MID AND SOUTH ESSEX MEDICINES OPTIMISATION COMMITTEE (MSEMOC) MID AND SOUTH ESSEX LOCALITY POLICY FOR THE ORDER OF HOME OXYGEN TO PATIENTS WHO ARE ...
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MID AND SOUTH ESSEX MEDICINES OPTIMISATION COMMITTEE
(MSEMOC)
MID AND SOUTH ESSEX LOCALITY
POLICY FOR THE ORDER OF HOME OXYGEN TO PATIENTS WHO
ARE KNOWN TO SMOKE
1
ORDERING OF HOME OXYGEN
TO PATIENTS WHO ARE KNOWN TO SMOKE
CONTENTS
Page
ABBREVIATIONS & DEFINITIONS 3
KEY CONTACT DETAILS 4
INTRODUCTION 5
PURPOSE 5
RESPONSIBILITIES OF HEALTHCARE PROFESSIONALS
GENERAL ROLES, RESPONSIBILITIES AND ACCOUNTABILITY 5
RISK ASSESSMENTS 5
CONSENT 6
TRAINING 7
REFERRAL PATHWAY & PROCESS 8
REPORTING OF INCIDENTS AND ESCALATION PROCESS 8
AUDIT 9
QUALITY AND EQUALITY IMPACT ASSESSMENT 10
Appendix 1: Inpatient Declaration 11
Appendix 2: Community Declaration 12
Appendix 3: Mental Capacity Assessment 13
Appendix 4: High Fire Risk Referral Pathway 14
Appendix 5: Additional Patient Information 15
Appendix 6: Additional Information for HCP’s 16
Appendix 7: Smoking Cessation referral service 17
Appendix 8: Non- acute breathlessness pathway 18
2
ORDERING OF HOME OXYGEN
TO PATIENTS WHO ARE KNOWN TO SMOKE
ABBREVIATIONS & DEFINITIONS
Abbreviation & Full Description
Definitions
BOC British Oxygen Company
BTS British Thoracic Society
EPUT Essex Partnership University NHS Foundation Trust
FRS Fire & Rescue Service
GP General Practitioner
IHORM Initial Home Oxygen Risk Mitigation Form
HCP Healthcare Professional
HOOF Home Oxygen Order Form
HOS Home Oxygen Service
RHOSAR Respiratory Home Oxygen Service – Assessment and Review
MDT Multi-disciplinary Team
SI Serious Incident
SIRI Serious Incident Requiring Investigation
E-cigarette An electronic cigarette or e-cigarette is a handheld electronic device
that tries to create the feeling of tobacco smoking. It works by heating
liquid to generate an aerosol, known as “vapour”, which the user
inhales.
Mid & South Comprises of
Essex Locality • NHS Mid Essex CCG.
• NHS Southend and Castlepoint & Rochford CCG.
• NHS Basildon and Thurrock CCG.
3KEY CONTACT DETAILS
Name Contact Details
East of England (EoE) Regional HOS Lead Sharon Cooper, Contracts Manager
NHS West Essex CCG
01992 566140, Ext. 1526 /
sharon.cooper18@nhs.net
Mid Essex CCG HOS Lead Paula Wilkinson FRPharmS
Chief Pharmacist Mid Essex CCG
01245 398729
paula.wilkinson@nhs.net
South East CCG HOS Lead Ms Zafiat Quadry
Head of Medicines Management CPR &
Southend.
01702 212400
zafiat.quadry@nhs.net
Southwest Essex CCG Denise Rabbette
Head of Medicines Optimisation
Thurrock CCG hosted service (on behalf of
Basildon and Brentwood CCG)
07811 010554
deniserabbette@nhs.net
Respiratory HOS Lead – Mid and South EPUT – HOSAR
Essex South East Essex Lead: Janis Dunne
Epunft.oxygen.spirometryteam@nhs.net
Tel: 01702372040
Oxygen Supplier British Oxygen Company (BOC)
Hours of operation: 9am - 6pm
Mon - Fri
Phone: 0800 136 603
Email: boc.hop@nhs.net
homecare.admin@boc.com
Essex Fire and Rescue Service www.essex-fire.gov.uk/HFS
0300 303 0088
4ORDERING OF HOME OXYGEN
TO PATIENTS WHO ARE KNOWN TO SMOKE
1 INTRODUCTION
1.1 This policy has been developed in order to promote patient safety and give due
consideration to the risks associated with smoking and the use of home oxygen
therapy. This includes the use of e-cigarettes. The risks associated with fire and
personal safety also affect family, health care professionals and the general public.
