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Home management of a COPD exacerbation runs in a fixed order: non-pharmacological strategies first and throughout, then more reliever, then — only if there is no improvement — a short course of prednisolone, antibiotics, or both. The two drugs have two different triggers: prednisolone for escalating breathlessness, antibiotics for signs of infection. They are not a pair. Knowing the order tells you where your session sits, and the escalation thresholds tell you when to stop treating and start phoning.1
The Lung Foundation Australia Improving COPD Exacerbation Algorithm is a one-page primary care guide to managing an exacerbation at home, designed to sit alongside the patient's own COPD Action Plan, and aligned with the COPD-X guidance that Australian primary care already works to.1,2 It is written for prescribers, which is precisely why it is worth a physiotherapist's time: it is the clearest available statement of what the GP is thinking when your patient rings them, and of where non-pharmacological care sits in that thinking.
The answer to the second question is more flattering than most physiotherapists expect. Non-pharmacological management is not a footnote at the end of the algorithm — it is step one, and the algorithm specifies its use at every step, including when the patient is well.1
What counts as an exacerbation
The definition is deliberately based on change rather than absolute severity: an acute change in the patient's baseline dyspnoea, cough and/or sputum that exceeds normal day-to-day variation.1 In the patient's own words, the algorithm lists the signs as:
- More breathless than usual — using more reliever than normal
- Usual activities or exercise feel harder than normal
- Coughing more than usual
- More sputum than usual, or a change in its colour, taste or consistency
The pathway, step by step
Non-pharmacological management — first, and continuing
The algorithm opens here and instructs that these strategies be used at every subsequent step, including when the patient is well.1 The named strategies are:
- Breathing techniques
- A breathlessness episode recovery plan
- Postures and positions
- Airway clearance
- Handheld fan or cool air
- Energy conservation
Every one of those six is core physiotherapy. This is the whole case for physiotherapy involvement in exacerbation management, stated by a prescribing guideline rather than by our own profession — and it is worth quoting to a referrer who is not sure what we would add.
Increase the reliever
Reliever is escalated and repeated as required, up to every 3–4 hours. The algorithm gives three options, and they are alternatives rather than a sequence:1
| Drug | Dose | Device |
|---|---|---|
| Salbutamol | 100 mcg, up to 8 actuations, one at a time | pMDI with a spacer |
| Terbutaline | 500 mcg, 1–2 actuations | Dry powder inhaler (DPI) |
| Ipratropium | 21 mcg, up to 4 actuations, one at a time | pMDI with a spacer |
One at a time and with a spacer are not incidental details. Eight actuations fired in quick succession into a spacer, or without one, do not deliver eight doses.
If not improving after about 2–3 days — consider a short course
This is the step most often misunderstood, because the two medicines answer two separate questions:1
| Medicine | Trigger | Course |
|---|---|---|
| Prednisolone | Escalating dyspnoea — worsening breathlessness that is significantly limiting usual daily activities | Oral, 30–50 mg daily for 5 days |
| Antibiotics | Signs of infection — increased sputum volume and/or purulence, with or without fever | Oral amoxicillin or doxycycline for 5 days |
A patient can legitimately receive one, the other, both or neither. Breathlessness without a sputum change does not call for an antibiotic; a purulent sputum change without escalating dyspnoea does not automatically call for prednisolone. Both courses are five days — longer courses and tapers are not part of this pathway.
If still not improving after about 1–2 days — priority review
Failure to improve on the short course triggers a same-day or urgent GP appointment, not a longer course at home.1 If a patient tells you they finished the prednisolone days ago and feel no better, the algorithm's answer is a review today.
