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Scandinavian Caring Sciences - 2004 - Wikby - The willingness to eat

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Chronic obstructive pulmonary disease (COPD)

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WHO fact sheet on chronic obstructive pulmonary disease (COPD) provides key facts and information on symptoms, diagnosis and treatment, risk factors and WHO response.

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Authors

Dan Higgins, RGN, ENB100, ENB998; John Guest, RN, ENB100; both are senior charge nurses, critical care, University Hospital Birmingham NHS Foundation Trust.

Abstract

Higgins, D., Guest, J. (2008) Acute respiratory failure 2: nursing management. Nursing Times; 104: 37, 22–23.

This is the second in a two-part unit on acute respiratory failure. Part 1 defined this condition, explored the causes of different types of failure and outlined basic respiratory assessment. This part outlines medical and nursing management of patients in acute respiratory failure.

Click here for PDFs of the articles and the Portfolio Pages corresponding to this unit

Learning objectives

1. Know about potential medical management strategies for patients with acute respiratory failure.

2. Understand the impact of acute breathlessness on patients’ activities of daily living.

Medical management

The medical management of patients with acute respiratory failure will vary depending on the cause and type of failure. Treatment should be targeted at the cause. Therapeutic goals should focus on preventing cellular damage from hypoxia, preventing acidosis from hypercapnoea and relieving patients’ symptoms and distress.

Airway obstruction is a clinical emergency. If this is the cause of respiratory failure it should be treated and a safe airway maintained as a priority. This may require simple clearance such as the removal of a foreign body, or secretions using suction. Patient positioning and manipulation of the airway will be required to open it if obstructed. Artificial airway adjuncts such as oropharyngeal airways may be required. Airway obstruction may occur for many reasons and the cause should be identified as soon as possible. Acute soft tissue swelling of the upper airway, as seen in anaphylactic shock, will require treatment in line with European Resuscitation Council guidelines (Resuscitation Council UK, 2008).

Oxygen therapy

Regardless of the aetiology of respiratory failure, virtually all patients with acute hypoxia will require oxygen supplementation. Oxygen therapy aims to supplement the inspired oxygen concentration to prevent tissue hypoxia and resultant cellular dysfunction. However, cellular oxygen delivery not only depends on inspired oxygen but also relies on haemoglobin concentration, its ability to saturate with oxygen, and cardiac output as a mechanism to deliver oxygen to the cells (Higgins, 2005).

Various devices are available to deliver oxygen including fixed and variable rate performance devices. The method of delivery depends on the concentration of oxygen required, patients’ compliance with therapy and the underlying pathophysiology (Jevon and Ewens, 2001).

In certain patients, such as those with chronic hypercapnoea, titration of oxygen therapy will require specialist advice and serial arterial blood gas analysis as high concentrations may be contraindicated. Oxygen therapy may require humidification, particularly at high flow rates. Humidification moistens the oxygen during administration, preventing dehydration of the mucous membranes and pulmonary secretions (Bennett, 2003).

Drug therapy

Bronchodilatory drugs cause relaxation of the smooth muscles in the airways, improving airway calibre. They may be administered using a variety of routes, in particular inhaled in the form of aerosol sprays or nebulisers.

Inhaled bronchodilators are an essential component in the treatment of asthma and obstructive airways disease. Peak expiratory flow rate measurements taken pre and post dose are usually recorded to assess effectiveness. Other medications – particularly anti-inflammatory drugs such as steroids – may be required.

Antimicrobial, antiviral or antifungal therapy is usually initiated if the cause of respiratory failure is considered to be of infective origin. Again, these drugs may be administered using a variety of routes and time periods.

Ventilatory support

Ventilatory support may be required in type 1 or type 2 respiratory failure. This may take the form of continuous positive airway pressure, non-invasive ventilation or invasive ventilation. Non-invasive ventilation has been shown to be a particularly effective treatment for COPD-related respiratory failure (British Thoracic Society Standards of Care Committee, 2002).

Other issues

All patients with acute respiratory failure should be assessed regularly by a physiotherapist to provide treatment and advice on sputum clearance and optimising gaseous exchange. Other medical management of acute respiratory failure includes serial blood gas analysis, electrocardiography and chest X-ray, in conjunction with management of potentially related disease processes or conditions. Further pulmonary function testing and investigative procedures may be required.

Nursing management

Patients with acute respiratory failure should be closely observed for potential deterioration. Respiratory assessment should occur on a frequent/continual basis. Monitoring may involve intermittent/continual pulse oximetry and regular peak expiratory flow rate measurement but should always include basic respiratory rate monitoring and general assessment. Physiological track and trigger warning systems are widely used to identify patients on general wards at risk of clinical deterioration (NICE, 2007). These systems provide a framework to access higher levels of care. Patients at risk of developing acute respiratory failure are an ideal group for these systems and their use should be encouraged. Any changes in physiological signs should be reported promptly to the senior practitioner.

Anxiety

Patients will most likely be frightened and anxious as a result of dyspnoea. While undertaking assessments and during subsequent care it is very important to try to alleviate these anxieties and provide reassurance. Simple techniques, such as patient positioning, may reduce symptoms by maximising lung expansion. Patients may advise which position they feel offers some relief. Communication skills, such as asking closed questions during assessment, may be used if patients are breathless to a point where they cannot answer in sentences.

Pulmonary secretions

Many processes leading to acute respiratory failure are associated with an increase in pulmonary secretions. Tissues or receptacles for sputum should be provided to assist patients to void secretions independently. If their ability to void is limited, assistance may be required in the form of oropharyngeal/nasopharyngeal suction. These procedures should not be undertaken without appropriate training. Sputum and other samples may be required for microbiological screening – this should be performed according to local guidelines.

Pain management

Pain, particularly associated with abdominal or thoracic surgery or injury, can limit chest expansion. If patients are experiencing pain, relief should be provided and future control optimised. Expert advice may be necessary because of the respiratory depressant effects of some analgesics. Liaison with multidisciplinary specialists such as acute or chronic pain specialists may be required.

Oxygen therapy

The majority of patients in acute respiratory failure will need oxygen supplementation. Before starting oxygen therapy, it is important to explain the reasons for this to them, their relatives and carers, and check their understanding (Jevon and Ewens, 2001). Unless in a medical emergency situation, the oxygen flow rate or percentage and duration of therapy should be prescribed. Nurses are best placed to select the most appropriate delivery system for a particular patient.

The system chosen should aim to deliver therapy with maximum effectiveness and optimise patient independence. The detrimental effects of oxygen therapy, such as the dehydration of mucosa, should be observed for and appropriate therapies such as gas humidification introduced where necessary. Tissue damage from a delivery device may occur – in particular, oxygen masks cause soreness behind the ears after longer-term use and nasal cannulas cause irritation to the nostrils. Small adaptations to the device, such as adding gauze padding, may prevent or alleviate this.

