to this and medicines optimisation incorporating
the patient’s perceptions and practicalities of
living with the disease and how this impacts
medicine-taking behaviour 16,17
• Inhalers – device best suited to patient,
appropriate for inspiratory flow, coordination,
dexterity etc – technique checked and corrected
by appropriately trained HCPs, ensuring maximal
lung deposition (further assisted by use of a
spacer device with metered dose inhalers (MDIs)).
Use of combination inhalers to minimise
polypharmacy 2,16,17
• Empowerment and education for patients and
HCPs (including co-created self-management
plans, strategies for managing exacerbations and
escalating therapy) safety-netting/signposting to
support groups, digital solutions and further
reliable information sources for example, from
the British Lung Foundation
• Air pollution (indoor and outdoor) – impact to
patient
• Environmental impact – waste/recycling, carbon
footprint and ozone damage by hydrofluoroalkane
propellants in MDIs
• Passive smoke – other members of the
household who smoke might impact on the
patient’s health (including eligibility for oxygen)
and could benefit from smoking cessation
interventions
• Multi-morbidity and frailty – effect of this on
functionality of the patient, including increased
likelihood of polypharmacy and potential
non-adherence to therapies 18
• Palliation – early discussions with patient and
referral for palliative input. 19
asthmatic features should have an ICS in
combination with a LABA)
• Smoking cessation can benefit most diseases
and should be offered as a ‘treatment’. 10 Studies
in the UK and overseas have demonstrated that
behavioural support plus access to
pharmacotherapy is effective in helping smokers
to quit. Regular meetings (group or one to one)
with a trained adviser using structured,
withdrawal-oriented behavioural therapy
combined with smoking cessation medications
such as nicotine replacement therapy (NRT),
bupropion or varenicline 11,12
• Vaccination – Annual flu and five-yearly
pneumococcal vaccinations to minimise incidence
of respiratory infections 2,13
• Mucolytic drug trial (anecdotally 4–6 weeks)
could be considered for chronic productive cough
but should be stopped if not beneficial and used
with caution in those with peptic ulceration
history 2,14
• Oral theophyllines may be beneficial in patients
who remain breathless despite trialling inhaled
therapy or for those who cannot use inhaled
therapy (noting potential for interactions and
requirement for plasma monitoring)
• Roflumilast (phosphodiesterase IV inhibitor) can
be used as adjunctive therapy in patients with
severe COPD associated with chronic bronchitis
and frequent exacerbations
• Oxygen – assessment for long term/ambulatory
oxygen therapy in non-smokers with more severe
chronic hypoxaemia (assessing risks to patient
and others of prescribing). Supplemental oxygen
should be used >15 hours a day; long-term oxygen
therapy is not effective for isolated nocturnal
hypoxaemia caused by COPD
• Prophylactic azithromycin may reduce
exacerbations in non-smokers who have had all
other interventions optimised yet continue to
have >1 of the following: frequent exacerbations
(typically >4 per year) with sputum production,
prolonged exacerbations with sputum production
or exacerbations resulting in hospitalisation. Note
this is unlicensed therapy requiring monitoring
before and during therapy
• ‘As required’, low dose lorazepam (0.5mg) and
morphine sulphate liquid (2.5mg) for anxiety and
breathlessness respectively, are useful in more
end stage disease where patients may suffer panic
attacks. 2,14,15
Quality standards and outcomes
NICE quality standards are a concise set of
prioritised statements designed to drive
measurable improvements in the three
dimensions of quality – patient safety, patient
experience and clinical effectiveness – for a
particular area of health or care. They are derived
from highquality guidance from, for example,
NICE or other sources accredited by NICE. The
COPD quality standard (last updated in 2016), in
conjunction with the guidance, should contribute
to the improvements outlined in the following
three outcomes frameworks published by the
Department of Health: 20
NHS Outcomes Framework 2015–16
Reducing premature mortality, enhancing quality
of life for people with long term conditions,
helping people to recover from episodes of ill
health or following injury and ensuring that
people have a positive experience of care.
Public Health Outcomes Framework 2013–16
Health improvement/healthcare public health
and preventing premature mortality.
Adult Social Care Outcomes Framework 2015–16
Delaying and reducing the need for care and support.
The quality standard is expected to contribute
to improvements in the following outcomes:
• COPD diagnosis
• morbidity
• mortality
• acute exacerbations
• hospital admissions
Other considerations
• Medication adherence – understanding barriers
17
HHE 2019 | hospitalhealthcare.com