If improving — complete, step down, review
The improving path is not simply “stop”. It is: complete the treatment course, step the reliever back down, then attend a follow-up review at which the GP is directed to:1
- Document the exacerbation in the clinical record
- Review inhaler technique and adherence
- Reinforce the COPD Action Plan
- Consider suitability for a rescue pack
- Consider stepping up maintenance therapy, or referring, if exacerbations are frequent or severe — for instance where they have led to hospitalisation or an emergency department presentation
Signs of emergency — the thresholds that end the session
The algorithm routes these straight to hospital, bypassing the steps above:1
- Sudden, severe worsening breathlessness
- Confusion, slurred speech or drowsiness
- Cyanosis — blue or grey lips or fingers
- SpO2 below 92%, or below the patient's own baseline
- Any major concerning features
- Not responding to outpatient treatment
Note the second one. Confusion, slurred speech and drowsiness in a patient with COPD may indicate hypercapnia, and a drowsy patient who seems to be settling is not settling. It is the sign most easily mistaken for improvement.
Rescue packs — and the four conditions
Prednisolone and antibiotics may be self-initiated where a rescue pack has been prescribed as part of a COPD Action Plan. The algorithm sets four criteria, and the patient must meet all of them:1
- Identify the signs of exacerbations and infections; and
- Understand when to initiate and complete a 5-day course of one or both medications; and
- Follow an individualised self-management plan agreed with their clinician; and
- Inform their healthcare professional when starting one or both medications — so the exacerbation is documented and a follow-up review is scheduled
Those four are an assessment, not a formality, and the first two are testable in a physiotherapy session in a way they often are not in a ten-minute consultation. A patient who cannot describe what would make them open the pack does not yet meet criterion one; a patient who took three days of prednisolone and stopped when they felt better does not meet criterion two.
Where a physiotherapist changes the outcome
Four points, drawn from the algorithm rather than from advocacy:
| Point in the pathway | What we contribute |
|---|---|
| Before it starts | All six named non-pharmacological strategies are physiotherapy, and the algorithm asks for them when the patient is well — a breathlessness recovery plan rehearsed in advance is worth more than one explained mid-episode.1 |
| Recognition | Falling exercise tolerance and rising reliever use are exacerbation criteria we measure and the GP does not see between visits.1 |
| Delivery | Up to eight actuations, one at a time, through a spacer, while acutely breathless. Technique review is explicitly on the follow-up list.1 |
| Preventing the next one | Frequent or severe exacerbations trigger a therapy step-up or referral. Rehabilitation after an exacerbation reduces readmission and improves quality of life, and is most effective started early.3,4 |
What this page is not
It is a guide to reading a prescribing pathway, not to using one. Physiotherapists in Australia do not prescribe prednisolone or antibiotics, and nothing here changes that. The doses are reproduced so that you can recognise what your patient has been given and whether they are taking it as intended — a five-day course that stopped on day three is a clinically relevant finding you can act on by picking up the phone.
The algorithm itself carries two limits worth repeating: it presents a selective list of PBS-subsidised medicines aligned with COPD-X guidance, and it is a general guide rather than a substitute for individual medical advice.1,2
Related reading
- COPD and COPD — clinical evidence — the condition, and what the trial evidence supports.
- Recognising a Flare-up — the same territory written for patients.
- Understanding Your Rescue Pack — the patient-facing companion to the self-initiation criteria.
- Steroids and Antibiotics — what each course does, and its implications for a session.
- Cardiorespiratory Rehabilitation — the intervention behind the “prevent the next one” step.
- Getting Your Inhaler Technique Right — and the device-by-device guides.
References & evidence base
- Lung Foundation Australia. Improving COPD Exacerbation Algorithm. FS0126V2. Brisbane: Lung Foundation Australia; 2026.
- Yang IA, George J, McDonald CF, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.78, October 2025 — a living guideline, revised quarterly. Brisbane: Lung Foundation Australia and Thoracic Society of Australia and New Zealand. Accessed 16 August 2026 at copdx.org.au
- Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD. GOLD; 2026.
- Puhan MA, Gimeno-Santos E, Cates CJ, Troosters T. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2016;(12):CD005305.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Corrections: If something on this page is wrong, out of date or unclear, we want to know. Email reception@inspireclinic.au with the page name and what you believe is incorrect. Substantive corrections are made promptly, and the guide’s version and last-updated date are changed to reflect it.