Actes et Prestations Affection de Longue Durée N°14 – Insuffisance Respiratoire Chronique Grave de l’Adulte Secondaire à une Bronchopneumopathie Chronique Obstructive

Objectives

This framework supports the diagnosis, treatment and follow-up of adults with severe chronic respiratory failure secondary to chronic obstructive pulmonary disease (COPD), including assessment of severity, rehabilitation, management of exacerbations and comorbidities, respiratory support, and selected investigations. It serves as a reference for care acts and services and for renewal of long-term-condition status, rather than as a clinical decision-support tool or a complete care-pathway guide.[1][2][3][4]

• Define eligibility for long-term-condition coverage where COPD is associated, outside an acute episode, with arterial oxygen tension below 60 mmHg, arterial carbon dioxide tension above 50 mmHg, and/or forced expiratory volume in one second below 50% of predicted normal values.[5]
• Support exemption from co-payment for eligible patients, initially granted for 10 years and subject to renewal.[5][2]
• Coordinate multidisciplinary care spanning diagnosis, specialist treatment, respiratory rehabilitation, therapeutic education, smoking cessation, management of acute exacerbations, and surveillance for disease- and treatment-related complications.[2][6][7]
• Provide personalised respiratory rehabilitation incorporating exercise retraining, muscle strengthening, respiratory physiotherapy, health education, and, where needed, nutritional, psychological, social and occupational support.[2][6][7]
• Provide respiratory support through long-term or short-term oxygen therapy, assisted ventilation, ventilation combined with oxygen therapy, and continuous positive airway pressure where sleep apnoea is present.[8]
• Consider bronchoscopic endobronchial coil placement for selected people with severe or very severe emphysema who meet clinical criteria and have received respiratory rehabilitation and optimal medical treatment.[7]

Implementation

Care is organised through an individualised, periodically revisable protocol agreed by the patient, treating doctor and health-insurance medical adviser. General practitioners and pulmonologists lead diagnosis and severity assessment, while pulmonologists coordinate specialist treatment, rehabilitation and review after hospitalisation; the protocol may be adapted for complications, comorbidities or required services outside the reference framework.[1][5][2]

• Establish care protocols in community or hospital settings and revise them in response to changes in health status and therapeutic advances.[1]
• Refer patients to physical and rehabilitation medicine, cardiology, addiction services, occupational health, dietetics, psychiatry, psychology, surgery, physical-activity instruction and occupational therapy according to clinical, social, occupational, nutritional, mental-health or rehabilitation needs.[2][6]
• Deliver respiratory rehabilitation individually or in groups of two to four people through physiotherapy, exercise retraining, strengthening and education; the described model comprises approximately 90-minute sessions across a course of 20 sessions, adapted to clinical progress.[2][6]
• Provide post-discharge nursing follow-up to monitor clinical status, treatment effects and adherence, review use of home measurements and oxygen therapy where relevant, educate patients and carers, and identify complications.[6]
• Use respiratory function tests, arterial blood-gas analysis, six-minute walk tests and other investigations according to diagnostic, severity-assessment, follow-up, complication, oxygen-therapy, ventilation or rehabilitation needs.[4]
• Reserve selected investigations for defined indications, including non-routine chest computed tomography, exercise testing to support rehabilitation, sleep studies for suspected associated sleep apnoea, natriuretic-peptide testing for suspected heart failure, alpha-1 antitrypsin testing for suspected primary emphysema, and theophylline assays where clinical circumstances warrant them.[3][4]
• Repeat six-minute walk testing before and after exercise retraining and according to clinical status; use exercise testing before rehabilitation and potentially during annual follow-up after rehabilitation.[4]
• Provide pharmacological treatment with inhaled short- and long-acting bronchodilators, selected inhaled corticosteroid combinations, antibiotics for bacterial superinfection, oral corticosteroids for acute exacerbations, smoking-cessation medicines and scheduled vaccination.[9][10]
• Restrict nebulised short-acting bronchodilators for acute exacerbations to respiratory-specialist prescribing, except that any doctor may administer them in emergency or mobile medical-assistance settings; reserve initial triple-inhaler prescribing for respiratory specialists and use theophylline only exceptionally.[9]
• Assess each patient’s need for therapeutic education without making participation a condition for reimbursement of disease-related acts or medicines, and deliver applicable programmes through those authorised by regional health agencies.[7]
• Assign initial and renewal prescribing of long-term oxygen therapy to specified respiratory or other qualified specialists, while permitting any doctor to prescribe short-term oxygen therapy; in residential care for older people, permit the coordinating doctor to renew therapy after consulting the prescriber.[8]
• Provide respiratory equipment through associated technical, administrative and general support, including equipment and consumable supply or rental, accessories, installation and follow-up services.[8][11]
• Cover necessary acts and services through compulsory health insurance under ordinary or applicable derogatory arrangements, while recording use outside marketing authorisation or reimbursable-product lists only where a relevant derogatory funding mechanism applies and patient-information conditions are met.[5]
• Recognise reimbursement limitations for exercise retraining, dietetic services, psychological support, physical-activity instruction and occupational therapy, which may instead be supported through hospital structures or networks.[2][6][7]
• Update the acts-and-services reference annually through the Haute Autorité de santé website and review individual protocols periodically.[12][1]

