Management of acute exacerbations of chronic obstructive pulmonary disease.

Patients with chronic obstructive pulmonary disease are at high risk for acute exacerbations. Strategies that may prevent exacerbations are smoking cessation, pulmonary rehabilitation, and influenza vaccination. Therapy includes bronchodilators, corticosteroids, and antibiotics. Rapid-acting beta2-agonists are bronchodilating agents of choice. Ipratropium should be considered in patients who fail or cannot tolerate beta2-agonists. Data do not support combining anticholinergics and beta2-agonists in acute exacerbations; however, new data do support systemic corticosteroids for their role in reducing airway inflammation. Antibiotics should be included in the regimen if two of the three following are present: increased dyspnea, increased sputum volume, and increased sputum purulence. Many exacerbations may be caused by viruses or noninfective sources, in which case antibiotics are not indicated. Oxygen administration with or without assisted ventilation may be required for short-term management.