2 PURPOSE
2.1 This policy applies to all Healthcare Professionals and sets out the procedure for
ordering home oxygen for patients who are known to smoke and are registered
with a Mid & South Essex GP practice.
2.2 It aims to ensure that all patients with a home oxygen supply receive care that is
consistent and evidence based, thus reducing risk to patients, their families and
carers, HCPs as well as the general public.
2.3 It aims to make certain all HCPs who undertake assessments for those patients
who continue to smoke do so in a consistent manner, minimising risk to the
patient, carers, clinical staff and general public and operate in accordance with
the BTS guidelines.
2.4 This policy includes the risk assessment process and guidance on how these
patients who require oxygen, but continue to smoke, should be managed. Advice
may need to be sought from an MDT, GP(s), BOC, FRS and/or social services on
a case by case basis.
3 RESPONSIBILITIES FOR HEALTHCARE PROFESSIONALS
General Roles, Responsibilities and Accountability
3.1 HCPs who recommend oxygen for patients are responsible for undertaking the
initial risk assessment to ensure oxygen is a suitable therapy, even if they do not
place the orders themselves (see 3.8).
3.2 All practitioners working under this policy should be supported and reviewed through
the appraisal process.
Risk Assessments
3.3 Before prescribing oxygen for use at home, the HCP must complete an Initial
Home Oxygen Risk Mitigation Form (IHORM) which is available on the BOC
website:
http://www.bochomeoxygen.co.uk/en/images/IHORM%20form_tcm1109-
421574.pdf
53.4 The information supplied on the IHORM should raise awareness of the risks
associated with providing home oxygen along with highlighting the potential
danger to patients utilising the service, thus ensuring the clinician makes a
considered risk based decision before submitting an order for oxygen.
3.5 HCPs should take the following actions:
NEW HOME OXYGEN REQUESTS FOR PATIENTS WHO SMOKE
(INCLUDING E-CIGARETTES)
• The HCP must offer to refer to the local smoking cessation service
before proceeding with ordering oxygen.
• To be in receipt of home oxygen a patient must sign the Declaration Form
(Appendix 1 or 2 as appropriate to be signed in hospital at the point oxygen is
being prescribed) that indicates they will only be supplied home oxygen if they
adhere to the following
o In receipt of smoking interventions through the local smoking cessation
service or equivalent
o Optimisation of inhaled therapy (if applicable)
o Management of breathlessness, including referral for pulmonary
rehabilitation (where clinically appropriate).
3.6 If there is any breach of 3.5 above then oxygen will not be ordered and if already
installed it will be withdrawn.
3.7 The HCP should inform the Consultant and GP of smoking status, the risk
assessment outcome and any resulting oxygen order. This should also be
documented on electric records. For sheltered accommodation, please inform
warden or property manager of risk.
3.8 If the HCP is satisfied home oxygen should be ordered they must complete the
HOOF using the online portal: https://www.bochealthcare.co.uk/hop/
3.9 The HCP will remain responsible for the ongoing support of the patient’s annual
reviews of the prescription, including continued evidence of smoking cessation
and monthly reviews of the concordance data (if applicable).
EXISTING HOME OXYGEN PATIENTS WHO SMOKE (INCLUDING E-
CIGARETTES)
• Offer to refer to the local smoking cessation service or equivalent
• Refer to the local FRS (Appendix 3) for a home safety assessment
• Inform and liaise with the patient’s GP in order they can support smoking cessation
and minimisation of risk to the patient and general public.
• Inform oxygen provider of current smoking status and any concerns.
6• Carry out joint home visit with fire service and BOC to reinforce risk and notify GP of
outcome, if patient continues to smoke then MDT will decide on whether to remove
oxygen.
• Provide patient / carer with additional information (Appendix 4), providing a video link
highlighting the risks.
• In order to continue to be in receipt of home oxygen the patient must sign the
Declaration Form (Appendix 1 or 2 as appropriate), agree they will abide by the terms
set out in the Declaration and that they will be at risk of home oxygen being removed
if the terms of Declaration are broken.
