Who / when
- Adults with breathlessness, chronic cough or sputum.
- COPD is likely with: heavy smoking (for example more than 20 cigarettes a day for more than 15 years); long exposure to smoke from burning fuel indoors, or to dust at work; onset after 40; slow worsening over years; daily cough and sputum that started before the breathlessness; symptoms that vary little from day to day.
- Childhood onset, allergies, symptom-free spells: think asthma (see the asthma protocol).
Think of TBWhere TB is common, suspect pulmonary TB in anyone with cough for more than 2 weeks, and test in line with your national programme.
Red flags: refer now
- Breathless at rest, unable to speak in sentences, or exhausted.
- Drowsy or confused.
- Cyanosis, or oxygen saturation that stays low despite treatment.
- Chest pain, low blood pressure, or new swelling of both legs.
- Coughing blood, weight loss or night sweats (also think of TB or cancer).
Severe flare-up: treat and referGive high-dose salbutamol, controlled oxygen and prednisolone (see Treat) and arrange transfer.
Assess
- Ask about tobacco (smoked and smokeless), cooking fuel and ventilation, and dust or fumes at work.
- Measure peak expiratory flow (PEF); give two puffs of salbutamol and measure again after 15 minutes. Improvement under 20% supports COPD; 20% or more suggests asthma.
- Measure PEF and oxygen saturation, if possible, at every visit and during flare-ups.
- Look for signs of infection: fever, more sputum, change in sputum colour.
- Check weight, ankles, pulse and blood pressure, and ask about other long-term conditions.
Classify
| Picture | Classify as | Action |
|---|
| Breathless at rest, drowsy, cyanosed or exhausted | Severe flare-up | Treat now and transfer |
| Breathless at rest | Severe COPD | Full stepwise treatment; review often; consider referral |
| Breathless with normal activity | Moderate COPD | Stepwise treatment |
| Symptoms suggest COPD but PEF improves by 20% or more | Probably asthma | Use the asthma protocol |
Treat
Stepwise relief (WHO PEN)
- Inhaled salbutamol, two puffs when needed, up to four times a day.
- Still troublesome: consider low-dose oral theophylline.
- If ipratropium inhalers are available, they can replace or be added to salbutamol (they cost more).
Flare-up (exacerbation)
- High-dose salbutamol by metered-dose inhaler and spacer (for example 4 puffs every 20 minutes for 1 hour) or by nebuliser.
- Severe flare-up: oral prednisolone 30 to 40 mg daily for about 7 days.
- Oxygen, if available, through a mask that limits the concentration to 24% or 28%.
- Antibiotics for every flare-up with signs of infection; choice and dose per national formulary.
Controlled oxygenPeople with COPD can be harmed by high-flow oxygen. Use a controlled (24 to 28%) mask where you have one, and watch for drowsiness.
Follow-up
- Review regularly: breathlessness, flare-ups since the last visit, inhaler technique, smoking and smoke exposure.
- Measure PEF and saturation if possible; record weight.
- Review within a few days after a flare-up.
Counsel
- Smoking and indoor smoke are the main causes of COPD. Stopping smoking is the most important treatment.
- Avoid dust and tobacco smoke; keep the cooking area well ventilated by opening windows and doors.
- Cook outside if possible, or use a stove with a chimney that takes smoke outside.
- Leave work with heavy dust or air pollution if you can; a mask helps only if it is the right design.
- Know the signs of a flare-up (more breathless, more or discoloured sputum) and come early.
Your lungs have been damaged by smoke. We cannot undo the damage, but stopping all smoke now, and using your inhaler, will help you breathe better and slow it down.
When to refer
- Same day: any red flag, or a flare-up not improving with treatment.
- Diagnosis uncertain, or symptoms that do not fit (weight loss, coughing blood).
- Frequent flare-ups, or breathlessness at rest despite the stepwise plan.
- Signs of heart failure (swollen legs, raised neck veins).
- Low oxygen saturation when well, for assessment for long-term oxygen where available.
Sources
World Health Organization. WHO package of essential noncommunicable (PEN) disease interventions for primary health care. 2020. World Health Organization. Basic emergency care: approach to the acutely ill and injured (WHO and ICRC). 2018. World Health Organization. WHO Model List of Essential Medicines. 2025.