Inpatient management of chronic obstructive pulmonary disease.

Initial steps in treating an acute exacerbation of COPD include identifying the underlying cause and addressing whether ICU admission is warranted. For nonintubated hospitalized patients, current recommendations include supplemental oxygen to achieve PaO2 of 60 to 65 mm Hg, inhaled bronchodilators, perhaps using both beta-adrenergic and anticholinergic agents, and intravenous corticosteroids. For patients with purulent exacerbations, antibiotics may confer benefit. Directed coughing to encourage secretion clearance is advised if the patient's spontaneous cough is inadequate. Finally, as discussed elsewhere in this issue, noninvasive positive pressure ventilation may lessen mortality and help avert the need for intubation in selected patients. Ancillary treatments include prophylaxis against venous thromboembolism and, as discharge nears, attention to updating vaccinations (e.g., pneumococcal and influenza) and to homegoing needs (e.g., instruction in bronchodilator administration techniques, adequacy of home care, and rehabilitation).