Three sets of guidelines for the management of COPD that are widely recogni
zed (from the European Respiratory Society [ERS], American Thoracic Society
[ATS], and British Thoracic Society [BTS]) are reviewed and compared. None
of the documents uses classic evidence-based documentation, and, in many i
nstances, the recommendations are empiric because of a lack of scientific e
vidence. Overall, there is strong agreement between the documents. All thre
e guidelines recommend inhaled bronchodilators as first-line therapy. Antic
holinergics are noted to be well. tolerated, although potential problems wi
th beta(2)-agonists are mentioned. The ERS and BTS suggest that inhaled cor
ticosteroids may be of value in patients documented to be steroid responder
s, whereas the ATS does not recommend their use at all. All three guideline
s support the use of oxygen and pulmonary rehabilitation. There are varying
levels of disagreement between the guidelines related to the role of spiro
metry, stratification of disease severity, and the use of theophylline and
systemic corticosteroids. Other differences include the role for nebulizers
and metered-dose inhalers, secretion clearance methodologies, and the trea
tment of acute COPD exacerbations and acute respiratory failure. All three
guidelines agree that more research is needed to improve our understanding
and management of COPD.