Red Flags
- Acute COPD exacerbation with severe respiratory acidosis (pH <7.35) — non-invasive ventilation; ICU if pH <7.25 or contraindicated[1]
- Eosinophilic exacerbation phenotype (blood eosinophils ≥0.3) — ICS-containing therapy reduces exacerbations[1]
- Pneumothorax in COPD — emergency intervention; tension pneumothorax suspected on low SpO₂ + tracheal deviation[1]
- Cor pulmonale or pulmonary hypertension features — echocardiography; consider long-term oxygen therapy if PaO₂ <7.3 kPa[1]
First-line treatment
Interventions
- Smoking cessation[1]Single most effective intervention; behavioural support plus pharmacotherapy (NRT, varenicline, bupropion); reduces lung-function decline rate
- Pulmonary rehabilitation[1]Structured supervised exercise + education + nutrition; reduces dyspnoea, improves exercise tolerance and QoL; offer at MRC ≥2 dyspnoea
- Long-term oxygen therapy (LTOT)[1]PaO₂ ≤7.3 kPa OR ≤8 kPa with cor pulmonale, polycythaemia, or peripheral oedema; ≥15 hours/day
- Vaccination[1]Annual influenza, pneumococcal (PCV13/PPSV23), COVID-19; pertussis booster
First-line drug therapy
| Drug | Class | Adult | Paediatric | Notes |
|---|---|---|---|---|
| Tiotropium (LAMA)[1] | Long-acting muscarinic antagonist (LAMA) | 18 mcg DPI once daily OR 2.5 mcg respimat 2 puffs daily | — | First-line maintenance for symptomatic COPD; reduces exacerbations and improves lung function |
| Indacaterol/glycopyrronium (LABA/LAMA)[1] | Combination LABA/LAMA | 85/43 mcg DPI once daily OR umeclidinium/vilanterol 62.5/25 mcg DPI once daily | — | Step up from monotherapy when symptomatic on LAMA alone or with frequent exacerbations |
| Beclomethasone/formoterol/glycopyrronium (LABA/LAMA/ICS)[1] | Triple combination inhaler | Per device — 2 puffs BD typical | — | Add ICS to LABA/LAMA if blood eosinophils ≥0.3 OR ≥1 severe exacerbation/year despite dual therapy |
| Salbutamol[1] | Short-acting beta-agonist (SABA) | 100 mcg pMDI 2 puffs PRN | — | Rescue inhaler for breakthrough symptoms; combine with ipratropium during exacerbations |
| Prednisolone (exacerbation)[1] | Oral glucocorticoid | 30 mg PO once daily × 5 days | — | Acute exacerbation; reduces relapse and accelerates recovery |
| Amoxicillin or doxycycline (exacerbation)[1] | Oral antibiotic | Amoxicillin 500 mg PO TID OR doxycycline 200 mg load then 100 mg PO BD × 5 days | — | Acute exacerbation with sputum purulence increase + sputum volume increase or breathlessness; choose per local resistance |
Tiotropium (LAMA)[1]
Long-acting muscarinic antagonist (LAMA)
- Adult
- 18 mcg DPI once daily OR 2.5 mcg respimat 2 puffs daily
- Paediatric
- —
First-line maintenance for symptomatic COPD; reduces exacerbations and improves lung function
Indacaterol/glycopyrronium (LABA/LAMA)[1]
Combination LABA/LAMA
- Adult
- 85/43 mcg DPI once daily OR umeclidinium/vilanterol 62.5/25 mcg DPI once daily
- Paediatric
- —
Step up from monotherapy when symptomatic on LAMA alone or with frequent exacerbations
Beclomethasone/formoterol/glycopyrronium (LABA/LAMA/ICS)[1]
Triple combination inhaler
- Adult
- Per device — 2 puffs BD typical
- Paediatric
- —
Add ICS to LABA/LAMA if blood eosinophils ≥0.3 OR ≥1 severe exacerbation/year despite dual therapy
Salbutamol[1]
Short-acting beta-agonist (SABA)
- Adult
- 100 mcg pMDI 2 puffs PRN
- Paediatric
- —
Rescue inhaler for breakthrough symptoms; combine with ipratropium during exacerbations
Prednisolone (exacerbation)[1]
Oral glucocorticoid
- Adult
- 30 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 PO TID OR doxycycline 200 mg load then 100 mg PO BD × 5 days
- Paediatric
- —
Acute exacerbation with sputum purulence increase + sputum volume increase or breathlessness; choose per local resistance
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 your rescue plan and contact your clinician same day[1]
- Sudden severe breathlessness with chest pain — call emergency services (could be pneumothorax, PE, MI, or severe exacerbation)[1]
Referral criteria
- Severe acute exacerbation requiring NIV or invasive ventilationEmergency department / respiratory or ICU[1]
- Frequent exacerbations (≥2/year) despite optimal triple therapyRespiratory medicine for phenotype-driven add-ons (azithromycin, roflumilast, dupilumab in eosinophilic)[1]
- Suspected alpha-1 antitrypsin deficiency, lung volume reduction candidacy, or transplant assessmentRespiratory medicine specialist centre[1]
Clinical summary
Diagnosis, inhaler therapy, and exacerbation management of COPD per NICE guidance, with bronchodilator-anchored stepped therapy.