COPD flare-up and breathing support: oxygen, non-invasive ventilation and hospital care

COPD, or chronic obstructive pulmonary disease, is the name for a group of lung conditions that cause breathing difficulties, including emphysema and chronic bronchitis. The NHS says the main symptoms are shortness of breath, a persistent chesty cough with phlegm, frequent chest infections and persistent wheezing. These tend to get worse gradually over time.

A flare-up, or exacerbation, is when symptoms suddenly worsen. The NHS says that it is common to have a few a year, particularly during winter. The NHS lists becoming more breathless, coughing more and a change in the colour or consistency of phlegm as signs of a chest infection, for which a doctor may prescribe a short course of antibiotics.

Most flare-ups are treated at home or by the GP surgery. A smaller number are severe enough to need hospital care. This page is about that second group, and about the breathing support that may be used there.

The NHS describes several treatments that are used in a flare-up. A particularly bad flare-up may be treated with a short course of steroid tablets to reduce inflammation in the airways, usually 5 days, because long-term use can cause side effects such as weight gain, mood swings and weakened bones. A doctor may give you a supply of steroid tablets or antibiotics to keep at home and start as soon as symptoms begin, as part of an agreed plan.

Antibiotics are prescribed for signs of a chest infection. Inhalers are used to make breathing easier, and nebulised medicine, in which a machine turns liquid medicine into a fine mist that you breathe in through a mouthpiece or face mask, may be used in severe cases if inhalers have not worked.

If you have a COPD action plan or rescue pack, follow it and let your GP surgery know you have started it. If you do not have one, a review after any flare-up is a good moment to ask about it.

The NHS pages on COPD do not set out a numbered checklist of emergency signs, so it is sensible to rely on your own COPD care plan and your clinical team for individual thresholds. In general, breathlessness that is much worse than usual and not settling with your usual inhalers, new confusion or drowsiness, blue lips, chest pain or being unable to speak in sentences are reasons to seek emergency help by calling 999 rather than waiting for a routine appointment.

The NHS explains that if you are taken to hospital because of a bad flare-up you may have non-invasive ventilation. In hospital the treatments described by the NHS, such as oxygen, nebulised medicine, steroids and antibiotics, can be given alongside ventilatory support when it is needed.

The NHS describes NIV as a portable machine connected to a mask that covers your nose or face, used to support your lungs and make breathing easier. It is called non-invasive because it works through a mask rather than a tube placed in the windpipe.

NICE quality standard QS10 is specific about when it is expected: people with an acute exacerbation of COPD and persistent acidotic hypercapnic ventilatory failure that is not improving after 1 hour of optimal medical therapy should have non-invasive ventilation. In plain terms, this means that the blood has become too acidic because carbon dioxide is building up, and that this has not improved despite the best drug treatment and oxygen given in the first hour.

The NHS and NICE sources used for this page do not describe how long NIV is used or how it is set up, so the details, including how long the mask is worn, are decided by the hospital team looking after you and are best discussed with them.

After a severe flare-up your breathing and strength may take time to return. NICE says pulmonary rehabilitation should be made available to appropriate people with COPD, including those who have had a recent hospitalisation for an acute exacerbation. The NHS describes it as a programme usually involving 2 or more group sessions a week for at least 6 weeks, with exercise training, education, dietary advice and psychological support.

NICE says that a severe exacerbation requiring hospitalisation is one of the reasons to consider changing or adding inhaled treatments, so it is worth asking for your inhalers to be reviewed. The NHS says that if you smoke, stopping is the most effective way to prevent COPD getting worse and that it is never too late.

If you are unable to exercise during a bad flare-up, the NHS says you may be offered electrical stimulation to strengthen weak muscles.

A small number of people need breathing support beyond a hospital stay. The NHS says that if COPD causes a low level of oxygen in the blood, you may be advised to have oxygen at home, used for at least 15 hours a day, and that you must not smoke when using oxygen because it is highly flammable. NICE says long-term oxygen should not be offered to people who continue to smoke despite support to stop, because of the risks of fires and burns.

NICE also says that people who are adequately treated but have chronic hypercapnic respiratory failure and needed assisted ventilation, whether invasive or non-invasive, during an exacerbation, or who are hypercapnic or acidotic on long-term oxygen, should be referred to a specialist centre to consider long-term non-invasive ventilation. This is a decision made by a specialist team after assessment rather than a routine step.

The NHS says the outlook for COPD varies from person to person. The damage to the lungs is permanent, but treatment can help slow the condition and control symptoms. Some people continue to get worse despite treatment, which is why NICE lists the severity and frequency of exacerbations and hospital admissions among the factors to think about when discussing prognosis.

Ways to reduce the chance of further flare-ups include stopping smoking, using inhalers as prescribed, attending pulmonary rehabilitation and having a clear action plan. NICE says that people who have a severe exacerbation requiring hospitalisation, or 2 moderate exacerbations within a year, may be offered changes to their inhaled treatment. Anyone with symptoms that keep returning should talk to their GP or COPD nurse rather than waiting for the next episode.

Emergency treatment of a COPD flare-up, including NIV, is provided through the NHS, with admission to a ward that has the equipment and trained staff. Long-term follow-up usually involves the GP, a practice or community respiratory nurse and, for more severe disease, a hospital respiratory team. A private respiratory consultant can be consulted for a second opinion on long-term treatment, but acute breathing emergencies are managed through 999 and A&E.