Montuschi COPD is also controversial (GICOPD 2001). Theophylline theophylline. In the absence of proven efﬁcacy and due leads to modest improvements in lung function without to higher costs and side effects, glucocorticoids are not gas exchange deterioration (Barbera et al 1992; Mahon generally recommended for stable COPD, though they et al 1999). Administration of intravenous theophylline are effective in the treatment of exacerbations. In the can be considered in more severe exacerbations (GICOPD absence of drugs which reduce progressive decline in lung 2001) although the available data do not support the use of function, which is the hallmark of this disease, cessation methylxanthines for the treatment of exacerbations of COPD of cigarette smoking, the main risk factor for COPD, is (Barr et al 2003). However, this requires close monitoring of the most effective measure. Numerous studies are being the plasma concentrations to avoid the occurrence of dose- carried out to deﬁne the pathophysiology of COPD, about dependent toxic effects (Lloberes et al 1988; Emerman et al which still relatively little is known. It is hoped that these 1990; Barbera et al 1992). Oral or intravenous glucocorti- studies will allow new and effective drugs to be discovered coids are recommended with bronchodilator therapy and, if and developed, as the current pharmacological treatment of necessary, antibiotics and oxygen therapy, for treatment in COPD is inadequate. hospital of exacerbations of COPD (Thompson et al 1996; Davies et al 1999; Niewoehner et al 1999; GICOPD 2001). The optimum dose of glucocorticoids is not known, but high doses increase the risk of signiﬁcant side effects. Generally 30 mg to 40 mg of oral prednisolone is administered for 10 to 14 days (GICOPD 2001). Prolonged treatment does not improve efﬁcacy, while increasing the risk of side effects. Antibiotics are only effective when exacerbations also occur with sputum purulence and increased sputum volume and/or fever, indicating a bacterial infection (Anthonisen et al 1987). Antibiotics must be effective against Streptococcus pneumo- niae, Haemophilus inﬂuenzae, and Moraxella catarrhalis. These are the bacterial microorganisms most frequently involved in exacerbations of COPD. However, the choice of antibiotics must be based on the antibiogram. Toxicity due to excessive oxygen therapy in the emergency department is still a prevalent problem which could be resolved by increasing patient awareness of the risk (Plant et al 2000a). In cases of severe exacerbations of COPD (stage III) mechanical ventilation is required which may be invasive (conventional) or non-invasive with the aim of reducing morbidity and mortality and improving symptoms. Non-invasive positive pressure ventilation (NIPPV) is an effective alternative to conventional mechanical ventilation in the intensive care unit and is even applicable in the general ward with specialized nursing staff (Brochard et al 1995; Plant et al 2000a). NIPPV reduces patient morbidity and length of stay in hospital by preventing the onset of nosocomial pneumonia, but it is less effective than intermittent positive pressure ventilation in patients with a pH persistently <7.30 (Plant et al 2000b). Conclusions Pharmacological treatment of COPD is currently symp- tomatic and is based on inhaled bronchodilators such as anticholinergics, selective β -adrenergic agonists and 2 420 Acknowledgments This report has been partly produced using faculty funds 2005–2006 from the Catholic University of the Sacred Heart in Rome. References Aaron SD, Vandemheen K, Fergusson D, et al. 2004. The Canadian Optimal Therapy for COPD trial: design, organization and patient recruitment. Can Respir J, 11:581-5. [ATS] American Thoracic Society. 1995. Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med, 152:S77-121. Anthonisen NR, Connett JE, Kiley JP, et al. 1994. Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA, 272:1497-505. Anthonisen NR, Manfreda J, Warren CP, et al. 1987. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med, 106:196-204. Barbera JA, Reyes A, Roca J, et al. 1992. Effect of intravenously adminis- tered aminophylline on ventilation/perfusion inequality during recovery from exacerbations of chronic obstructive pulmonary disease. Am Rev Respir Dis, 145:1328-33. Barnes PJ. 1999. Effect of β-agonists on inﬂammatory cells. J Allergy Clin Immunol, 104:S10-17. Barnes PJ. 2000. Inhaled corticosteroids are not beneﬁcial in chronic obstruc- tive pulmonary disease. Am J Respir Crit Care Med, 161:342-4. Barnes PJ. 2003. Theophylline: new perspectives for an old drug. Am J Respir Crit Care Med, 167:813-18. Barnes PJ. 2006. Theophylline for COPD. Thorax, 61:742-4. Bellia V, Foresi A, Bianco S, et al. 2002. Efﬁcacy and safety of oxitropium bromide, theophylline and their combination in COPD patients: a double-blind, randomised, multicentre study. Respir Med, 96:881-9. Belman MJ, Botnick WC, Shin JW. 1996. Inhaled bronchodilators reduce dynamic hyperinﬂation during exercise in patients with chronic obstruc- tive pulmonary disease. Am J Respir Crit Care Med, 153:967-75. Berger R, Smith D. 1988. Effect of inhaled metaproterenol on exercise performance in patients with stable “ﬁxed” airway obstruction. Am Rev Respir Dis, 138:624-9. Bleecker ER, Britt EJ. 1991. Acute bronchodilating effects of ipratropium bromide and theophylline in chronic obstructive pulmonary disease. Am J Med, 91:24-7. Boyd G, Morice AH, Pounsford JC, et al. 1997. An evaluation of salmeterol in the treatment of chronic obstructive pulmonary disease (COPD). Eur Respir J, 10:815-21. International Journal of COPD 2006:1(4)