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.
Key red flags
Worsened breathlessness/cough/sputum requiring short-acting bronchodilator increase and often oral steroid or antibiotic, without life-threatening physiological disturbance.
Investigation priorities
Grade immediate risk and decide location of care.
Management branches
Hospital-level exacerbation or significant physiological disturbance.
- Use ABCDE, controlled oxygen to 88-92%, monitoring and early blood gas. Call senior help for confusion, exhaustion, severe acidosis or haemodynamic instability.
- 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.
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.
Salbutamol plus ipratropiumSalbutamol 2.5-5 mg nebulised plus ipratropium 500 micrograms nebulised; repeat bronchodilator according to response and monitored protocol.