• If the patient is not prepared to sign the Declaration Form or is not willing to complete
a course provided through the smoking cessation service, then the clinical decision
will be to remove the oxygen.
• Update Electronic Referral System on SystmOne with patient’s smoking status and
document this information on the patient’s home screen as an alert.
• Smokealyzer to be used to confirm patient’s smoking status.
CONSENT
3.11 HCPs should ensure the patient is able to understand the information given to
them and are able to give their valid consent. This may necessitate the use of a
professional interpreter and the translation of written information. A capacity
assessment should be considered for those patients who are deemed unable to
consent with reference to Trust/Organisation policies.
3.12 In line with the Mental Capacity Act 2005, HCPs must conduct a Mental
Capacity Assessment (MCA) and a decision must be made and recorded that a
person lacks capacity to make the decision in question, before a best interests
decision can be made. See appendix 3.
3.13 If the patient has authorised an attorney to make decisions about their health
under a Lasting Power of Attorney (LPA) or Court Deputy they have authority to
make decisions in the patient’s best interests where it has been deemed there is
lack of mental capacity. The original LPA certificate would need to be produced
and a copy taken.
3.14 HCPs wishing to make a best interest decision will take a collaborative approach
and a decision will only be made following discussion and agreement made at an
MDT meeting.
3.15 All outcomes of the assessment and decisions must be documented within the
clinical record.
Training
3.14 All Part B practitioners acting under this policy must have attended prescriber
training provided by BOC
74.0 REFERRAL PATHWAY AND PROCESS
4.1 All patients who are supplied home oxygen, regardless of their smoking status,
are required to sign the Declaration Form (Appendix 1 or 2 as appropriate) and
be given written and verbal information (Appendix 4) regarding the risks and
safety issues when using oxygen. The Declaration Form will be signed by both
the patient and the HCP. One copy will be given to the patient and another copy
will be kept on the patient’s medical notes (should also be uploaded on to
patient’s notes electronically). A copy of the signed Declaration Form should also
be sent to the patient’s GP for their records.
4.2 The HCP will only continue to order oxygen therapy to people known to smoke if
all conditions described in Declaration Form are met.
4.3 If the patient has placed themselves, their carer, HCPs or the general public at
high risk through smoking whilst in receipt of oxygen therapy, or shortly after
within an oxygen rich environment, then instigation of the Incident Management
Procedures (see Section 5) will take place, which may result in oxygen removal.
4.4 Very high-risk patients are defined as patients who “exhibit unsafe clinical or
behavioural traits involving oxygen and smoking’, such as:
• Attempting to hide their smoking materials or activities.
• Having a history of non-compliance with smoking rules.
• Being reported to an HCP for smoking whilst in receipt of oxygen.
• Experiencing a smoking related accident or incident whilst in receipt of
oxygen,
• Smoking in a patient sleeping room or other areas designated as non-
smoking areas.
4.5 All personal patient information must be kept secure in line with local Information
Governance policies.
4.6 All risks and events should be recorded by the HCP as per their organisations
own local incident reporting system.
5.0 REPORTING OF INCIDENTS AND ESCALATION PROCESS
5.1 All SIRIs must be reported to BOC. BOC are required to email the SIRI to the
relevant CCG HOS Lead, to their Quality Lead/Team and cc to WECCG and the
Regional Lead.
5.2 The incident management and escalation process includes the following steps;
however, the list is not exhaustive:
• Refer to EOE management of SIRIs
• Reporting of all very high risks or incidents to BOC.
• Completion of internal incident report e.g. DATIX.
• Urgent referral to smoking cessation.
• Urgent referral to the FRS (see Appendix 3) for a home safety assessment
• Inform and liaise with the patient’s GP and/or Consultant.
8• Organise an urgent MDT to include the patient, carer, GP, FRS, BOC,
RHOSAR (where appropriate) and associated agencies involved in the
patient’s care.
• Confirm in writing to the patient the position taken by the MDT, including
the rationale for the decision to either remove or conditions to be imposed
if continuing the oxygen provision and copy in all relevant stakeholders.
Raise safeguarding if relevant.
• Upload information to patient’s ERS on SystmOne.
• Record SIRI alerts on patients records
• Ensure alerts are also added to patient’s home screen.
