Chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a progressive and debilitating respiratory condition that can be life limiting. It is characterised by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible.

Symptoms of COPD include chronic cough, sputum production and shortness of breath, especially on exertion. These symptoms often worsen over time and lead to functional impairment, social isolation and decreased quality of life.

Admission with a first episode of infective exacerbation of COPD is a serious event.

Mortality rates can be as high as 10% within the first year after an initial hospital admission. Median survival varies considerably depending on disease severity, comorbidities and whether ventilation support or ICU admission is required. Early diagnosis and appropriate management of exacerbations may help reduce hospital admissions, minimise complications and improve outcomes.

Acute exacerbations

A COPD exacerbation is characterised by an acute worsening of symptoms that is more severe than normal day-to-day fluctuations in symptoms. Triggers may be viral and bacterial infections, and exposure to environmental pollutants.

Symptoms include:

• increased breathlessness
• reduced exercise tolerance
• tachypnoea
• fever
• increased cough and sputum production or purulence.

Assessment of severity

If an exacerbation is suspected, assess severity using the patient's medical history and physical examination. In severe cases (FEV1 < 40% predicted), blood gas measurements, chest x-rays and electrocardiography (ECG) may be required.

Classification of COPD severity, by symptoms:

Adapted from: Stepwise Management of Stable COPD, by the Lung Foundation of Australia.

Investigations

Investigations in acute COPD should be guided by clinical severity and likelihood of changing management, rather than performed routinely.

Blood gases

Arterial blood gases provide the most accurate assessment of acidosis, PaO₂ and PaCO₂, although this is not always reasonable in acute presentations.

If arterial blood gas analysis is unavailable, venous blood gas analysis should be used as a screening tool for acute hypercapnic respiratory failure (AHRF) in the emergency care setting.

Consider a diagnosis of AHRF with venous pH < 7.35 and PaCO₂ > 50 mmHg.

Other tests

Chest x-ray and ECG help to identify alternative diagnoses and complications, such as pulmonary oedema, pneumothorax, pneumonia, empyema, arrhythmias, myocardial ischaemia and others.

Management

An exacerbation of COPD may involve an increase in airflow limitation, excess sputum production, airway inflammation, infection, hypoxia, hypercarbia and acidosis. Treatment is directed at each of these problems.

Refer to these Therapeutic Guideline resources:

• COPD exacerbations –  NSW Health login required
• Stable COPD –  NSW Health login required

Admission

Consider hospital admission for a patient with an acute COPD exacerbation, e.g. increased dyspnoea, cough or sputum, plus one or more of the following:

• Inadequate response to initial ED and/or outpatient management, e.g. persistent severe dyspnoea or work of breathing.
• Marked functional decline, e.g. unable to walk between rooms when previously mobile.
• Unable to eat or sleep because of dyspnoea.
• Functional decline and/or unable to perform activities of daily living or manage independently at home.
• Significant comorbidity or suspected complication requiring inpatient care, e.g. pneumonia, pneumothorax, pulmonary oedema or heart failure, myocardial ischaemia, venous thromboembolism, sepsis.
• Altered level of consciousness, confusion or drowsiness (consider hypercapnia and other causes).
• Persistent or worsening hypoxaemia despite controlled oxygen or worsening peripheral oedema or cor pulmonale.
• New arrhythmia or other acute cardiorespiratory instability.
• AHRF, respiratory acidosis or requirement for ventilatory support, e.g. non-invasive ventilation (NIV) or escalation of care.

Discharge

The COPD Action Plan from Lung Foundation Australia is designed to help individuals living with COPD manage the early signs of a flare-up (exacerbation), to help reduce the risk of a severe exacerbation or hospital admission.

Ventilation

• NIV should be administered in an ICU, ED, close observation unit or monitored bed unit, where there is adequate staff with the capability (skills, knowledge and competence) to care for a patient on NIV.
• Patients must be able to maintain protection of their airway prior to initiating NIV.
• Patients must have a clinical indication for NIV to be initiated.

Refer to the clinical practice guide: Non-invasive ventilation for patients with acute respiratory failure.

Clinical indication for NIV

Acute exacerbation of COPD in the context of acute hypercapnic respiratory failure (pH < 7.35 and elevated PaCO₂).

In patients with acute exacerbation of COPD, with a high work of breathing and arterial or venous pH < 7.35, early commencement of NIV is associated with improved outcomes.

Contraindications for NIV

Resources

COPD-X handbook
Guidelines for managing COPD, addressing case finding and confirming diagnosis, optimising function, preventing deterioration, developing a care plan and managing exacerbations.
Source: Lung Foundation Australia

Non-invasive ventilation for patients with acute respiratory failure
This guide supports local health districts and hospitals to develop local procedures and guidelines for NIV for critically ill patients with acute respiratory failure.
Source: Agency for Clinical Innvovation

The COPD Assessment Test (CAT): for healthcare professionals and researchers
A questionnaire for people with COPD, designed to measure the impact of COPD on a person's life, and how this changes over time.
Source: GSK

Chronic obstructive pulmonary disease clinical care standard
This standard aims to reduce preventable hospitalisations and improve overall outcomes for people with COPD, by supporting best practice in the assessment and management of COPD, including exacerbations.
Source: Australian Commission on Safety and Quality in Health Care

Change log

Date	Section updated	Change
August 2026	All	Updated to reflect guidance from updated clinical practice guidelines listed in resources.