• Assess the severity of the exacerbation. The following physical signs are features of a severe exacerbation:
• Marked dyspnoea and tachypnoea.
• Pursed-lip breathing.
• Use of accessory muscles at rest.
• Acute confusion.
• New-onset cyanosis or peripheral oedema.
• Marked reduction in activities of daily living.
• Consider the need for hospital admission.
• Do not send sputum samples for culture routinely.
• Assess oxygen saturation using pulse oximetry.

• Most people with an exacerbation can be managed at home. However, some people need hospital admission for interventions that are not available at home such as oxygen, nebulizers, intravenous antibiotics, or ventilation.
• Consider hospital admission if any of the following are present:
• Severe breathlessness, rapid onset, confusion, cyanosis, worsening peripheral oedema, or impaired consciousness.
• The person is unable to cope or lives alone.
• Their general condition is poor or deteriorating (poor activity, confined to bed, or on long-term oxygen therapy).
• Significant comorbidity (particularly cardiac disease or type 1 diabetes mellitus).
• A low oxygen saturation (less than 90%).
• Ensure that pulse oximetry is available.
• New acute changes on chest x-ray, if requested and available locally and urgently. X-ray is mainly requested mainly to exclude alternative or concomitant diagnoses, for example bronchopneumonia.
• Hospital-at-home schemes, provided by community respiratory teams, may be available in some areas and are an alternative to hospital admission.
• Follow locally agreed care pathways.
• Data are insufficient to make firm recommendations about which patients with an exacerbation are most suitable for hospital-at-home.
• Hospital-at-home schemes may be suitable for people with few of the above indications for hospital admission who prefer treatment at home.
• Whilst awaiting transfer to hospital, check oxygen saturation on air in people with a severe acute exacerbation and give oxygen (if available) if less than 90%. If available, refer to local protocols. If local protocols are unavailable:
• Follow instructions on an oxygen alert card (if the person has been given one because of a previous episode of hypercapnic respiratory failure).
• If the person does not have an oxygen alert card, use a 28% Venturi mask at a flow rate of 4 L/min, and aim for an oxygen saturation of 88–92%.
• If the oxygen saturation remains below 88% despite a 28% Venturi mask, change to nasal cannulae at 2–6 L/min or a simple mask at 5 L/min with target saturation of 88–92%. In this situation, request an emergency ambulance and alert the accident and emergency department or medical admissions unit that the patient requires immediate senior assessment on arrival.
• If the oxygen saturation decreases after commencing oxygen, change to a 24% Venturi mask at a flow rate of 2 L/min.

• Advise the person to take increased doses or increase the frequency of use of short-acting bronchodilators, for example by doubling the dose or frequency of use.
• Advise the person to keep to the same delivery system (inhaler with spacer or nebulizer) during an exacerbation as is used on a day-to-day basis, if possible. Explain that both delivery systems (inhaler and spacer or nebulizer) are equally effective, and hospitals use nebulizers mainly for convenience.
• If a person does not usually use a spacer device, recommend using one, as they may find it easier to use and it will help to deliver a maximum dose.
• If the person is likely to become fatigued, a nebulizer may be more appropriate.
• Prescribe systemic corticosteroids for people with a significant increase in breathlessness that interferes with daily activities.
• Prescribe prednisolone 30 mg orally once daily for 7–14 days.
• Consider osteoporosis prophylaxis for people requiring frequent courses of oral corticosteroids. See the CKS topic on Osteoporosis - preventing steroid-induced.
• See the sections on Contraindications and cautions, Adverse effects, Drug interactions, and Monitoring in the CKS topic on Corticosteroids - oral.
• Prescribe oral antibiotics for people with a history of more purulent sputum or clinical signs of pneumonia. Consult local antibiotic prescribing guidelines.
• Initial empirical treatment should usually be:
• Amoxicillin 500 mg three times daily for 5 days or a tetracycline (for example doxycycline 200 mg on the first day then 100 mg once daily, for a total of 5 days).
• If the person is allergic to penicillin and doxycycline is contraindicated, prescribe a macrolide (for example erythromycin 500 mg four times daily or clarithromycin 500 mg twice daily for 5 days).
• If the person has antibiotic resistance risk factors (comorbid disease, severe COPD, frequent exacerbations, or antibiotic use in the past 3 months), prescribe co-amoxiclav 625 mg three times daily for 5 days.

• Follow up all people who have had an exacerbation of COPD when they are clinically stable (for example, 6 weeks after the onset of symptoms of the exacerbation).
• At follow up:
• Manage any residual or changed symptoms.
• Optimize medical treatment to reduce the risk of further exacerbations. See Drug treatment and Referral in Scenario: Stable COPD.
• Consider referral or re-referral to pulmonary rehabilitation. See Referral for pulmonary rehabilitation in Scenario: Stable COPD.
• Review the self-management plan. See Self-management plan in Scenario: Stable COPD.
• Check for any problems arising with medications. See Advice about medications in Scenario: Stable COPD.

For information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).