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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Acute exacerbation of COPD

Respiratory · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

RapidFull
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Escalate

Confusion, drowsiness, exhaustion, haemodynamic instability, new SpO2 below 88%, severe work of breathing, silent/poor air entry, pH below 7.35 with PaCO2 above 6.5 kPa, or inability to cope at home requires urgent hospital care. pH below 7.25, impending arrest or NIV failure requires immediate critical-care review.

Synopsis

Identify an exacerbation while excluding dangerous alternatives, deliver controlled oxygen and cause-directed treatment, and start NIV promptly when acute hypercapnic acidosis persists.

  • An exacerbation is sustained worsening beyond normal day-to-day variation—typically breathlessness, cough and/or sputum—that requires treatment change; it remains a diagnosis after assessing alternatives.
  • Actively exclude pneumonia, pulmonary embolism, pneumothorax, acute heart failure, ACS/arrhythmia and sedative/opioid effects when features are atypical or severe.
  • Give controlled oxygen to SpO2 88-92% pending blood gases in COPD at risk of hypercapnic respiratory failure; do not withhold oxygen from hypoxaemia.
  • Increase short-acting bronchodilation: salbutamol 2.5-5 mg nebulised or repeated pMDI/spacer; add ipratropium 500 micrograms nebulised in more severe attacks.
  • Give prednisolone 30 mg orally once daily for 5 days when breathlessness significantly increases and interferes with daily activities; do not prolong routinely.
  • Antibiotics are not automatic. Consider them with sputum purulence plus increased volume or breathlessness, severe illness, ventilation need or high complication risk.
  • First-choice oral antibiotic options for 5 days are amoxicillin 500 mg three times daily, doxycycline 200 mg day 1 then 100 mg daily, or clarithromycin 500 mg twice daily; use microbiology history and allergy.
  • If pH remains below 7.35 and PaCO2 above 6.5 kPa after about 1 hour of optimal treatment, start NIV promptly when appropriate with a documented escalation plan.
  • Repeat gases after oxygen/ventilation changes; improvement in pH, respiratory rate and consciousness is more important than normalising chronic PaCO2.
  • Before discharge optimise inhalers, check technique, establish rescue/self-management advice, arrange follow-up and assess rehabilitation, smoking treatment and home-support needs.

    • Key red flags

    Moderate exacerbation

    Worsened breathlessness/cough/sputum requiring short-acting bronchodilator increase and often oral steroid or antibiotic, without life-threatening physiological disturbance.

    Acute hypercapnic respiratory failure

    pH below 7.35 with PaCO2 above 6.5 kPa after initial treatment, often with tachypnoea, fatigue or drowsiness. This is a ventilatory emergency and usually an NIV pathway.

    Pneumonia or pneumothorax

    Focal crackles/bronchial breathing, pleuritic pain/fever or sudden unilateral reduced air entry redirects imaging and management; do not intensify nebulisers alone.

    Cardiac or thromboembolic mimic

    Chest pain, syncope, disproportionate hypoxaemia, calf symptoms, raised JVP/oedema, new arrhythmia or troponin/BNP context suggests PE, ACS or heart failure.

    Unsafe home situation

    Severe baseline disease, rapid onset, poor response, inability to eat/sleep/walk, frailty, inadequate support or diagnostic uncertainty lowers the admission threshold even if initial observations are borderline.

    Investigation priorities

    01
    ABCDE, NEWS2 scale 2, SpO2 and baseline functionFirst step

    Grade immediate risk and decide location of care.

    Management branches

    ImmediateFirst-hour treatment

    Hospital-level exacerbation or significant physiological disturbance.

    1. Use ABCDE, controlled oxygen to 88-92%, monitoring and early blood gas. Call senior help for confusion, exhaustion, severe acidosis or haemodynamic instability.
    2. Give salbutamol 2.5-5 mg nebulised and ipratropium 500 micrograms nebulised, or repeated pMDI/spacer if suitable; use an air-driven nebuliser with separately titrated oxygen in hypercapnic-risk patients where available.
    3. Give prednisolone 30 mg orally and assess antibiotic indication. Obtain CXR, ECG, bloods and targeted microbiology/mimic testing without delaying respiratory support.
    4. Reassess within 1 hour: symptoms, RR, consciousness, SpO2/device, pH/PaCO2 and ability to eat/mobilise; define escalation ceiling and involve respiratory/critical care early if high risk.

    Key medicines

    Controlled oxygen24% Venturi at 2-3 L/min or 28% Venturi at 4 L/min (or nasal cannulae 1-2 L/min) initially, titrated to SpO2 88-92% pending gases unless an individual alert-card target applies.Repeat gases 30-60 minutes after change; increase support if hypoxaemia persists rather than accepting dangerous saturation. Critical illness may require initial high-concentration oxygen before rapid titration.
    Salbutamol plus ipratropiumSalbutamol 2.5-5 mg nebulised plus ipratropium 500 micrograms nebulised; repeat bronchodilator according to response and monitored protocol.Monitor pulse, rhythm, potassium and lactate; ipratropium can worsen glaucoma if aerosol reaches eyes. Transition to hand-held inhalers as recovery permits.
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    Sources and review status5 sources · checked 27 Aug 2026 · clinical review pending+
    Sources

    Sources and review status

    National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

    • NICE NG115: COPD diagnosis and managementExacerbation steroid, oxygen, NIV and discharge principles.
    • NICE NG114: COPD acute exacerbation antimicrobial prescribingAntibiotic indications, choices, doses and 5-day duration.
    • BTS enhanced emergency assessment pathways for asthma and COPDJuly 2026 risk stratification and NIV timing.
    • BTS emergency oxygen guidelineControlled oxygen devices, targets and repeat gases.
    • MHRA fluoroquinolone restrictionsJanuary 2024 restrictions and serious adverse effects.

    Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

    Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom