialist advice and possible reasons for making a referral. Also, refer to page 15 of the QRG for follow-up and review of people with COPD in primary care. Related recommendations : The following functions should be considered when defining the activity of the multidisciplinary team: assessing patients (including performing spirometry, assessing the need for oxygen, the need for aids for daily living and the appropriateness of delivery systems for inhaled therapy). care and treatment of patients (including non-invasive ventilation, pulmonary rehabilitation, hospital-at-home/early discharge schemes, providing palliative care, identifying and managing anxiety and depression, advising patients on relaxation techniques, dietary issues, exercise, social security benefits and travel). advising patients on self-management strategies identifying and monitoring patients at high risk of exacerbations and undertaking activities which aim to avoid emergency admissions advising patients on exercise education of patients and other health professionals. [1.2.12.2] It is recommended that respiratory nurse specialists form part of the multidisciplinary COPD team. [1.2.12.3]
- NOTES FOR PRESENTERS: Recommendations in full: Follow-up of all patients with COPD should include: -highlighting the diagnosis of COPD in the case record and recording this using Read codes on a computer database -recording the values of spirometric tests performed at diagnosis (both absolute and percent predicted) -offering smoking cessation advice -recording the opportunistic measurement of spirometric parameters (a loss of 500 ml or more over 5 years will select out those patients with rapidly progressing disease who may need specialist referral and investigation). [1.2.14.1] Patients with COPD should be reviewed at least once per year, or more frequently if indicated, and the review should cover the issues listed in table 6. [1.2.14.2] For most patients with stable severe disease regular hospital review is not necessary, but there should be locally agreed mechanisms to allow rapid access to hospital assessment when necessary. [1.2.14.3] When patients with very severe COPD are reviewed in primary care, they should be seen at least twice a year, and specific attention should be paid to the issues listed in table (refer to page 15 of the QRG). [1.2.14.4] Patients with severe disease requiring interventions such as long-term non-invasive ventilation should be reviewed regularly by specialists. [1.2.14.5]
- NOTES FOR PRESENTERS: Key points to raise Please refer your audience to page 17 of the QRG for factors to consider when deciding where to manage exacerbations. Pages 18 and 19 also show an algorithm for investigating and managing exacerbations of COPD. An exacerbation is a sustained worsening of the patientās 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. The change in these symptoms often necessitates a change in medication.
- NOTES FOR PRESENTERS: Recommendations in full: NIV should be used as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. [1.3.7.1] It is recommended that NIV should be delivered in a dedicated setting with staff who have been trained in its application, who are experienced in its use and who are aware of its limitations. [1.3.7.2] When patients are started on NIV there should be a clear plan covering what to do in the event of deterioration and ceilings of therapy should be agreed. [1.3.7.3] Additional information: Adequately treated patients with chronic hypercapnic respiratory failure who have required assisted ventilation (whether invasive or non-invasive) during an exacerbation or who are hypercapnic or acidotic on LTOT should be referred to a specialist centre for consideration of long-term NIV [1.2.6.1]
- NOTES FOR PRESENTERS: Recommendations in full: Opioids should be used when appropriate to palliate breathlessness in patients with end-stage COPD which is unresponsive to other medical therapy. [1.2.12.8] Benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen should also be used when appropriate for breathlessness in patients with end-stage COPD unresponsive to other medical therapy. [1.2.12.9] Patients with end-stage COPD and their family and carers should have access to the full range of services offered by multidisciplinary palliative care teams, including admission to hospices. [1.2.12.10] NICE will be publishing quality standards for āEnd of life care for adultsā in November 2011 which should be considered as part of palliative care.