Other medication

If aerosol-inhaled medications are prescribed, effective delivery will only occur through patient compliance. Therapeutic effectiveness can be improved by providing education on inhaler technique. It is imperative that appropriate devices are chosen and patients’ technique is adequate (Bennett, 2003). When administering nebulisers, patients should be sat upright (as tolerated), be encouraged to take normal breaths and avoid talking in order to maximise drug delivery (Bennett, 2003). Nebulised medication may be administered using air flow or oxygen and nurses should ensure the type of gas used to deliver the drug is prescribed. Certain concentrations of oxygen may be contraindicated in certain patients. Practitioners should also bear in mind that patients may be dependent on a certain oxygen flow before nebulisation and interrupting this may be contraindicated.

Attempts should be made to minimise oxygen consumption (Smyth, 2005). This can be achieved by minimising patient exertion. They should be assisted with activities of daily living such as meeting hygiene needs, and all essential items, such as sputum pots, drinks and nurse call bells, should be within easy reach. Patients will also require time to ‘catch their breath’ following exertion, so activities should be planned with this in mind.

Conclusion

Acute respiratory failure is a process that, if not recognised and treated early, can be fatal. Many patients are at risk for a variety of reasons so the key element is early recognition, assessment and management.

Treating acute respiratory failure and any respiratory disease needs a multidisciplinary, collaborative approach. Nurses are in an ideal position to assess patients’ risk of developing respiratory failure, to monitor them, and evaluate their care and coordinate a multidisciplinary approach.

Bennett, C. (2003) Nursing the breathless patient. Nursing Standard; 17: 17, 45–51.

British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax; 57: 13, 192–211.

Higgins, D. (2005) Oxygen therapy. Nursing Times; 101: 4, 30–31.

NICE (2007) Acutely Ill Patients in Hospital. Recognition of and Response to Acute Illness in Adults in Hospital. www.nice.org.uk

Resuscitation Council (UK) (2008) Emergency Treatment of Anaphylactic Reactions. Guidelines for Healthcare Providers. www.resus.org.uk

The full reference list for this unit can be found in the corresponding Portfolio pages

Portfolio pages online Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.

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This is the first in a two-part unit on acute respiratory failure. Part 1 explores respiratory failure and its causes and identifies ways of recognising patients in acute respiratory failure.

Abstract

Higgins, D., Guest, J. (2008) Acute respiratory failure 1: assessing patients. Nursing Times; 104: 36, 24–25.

Authors
Dan Higgins, RGN, ENB100, ENB998; John Guest, RN, ENB100; both are senior charge nurses, critical care, University Hospital Birmingham NHS Foundation Trust.

Click here for PDFs of the articles and the Portfolio Pages corresponding to this unit

Learning objectives

1. Be able to describe a systematic and comprehensive approach to assessing patients with acute respiratory failure.

2. Understand the clinical significance of basic respiratory assessment criteria.

Respiratory failure is an inability to maintain adequate gaseous exchange. Normal respiration occurs through negative pressure ventilation – air is drawn into the lungs as the diaphragm contracts and the intercostal muscles move the ribcage out. The impetus for this comes from the lowering of blood pH, caused mainly by raised carbon dioxide levels in the blood as a result of normal cellular respiration. The functional lung units (alveoli) are filled with air, which has a higher concentration of oxygen than the blood in the capillary network surrounding the alveoli. Oxygen moves into the blood by diffusion where it binds with haemoglobin to form oxyhaemoglobin, which is transported around the body. At the same time carbon dioxide moves from the blood to the alveoli and is then excreted via exhalation.

Broadly speaking, respiratory failure falls into two groups: type 1 and type 2.

Type 1 respiratory failure

Type 1 refers to hypoxaemia, in which there is a decrease in the oxygen supply to a tissue. Hypoxaemia is mainly caused by a disturbance between the ventilation (gas) and perfusion (blood) relationship within the lungs. Levels of carbon dioxide in the blood can remain normal or reduce as the amount of gas breathed in and out each minute increases to compensate for lack of oxygen.

Common causes of type 1 respiratory failure include:

Atelectasis: a collapse of lung units;

Pneumonia: an inflammation of the lung tissue, usually of infective origin;

Pulmonary oedema: an accumulation of fluid in the lungs.

Cell metabolism in the presence of reduced oxygen leads to accumulation of acid. This has negative effects on organ performance and metabolism and, ultimately, leads to cellular death.

Type 2 respiratory failure

Type 2 refers to hypercapnoea, the presence of an abnormally high level of carbon dioxide in the circulating blood, which can occur with or without hypoxia. This type of respiratory failure is primarily caused by a reduction in the amount of gas inhaled and exhaled over time (minute ventilation), usually expressed as hypoventilation.

The inability to excrete carbon dioxide results in a systemic acidosis, which has negative effects on organ performance and metabolism, ultimately leading to cellular death. In chronic situations the body responds to the acidosis by producing more buffers, thus ‘compensating’ for the failure. This process is typically seen in patients with COPD and can be exacerbated by acute illness, such as chest infection.

Common causes of type 2 respiratory failure include:

Depression of the respiratory centre such as opiate overdose;

Acute chest disease: infection, asthma, pneumonia;

Spinal injury;

Acute neuromuscular disease: myasthenic crisis, Guillain-Barre syndrome;

Pneumothorax or haemothorax;

Airway obstruction: foreign bodies or swelling/oedema.

Patient assessment

Acute respiratory failure is a life-threatening condition. It is important to undertake an accurate assessment so the most appropriate nursing care and treatment can be administered and then evaluated effectively (Jevon and Ewens, 2001).

General presentation
Patients with respiratory failure may appear anxious or exhausted or they may be unresponsive. Hypoxia and hypercapnoea can alter mental state, and confusion or delirium may be present. Skin colour may be pale and central cyanosis may be evident; this is usually demonstrated as a blue tinge to the skin and mucous membranes, particularly the lips. Patients with hypercapnoea may appear flushed as a result of vasodilation associated with high carbon dioxide levels.

Patients may adopt a certain posture, intended to maximise lung expansion, such as sitting forward with shoulders hunched. They may experience further respiratory distress when lying down (orthopnoea). Pursed-lipped breathing may also be present as a compensatory mechanism to improve gas exchange.

Ability to talk and communicate can indicate the degree of the respiratory failure. Patients who are severely breathless will seldom talk in sentences and tend to give short answers to questions or use non- verbal communication.

The airway
Airway patency, artificial or otherwise, should be assessed in the first instance. Airway sounds should be listened for – snoring or stertorous breathing may indicate partial airway obstruction. Stridor – a harsh, vibrating sound, may be present during inspiration or expiration and may indicate partial obstruction. Secretions in the upper airway may also be heard as low gurgling sounds. Airway obstruction should be treated immediately.

Respiratory rate and characteristics
Changes in respiratory rate can be the most important early clinical manifestation of critical illness (Goldhill et al, 1999). Respiratory rate should be measured and recorded in all patients, particularly those at risk, as recommended in local policies and guidelines to provide trends for further analysis. Electronic devices are available to perform this task but may be unreliable so ‘manual’ measurement – counting the number of breaths per minute – is recommended.

