Assess the severity of the exacerbation by taking a detailed history and performing a physical examination, including checking for signs of life-threatening features such as cyanosis, drowsiness, or exhaustion, and measuring oxygen saturation if possible NICE CKS.
Administer controlled oxygen to adults and high-flow oxygen to children, aiming for an oxygen saturation of 94–98%, without delaying treatment if pulse oximetry is unavailable NICE CKS.
Give nebulised salbutamol (5 mg if over 5 years, 2.5 mg if 2–5 years) preferably via oxygen-driven nebuliser, and nebulised ipratropium bromide (0.5 mg for adults, 0.25 mg for children 2–12 years) in life-threatening cases NICE CKS.
Repeat doses of nebulised bronchodilator every 20–30 minutes if there is an inadequate response to initial treatment NICE CKS.
For patients unable to use nebulisers, give salbutamol (100 micrograms) by pMDI and spacer, one puff every 60 seconds, up to 10 puffs, inhaled separately using tidal breathing NICE CKS.
Start systemic corticosteroids immediately, with oral prednisolone (40–50 mg for adults and children 16+; 30–40 mg for 6–15 years; 20 mg for 2–5 years; 10 mg for under 2 years). If oral administration is not possible, give IM methylprednisolone or IV hydrocortisone as appropriate NICE CKS.
Arrange urgent transfer to hospital if signs of life-threatening exacerbation are present or if symptoms do not respond to initial treatment NICE CKS.