If the decision is to remove oxygen, then there should be a clear target date for
removal and BOC should be informed.
5.3 Taking oxygen away from a patient is often difficult and, where possible, will
require the support or understanding of the patient and family.
BOC should be brought into this process for support if required.
5.4 Additional face to face or telephone follow-up may be required to agree a
comprehensive management plan. The patient will continue to receive oxygen
until arrangements are made to remove it. Removal should be completed within
48 hours of the MDT’s decision. The management plan should make clear the
option to review the position once there is evidence of sustained change of
behaviour. If appropriate, other services to support the person’s disease
management should be considered, such as pulmonary rehabilitation and
MYCOPD, where available.
5.5 It should be made clear in correspondence to the patient the implications of loss
of oxygen and options available in the event the patient’s condition deteriorates
after the oxygen has been removed.
5.6 In some instances, the patient may refuse to accept the conclusion of the MDT.
Additional MDTs may be required until resolution. Arrangements should be
sought from the patient in order to gain consensual access to the property to
remove the oxygen equipment.
5.7 Where there is extreme risk, the involvement of the police should be considered,
though this should be done on an exceptional basis only where patients refuse to
return all of the home oxygen equipment.
5.8 The Home Oxygen Portal will flag a patient who previously had oxygen from BOC
and which was subsequently removed due to a health and safety risk. This is a
precaution to alert HCPs of a particular patient’s history.
6.0 AUDIT
6.1 Compliance with this policy will be documented in the patient notes and through
the quality control procedures mentioned in this policy.
6.2 Mid and South Essex CCGs will monitor all clinical incidents through their risk
management software systems.
96.3 Audit of the service will inform of quality control associated with equipment,
service activity and outcomes.
7.0 QUALITY AND EQUALITY IMPACT ASSESSMENT
7.1 This policy has been subjected to a Quality and Equality Impact Assessment.
This concluded that this policy will not create any adverse effect or discrimination
on any individual or particular group and will not negatively impact upon the
quality of health and social care services commissioned by the Commissioners.
7.2 All patients deserve our care, to be valued as a person and to be treated
equally. The decision to remove or not install home oxygen does not rest on
discriminatory grounds but on patient and public safety.
8.0 OXYGEN REMOVAL PATHWAY
8.1 Taking oxygen away from a patient is often difficult and, where possible, will
require the support or understanding of the patient and family.
8.2 If the patient has had a near miss, warning and education but still found
smoking again, then MDT can make the decision to remove oxygen in a non-
compliant patient.
8.3 An agreement should be reached with patients of an agreed period over
which to improve adherence and if adherence is still suboptimal and risk level
is still high, the oxygen should be removed.
8.4 If the decision is to remove oxygen, then there should be a clear target date
for removal and BOC should be informed
8.5 Removal should be completed within 48 hours of the MDT’s decision.
Before removal of home oxygen please ensure answer to questions
below is ‘YES’:
• Has the patient been reassessed by a health professional experienced in
managing home oxygen or part of the home oxygen assessment team?
• Is there a clear indication for removal?
• Is the patient (and/or significant other) aware removal may occur?
• Have all interventions to improve adherence or reduce risk been considered
and implemented with an evaluation following implementation?
• Have appropriate alternative treatment strategies been considered and
implemented as part of the removal process?
• Have the wider health care team been part of the decision to remove home
oxygen but if not informed of the decision prior to removal?