The normal resting respiratory rate for adults is 10–15 breaths per minute but some people with long-term conditions may have higher ‘normal’ rates. A change or increase in respiratory rate should alert nurses that a patient may be deteriorating and further monitoring should be put in place with prompt review by senior staff. Normal breathing is regular and rhythmic and any abnormalities in breathing pattern should be noted and reported as they may indicate neurological dysfunction or acid base disturbance.

Assessment of respiratory sounds may include inspiratory or expiratory ‘wheeze’, which may indicate bronchospasm. Upper airway secretions may also be heard as gurgling sounds.

Chest movement should be assessed for its symmetry and pattern. The chest wall should be observed for overall integrity – recession of any part may indicate rib fracture or flail segments. Decreased movement in one side may indicate a pneumothorax or collapsed lung/area of lung. Accessory muscles, such as the sternocleidomastoid and the scalene muscles, may be used in respiratory failure as an attempt to improve gas exchange. Abdominal muscles may also be used in order to improve diaphragmatic contraction. Patients with airway obstruction may demonstrate a paradoxical movement of the abdomen and chest wall.

Respiratory volumes, including vital capacity and tidal volume, may be measured using a spirometer. These volumes may be particularly useful when viewed as a trend or in the management of longer-term respiratory problems. Subjective assessment of breath size may be particularly useful in the acute situation.

Breathing should be noted as shallow, deep or normal and, again, this should be compared against patients’ normal rate. Peak expiratory flow rate is a convenient, inexpensive measurement of airway calibre and most useful when expressed as a percentage of patients’ previous best value (British Thoracic Society Standards of Care Committee, 2002) or charted as a trend. Peak expiratory flow rates of 50–70% of patients’ personal best indicate severe airway obstruction (Smyth, 2005).

Acute respiratory failure is often linked with increased pulmonary secretions. The volume and type of these should both be noted and specimens sent for microbiological analysis as necessary. Green or yellowish purulent secretions may indicate an infective process, whereas white or pink frothy secretions may indicate pulmonary oedema and a cardiogenic cause of failure. The type, frequency and causes of stimulation of any cough should also be noted.

Pulse oximetry

Pulse oximetry has a useful role in assessing patients with respiratory failure. It measures the percentage of haemoglobin that is saturated with oxygen. However, it does not provide information on haemoglobin concentration, oxygen delivery to the tissues or ventilatory function, so patients may have normal oxygen saturations yet still be hypoxic (Higgins, 2005). The reliability of pulse oximeters is also questionable in patients who are cold, vasoconstricted or shivering. Any information that is gained using pulse oximetry must be viewed in conjunction with information from physical assessments (Casey, 2001).

Arterial blood gas analysis

Arterial blood gas and acid base balance analysis can contribute significantly to managing patients who are in respiratory failure and the effectiveness of any treatment. It allows accurate measurement of blood acidity/alkalinity as well as measurement of levels of arterial oxygen and carbon dioxide. Interpretation of results is often complex.

Key references

British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax; 57: 13, 192–211.

Casey, G. (2001) Oxygen transport and the use of pulse oximetry. Nursing Standard; 15: 47, 46–53.

Goldhill, D.R. et al (1999) Physiological values and procedures in the 24 hours before ICU admission from the ward. Anaesthesia; 54: 529–534.

Higgins, D. (2005) Pulse oximetry. Nursing Times; 101: 6, 34–35.

Smyth, M. (2005) Acute respiratory failure: part 2. Failure of ventilation: Exploring the other cause of acute respiratory failure. American Journal of Nursing; 105: 6, 72AA–72DD.

Portfolio pages online

Portfolio Pages can be filed in your professional portfolio as evidence of your learning and professional development. They contain learning activities that correspond to the learning objectives in this unit, presented in a convenient format for you to print out or work through on screen.

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What is happening to life expectancy in England?

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Veena Raleigh examines trends in life expectancy at birth up to 2020 and the impact of Covid-19 in 2020, gender differences, inequalities, causes of the changing trends since 2011, and how the UK’s life expectancy compares with other countries.

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A stroke due to bleeding in or around the brain is known as a haemorrhagic stroke. This guide explains the different types of stroke caused by bleeding, and how they are diagnosed and treated.

The information on this page can be accessed in the following formats:

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A stroke due to bleeding in or around the brain is known as a haemorrhagic stroke. This guide explains the different types of stroke caused by bleeding, and how they are diagnosed and treated. The information on this page can be accessed in the following formats:

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Learn all about human body anatomy with Innerbody’s award-winning Anatomy Explorer. View over 1,000 3D diagrams and illustrations.

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There are 12 major anatomy systems: Skeletal, Muscular, Cardiovascular, Digestive, Endocrine, Nervous, Respiratory, Immune/Lymphatic, Urinary, Female Reproductive, Male Reproductive, Integumentary. Select a system below to get started.

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Skip to Main Content

It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results.

Learn Site

The Visible Body Learn Site is a free introduction to each human body system. The Learn Site presents anatomy & physiology in a way that's easy to digest, complete with illustrations and 3D animations that explain basic human biology concepts.

Awesome Anatomy

Explore and learn about anatomy and physiology in 3D through virtual dissections, body system walkthroughs, and guest lectures!

Click on triple bar menu at the top right corner of the video to see the full playlist.

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Learning Resources: Visible Body: Human Anatomy Atlas 2020: Free Anatomy Study Aids

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Skip to Main Content It looks like you're using Internet Explorer 11 or older. This website works best with modern browsers such as the latest versions of Chrome, Firefox, Safari, and Edge. If you continue with this browser, you may see unexpected results. The Visible Body Learn Site is a free introduction to each human body system.

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Skull - anterior view

Anatomy basics

Before you start learning about the anatomical structures themselves, you'll need to make sure that you understand basic anatomy lingo, like terminology and directions.

With several unknown anatomy terms to master in a very short time, learning anatomical terminology can feel a bit like learning a new language. But, with a bit of time and practice, it will quickly feel like one you've been speaking all of your life! To gain a solid foundation, check out the following materials. Here, you'll find everything you need to know about anatomical terminology and directions.

As well as terminology and directional planes, you'll also need to know the specific anatomical names of different body movements. Check out the comprehensive study unit explaining them below. Afterwards, you can test how well you've understood them with one of the integrated quizzes!

Anatomy regions

Upper extremity

If you think of your body as a house, the bones and muscles are the walls and foundation. That is why the upper extremity is usually one of the first topics on your anatomy syllabus. What's more, injuries of the shoulder and arm are some of the most commonly seen in everyday patient care - so a solid knowledge of their anatomy will serve you well!

Do you know the name of the vein punctured by the needle when you have your blood drawn? How about the name of the nerve that can lead to tingles if you lean on your elbows for a long time? The answers and more information you can find in the following learning materials.

Lower extremity

Now that you know all about the upper extremity, it makes sense to move a bit further south to learn about the lower extremity. Ever had a broken leg? Fractures and tendon injuries of the leg, knee and foot are commonly seen so there's no getting out of learning anatomy from the hip, all the way to the toes. ;-)

The lower limb has four main parts: the hip, thigh, leg, and foot. Flexibility is provided by the hip, knee, and ankle joints which allow you to kick, jump, squat, and shake it on the dance floor. Dive into this topic with the following learning materials.

