Quality statement 8	Nocturnal oxygen therapy (NOT): (a) Patients with optimally treated cardiac failure, who are not eligible for LTOT, should only be offered NOT if there is evidence of sleep disordered breathing causing daytime symptoms. (b) Patients with chronic hypercapnic respiratory failure with nocturnal hypoxaemia, who are not eligible for LTOT, should only be offered NOT in conjunction with NIV.
Rationale	Treatment of patients with cardiac failure who are symptomatic from sleep disordered breathing with NOT leads to a reduction in daytime sleepiness and a modest improvement in exercise capacity. There is no evidence that patients with chronic respiratory disease who fail to meet the criteria for LTOT but who desaturate at night derive any long-term symptomatic or survival benefits from NOT. NOT is therefore not recommended in this group of patients (eg, COPD, interstitial lung disease (ILD)). Some patients with chronic respiratory disease, including those with CF, neuromuscular weakness or obesity hypoventilation, are at risk of developing nocturnal hypoxaemia in the setting of chronic hypercapnic respiratory failure. These patients should not receive NOT alone as they may develop uncontrolled type 2 respiratory failure. However, they may benefit from NOT given with NIV support.
	Some patients with chronic respiratory disease, including those with CF, neuromuscular weakness or obesity hypoventilation, are at risk of developing nocturnal hypoxaemia in the setting of chronic hypercapnic respiratory failure. These patients should not receive NOT alone as they may develop uncontrolled type 2 respiratory failure. However, they may benefit from NOT given with NIV support.
Quality measure	Structure: Evidence that NOT is provided for patients with cardiac failure with evidence of sleep disordered breathing on a sleep study causing daytime symptoms. Evidence that NOT is only provided for respiratory patients with hypercapnic respiratory failure in conjunction with NIV. Process: The proportion of patients with cardiac failure receiving NOT who have had a sleep study and completed an Epworth Sleepiness Scale before and after treatment. The proportion of patients with hypercapnic respiratory failure receiving NOT who are also being treated with NIV. Numerator 1: The number of patients with cardiac failure receiving NOT who have had a sleep study and completed an Epworth Sleepiness Scale before and after treatment. Denominator 1: The number of patients with cardiac failure receiving NOT.
	Numerator 2: The number of patients with chronic hypercapnic respiratory failure receiving NOT who are also being treated with NIV. Denominator 2: The number of chronic hypercapnic respiratory patients receiving NOT.
Description of what the quality statement means for each audience	Service providers: Ensure systems are in place to offer a sleep study and symptom assessment of cardiac patients before and after treatment. Ensure systems are in place to offer NOT in conjunction with NIV for respiratory patients in chronic hypercapnia respiratory failure. Healthcare professionals: Ensure clinical assessment of cardiac failure patients includes assessment of symptoms of sleep disordered breathing. Ensure awareness of risks of providing NOT alone without NIV treatment in chronic hypercapnic respiratory patients. Commissioners: Ensure that sufficient facilities, staff and equipment are available to diagnose and to treat patients with NOT when clinically indicated. People who require home oxygen: Are referred for assessment if demonstrating symptoms or signs of sleep disordered breathing or uncontrolled ventilatory failure in context of cardiac failure or chronic respiratory disease.
Relevant existing indicators/data sources	Local data collection/audit.
Source references	BTS Guidelines for Home Oxygen Use in Adults June 2015.3