Chronic obstructive pulmonary disease

Red Flags

Acute COPD exacerbation with severe respiratory acidosis (pH <7.35) — non-invasive ventilation; ICU if pH <7.25 or contraindicated^[1]
Pneumothorax in COPD — emergency intervention; tension pneumothorax requires immediate decompression^[1]
COPD with cor pulmonale features — echocardiography; consider long-term oxygen therapy if PaO₂ ≤55 mmHg^[1]
Younger COPD patient (<40 years) or basal-predominant emphysema — alpha-1 antitrypsin testing; family screening^[1]

Smoking and biomass-fuel cessation^[1]
Single most effective intervention; behavioural support plus pharmacotherapy. Avoid biomass cooking-fuel smoke exposure (significant cause of non-smoking COPD)
Pulmonary rehabilitation^[1]
Structured exercise + education + nutrition; reduces dyspnoea and improves QoL
Vaccination^[1]
Annual influenza, pneumococcal, COVID-19; pertussis booster

Drug	Class	Adult	Paediatric	Notes
Tiotropium (LAMA)^[1]	Long-acting muscarinic antagonist	18 mcg DPI once daily	—	First-line maintenance for symptomatic COPD; widely available; cost-effective
Formoterol-budesonide (LABA-ICS)^[1]	Combination inhaler	6/200 mcg DPI 1 puff BD	—	Step up when exacerbations frequent; ensure TB ruled out before starting ICS
Indacaterol/glycopyrronium (LABA/LAMA)^[1]	Combination LABA/LAMA	85/43 mcg DPI once daily	—	Step up from monotherapy when symptomatic on LAMA alone
Salbutamol^[1]	Short-acting beta-agonist (SABA)	100 mcg pMDI 2 puffs PRN	—	Rescue inhaler for breakthrough symptoms
Prednisolone (exacerbation)^[1]	Oral glucocorticoid	30–40 mg PO once daily × 5 days	—	Acute exacerbation; reduces relapse and accelerates recovery
Amoxicillin or doxycycline (exacerbation)^[1]	Oral antibiotic	Amoxicillin 500 mg TID or doxycycline 100 mg BD × 5 days	—	Acute exacerbation with sputum purulence increase

Tiotropium (LAMA)^[1]

Long-acting muscarinic antagonist

First-line maintenance for symptomatic COPD; widely available; cost-effective

Formoterol-budesonide (LABA-ICS)^[1]

Combination inhaler

Step up when exacerbations frequent; ensure TB ruled out before starting ICS

Indacaterol/glycopyrronium (LABA/LAMA)^[1]

Combination LABA/LAMA

Step up from monotherapy when symptomatic on LAMA alone

Salbutamol^[1]

Short-acting beta-agonist (SABA)

Rescue inhaler for breakthrough symptoms

Prednisolone (exacerbation)^[1]

Oral glucocorticoid

Acute exacerbation; reduces relapse and accelerates recovery

Amoxicillin or doxycycline (exacerbation)^[1]

Oral antibiotic

Acute exacerbation with sputum purulence increase

Take maintenance inhalers every day even when breathing well — they prevent flares; rescue inhaler is for breakthrough symptoms only^[1]
Increased breathlessness, change in sputum colour or volume, fever — start rescue plan and contact clinician same day^[1]
Avoid biomass cooking smoke and tobacco smoke — both worsen COPD progression^[1]

Severe acute exacerbation requiring NIV or invasive ventilationEmergency department / respiratory or ICU^[1]
Frequent exacerbations (≥2/year) despite optimal triple therapyPulmonology for phenotype-driven add-ons (azithromycin, roflumilast)^[1]
Suspected alpha-1 antitrypsin deficiency or other rare COPD aetiologyPulmonology specialist centre^[1]

Diagnosis and stepped management of COPD — Indian Chest Society / NCCP perspective with primary-care-focused workflow and inhaler choices.

1.Indian Chest Society and National College of Chest Physicians (India) — Recommendations for the Diagnosis and Management of Chronic Obstructive Pulmonary Disease (2022)