Trunk

Upper and lower limbs: check!

Let's move to the trunk, commonly known as the torso. The trunk is composed of several regions known as the thorax, abdomen, pelvis, and back. Running through the center of the back is the vertebral column, which contains the spinal cord. The musculature of the back helps you maintain your posture, bend your trunk, move your arms, shrug your shoulders, and much more.

Large abdominal muscles, for example the rectus abdominis, also contribute to the trunk. This is the muscle behind the famous 'six-pack' that many fitness enthusiasts strive for. Curious? Read on.

Thorax

You're now ready to learn about one of the most interesting topics in anatomy - internal organs. Let's begin with those found in the thorax. Impairments of the heart and the lungs can easily lead to life-threatening conditions. Learning these will help you to be prepared in cases of emergency and also in caring for patients with chronic disorders.

In the world of anatomy, the chest is called the thorax and it is located between the neck and the abdomen. This region can be considered the epicentre of the circulatory system and the primary player in breathing, the latter function being mainly controlled by the diaphragm.

The thorax is as complex on the inside as it is on the outside. Internally it consists of the thoracic cavity that, first and foremost, houses the lungs. Altogether, the lungs occupy a surface area equivalent to the size of a tennis court. Sandwiched between the lungs is the mediastinum, a space that contains blood vessels, nerves, lymphatics, and most importantly, the heart. This vital organ pumps 5 liters of blood every minute of your waking day through the entire body. Read on to find out more!

Abdomen and pelvis

Continuing inferiorly to the thorax, we find the abdomen and pelvis. These two regions are often taught separately for didactic purposes, but their contents blend together into one large abdominopelvic cavity. The largest organ system located here is the gastrointestinal tract. The intestines, which are mainly responsible for absorption, snail through these regions for a total of 7.5 meters, the equivalent of four human beings stacked upright on top of each other.

Four important accessory organs that help the gastrointestinal tract to perform its functions are the liver,gallbladder, pancreas,and spleen. They help especially with the digestion of proteins and fats, as well as metabolic processing.

It's easy to think that the abdomen and pelvis are already overfilled with the structures of the gastrointestinal tract, but there is in fact more! Organs like the kidneys, ureters, urinary bladder, and several reproductive structures are also located here. They form entire systems that work in unison to ensure that you eliminate wastes, react to stressful or scary situations, and reproduce. More details are provided below:

Head and neck

For a lot of students, the head and neck will be the next topic on your anatomy curriculum. Knowing these structures by heart will help you to easily access and describe vital functions.

A strong and mobile neck supports a five-kilogram head, which in turn contains the brain. Vital nerves and blood vessels pass through the neck while traveling between the head and the rest of the body, so understanding these regions is important.

Now that we've covered some basics, let's focus on the head. It consists of several bones joined together that form the bony skull, or cranium, parts of which enclose the brain, and some which form the facial skeleton. The head comprises several associated structures, such as eyes, a nose, ears, and a mouth. These are involved in a variety of functions, like vision, smell, hearing, eating and speaking, to name a few.

The neck serves as a passageway between the head and thorax. The nasal and oral cavities are continued by the pharynx, commonly called the throat. This muscular passage facilitates the movement of liquids, food, and air towards your food pipe (esophagus) and windpipe ( trachea), respectively. The neck also houses many cartilages, muscles, organs, blood vessels, and nerves like the larynx (voice box), thyroid gland and cervical plexus.

Neuroanatomy

Brain injuries, like strokes or lesions of the spinal cord, can have a huge impact on a patient's life, so let's learn more about the structures implicated and how they communicate with the rest of the body.

How does the brain communicate with other regions, for instance the hand, to produce a movement or to sense objects? Through nerves, a concept explained by neuroanatomy. The nervous system controls every function of the human body. For example, it is involved in physiological processes like body temperature, voluntary movements, and higher-order thinking such as consciousness and emotional behavior.

The nervous system is made up of two structural divisions, central and peripheral. The central nervous system (CNS) consists of the brain and the spinal cord, which are protected by layers called meninges and bathed in cerebrospinal fluid. The brain is the master regulator of the body and has four main parts: cerebrum, subcortical structures, brainstem, and cerebellum.

The cerebrum is divided into five lobes and forms the largest part of the human brain, being responsible for cognition. However, every part of the brain is equally important. Do you know the main hero keeping a patient alive during a 'vegetative state' or a coma? It's the sole work of the brainstem, as the cerebrum is dysfunctional during such times.

The spinal cord is the continuation of the brainstem, traveling through the vertebral column. It consists of five regions known as cervical, thoracic, lumbar, sacral, and coccyx. Spinal nerves emerge from the spinal cord through the vertebrae, carrying nerve impulses to and from the periphery. The brain and spinal cord communicate via neural pathways called tracts. Ascending tracts carry peripheral information up towards the brain, while descending tracts transport information back down from the brain.

The peripheral nervous system (PNS) refers to all neural tissue located outside the CNS. It consists of 12 pairs of cranial nerves, the 31 pairs of spinal nerves mentioned previously, and all their branches. The PNS reaches and innervates every single anatomical structure of the human body.

Histology

You are now ready to dive even deeper, to a microscopic level. In histology you study normal cells and tissues specific for each organ, mainly with the use of a microscope. The sound knowledge of these normal histologic structures is essential for understanding the histopathology or pathology of any disease, which often cause specific changes in cells and tissues.

There's no denying it: histology is hard. But keep calm and improve your knowledge with our histology slide quizzes!

Sectional anatomy

Cross-sections are obtained by taking real slices of organs, vessels, nerves, bones, soft tissue, or even the entire human body based on a cadaver. They provide the perception of 'depth', creating three-dimensional relationships between anatomical structures in your mind's eye. They build the entire picture, improve your understanding, consolidate the information and facilitate recall.

In addition, radiological techniques like ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) are based on cross sectional anatomy. In everyday patient care these are essential for precise diagnoses, planning therapy and performing interventions.

Learning the anatomy of the body in cross-sections will be a great starting point to solidify your anatomy knowledge and to be able to identify structures in radiology.

Anatomy curriculum for...

A sound knowledge of anatomy is clinically relevant for all health care professionals. However, you will encounter a slightly different curricula depending on the subject you are studying. Below, we've summarised the main anatomical areas of study for various healthcare professions.

Medical students

Doctors are the ones making diagnoses, interpreting tests and deciding on the appropriate course of treatment. Therefore it is necessary that medical students get the most detailed education when it comes to anatomy. Their courses range from gross and microscopic anatomy, neuroanatomy and histology to cadaveric and cross sectional anatomy. You name it, they have to learn it.

Nursing students

Nurses assist doctors in treating and caring for patients based on therapeutic plans. That's why nursing students also need a good working knowledge of anatomy. However, their courses don't go into such detail as for medical students, e.g. cadaveric dissections and radiological anatomy are not part of their curriculum.

