Quality standard
Quality statement 7: Non-invasive ventilation
Quality statement 7: Non-invasive ventilation
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. [2011, updated 2016]
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
The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured, and can be adapted and used flexibly.
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.
Data source: COPD secondary care reports of the Royal College of Physicians National Respiratory Audit Programme include data on people receiving a continued diagnosis of acidotic hypercapnic ventilatory failure according to their blood gases after receiving 1 hour of optimal treatment, and on people receiving treatment with non-invasive ventilation.
Outcome
Mortality rates.
Data source: COPD secondary care reports of the Royal College of Physicians National Respiratory Audit Programme include data on people who died while in hospital from a COPD exacerbation.
What the quality statement means for different audiences
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 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.
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 cannot 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. NICE guideline NG115 (2018, updated 2019), recommendation 1.3.30 and 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, and which is beyond usual day‑to‑day variations and acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased mucus production and change in mucus colour. [Adapted from NICE's guideline on diagnosing and managing chronic obstructive pulmonary disease in over 16s, terms used in this guideline]
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. Coexistent hypoxaemia is usually mild and easily corrected. Conventionally, a pH of less than 7.35 and a PCO2 greater than 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 of less than 7.25, have been used as a threshold for considering provision of invasive mechanical ventilation. [Adapted from NICE's guideline on diagnosing and managing chronic obstructive pulmonary disease in over 16s and expert consensus]
Optimal medical therapy
Controlled oxygen therapy, nebulised bronchodilator therapy, systemic corticosteroids and antibiotics if indicated, in line with the NICE guideline. [Adapted from NICE's guideline on diagnosing and managing chronic obstructive pulmonary disease in over 16s]
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. [NICE's guideline on diagnosing and managing chronic obstructive pulmonary disease in over 16s and expert consensus]