A COPD flare is usually treated with a fast-acting inhaler or nebulized medicine that opens the airways, such as albuterol (salbutamol) or ipratropium. A clinician may also prescribe a short course of steroid tablets, such as prednisone or prednisolone, to reduce airway swelling. Antibiotics are used only when a bacterial infection is suspected. The right choice depends on symptoms, medical history, and how the flare is affecting breathing.
A COPD flare, also called an exacerbation, happens when symptoms of chronic obstructive pulmonary disease suddenly become worse than usual. Breathing may become more difficult, coughing or wheezing may increase, and mucus production may change. Treatment aims to open the airways, reduce inflammation when needed, and treat a possible infection. Some flares can be managed at home with a prescribed treatment plan, while others require hospital care.
Which medicines are used first for a COPD flare?
Fast-acting bronchodilators are commonly the first medicines used to relieve worsening breathlessness and wheezing. Bronchodilators relax the muscles around the airways, helping air move more easily in and out of the lungs. They do not cure COPD, but they can provide short-term relief during a flare.
According to the U.S. National Library of Medicine's MedlinePlus guide to quick-relief COPD medicines, rescue medicines are used when symptoms such as coughing, wheezing, or difficulty breathing occur. Common options include:
- Salbutamol (albuterol): A short-acting beta-2 agonist that relaxes tightened airway muscles and helps improve airflow.
- Ipratropium: A short-acting antimuscarinic medicine that helps prevent airway muscles from tightening.
- Salbutamol or albuterol combined with ipratropium: A combination that uses two types of bronchodilators to help open the airways.
These medicines may be delivered through an inhaler, sometimes with a spacer, or through a nebulizer that turns liquid medicine into a mist. A nebulizer may be useful when a person is having difficulty using an inhaler effectively or needs treatment in a clinical setting. The appropriate medicine, amount, and frequency depend on the person's prescribed plan.
When are steroid tablets needed?
Some COPD flares cause enough airway inflammation to require a short course of an oral corticosteroid, commonly called a steroid. Prednisolone and prednisone are examples. These medicines reduce inflammation in the airways and can help improve breathing during an exacerbation.
The UK National Health Service (NHS) guidance on COPD treatment explains that steroid tablets may be prescribed during a particularly bad flare-up. A short course of around five days is commonly recommended in the guidance, although the exact prescription may vary according to clinical circumstances and local recommendations.
Steroid tablets are not necessary for every flare. A healthcare professional considers how much breathing has worsened, whether everyday activities are affected, the person's medical history, and the potential benefits and risks of treatment. People who have a prescribed rescue supply should follow their written action plan rather than starting tablets in a way that has not been agreed with their healthcare team.
Repeated or prolonged steroid treatment can increase the risk of side effects, including mood changes, weight gain, and weakened bones. A short course can also cause problems in some people, so the prescriber may need to consider other conditions and medicines. Do not extend a course or take extra tablets without medical advice.
Do antibiotics treat every COPD flare?
No. Antibiotics are used when a bacterial infection is suspected, not automatically whenever COPD symptoms worsen. Viral respiratory infections, air pollution, and other irritants can also contribute to a flare, and antibiotics do not treat viruses.
The UK's National Institute for Health and Care Excellence (NICE), in its guidance on antibiotics for acute COPD exacerbations, recommends considering several factors before prescribing an antibiotic. These include the person's overall symptoms, whether the amount or thickness of mucus has increased, whether its colour has changed, previous exacerbations, and the risk of complications or antibiotic resistance.
When an antibiotic is appropriate, the clinician selects the medicine based on the suspected infection, previous test results when available, allergies, other medicines, and local prescribing guidance. Antibiotic treatment is usually taken by mouth when the person can take oral medicines and does not need intravenous treatment.
A change in mucus colour alone does not establish that a bacterial infection is present. Similarly, worsening breathlessness can have causes other than a bacterial infection. Taking antibiotics unnecessarily can cause side effects, such as diarrhoea, and contributes to antibiotic resistance. If an antibiotic has been prescribed and symptoms worsen rapidly, the person becomes very unwell, or improvement does not begin within the timeframe agreed with the clinician, medical advice is needed.
Should regular COPD inhalers be continued during a flare?
Regular maintenance inhalers are different from fast-acting rescue medicines. Long-acting bronchodilators help keep the airways open over time, while some combination inhalers also contain an inhaled corticosteroid to reduce airway inflammation. These medicines are generally used according to a daily schedule to control COPD and help prevent future problems.
MedlinePlus information on COPD control medicines explains that maintenance medicines are intended for regular use rather than as a substitute for quick-relief treatment during a flare. In most cases, people should continue their prescribed maintenance medicines unless their healthcare professional advises otherwise. The clinician may review the treatment plan if exacerbations continue or existing medicines are not providing enough relief.
Do not assume that every inhaler works as a rescue medicine. Some long-acting inhalers are designed for regular use and may not provide the rapid relief needed during a flare. If it is unclear which inhaler is intended for immediate symptoms, a pharmacist, doctor, or respiratory nurse can help clarify the plan.
What if inhalers and tablets are not enough?
A more serious COPD flare may require assessment and treatment in a hospital. Bronchodilators may be given through a nebulizer, and corticosteroids may be given by mouth or through a vein, depending on the person's condition and ability to take oral medicine. Supplemental oxygen may be needed when blood oxygen levels are low. Some people also need breathing support through a mask or another form of assisted ventilation.
The National Heart, Lung, and Blood Institute (NHLBI) guidance on COPD symptoms and flare-ups advises seeking emergency care for serious warning signs, including difficulty catching the breath or talking, blue or gray lips or fingernails, reduced alertness, or symptoms that are not responding to the recommended treatment. These problems should not be managed by repeatedly taking extra doses at home.
Prompt assessment is also important when breathlessness is getting worse, a fever develops, or coughing and mucus changes persist. A clinician may need to check for an infection or another problem that requires different treatment.
How should you use a COPD flare action plan?
A written COPD action plan helps a person understand what to do when symptoms change. It should identify the prescribed rescue inhaler, explain when to contact the healthcare team, and state whether a supply of steroid tablets or antibiotics has been provided for specific circumstances.
Some people are given a home supply of these medicines because they have a history of exacerbations. However, the presence of a medicine at home does not mean it should be taken for every change in breathing. Use standby antibiotics or steroid tablets only when the written plan or treating clinician's instructions say they are appropriate for the current situation.
Keep track of how often rescue medicine is needed and whether it is helping. Needing it more frequently than usual, obtaining little relief, or experiencing repeated flares may mean the treatment plan needs review. A healthcare professional can check inhaler technique, assess possible triggers, and decide whether a change in long-term treatment is appropriate.
Seek emergency medical care if breathing becomes extremely difficult, speaking is difficult because of breathlessness, the lips or skin around the nails turn blue or gray, or a person becomes confused or unusually drowsy. Do not delay emergency care while waiting for home medicines to work.