10APPENDIX 1
HOME OXYGEN PRE-ASSESSMENT FORM
INPATIENT DECLARATION*
Patient agreement to non-smoking status to enable safe assessment and supply of oxygen at home
You are being assessed/re-assessed for eligibility for oxygen at home
In order to safely order oxygen for you it is essential that you are a non-smoker (including
the use of e-cigarettes) and have been a non-smoker for at least 3 months prior to
admission
We will ask you to declare non-smoking status prior to undertaking the assessment
NAME: ADDRESS:
DOB: NHS No:
1. I am the patient named above
YES / NO
2. I have discussed with a health care professional and understand the
reasons for not smoking whilst oxygen equipment is in the house YES / NO
3. I confirm I have never smoked cigarettes or e-cigarettes
YES / NO
If yes, go to question 7
4. I confirm I am a non-smoker and have been a non-smoker for at least
3/6 months prior to this assessment today YES / NO
This period does not include the time spent in hospital
5. I confirm I have been offered support to stop smoking YES / NO
6. I confirm I have accepted support to stop smoking YES / NO
7. I confirm I will not smoke or allow any other person to smoke in my
home whilst I am receiving oxygen therapy YES / NO
8. I confirm I understand the safety risks if I do smoke or anyone else
smokes in my home whilst I am receiving oxygen therapy, and the oxygen YES / NO
therapy may be discontinued and the equipment removed
9. I confirm I understand that oxygen therapy may not be effective for my
condition if I continue to smoke YES / NO
Person making the declaration:
………………………………..... (print) ………………………… (sign) …………….. (date)
Health Care Professional:
…………………………………. (print) ……………..………….. (sign) …………….. (date)
* Please use the separate ‘community’ form where the individual is not currently an in-patient.
A copy of the signed declaration form should be given to the patient and the original should be
held on the patient’s notes.
11APPENDIX 2
HOME OXYGEN PRE-ASSESSMENT FORM
COMMUNITY DECLARATION*
Patient agreement to non-smoking status to enable safe assessment and supply of oxygen at home
You are being assessed/re-assessed for eligibility for oxygen at home
In order to safely order oxygen for you it is essential that you are a non-smoker (including
the use of e-cigarettes) and have been a non-smoker for at least 3 months. In addition,
please be prepared to undertake smokealyzer to prove non-smoking status.
We will ask you to declare non-smoking status prior to the team undertaking the
assessment
NAME: ADDRESS:
DOB: NHS No:
1. I am the patient named above
YES / NO
2. I have discussed with a health care professional and understand the
reasons for not smoking whilst oxygen equipment is in the house YES / NO
3. I confirm I have never smoked cigarettes or e-cigarettes YES / NO
If yes, go to question 7
4. I confirm I am a non-smoker and have been a non-smoker for at least YES / NO
3/6 months prior to this assessment today
This period does not include the time spent in hospital
5. I confirm I have been offered support to stop smoking YES / NO
6. I confirm I have accepted support to stop smoking YES / NO
7. I confirm I will not smoke or allow any other person to smoke in my
home whilst I am receiving oxygen therapy YES / NO
8. I confirm I understand the safety risks if I do smoke or anyone else
smokes in my home whilst I am receiving oxygen therapy, and the oxygen YES / NO
therapy may be discontinued and the equipment removed
9. I confirm I understand that oxygen therapy may not be effective for my
condition if I continue to smoke YES / NO
Person making the declaration:
……………………………........ (print) ………………………… (sign) …………….. (date)
Health Care Professional:
…………………………………. (print) ……………..………….. (sign) …………….. (date)
* Please use the separate ‘community’ form where the individual is not currently an in-patient
A copy of the signed declaration form should be given to the patient and the original should be
held on the patient’s note.
12APPENDIX 3
MENTAL CAPACITY ISSUES
All Patients
Does the patient have mental capacity to decide about the actions in the event of decision Y/N
making relating to the use of oxygen whilst smoking?
If no, please give reason and details:
If yes, have they been consulted about their healthcare choices and this Suggested Action Y/N
Plan been discussed and agreed with the patient?
If no, please give further details:
Patients without capacity only:
Have they an appointed a Lasting Power of Attorney for health matters or a Court Y/N
Deputy?
If yes, please give details
If no, does the person have a next of kin or someone close to them who is willing and Y/N
able to informally contribute to discussions?
If yes, please give details below under ‘Views of significant others’
If no, has the patient been appointed an IMCA who can represent the patient in Y/N
discussion of serious medical treatment?
If yes, please provide their details and whether they have been consulted about Mid and South Essex Oxygen &
Smoking policy
Views of significant others
The patients next of kin or advocate have been consulted about this advice and plan Y/N
Summary of discussion/views of significant others including if there are differing
opinions: (which may be relevant to future best interest decisions)
13Appendix 4
ESSEX HIGH FIRE RISK REFERRAL PATHWAY
Fire and Rescue Service (FRS)
A monthly list of all patients on home oxygen therapy will be sent to the local FRS by
BOC.BOC sends the fire reports on a fortnightly basis to FRS; this report contains the new/removed
patients so records can be updated.
