Stable COPD: oxygen ther - NICE Pathways
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Stable COPD: o
oxygen
xygen ther
therap
apyy
NICE Pathways bring together everything NICE says on a topic in an interactive
flowchart. NICE Pathways are interactive and designed to be used online.
They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:
http://pathways.nice.org.uk/pathways/chronic-obstructive-pulmonary-disease
NICE Pathway last updated: 11 June 2019
This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.
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1 Person aged 16 or over with stable COPD
No additional information
2 Risks of oxygen therapy
Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory
depression.
3 Short-burst oxygen therapy
Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who
have mild or no hypoxaemia at rest.
See the NICE guideline to find out why we made this recommendation and how it might affect
practice.
4 Long-term oxygen therapy
Assess the need for oxygen therapy in all people with:
very severe airflow obstruction (FEV1 below 30% predicted)
cyanosis (blue tint to skin)
polycythaemia
peripheral oedema (swelling)
a raised jugular venous pressure
oxygen saturations of 92% or less breathing air.
Also consider assessment for people with severe airflow obstruction (FEV1 30-49% predicted).
Assess people for LTOT by 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.
Consider LTOT1 for people with COPD who do not smoke and who:
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The MHRA has published an alert on the risk of death and severe harm from failure to obtain and continue flow
from oxygen cylinders (2018).
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have a PaO2 below 7.3 kPa when stable or
have a PaO2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the
following:
secondary polycythaemia
peripheral oedema
pulmonary hypertension.
Conduct and document a structured risk assessment for people being assessed for LTOT who
meet the criteria outlined above. As part of the risk assessment, cover the risks for both the
person with COPD and the people who live with them, including:
the risks of falls from tripping over the equipment
the risks of burns and fires, and the increased risk of these for people who live in homes
where someone smokes (including e-cigarettes).
Base the decision on whether LTOT is suitable on the results of the structured risk assessment.
For people who smoke or live with people who smoke, but who meet the other criteria for LTOT,
ensure the person who smokes is offered smoking cessation advice and treatment, and referral
to specialist stop smoking services (see NICE's recommendations on stop smoking
interventions and services and medicines optimisation).
Do not offer LTOT to people who continue to smoke despite being offered smoking cessation
advice and treatment, and referral to specialist stop smoking services.
Advise people who are having LTOT that they should breathe supplemental oxygen for a
minimum of 15 hours per day.
Do not offer LTOT to treat isolated nocturnal hypoxaemia caused by COPD.
To ensure everyone eligible for LTOT is identified, pulse oximetry should be available in all
healthcare settings.
Oxygen concentrators should be used to provide the fixed supply at home for LTOT.
People who are having LTOT should be reviewed at least once per year by healthcare
professionals familiar with LTOT. This review should include pulse oximetry.
See the NICE guideline to find out why we made these recommendations and how they might
affect practice.
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myAIRVO2
NICE has published a medtech innovation briefing on myAIRVO2 for the treatment of chronic
obstructive pulmonary disease.
OxyMask
NICE has published a medtech innovation briefing on OxyMask for delivering oxygen therapy.
Nasal Alar SpO2 sensor
NICE has published a medtech innovation briefing on Nasal Alar SpO2 sensor for monitoring
oxygen saturation by pulse oximetry.
Quality standards
The following quality statement is relevant to this part of the interactive flowchart.
Chronic obstructive pulmonary disease in adults
3. Assessment for long-term oxygen therapy
5 Ambulatory oxygen therapy
Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild
or no hypoxaemia at rest.
See the NICE guideline to find out why we made this recommendation and how it might affect
practice.
Consider ambulatory oxygen therapy in people with COPD who have exercise desaturation and
are shown to have an improvement in exercise capacity with oxygen, and have the motivation to
use oxygen.
Prescribe ambulatory oxygen to people who are already on LTOT, who wish to continue oxygen
therapy outside the home, and who are prepared to use it.
Only prescribe ambulatory oxygen therapy after an appropriate assessment has been
performed by a specialist. The purpose of the assessment is to assess the extent of
desaturation, the improvement in exercise capacity with supplemental oxygen, and the oxygen
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flow rate needed to correct desaturation.
Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems
should be available for people with COPD.
When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen
use and oxygen flow rate needed.
OxyMask
NICE has published a medtech innovation briefing on OxyMask for delivering oxygen therapy.
6 Follow-up and monitoring
See Chronic obstructive pulmonary disease/Chronic obstructive pulmonary disease overview
/Follow-up and monitoring
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Glossary
Acute exacerbations of COPD
(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)
COPD exacerbation
(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)
Exacerbation of COPD
(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)
Exacerbations of COPD
(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)
Exacerbation
(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)
Exacerbations
(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)
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Acute exacerbation of COPD
(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)
Asthmatic features/features suggesting steroid responsiveness
(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%])
ASA
American Society of Anesthesiologists
ATS
American Thoracic Society
BODE
body mass index, airflow obstruction, dyspnoea and exercise capacity
BTS
British Thoracic Society
CAT
COPD assessment test
CEN
Comité Européen de Normalisation (European Committee for Standardisation)
COPD
chronic obstructive pulmonary disease
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cor pulmonale
(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)
ECG
electrocardiogram
ERS
European Respiratory Society
FEV1
forced expiratory volume in 1 second
FVC
forced vital capacity
GOLD
global initiative for chronic obstructive lung disease
ICS
inhaled corticosteroid
LABA
long-acting beta2 agonist
LAMA
long-acting muscarinic antagonist
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LTOT
long-term oxygen therapy
MRC
Medical Research Council
Mild or no hypoxaemia
(people who are not taking long-term oxygen therapy and who have a mean PaO2 greater than
7.3 kPa)
NIV
non-invasive ventilation
NRT
nicotine replacement therapy
PaO2
partial pressure of oxygen in arterial blood
PaCO2
partial pressure of carbon dioxide in arterial blood
PEF
peak expiratory flow
SABA
short-acting beta2 agonist
SAMA
short-acting muscarinic antagonist
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SaO2
oxygen saturation of arterial blood
Theophylline
(here, the term theophylline refers to slow-release formulations of the drug)
TLCO
carbon monoxide lung transfer factor
Sources
Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018) NICE
guideline NG115
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.
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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
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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.
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