- NOTES FOR PRESENTERS: Due to the breadth and complexity of the guideline, NICE worked with the GDG and other professionals to identify the recommendations that would have the most significant resource impact. This costing work concentrated on the new recommendations in the 2010 guidance. These were recommendations 1.2.2.5 to 1.2.2.9 . The costing model is based on the national average prevalence of COPD of 1.6%. The costing template allows the user to select specific PCTs and calculate the incremental cost of implementing the guidance using the prevalence specific to that area. The costing template can be found at: http://guidance.nice.org.uk/CG101/CostingTemplate/xls/English. The daily dose for each drug was estimated using pack prices have been taken from the British National Formulary 60. A hospital admission for COPD is estimated to cost commissioners Ā£1960 (the weighted average cost calculated from national tariff cost information and activity levels taken from reference cost data.) Only inpatient costs are included in this average; intensive care unit, high dependency unit and ambulance costs are not included. The tariffs for COPD also include people admitted with bronchitis. On the basis of primary diagnosis data extracted from Hospital Episode Statistics, it was calculated that 86% of the total activity in relation to COPD and bronchitis is for COPD. Current prescribing for COPD has been estimated using data provided by the NHS Information Centre using the IMS Disease Analyzer. The analysis was based on 982,246 patients in 113 practices available from 1 January to 31 December 2009. The therapies used in the analysis report are listed below: Beclometasone (Clenil Modulite, QVAR) Budesonide Fluticasone Ipratropium (Atrovent) Salbutamol (Ventolin, Salamol) Salmeterol (Serevent) Fluticasone proprionate + salmeterol (Seretide) Budesonide + formoterol (Symbicort) Terbutaline Tiotropium (Spiriva) Current prescribing costs were estimated by applying the annual costs listed in table 3 of the costing report, multiplied by the number of patients. The current annual primary care prescribing costs for COPD is estimated to be Ā£268.5 million. This is similar to an impact assessment report released by the Department of Health in 2010, which estimated the total cost of all drugs used for COPD at Ā£263.3 million. Changes in prescribing practice were estimated on the basis of the updated prescribing pathway and following discussions with clinical experts. It should be highlighted that predictions made around future prescribing practice are made for financial planning purposes only and should not be taken as recommended practice, or used as targets. The costing report for this guideline can be found at: http://guidance.nice.org.uk/CG101/CostingReport/pdf/English
- NOTES FOR PRESENTERS: These questions are suggestions that have been developed to help provide a prompt for a discussion at the end of your presentation ā please edit and adapt these to suit your local situation. Additional questions: How does our service for patients needing non-invasive ventilation compare with the guideline recommendations?
- NOTES FOR PRESENTERS: NHS Lung Improvement. Visit the NHS Lung Improvement webpages (www.improvement.nhs.uk/lung) for more information and help in implementing the recommendations in this guideline.
- NOTES FOR PRESENTERS: If you are showing this presentation when connected to the internet, click on the blue button to go straight to the NHS Evidence website topic page for Chronic Obstructive Pulmonary Disease. For the home page go to www.evidence.nhs.uk
- NOTES FOR PRESENTERS: You can download the guidance documents from the NICE website. The NICE guideline ā all the recommendations. A quick reference guide ā a summary of the recommendations for healthcare professionals. āUnderstanding NICE guidanceā ā information for patients and carers. The full guideline ā all the recommendations, details of how they were developed, and reviews of the evidence they were based on. For printed copies of the quick reference guide or āUnderstanding NICE guidanceā, phone NICE publications on 0845 003 7783 or email publications@nice.org.uk and quote reference numbers N2199 (quick reference guide) and/or N2200 (āUnderstanding NICE guidanceā). NICE has developed tools to help organisations implement this guideline, which can be found on the NICE website. Costing tools ā a costing report gives the background to the national savings and costs associated with implementation, and a costing template allows you to estimate the local costs and savings involved. Audit support ā for monitoring local practice. Baseline assessment tool - the document can help you identify which areas of practice may need more support, decide on clinical audit topics and prioritise implementation activities.
- NOTES FOR PRESENTERS: The NICE COPD quality standard can be found at: http://www.nice.org.uk/guidance/qualitystandards/chronicobstructivepulmonarydisease/copdqualitystandard.jsp
- NOTES FOR PRESENTERS: Key points to raise: There are two components to a quality standard. These are qualitative statements and quantitative measures. Quality standards also include audience descriptors, definitions and data sources which support the statement measures. Qualitative statements are descriptive statements of the key infrastructure and clinical requirements for high quality care, as well as the desirable or expected outcomes. Commissioners will be interested in quality standards as markers of high quality care and patients and the public will see clear statements of what they can expect to receive from high quality services.