BOC Healthcare has worked very closely with the FRS to develop a working partnership to
improve the safety of patients. At risk patients are eligible for a free visit from the community
fire safety officer, which includes a discussion on fire safety and safe exit routes in the event
of a fire.
Please contact your local FRS for further information. If a patient is found not to have a
working smoke alarm/detector in their property, they are advised to make contact with FRS
to have one installed as soon as possible. Patients who ignore fire safety advice e.g.
smoking on or around oxygen therapy will also be referred to their local FRS.
Essex Fire & Rescue Service 0300 303 0088
www.essex-fire.gov/HFS
BOC 9am - 6pm Mon - Fri
Phone: 0800 136 603
14APPENDIX 5
INFORMATION FOR PATIENTS
Links/Leaflets
• Dangers of smoking with oxygen
504335-Healthcare
Dangers of Smoking W
• Fire hazard Paraffin Based Skin Products
National Patient
Safety Agency_tcm11
• Oxygen Therapy Awareness video in partnership with Essex Fire and Rescue Service
https://youtu.be/OSouYewJ2jw
15APPENDIX 6
INFORMATION FOR Healthcare Professionals.
BOC Clinical Advice - http://www.bochomeoxygen.co.uk/en/clinicians/index.html
• Clinician Handbook
406765_Healthcare_
A_Guide_for_Professi
• Adult Home Oxygen Handbook
406900_Healthcare_
Patient_Home_Oxyge
• IHORM FORM & GUIDANCE
IHORM IHORM Guidance
form_tcm1109-42157 Notes_tcm1109-4234
• HOOF HELP GUIDE (PART A PRESCRIBERS)
HOOF Help Guide
(Part A)_tcm1109-457
• HOOF HELP GUIDE (PART B PRESCRIBERS – Respiratory Specialist Services)
HOOF Help Guide
(Part B)_tcm1109-457
• BTS Guidelines for Home Oxygen Use In Adults
https://thorax.bmj.com/content/70/Suppl_1/i1
• NICE Guidance – Chronic obstructive pulmonary disease in over 16s: diagnosis and
management
https://www.nice.org.uk/guidance/ng115
16Appendix 7
SMOKING CESSATION REFERRAL SERVICE
• CASTLEPOINT AND ROCHFORD Smoking Cessation Referral Service: Essex lifestyle
service – call 0300 303 9988 and register on ‘priority me’ and they refer on.
Email: provide.essexlifestyles@nhs.net.
• SOUTHEND Stop Smoking Service
https://www.southend.gov.uk/StopSmoking
Telephone: 01702 212000
Email: southessex.stopsmoking@nhs.net.
• Thurrock Healthy Lifestyle Service
A Thurrock health service which supports, advises and informs on ways to stop smoking,
eat healthily and get active.
Telephone: 0800 292 2299 (Monday to Friday 9am to 6pm)
Email: thls@thurrock.gov.uk
• Basildon Provide Service
Call us on: 0300 303 9988 (Monday to Friday 8am to 8pm)
Email us on: provide.essexlifestyles@nhs.net.
• Mid Essex Stop Smoking Service
Call us on: 0300 303 9988 (Monday to Friday 8am to 8pm)
Email us on: provide.essexlifestyles@nhs.net.
17Appendix 8
Non-acute Breathlessness
This is a basic guide to the assessment of adults presenting with
breathlessness for ≥ 4 weeks
ASK RED FLAGS:
When did the breathlessness start? Respiratory rate and Body mass index Unexplained weight loss, night sweats
What causes it? pattern. Position of patient Haemoptysis
SPO2 Blood pressure
What relieves it? • Any episodes at night? Rapid or slow respiratory rate
Respiratory & Cardiac Pulse (rate & rythmn)
Can the patient walk up a flight of stairs? SpO2 10 then refer to sleep assessment service
COPD
• Progressive breathlessness associated with exertion, • Arrange diagnostic spirometry
smoking history (≥10 pack years) • Chest sounds may be abnormal • Refer to NICE COPD guidelines
• Spirometry obstructive, CXR may be abnormal,
oxygen saturations may be low
Arrhythmias
• Exertional breathlessness • Most common AF, Bradycardia
• May present with palpitations, pre-syncope / syncope, fatigue • Refer to NICE arrhythmias guidelines
• ECG abnormal, check thyroid function • Refer for cardiology opinion where appropriate
• Progressive exertional breathlessness, fatigue Anaemia
• Pale, may have lemon tinge or jaundice. Investigate potential causes
• Hb low, MCV low, arrange ferritin, B12 & folate
• Breathlessness variable in intensity and timing, associated with • Asthma
history of atopy • Arrange PEFR diary • Spirometry with reversibility
• May have wheeze in lung fields, examination may be normal • Refer to BTS SIGN asthma guidelines.
