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]
First-line treatment
Interventions
- 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
First-line drug therapy
| 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
- Adult
- 18 mcg DPI once daily
- Paediatric
- —
First-line maintenance for symptomatic COPD; widely available; cost-effective
Formoterol-budesonide (LABA-ICS)[1]
Combination inhaler
- Adult
- 6/200 mcg DPI 1 puff BD
- Paediatric
- —
Step up when exacerbations frequent; ensure TB ruled out before starting ICS
Indacaterol/glycopyrronium (LABA/LAMA)[1]
Combination LABA/LAMA
- Adult
- 85/43 mcg DPI once daily
- Paediatric
- —
Step up from monotherapy when symptomatic on LAMA alone
Salbutamol[1]
Short-acting beta-agonist (SABA)
- Adult
- 100 mcg pMDI 2 puffs PRN
- Paediatric
- —
Rescue inhaler for breakthrough symptoms
Prednisolone (exacerbation)[1]
Oral glucocorticoid
- Adult
- 30–40 mg PO once daily × 5 days
- Paediatric
- —
Acute exacerbation; reduces relapse and accelerates recovery
Amoxicillin or doxycycline (exacerbation)[1]
Oral antibiotic
- Adult
- Amoxicillin 500 mg TID or doxycycline 100 mg BD × 5 days
- Paediatric
- —
Acute exacerbation with sputum purulence increase
Safety-net
- 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]
Referral criteria
- 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]
Clinical summary
Diagnosis and stepped management of COPD — Indian Chest Society / NCCP perspective with primary-care-focused workflow and inhaler choices.