Physiotherapy students

As the health professionals specialised to support patients with impairments of joints, muscles or bones, the main anatomy focus for physiotherapy students is the musculoskeletal system. Therefore most schools focus on gross anatomy and miss out topics like histology or radiological anatomy.

Learning tips and strategies

Anatomy learning tips

There are some do's and dont's that you should always keep in mind when studying. Avoiding the procrastination vortex, navigating learning myths, memorization tricks, passing exams... there are a lot of factors to take into consideration. Find our top tips on how to best get through it all below!

Want to know more? Check out our in-depth guide to the best learning techniques and resources.

3D anatomy tools

There's a lot of debate regarding the advantages and disadvantages of learning anatomy in 3D. It's not an ideal way to learn in all situations, but muscle anatomy is one area where we really recommend it. Muscles help us move, and muscle movement occurs in a three-dimensional plane, so it only makes sense to learn them with the aid of 3D tools.

Click on the link below to check out our huge range of 3D muscle anatomy videos!

Muscle anatomy charts

Need an extra hand to learn muscle anatomy? Along with our 3D muscle function videos, our muscle anatomy charts will help you to learn muscle anatomy with ease. What can you expect from them? Charts divide muscles into body regions and groups, with attachments, innervations and functions clearly labeled. They're a huge time-saver!

Browse the full range of muscle anatomy charts - and grab your free copy of the Lower Limb Muscle Chart!

Further learning resources

You should now be familiar with the different anatomy topics that we cover here at Kenhub. Learning other topics as part of your studies, like Pathology, Physiology, Biochemistry and Biology? Here are some resources to help you even further! :-)

General

Khan academy (Health and Medicine)
Biology corner (Biology)
Interactive biology (Biology)
Speed pharmacology (Pharmacology tutorials)
Osmosis (Pathophysiology)
Histology World
University of Michigan (Histology)
Pathology Outlines (Pathology)
Pathoma (Pathology)
Goljan (Rapid Review Pathology)
Head Neck Brain Spine (Radiology)

Medicine

Dr. Najeeb (USMLE)
Picmonic (USMLE)
First Aid Basic Sciences (USMLE)
USMLE R-X
U-World (USMLE)
Kaplan (USMLE)
Medcram (Medical school topics)
Armando Hasudungan (Medical school topics tutorials)
Handwritten tutorials (Medical school topics tutorials)
iMedicalSchool (Medical school tutorials)
One Minute Medical School (Medical school tutorials)
Harvard Medical School (Biomedical research and education)
US National Library of Medicine (Medical videos)

Nursing

Allnurses (Nurses community for nursing and students)
American Nurses Association
Volunteer Opportunities for nursing students
CasesBlog (Clinical cases and images)
Virginia Henderson International Nursing Library
Trauma care (Cases, library and resources)
Practical clinical skills (train ECGs and more)
Learningnurse (Assessments, E-learning tools, Quizzes)

Physiotherapy

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Anatomy fun facts

Wowed by the complexity of the human body? Here are some fun facts to continue to blow your mind...

The human body contains nearly 100 trillion cells.

There are at least 10 times as many bacteria in the human body as cells.

The average adult takes over 20,000 breaths a day.

The human brain contains about 100 billion nerve cells.

Water makes up more than 50 percent of the average adult's body weight.

Sources

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Human anatomy study guide: want to learn more about it?

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Before you start learning about the anatomical structures themselves, you'll need to make sure that you understand basic anatomy lingo, like terminology and directions. With several unknown anatomy terms to master in a very short time, learning anatomical terminology can feel a bit like learning a new language.

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AnatomyZone - Your Guide to Human Anatomy

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AnatomyZone is the leading resource for simple and concise 3D anatomy tutorials, with over 200 videos and a new range of interactive 3D anatomy models.

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MS Society UK | Information, research and support

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Multiple sclerosis news, information, research, and support for everyone affected by MS

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Chronic obstructive pulmonary disease (COPD)

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WHO fact sheet on chronic obstructive pulmonary disease (COPD) provides key facts and information on symptoms, diagnosis and treatment, risk factors and WHO response.

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Assessment for long-term oxygen therapy

Quality statement

People with stable chronic obstructive pulmonary disease (COPD) and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need long-term oxygen therapy (LTOT).

Rationale

LTOT is used to treat people with stable COPD who have developed daytime hypoxaemia. People with COPD and a persistent resting stable oxygen saturation of 92% or less should be assessed for their suitability for LTOT, which can improve survival, pulmonary haemodynamics, polycythaemia and neuropsychological health.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need LTOT.

Process

Proportion of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less who have their arterial blood gases measured to assess whether they need LTOT.

Numerator - the number in the denominator who have their arterial blood gases measured to assess whether they need LTOT.

Denominator - the number of people with stable COPD and a persistent resting stable oxygen saturation level of 92% or less.

Outcomes

a) Hospital admission for acute exacerbation.

Data source: Local data collection.

b) Quality of life.

Data source: Local data collection.

What the quality statement means for different audiences

Service providers (primary and secondary care services) ensure that systems are in place for people with stable COPD and a persistent resting oxygen saturation level of 92% or less to have their arterial blood gases measured to assess whether they need LTOT.

Healthcare professionals ensure that they measure the arterial blood gases of people with stable COPD and a persisting resting oxygen saturation level of 92% or less to assess whether they need LTOT.

Commissioners (clinical commissioning groups) ensure that they commission services in which people with stable COPD and a persisting resting oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need LTOT.

People with COPD that is stable and who have low levels of oxygen in their blood (when checked using a device that clips to their finger) have this confirmed by a blood test, to assess whether they need long-term oxygen therapy. Long-term oxygen therapy is treatment with oxygen breathed in through a tube (placed just inside the nose) or a mask connected to an oxygen supply. It is usually given for at least 15 hours during the day or night.

Source guidance

Definitions

Long-term oxygen therapy (LTOT)

Assessment for LTOT

Assessing people for LTOT should comprise 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. [ NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.57]

Stable COPD

Persistent resting stable oxygen saturation

An oxygen saturation (measured with a pulse oximeter) that is persistently 92% or less when the person is in a chronic stable state and is at rest (is not, and has not recently, been exercising). [Expert opinion]

Pulmonary rehabilitation for stable COPD and exercise limitation

Quality statement

People with stable chronic obstructive pulmonary disease (COPD) and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Rationale

Pulmonary rehabilitation programmes improve a person's exercise capacity, quality of life, symptoms and levels of anxiety and depression.

Quality measures

Evidence of local arrangements and written clinical protocols to ensure that people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Process

a) Proportion of people with stable COPD and exercise limitation due to breathlessness who are referred to a pulmonary rehabilitation programme.

Numerator - the number in the denominator who are referred to a pulmonary rehabilitation programme.

Denominator - the number of people with stable COPD and exercise limitation due to breathlessness.

b) Proportion of referrals of people with stable COPD and exercise limitation due to breathlessness that result in the person attending a pulmonary rehabilitation programme.

Numerator - the number in the denominator that result in the person attending a pulmonary rehabilitation programme.

Denominator - the number of referrals of people with stable COPD and exercise limitation due to breathlessness to pulmonary rehabilitation programmes.

c) Proportion of attendances of people with stable COPD and exercise limitation due to breathlessness that result in the person completing a pulmonary rehabilitation programme.