• CXR / spirometry may be normal, may have raised eosinophils
• Anxiety or depression, tingling around face & hands, voice changes, Dysfunctional Breathing
a sensation of difficulty with inspiration • Examples include vocal cord dysfunction and hyperventilation
• Depression & anxiety screening questionnaires may be positive • Assess Nijmegen score if >23 refer to dysfunctional breathing services
• Consider CBT / psychological therapies: www.physiohypervent.org
• Unexplained breathlessness on minimal exertion, 'silly cough', Lung Fibrosis
exposure to asbestos / birds / coal / silica • Arrange CXR
• Finger clubbing, “velcro” creps in lung fields • Refer to pulmonary specialist
• Spirometry may be normal OR restrictive • Consider spirometry
• Progressive exertional breathlessness Cardiac Valve Disease
• May present with exertional chest pains and or syncope • Arrange / refer for echocardiogram
• Heart murmur likely • Refer for cardiology opinion where appropriate
• Gradual increase in breathlessness, persistent cough ( > 3 weeks), Lung Cancer
haemoptysis, hoarseness, chest or shoulder pain, weight loss, Urgent referral to lung cancer service
smoking history • Finger clubbing, lymphadenopathy, See NICE guidance on urgent lung cancer referrals
abnormal lung field signs • Arrange urgent CXR
History of PE / DVT / pleuritic chest pains / recent surgery / immobility / Chronic Pulmonary Emboli
pregnancy / malignancy / obesity / IV drug user / recent long haul travel Refer to acute services
SpO2: low or normal, pulse rate If D-dimer negative, young patient or recent viral injury:
Chest signs and ECG may be abnormal consider pericarditis (saddleback changes on ECG)
THESE ARE COMMON CAUSES OF BREATHLESSNESS. OTHERS EXIST AND CONDITIONS MAY COINCIDE. A 18
REFERRAL IS NECESSARY IN THE ABSENCE OF A DEFINITIVE DIAGNOSIS.
Produced by EoE Respiratory SCN (Dec 2014). For more information please visit www.eoescn.nhs.ukReferences • BTS Guidelines for home oxygen use in adults https://www.brit-thoracic.org.uk/document-
library/guidelines/home-oxygen-for-adults/bts-guidelines-for-home-oxygen-use-in-adults/
• East of England Strategy Clinical Network https://www.respiratoryfutures.org.uk/media/1518/eoe-rscn-
breathlessness-algorithm-final.pdf
• BOC Home oxygen form & Guidance http://www.bocclinicalservices.co.uk/en/healthcare-
professionals/hoof/index.html
• BOC Clinical Advice http://www.bochomeoxygen.co.uk/en/clinicians/index.html
• BOC Home Oxygen Handbook
https://www.bochealthcare.co.uk/en/images/406900_Healthcare_Patient_Home_Oxygen_Handbook_NHS_
A4_RZ_tcm409-66361.pdf
• BOC Dangers of smoking whilst using oxygen therapy http://www.bochomeoxygen.co.uk/en/images/504335-
Healthcare%20Dangers%20of%20Smoking%20With%20Oxygen%20leaflet%20Rev2_04_tcm1109-
254550.pdf
• NHS National Patient Safety Agency Fire Hazard Paraffin Based Skin Products. https://www.sps.nhs.uk/wp-
content/uploads/2018/02/2007-NRLS-1028J-paraffin-hazarleaflet-2007-11-V-EN.pdf
Acknowledgements Mid and South Essex CCGs Medicines Management Teams, Essex Partnership University Foundation Trust
(EPUT)
Version 1
Author HCPMSEMOC working group
Approved by MSEMOC; MSE Joint Committee
Date Approved May 2021; May 2021
Review Date May 2026 or sooner if subject to any new updates nationally
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