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COPD exacerbation

Emergencies

Controlled oxygen: target 88–92% (24% or 28% Venturi) until a gas shows CO₂ is normal.

Prednisolone 30 mg for 5 days. Antibiotics only if sputum is purulent or there is pneumonia.

Act now

  1. 1

    Sit up; 24% or 28% Venturi oxygen to 88–92%.

  2. 2

    Nebulised salbutamol and ipratropium, driven by air if CO₂ is raised.

  3. 3

    Arterial blood gas.

  4. 4

    Prednisolone 30 mg orally.

Assess

  • ABCDE: RR, SpO₂, work of breathing, drowsiness or flap (CO₂ retention).
  • Usual baseline: exercise tolerance, home oxygen, previous NIV or ICU. Check for a ReSPECT form or ceiling of care.
  • Other causes: pneumothorax, pneumonia, PE, heart failure.

Investigations

  • ABG (repeat 30–60 minutes after any oxygen change), CXR, ECG, FBC, U&E, CRP; sputum culture if purulent; theophylline level if on it.

Manage

  • Antibiotics if purulent sputum or consolidation — follow local policy.
  • Respiratory acidosis (pH under 7.35 and PaCO₂ over 6.5 kPa) persisting despite optimal treatment: NIV.
  • IV aminophylline only with senior input if response to nebulisers is inadequate.
  • Agree a ceiling of care early, ideally with the patient.

Escalate when

  • Needing NIV, pH under 7.25, drowsy, or tiring: senior and critical care.

Doses and prescribing

Salbutamol

2.5–5 mg nebulised, repeated as needed.

Ipratropium bromide

500 micrograms nebulised up to 4 times daily.

Prednisolone

30 mg oral once daily for 5 days.

Amoxicillin

500 mg oral 3 times daily for 5 days (or doxycycline or clarithromycin if allergic) when antibiotics are indicated.

Check the BNF and your local formulary before prescribing.

Written to current guidance (NICE NG115) · sources checked 14 Nov 2026. We watch NICE for updates weekly.

Sources (3)

Reviewed by Aboodee Alhasso, MPharm MRCPharm IP on 14 Nov 2026

Calculators for this

For healthcare professionals, as an aid to clinical judgement — not a substitute for it. Follow your local policy and ask a senior when in doubt.