Numerator - the number in the denominator that result in the person completing a pulmonary rehabilitation programme.

Denominator - the number of attendances of people with stable COPD and exercise limitation due to breathlessness at pulmonary rehabilitation programmes.

Outcomes

a) Hospital admissions for acute exacerbation.

b) Quality of life.

What the quality statement means for different audiences

Service providers (secondary care and community services) ensure that systems are in place for people with stable COPD and exercise limitation due to breathlessness to be referred to a pulmonary rehabilitation programme.

Healthcare professionals refer people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

Commissioners (clinical commissioning groups) ensure that they commission services in which people with stable COPD and exercise limitation due to breathlessness are referred to a pulmonary rehabilitation programme.

People with COPD that is stable and who have difficulty walking and have to walk slowly and stop often or soon become breathless, are referred to a pulmonary rehabilitation programme. This includes exercises, information about COPD, diet advice and support depending on the person's needs.

Source guidance

Definitions of terms used in this quality statement

Exercise limitation

Medical Research Council dyspnoea scale of breathlessness grade 3 and above. A breathlessness of grade 3 is defined as 'walks slower than contemporaries on level ground because of breathlessness, or has to stop for breath when walking at own pace'. [ NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.1.3]

Pulmonary rehabilitation programme

Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. Programmes should be available within a reasonable time from referral. [Adapted from NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.83]

Programmes comprise individualised exercise programmes and education, and:

are at least 6 weeks in duration and include a minimum of twice-weekly supervised sessions

include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training

include a defined, structured education programme.

Equality and diversity considerations

Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment.

Pulmonary rehabilitation after an acute exacerbation

Quality statement

People admitted to hospital for an acute exacerbation of chronic obstructive pulmonary disease (COPD) start a pulmonary rehabilitation programme within 4 weeks of discharge.

Rationale

Starting a pulmonary rehabilitation programme within 4 weeks of hospital discharge after an acute exacerbation reduces the short-term risk of hospital readmission, and improves the quality of life and the short-term exercise capacity of people with COPD.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that people with COPD admitted to hospital for an acute exacerbation start a pulmonary rehabilitation programme within 4 weeks of discharge.

Process

Proportion of people discharged from hospital after an acute exacerbation of COPD who start a pulmonary rehabilitation programme within 4 weeks of discharge.

Numerator - the number in the denominator who start a pulmonary rehabilitation programme within 4 weeks of discharge.

Denominator - the number of people discharged from hospital after an acute exacerbation of COPD.

Outcomes

a) Hospital admissions for acute exacerbations.

b) Quality of life.

What the quality statement means for different audiences

Service providers (secondary care and community services) ensure that systems are in place for people admitted to hospital for an acute exacerbation of COPD to start a pulmonary rehabilitation programme within 4 weeks of discharge.

Healthcare professionals ensure that people admitted to hospital for an acute exacerbation of COPD are referred for and receive a pulmonary rehabilitation programme within 4 weeks of discharge.

Commissioners (clinical commissioning groups) ensure that they commission services in which people who are admitted to hospital for an acute exacerbation of COPD are referred for and receive a pulmonary rehabilitation programme within 4 weeks of discharge.

People with COPD who have had a hospital stay because of a sudden flare up of their symptoms (called an acute exacerbation) start a pulmonary rehabilitation programme within 4 weeks of leaving hospital. This includes exercises, information about COPD, diet advice and support depending on the person's needs.

Source guidance

Definitions of terms used in this quality statement

Acute exacerbation

An exacerbation is a sustained worsening of a person's symptoms from their usual stable state and which is beyond usual day-to-day variations and acute in onset. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in sputum colour. [Adapted from NICE's guideline on chronic obstructive pulmonary disease]

Pulmonary rehabilitation programme

Pulmonary rehabilitation programmes should be held at times that suit people with COPD and in locations that are easy for people with COPD to get to, and have good access for people with disabilities. Programmes should be available within a reasonable time from referral. [Adapted from NICE's guideline on chronic obstructive pulmonary disease, recommendation 1.2.83]

Programmes comprise individualised exercise programmes and education, and:

are at least 6 weeks in duration and include a minimum of twice-weekly supervised sessions

include supervised, individually tailored and prescribed, progressive exercise training including both aerobic and resistance training

include a defined, structured education programme.

Equality and diversity considerations

Pulmonary rehabilitation is not suitable for people with unstable cardiac disease, locomotor or neurological difficulties precluding exercise such as severe arthritis or peripheral vascular disease, and people in a terminal phase of an illness or with significant cognitive or psychiatric impairment.

Some people with COPD may not be well enough to attend a pulmonary rehabilitation programme within 4 weeks of an acute exacerbation, may not have attended hospital after an acute exacerbation of COPD or may not have been admitted to hospital after their exacerbation of COPD.

Emergency oxygen during an exacerbation

Quality statement

People receiving emergency oxygen for an acute exacerbation of chronic obstructive pulmonary disease (COPD) have their oxygen saturation levels maintained between 88% and 92%.

Rationale

During an exacerbation, people with COPD may experience a worsening of gas exchange in the lungs, which can lead to low blood oxygen levels. Emergency oxygen is often given during the treatment of an exacerbation, either in the community, during transfer to hospital in an ambulance or while being assessed at hospital.

In some people, uncontrolled oxygen therapy may reduce the depth and frequency of breathing, leading to a rise in blood carbon dioxide levels and a fall in the blood pH (acidosis). Controlled oxygen therapy must therefore be administered by a delivery device and at a flow rate that helps the oxygen saturation to be maintained between 88% and 92%.

Quality measures

Structure

Evidence of local arrangements and written clinical protocols to ensure that people receiving emergency oxygen for an acute exacerbation of COPD have their oxygen saturation levels maintained between 88% and 92%.

Process

Proportion of people receiving emergency oxygen for an acute exacerbation of COPD who have their oxygen saturation levels maintained between 88% and 92%.

Numerator - the number in the denominator whose oxygen saturation levels are maintained between 88% and 92%.

Denominator - the number of people with an acute exacerbation of COPD receiving emergency oxygen.

Outcomes

a) Frequency of non-invasive ventilation due to oxygen toxicity.

What the quality statement means for different audiences

Service providers (community and secondary care services, ambulance trusts, A&E departments) ensure that devices and flow rates are used to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.

Healthcare professionals ensure that devices and flow rates are used to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.

Commissioners ensure that they commission services that use devices and flow rates to enable oxygen saturation levels to be maintained between 88% and 92% in people receiving emergency oxygen for an acute exacerbation of COPD.

People with COPD who need emergency oxygen because of a sudden flare up of their symptoms (called an acute exacerbation) receive the correct amount of oxygen to keep the oxygen levels in their blood at a safe level.

Source guidance

Definition of terms used in this quality statement

Acute exacerbation

An exacerbation is a sustained worsening of a person's symptoms from their stable state beyond usual day-to-day variations and is acute in onset. Commonly reported symptoms are: worsening breathlessness, cough, increased sputum production and change in the colour of the sputum. [Adapted from NICE's guideline on chronic obstructive pulmonary disease]

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.