The material specifies clinical follow-up, tolerance review, adherence checks and complication surveillance, but does not set out formal performance indicators, reporting requirements, audit arrangements, surveillance targets or wider accountability mechanisms.[2][6][3][4][7][8][11]

Monitoring & Evaluation

Monitoring focuses principally on individual clinical assessment and periodic review rather than on a population-level performance framework. The acts-and-services reference document is updated annually and published through the Haute Autorité de santé website, while individualised care protocols are periodically revised in response to changes in health status and therapeutic advances.[12][1]

• Assess eligibility using arterial blood-gas and lung-function thresholds, including arterial oxygen tension below 60 mmHg, arterial carbon dioxide tension above 50 mmHg outside an acute episode, and/or forced expiratory volume in one second below 50% of predicted values.[5]
• Monitor clinical status through follow-up consultations, post-hospitalisation assessment after exacerbations, treatment-tolerance review, adherence checks, and surveillance for disease- and treatment-related complications.[2][6]
• Review oxygen-therapy use, home measurements where applicable, patient and carer understanding, treatment effects, and signs of complications during post-discharge nursing visits.[6]
• Use respiratory function tests, arterial blood gases, six-minute walk testing, and other investigations to assess diagnosis, severity, disability, progression, oxygen-therapy and ventilation needs, complications, and rehabilitation requirements.[4]
• Repeat six-minute walk testing before and after exercise retraining and according to clinical status; exercise testing may also be used before rehabilitation and in annual post-rehabilitation follow-up.[4]
• Undertake selected laboratory investigations according to need, including haemogram testing with platelets for complications, electrolyte testing according to clinical status and treatment, and creatinine with estimated glomerular filtration rate for renal assessment and follow-up.[3]
• Reserve BNP or ProBNP testing for suspected heart failure, alpha-1 antitrypsin testing for suspected primary emphysema, and theophylline measurement for relevant treatment risks or clinical change.[3]

The supplied material does not set out formal programme indicators, targets, routine reporting requirements, audit arrangements, surveillance systems, evaluation methodology, or explicit accountability structures.[2][6][3][4][7][8][11]

Costing & Financing

Financing is primarily framed through compulsory health-insurance coverage, long-term-condition exemption, reimbursement rules, and listed support arrangements rather than through a dedicated programme budget. Eligible patients may receive exemption from co-payment for care required for the long-term condition, initially for 10 years and subject to renewal.[1][5][2]

• Cover necessary acts and services through compulsory health insurance under ordinary rules or applicable derogatory arrangements.[5]
• Apply derogatory funding mechanisms to uses outside marketing authorisation or outside the list of reimbursable products and services only where such a mechanism is applicable and required conditions, including patient information, are met.[5]
• Recognise that exercise retraining within respiratory rehabilitation is not reimbursed under the legislation described, although support may be available through hospital structures or a care network.[2][6]
• Recognise that dietetic services, psychological support, physical-activity instruction, and occupational therapy are not reimbursed under the legislation described and may require hospital- or network-based support.[6]
• Provide that therapeutic education does not determine the reimbursement rate for disease-related acts or medicines; authorised programmes of regional health agencies may provide an implementation route.[7]
• Include reimbursable or support-related categories for respiratory equipment and services, such as assisted ventilation, oxygen therapy, aerosol equipment, nutritional products, equipment supply or rental, consumables, installation, and follow-up services.[8][11]
• Reimburse certain nicotine-replacement products and provide an annual package of 150 euros for non-listed nicotine-replacement products until 31 December 2018.[9]

No programme budget, unit cost schedule, total expenditure estimate, financing allocation, resource-mobilisation strategy, quantified funding gap, or economic assumption is specified in the supplied extracts.[1][5][2][6][4][9][10][8][11]