- NOTES FOR PRESENTERS: This quality standard covers the assessment, diagnosis and clinical management of chronic obstructive pulmonary disease (COPD) in adults. The scope of the quality standard does not include prevention, screening or case finding. This quality standard describes markers of high-quality, cost-effective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for people with COPD in the following ways: -Preventing people from dying prematurely. -Enhancing quality of life for people with long-term conditions. -Helping people to recover from episodes of ill health, or following injury. -Ensuring that people have a positive experience of care. -Treating and caring for people in a safe environment and protecting them from avoidable harm.
- NOTES FOR PRESENTERS: Quality statement 1: People with COPD have one or more indicative symptoms recorded, and have the diagnosis confirmed by postābronchodilator spirometry carried out on calibrated equipment by healthcare professionals competent in its performance and interpretation. Quality measure: Structure: a) Evidence of local arrangements to ensure that clinical diagnoses of COPD include a record of one or more indicative symptoms. b) Evidence of local arrangements to ensure that people diagnosed with COPD have the diagnosis confirmed by post-bronchodilator spirometry. c) Evidence of local arrangements to ensure that postābronchodilator spirometry is carried out on correctly calibrated equipment. d) Evidence of local arrangements to ensure that those carrying out postābronchodilator spirometry are competent in its performance and interpretation. Process: a) Proportion of people with COPD who have one or more indicative symptoms recorded. Numerator ā the number of people in the denominator with one or more indicative symptoms recorded. Denominator ā the number of people with COPD. b) Proportion of people with COPD who have the diagnosis confirmed by postābronchodilator spirometry. Numerator ā the number of people in the denominator who have confirmatory postābronchodilator spirometry. Denominator ā the number of people with COPD.
- NOTES FOR PRESENTERS: Quality statement 2: People with COPD have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. Quality measure: Structure: Evidence of local arrangements to provide people with COPD an individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. Process: Proportion of people with COPD who have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. Numerator ā the number of people in the denominator who have a current individualised comprehensive management plan, which includes high-quality information and educational material about the condition and its management, relevant to the stage of disease. Denominator ā the number of people with COPD.
- NOTES FOR PRESENTERS: Quality statement 3: People with COPD are offered inhaled and oral therapies, in accordance with NICE guidance, as part of an individualised comprehensive management plan. Quality measure: Structure: a) Evidence of local arrangements to ensure that healthcare professionals prescribing inhaled and oral therapies follow NICE guidance. b) Evidence of local arrangements to ensure that inhaled and oral therapies are prescribed as part of an individualised comprehensive management plan. Process: a) Proportion of people with COPD who are offered inhaled and oral therapies in accordance with NICE guidance. Numerator ā the number of people in the denominator offered inhaled and oral therapies in accordance with NICE guidance. Denominator ā the number of people with COPD. b) Proportion of people with COPD who receive their inhaled and oral therapies as part of an individualised comprehensive management plan. Numerator ā the number of people in the denominator receiving their inhaled and oral therapies as part of an individualised comprehensive plan. Denominator ā the number of people with COPD receiving inhaled and oral therapies.
- NOTES FOR PRESENTERS: Quality statement 4: People with COPD have a comprehensive clinical and psychosocial assessment, at least once a year or more frequently if indicated, which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Quality measure: Structure: a) Evidence of local arrangements to ensure that people with COPD have a comprehensive clinical and psychosocial assessment at least once a year, or more frequently if indicated. b) Evidence of local arrangements to ensure that clinical and psychosocial assessments include degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Process: Proportion of people with COPD who had a comprehensive clinical and psychosocial assessment in the previous 12 months which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Numerator ā the number of people in the denominator who had a comprehensive clinical and psychosocial assessment in the previous 12 months which includes degree of breathlessness, frequency of exacerbations, validated measures of health status and prognosis, presence of hypoxaemia and comorbidities. Denominator ā the number of people with COPD.