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

Structure

Evidence of local arrangements to 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.

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.

Outcome

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 (clinical commissioning groups) 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 can't 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

Definitions of terms used in this quality statement

Acute exacerbation

An acute 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 sputum production and change in sputum colour. [Adapted from NICE's guideline on chronic obstructive pulmonary disease]

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. Co-existent hypoxaemia is usually mild and easily corrected. Conventionally, a pH <7.35 and a PCO2 >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 <7.25, have been used as a threshold for considering provision of invasive mechanical ventilation. [Adapted from NICE's guideline on chronic obstructive pulmonary disease and expert consensus]

Non-invasive ventilation

Non-invasive ventilation should be given once it is recognised that a person is not responding to 1 hour of optimal medical therapy. [Expert consensus]

Optimal medical treatment

Referral to smoking cessation services

Quality statement

People who smoke are offered a referral to an evidence-based smoking cessation service.

Rationale

Smoking cessation services provide the most effective route to stopping smoking, but many people who smoke do not use these services when they try to stop. It is therefore important that practitioners are aware of and make use of the opportunities to refer people who smoke to an evidence-based smoking cessation service.

Quality statement 5 in the NICE quality standard on antenatal care sets out the high-quality requirements for ensuring that pregnant women who smoke are referred to an evidence-based smoking cessation service.

Quality measures

Structure

Evidence of local arrangements to ensure that people who smoke are offered a referral to an evidence-based smoking cessation service.

Data source: Local data collection.

Process

Proportion of people who smoke who are referred to an evidence-based smoking cessation service.

Numerator - the number of people in the denominator who are referred to an evidence-based smoking cessation service.

Denominator - the number of people identified as smokers in any healthcare setting.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for people who smoke to be offered a referral to an evidence-based smoking cessation service.

Healthcare practitioners offer people who smoke a referral to an evidence-based smoking cessation service.

Commissioners ensure that they commission services that offer people who smoke a referral to an evidence-based smoking cessation service.

What the quality statement means for patients, service users and carers

People who smoke are offered a referral to an evidence-based smoking cessation service to help them stop smoking.

Source guidance

Stop smoking interventions and services (2018) NICE guideline NG92, recommendation 1.6.1

Smoking: stopping in pregnancy and after childbirth (2010) NICE guideline PH26, recommendations 1, 2, 3 and 8

Smoking: acute, maternity and mental health services (2013) NICE guideline PH48, recommendations 1, 2, 3, 7, 9 and 14

Varenicline for smoking cessation (2007) NICE technology appraisal guidance 123, recommendations 1.1 and 1.2.

Definitions of terms used in this quality statement

Healthcare practitioners

These include, but are not limited to, doctors, nurses, midwives, pharmacists, dentists, opticians and allied health professionals.

Evidence-based smoking cessation services

These are local services providing accessible, evidence based and cost effective support to people who want to stop smoking.

This statement is linked to statement 1, because advice on how to stop may include a referral to an evidence-based smoking cessation service.

Quality statement 5 in the NICE quality standard on antenatal care states that 'Pregnant women who smoke are referred to an evidence-based stop smoking service at the booking appointment' and the appropriate referral criteria are defined. The supporting information also states that the midwife may provide the pregnant woman with information (in a variety of formats, for example, a leaflet) about the risks to the unborn child of smoking when pregnant and the hazards of exposure to secondhand smoke for both mother and baby.

Equality and diversity considerations

Evidence-based smoking cessation services should target minority ethnic and socioeconomically disadvantaged communities in the local population; it is important to ensure that services are easily accessible by people from these groups and that they are encouraged to use them.

Lesbian, gay, bisexual and transgender (LGBT) groups have higher smoking prevalence rates than the general population, and as such, services should be accessible and commissioned to address this need.

Healthcare practitioners should be sensitive to the issue of smoking in young people. NICE guidance recommends that young people aged 12-17 who smoke should be offered information, advice and support on how to stop smoking and be encouraged to use evidence-based smoking cessation services.

Practitioners should be aware that some pregnant women find it difficult to say that they smoke because the pressure not to smoke during pregnancy is so intense.

Planning applications

Quality statement

Local planning authorities assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Rationale

The built environment can affect the emission of road-traffic-related air pollutants by influencing how and how much people travel, for example, by ensuring good connections to walking and cycling networks. Buildings can affect the way air pollutants are dispersed through street design and the resulting impact on air flow. Addressing air pollution at the planning stage for major developments may reduce the need for more expensive remedial action at a later stage. It can also help to maintain people's health and wellbeing during and after construction. Assessing proposals to minimise and mitigate road-traffic-related air pollution will help to ensure they are robust and evidence based.

Quality measures

Structure

a) Evidence of local processes and guidance that ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution.

Data source: Local data collection, for example, review of supplementary planning guidance.

b) Evidence of a local framework for assessing proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments.

Data source: Local data collection, for example, review of supplementary planning guidance.

Process

Proportion of planning applications for major developments granted permission with conditions or obligations to minimise and mitigate road-traffic-related air pollution.

Numerator - the number in the denominator with conditions or obligations to minimise and mitigate road-traffic-related air pollution.

Denominator - the number of planning applications for major developments granted permission.

Data source: Local data collection, for example, local planning application system.

Outcome

a) Proportion of journeys made by local residents that are by walking, cycling, public transport or zero- or low-emission vehicles.

b) Annual and hourly mean concentrations for nitrogen dioxide (NO ₂).

c) Annual and daily mean concentrations for particulate matter of 10 micrometres or less in diameter (PM ₁₀).

d) Annual mean concentration for fine particulate matter of 2.5 micrometres or less in diameter (PM 2.5).

What the quality statement means for different audiences

Local planning authorities ensure planning applications for major developments include proposals to minimise and mitigate road-traffic-related air pollution during and after construction. Local planning authorities provide guidance for applicants and have a clear framework for assessing proposals in line with the Local Plan, local transport plan and other key strategies. Local guidance should make it clear that proposals to minimise or mitigate road-traffic-related air pollution must be evidence based. Local planning authorities monitor compliance with planning conditions or obligations to minimise and mitigate road-traffic-related air pollution.

Local authority planning officers assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications for major developments using an agreed local framework to ensure they are evidence based. Local authority planning officers encourage applicants to modify their planning applications if necessary, to include evidence-based approaches to minimise or mitigate road-traffic-related air pollution.

Planning applicants for major developments know that the local planning authority will assess proposals to minimise and mitigate road-traffic-related air pollution in planning applications to ensure they are evidence based. Planning applicants can get information on what the local planning authority is looking for and how the proposals will be assessed. Planning applicants for major developments modify their application to improve the approach to minimising or mitigating road-traffic-related air pollution if required by the local authority.

People in the community know that their local planning authorities require developers to show how they will minimise road-traffic-related air pollution and improve local air quality around big building projects when they apply for planning permission. This is to help protect local people from the effects of air pollution on their health.

