How should we manage an acute exacerbation of COPD?

Would you order a chest film to evaluate an acute exacerbation of chronic obstructive pulmonary disease (COPD)? Which medication would you first prescribe-a short-acting inhaled beta-2 agonist or an anticholinergic bronchodilator? These are important questions for family physicians who commonly manage acute exacerbations of COPD. The guideline summarized here was developed by a joint expert panel of the American College of Physicians-American Society of Internal Medicine and the American College of Chest Physicians. Three outcomes were considered: treatment efficacy, 6-month mortality, and relapse, as defined by return visit to the emergency department within 14 days of initial presentation. Systematic reviews with evidence tables were used to analyze data. The rationale for each recommendation is clear and well documented. We added strength-of-recommendation ratings, which are not in the original guideline.