Smoker, chronic dyspnea, barrel chest
ABCDE Controlled O₂ (88–92%); nebs; steroids ± antibiotic; ABG; NIV for acidotic type-2 failure.
Calculators: news2
Maintenance initiation (GOLD 2026): LABA+LAMA is the preferred initial therapy for exacerbating patients (Group E, ≥1 moderate/severe exacerbation/yr); add ICS to LABA+LAMA if blood eosinophils ≥300/µL. Ipratropium is for acute nebulized use, not chronic monotherapy
Exacerbation: Bronchodilators + Prednisone 40 mg ×5 d + Antibiotic (azithromycin/doxycycline) + controlled O₂ (SpO₂ 88–92%) + BiPAP
Decision tree Respiratory acidosis (pH <7.35, rising CO₂)?
Yes NIV appropriate (conscious, airway protected)?
Yes NIV + nebs + steroids + controlled O₂; reassess gases
No Nebs + steroids ± antibiotic + controlled O₂ (88–92%)
Order set ABG CXR Salbutamol + ipratropium Steroids + antibiotic if indicated Controlled O₂ (88–92%) Consider NIV Escalate / ICU pH <7.35 with rising PaCO₂ NIV failure or contraindicated ↓GCS, hemodynamic instability Criteria Admit Exacerbation with acidosis, hypoxia, or comorbidity
ICU NIV failure, ↓GCS, instability
Intubate NIV failure / contraindicated / severe acidosis
Ventilate Type-2 failure not responding to NIV
Discharge Back to baseline function/gases, on inhalers/steroids ± home O₂, plan
Key Only smoking cessation + home O₂ (PaO₂≤55/SpO₂≤88%) reduce mortality. Rome criteria (GOLD 2026): severe exacerbation = PaO₂ ≤60 and/or PaCO₂ >45 with pH <7.35. Post-severe exacerbation: triple therapy + structured discharge bundle; dupilumab if eosinophilic COPD (BEC ≥300/µL). Clinical detail — differentials, red flags, pitfalls, disposition Red flags pH <7.35 rising CO₂ ↓GCS Haemodynamic instability Differentials Heart failure Pneumonia PE Pneumothorax Common mistakes Uncontrolled high-flow O₂ Delaying NIV Disposition & follow-up NIV for acidotic type-2 failure; ICU if failing.
Discharge package Medications Inhalers ± steroid course/antibiotic; consider home O₂ assessment
Follow-up Respiratory review; pulmonary rehab
Vaccination Influenza + pneumococcal
Lifestyle Smoking cessation essential
Warning symptoms Worsening breathlessness, purulent sputum, fever, drowsiness
💊 Treatment detail — doses & preparation Salbutamol (albuterol) SABA
Dose Nebuliser 2.5–5 mg q15–20 min ×3 then q1–4h; MDI 2–10 puffs via spacer
Preparation 2.5/5 mg nebules + O₂-driven nebuliser at 6–8 L/min
Monitor HR, tremor, K⁺ (shifts intracellularly — used in hyperK), SpO₂
Ipratropium bromide SAMA
Dose 500 mcg nebulised q4–6h (acute severe asthma/COPD)
Preparation 500 mcg nebules; MDI 20 mcg/puff 2 puffs QID maintenance
Monitor Dry mouth, glaucoma caution (mask seal)
Tiotropium LAMA
Dose 18 mcg inhaled OD (HandiHaler) or 2.5 mcg ×2 puffs OD (Respimat)
Preparation Dry-powder capsule — inhale only, never swallow
Monitor COPD control step-up; urinary retention/glaucoma caution
Prednisolone corticosteroid
Dose Flares: 40 mg OD ×1–2 wk then taper over 6–8 wk; COPD/asthma: 40–50 mg ×5 d (no taper)
Preparation 5/25 mg tablets; gastro-resistant or plain with food
Monitor Glucose, BP, mood; bone protection if >3 mo (Ca²⁺/D ± bisphosphonate)
Amoxicillin/doxycycline exacerbation antibiotic
Dose Amoxicillin 500 mg TDS ×5 d (or doxycycline 100 mg BD) — only if purulent sputum/increased dyspnoea
Preparation Capsules/tablets
Monitor Response at 48–72 h
📖 GOLD COPD Reviewed July 2026