Source guidance

Definitions of terms used in this quality statement

Major developments

Development involving any one or more of the following:

the winning and working of minerals or the use of land for mineral-working deposits

waste development

the provision of dwelling houses where:

the number of dwelling houses to be provided is 10 or more or

the development is to be carried out on a site having an area of 0.5 hectares or more and the number of dwelling houses is not known

the provision of a building or buildings where the floor space to be created by the development is 1,000 square metres or more or

development carried out on a site having an area of 1 hectare or more.

Equality and diversity considerations

Local planning authorities should ensure that proposals to encourage active travel in planning applications for major developments are accessible to people with limited mobility or disabilities.

Advice for people with chronic respiratory or cardiovascular conditions

Quality statement

Children, young people and adults with chronic respiratory or cardiovascular conditions are given advice at routine health appointments on what to do when outdoor air quality is poor.

Rationale

Periods of poor air quality are associated with adverse health effects, including asthma attacks, reduced lung function, and increased mortality and admissions to hospital. Providing advice to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments will support self-management, improve their awareness of how to protect themselves when outdoor air quality is poor and prevent their condition escalating.

Quality measures

Structure

a) Evidence that healthcare professionals carrying out routine health appointments with children, young people and adults with chronic respiratory or cardiovascular conditions are aware of the advice they should provide on what to do when outdoor air quality is poor.

Data source: Local data collection, for example, training records.

b) Evidence of local processes to ensure that children, young people and adults with chronic respiratory or cardiovascular conditions attending routine health appointments are given advice on what to do when outdoor air quality is poor.

Data source: Local data collection, for example, service protocols.

Process

Proportion of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment that were given advice on what to do when outdoor air quality is poor.

Numerator - the number in the denominator that were given advice on what to do when outdoor air quality is poor.

Denominator - the number of children, young people and adults with chronic respiratory or cardiovascular conditions attending a routine health appointment.

Data source: Local data collection, for example, audit of patient records.

Outcome

a) Level of awareness among children, young people and adults with chronic respiratory or cardiovascular conditions on what to do when outdoor air quality is poor.

Data source: Local data collection, for example, survey of children, young people and adults with chronic respiratory or cardiovascular conditions.

b) Rate of hospital attendance or admission for respiratory or cardiovascular exacerbations.

Data source: NHS Digital's Hospital Episode Statistics includes data on admissions and A&E attendances for asthma attacks, acute chronic obstructive pulmonary disease exacerbations, heart attacks, strokes, heart failure and angina attacks.

What the quality statement means for different audiences

Service providers (such as general practices, community health services, hospitals and community pharmacies) ensure that healthcare professionals are aware that information on air quality is available, what it means and what actions are recommended. Service providers ensure that processes are in place to provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions (and their families or carers, if appropriate) at routine health appointments. Providers ensure that advice includes how to find out when outdoor air quality is expected to be poor such as from the Department for Environment, Food and Rural Affairs' Daily Air Quality Index.

Healthcare professionals (such as doctors, nurses, healthcare assistants and pharmacists) provide advice on what to do when outdoor air quality is poor to children, young people and adults with chronic respiratory or cardiovascular conditions who are attending a routine health appointment (and their families and carers, if appropriate). They also provide information on how to find out when outdoor air quality is expected to be poor, for example using the Department for Environment, Food and Rural Affairs' Daily Air Quality Index.

Commissioners (such as clinical commissioning groups and NHS England) commission services that provide advice on what to do when outdoor air quality is poor to children, young people and adults (and their families and carers, if appropriate) at routine health appointments.

People with long-term breathing or heart conditions (and their family and carers, if appropriate) are given advice at routine health appointments on what to do when outdoor air quality is poor and how to find out when it is likely to be poor.

Source guidance

Chronic obstructive pulmonary disease in over 16s: diagnosis and management (2018, updated 2019) NICE guideline NG115, recommendations 1.2.123, 1.2.124 and 1.2.125

Chronic heart failure in adults: diagnosis and management (2018) NICE guideline NG106, recommendations 1.1.8 and 1.1.9

Asthma: diagnosis, monitoring and chronic asthma management (2017, updated 2020) NICE guideline NG80, recommendations 1.10.1, 1.10.3 and 1.10.4

Air pollution: outdoor air quality and health (2017) NICE guideline NG70, recommendation 1.7.7

Stroke rehabilitation in adults (2013) NICE guideline CG162, recommendation 1.3.3

Hypertension in adults: diagnosis and management (2019) NICE guideline NG136, recommendation 1.4.23

Stable angina: management (2011, updated 2016) NICE guideline CG126, recommendations 1.2.6 and 1.2.7

Definitions of terms used in this quality statement

Routine health appointments

Annual reviews and other appointments focused on supporting management of chronic respiratory or cardiovascular conditions.

Advice on what to do when outdoor air quality is poor

Advice should include how to minimise exposure to outdoor air pollution and manage any related symptoms such as:

Avoiding or reducing strenuous activity outside, especially in highly polluted locations such as busy streets, and particularly if experiencing symptoms such as sore eyes, a cough or sore throat.

Adults over 17 to use an asthma reliever inhaler more often, as needed.

Children and young people aged 5 to 16 to contact a healthcare professional for a review if their asthma control deteriorates. If they have not been taking their inhaled corticosteroid consistently, explain that restarting regular use may help them to regain control of their asthma.

Closing external doors and windows facing a busy street at times when traffic is heavy or congested to help stop highly polluted air getting in.

Poor outdoor air quality

The Daily Air Quality Index describes air pollution on a scale of 1 to 10 and is divided into 4 bands from low to very high. Health effects may occur when air pollution is moderate (4 to 6), high (7 to 9) or very high (10).

Effective interventions library

Effective interventions library

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

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.

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.

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 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.

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Quality statement People with stable chronic obstructive pulmonary disease (COPD) and a persistent resting stable oxygen saturation level of 92% or less have their arterial blood gases measured to assess whether they need long-term oxygen therapy (LTOT). Rationale LTOT is used to treat people with stable COPD who have developed daytime hypoxaemia.

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We are here to help

Services and Support for Acquired Brain Injury

Out of the blue

A new awareness video #outoftheblue

1800 400 478

for Information and Support

At Headway, we understand that life after a brain injury can be overwhelming for both the survivor and family members. There is so much to cope with - changes in relationships with family and friends, financial strain, difficulty adjusting to changes in work - many people with ABI feel worthless, misunderstood, lonely and frustrated. Headway is here to help and support you. We strive to create a place where people living with ABI can feel supported to rebuild their lives.

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Headway Ireland | Brain Injury Services & Support

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Services and Support for Acquired Brain Injury A new awareness video #outoftheblue for Information and Support At Headway, we understand that life after a brain injury can be overwhelming for both the survivor and family members.

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Helpful booklets, leaflets and action plans developed with healthcare professionals who specialise in asthma - and people with asthma who know what it's like to live with the condition.

Go to the resources section

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Helpful booklets, leaflets and action plans developed with healthcare professionals who specialise in asthma - and people with asthma who know what it's like to live with the condition. Go to the resources section