- NOTES FOR PRESENTERS: Quality statement 5: People with COPD who smoke are regularly encouraged to stop and are offered the full range of evidence-based smoking cessation support. Quality measure: Structure: a) Evidence of local arrangements to ensure that people with COPD who smoke are regularly encouraged to stop. b) Evidence of local arrangements to provide the full range of evidence-based smoking cessation support. Process: Proportion of people with COPD who smoke who are offered the full range of evidence-based smoking cessation support. Numerator ā the number of people in the denominator offered the full range of evidence-based smoking cessation support. Denominator ā the number of people with COPD who smoke. Outcome: Smoking quit-rate for people with COPD attending NHS stop-smoking services.
- NOTES FOR PRESENTERS: Quality statement 6: People with COPD meeting appropriate criteria are offered an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme. Quality measure: Structure: a) Evidence of local arrangements to provide multidisciplinary pulmonary rehabilitation programmes. b) Evidence of local arrangements to ensure effectiveness of multidisciplinary pulmonary rehabilitation programmes, by collection and audit of health outcome data. c) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes can be accessed in a timely manner. d) Evidence of local arrangements to ensure multidisciplinary pulmonary rehabilitation programmes are geographically accessible. Process: Proportion of people with COPD meeting appropriate criteria who receive an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme . Numerator ā the number of people in the denominator receiving an effective, timely and accessible multidisciplinary pulmonary rehabilitation programme . Denominator ā the number of people with COPD meeting appropriate criteria for pulmonary rehabilitation. Outcome: a) Improvements in exercise capacity as measured by a validated field exercise test, for example the 6-minute walk test or the incremental shuttle walking test. b) Improvements in health-related quality of life measured by a validated questionnaire, for example St Georgeās Respiratory Questionnaire (SGRQ).
- NOTES FOR PRESENTERS: Quality statement 7: People who have had an exacerbation of COPD are provided with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Quality measure: Structure: Evidence of local arrangements to provide people who have had an exacerbation of COPD with individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Process: Proportion of people who have had an exacerbation of COPD who are given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Numerator ā the number of people in the denominator given individualised written advice on early recognition of future exacerbations, management strategies (including appropriate provision of antibiotics and corticosteroids for self-treatment at home) and a named contact. Denominator ā the number of people who have had an exacerbation of COPD.
- NOTES FOR PRESENTERS: Quality statement 8: People with COPD potentially requiring long-term oxygen therapy are assessed in accordance with NICE guidance by a specialist oxygen service. Quality measure: Structure: Evidence of local arrangements, to ensure that people with COPD potentially requiring long-term oxygen therapy (LTOT) are assessed in accordance with NICE guidance by a specialist oxygen service. Process: Proportion of people with COPD with oxygen saturation less than or equal to 92% when stable, who are assessed for LTOT in accordance with NICE guidance by a specialist oxygen service. Numerator ā the number of people in the denominator assessed for LTOT in accordance with NICE guidance by a specialist oxygen service. Denominator ā the number of people with COPD with oxygen saturation less than or equal to 92% when stable. It is noted that an assessment for long-term oxygen therapy should be considered in a range of clinical circumstances and not only for people with less than or equal to 92% oxygen saturation when stable (please see definitions section). However, to aid measurability, the specific population of those with less than or equal to 92% oxygen saturation when stable has been chosen.ality measure:
- NOTES FOR PRESENTERS: Quality statement 9: People with COPD receiving long-term oxygen therapy are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD. Quality measure: Structure: Evidence of local arrangements to ensure that people with COPD receiving long-term oxygen therapy (LTOT) are reviewed in accordance with NICE guidance, at least annually, by a specialist oxygen service as part of the integrated clinical management of their COPD. Process: Proportion of people with COPD receiving LTOT, who have had a review in the previous 12 months by a specialist oxygen service in accordance with NICE guidance, as part of the integrated clinical management of their COPD. Numerator ā the number of people in the denominator reviewed in the previous 12 months by a specialist oxygen service in accordance with NICE guidance, as part of the integrated clinical management of their COPD. Denominator ā the number of people with COPD receiving LTOT.
- NOTES FOR PRESENTERS: Quality statement 10: People admitted to hospital with an exacerbation of COPD are cared for by a respiratory team, and have access to a specialist early supported-discharge scheme with appropriate community support.
- NOTES FOR PRESENTERS: Quality measure: Structure: a) Evidence of local arrangements to ensure people with COPD admitted to hospital with an exacerbation are cared for by a respiratory team. b) Evidence of local arrangements to provide a specialist early supported discharge scheme, with appropriate community support, for people with COPD admitted to hospital with an exacerbation. Process: a) Proportion of people with COPD admitted to hospital with an exacerbation who are cared for by a respiratory team. Numerator ā the number of people in the denominator cared for by a respiratory team. Denominator ā the number of people with COPD admitted to hospital with an exacerbation. b) Proportion of people with COPD admitted to hospital with an exacerbation, and who meet the criteria for early supported discharge, who are placed on a specialist early supported discharge scheme with appropriate community support. Numerator ā the number of people in the denominator placed on a specialist early supported discharge scheme with appropriate community support. Denominator ā the number of people with COPD admitted to hospital with an exacerbation and meeting the criteria for early supported discharge. Outcome: Reduction in mean length of stay of people admitted to hospital with an exacerbation of COPD.
- NOTES FOR PRESENTERS: Quality statement 11: People admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure are promptly assessed for, and receive, nonāinvasive ventilation de livered by appropriately trained staff in a dedicated setting.
- NOTES FOR PRESENTERS: Quality measure Structure: a) Evidence of local arrangements for the prompt assessment and delivery of non-invasive ventilation (NIV) to people admitted to hospital with an exacerbation of COPD and persistent acidotic ventilatory failure. b) Evidence of local arrangements to ensure that people admitted to hospital and receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure, have NIV delivered by appropriately trained staff in a dedicated setting. Process: a) Proportion of people admitted to hospital with an exacerbation of COPD and with persistent acidotic ventilatory failure, who are promptly assessed for NIV, and for whom any subsequent delivery is promptly undertaken. Numerator ā the number of people in the denominator promptly assessed for NIV, and for whom any subsequent delivery is promptly undertaken. Denominator ā the number of people admitted to hospital with an exacerbation of COPD and persistent acidotic ventilatory failure. b) Proportion of people admitted to hospital and receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure, who have it delivered by appropriately trained staff in a dedicated setting. Numerator ā the number of people in the denominator having NIV delivered by appropriately trained staff in a dedicated setting. Denominator ā the number of people admitted to hospital receiving NIV for an exacerbation of COPD and persistent acidotic ventilatory failure. Outcome: a) Reduction in hospital mortality rate of patients admitted with an exacerbation of COPD. b) Reduction in median length of stay of patients admitted with an exacerbation of COPD. c) Reduction in complications, specifically ventilator-associated pneumonia. d) Reduction in the need for intubation.
- NOTES FOR PRESENTERS: Quality statement 12: People admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. Quality measure: Structure: Evidence of local arrangements to ensure that people admitted to hospital with an exacerbation of COPD are reviewed within 2 weeks of discharge. Process: Proportion of people discharged from hospital following an admission with an exacerbation of COPD, who are reviewed within 2 weeks of discharge. Numerator ā the number of people in the denominator reviewed within 2 weeks of discharge. Denominator ā the number of people discharged from hospital following admission with an exacerbation of COPD.
- NOTES FOR PRESENTERS: Quality statement 13: People with advanced COPD, and their carers, are identified and offered palliative care that addresses physical, social and emotional needs. Quality measure: Structure: a) Evidence of local arrangements to ensure that people with advanced COPD, and their carers, are identified and offered palliative care. b) Evidence of local arrangements to ensure that palliative care is provided for people with advanced COPD and their carers, and addresses physical, social and emotional needs. Process: Proportion of people with advanced COPD, and their carers, who receive palliative care that addresses physical, social and emotional needs. Numerator ā the number of people in the denominator receiving palliative care that addresses physical, social and emotional needs. Denominator ā the number of people with advanced COPD, and their carers, identified as needing palliative care.
- NOTES FOR PRESENTERS: Additional information: The final slide is not intended to be part of the presentation, it asks for feedback on whether this implementation tool meets your requirements and whether it will help you to put this NICE guidance into practice - your opinion would be appreciated. To open the links in this slide set right click over the link and choose āopen linkā