Therapy	Outpatient management	Inpatient management	Benefits	Disadvantages/common adverse effects	Typical dosage
Antibiotic, broad spectrum (e.g., amoxicillin/clavulanate [Augmentin], macrolides, second- or third-generation cephalosporins, quinolones)	Consider if sputum is purulent or after treatment failure	Use if local microbial patterns show resistance to narrow-spectrum agents	Decreases risk of treatment failure and mortality compared with narrow-spectrum agents	Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed	Amoxicillin/clavulanate: 875 mg orally twice daily or 500 mg orally three times daily for 5 days
	Use if local microbial patterns show resistance to narrow-spectrum agents
					Levofloxacin (Levaquin): 500 mg daily for 5 days
Antibiotic, narrow spectrum (e.g., amoxicillin, ampicillin, trimethoprim/sulfamethoxazole [Bactrim, Septra], doxycycline, tetracycline)	Consider if sputum is purulent or after treatment failure	Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently	Believed to decrease mortality risk, but has not been tested in placebo-controlled trials	Antibiotic resistance, diarrhea, yeast vaginitis; side effects specific to the antibiotic prescribed	Amoxicillin: 500 mg orally three times daily for 3 to 14 days Doxycycline: 100 mg orally twice daily for 3 to 14 days
	Use if local microbial patterns show minimal resistance to these agents and if patient has not taken antibiotics recently
Anticholinergic, short acting (e.g., ipratropium [Atrovent])	May add to beta agonist; if patient is already taking an anticholinergic, increase dosage	May add to beta agonist; if patient is already taking an anticholinergic, increase dosage	Improves dyspnea and exercise tolerance	Dry mouth, tremor, urinary retention	Ipratropium: 500 mcg by nebulizer every 4 hours as needed; alternatively, 2 puffs (18 mcg per puff) by MDI every 4 hours as needed*
Beta agonist, short acting (e.g., albuterol, levalbuterol [Xopenex])	Increase dosage	Increase dosage	Improves dyspnea and exercise tolerance	Headache, nausea, palpitations, tremor, vomiting	Albuterol: 2.5 mg by nebulizer every 1 to 4 hours as needed, or 4 to 8 puffs (90 mcg per puff) by MDI every 1 to 4 hours as needed*
Corticosteroid	Consider using oral corticosteroids in moderately ill patients, especially those with purulent sputum	Use oral corticosteroids if patient can tolerate; if not suitable for oral therapy, administer intravenously	Decreases risk of subsequent exacerbation, rate of treatment failures, and length of hospital stay Improves FEV1 and hypoxemia	Gastrointestinal bleeding, heartburn, hyperglycemia, infection, psychomotor disturbance, steroid myopathy	Oral prednisone: 30 to 60 mg once daily Intravenous methylprednisolone (Solu-Medrol): 60 to 125 mg 2 to 4 times daily
Mechanical ventilation	NA	Use if patient cannot tolerate NIPPV; has worsening hypoxemia, acidosis, confusion, or hypercapnia despite NIPPV; or has comorbid conditions such as myocardial infarction or sepsis	Decreases short-term mortality risk in severely ill patients	Aspiration, cardiovascular complications, need for sedation, pneumonia	Titrate to correct hypercarbia and hypoxemia
NIPPV	NA	Use in patients with worsening respiratory acidosis and hypoxemia when oxygenation via high-flow mask is inadequate	Improves respiratory acidosis and decreases respiratory rate, breathlessness, need for intubation, mortality, and length of hospital stay	Expensive, poorly tolerated by some patients	Titrate to correct hypercarbia and hypoxemia
Oxygen supplementation	NA	Use in patients with hypoxemia (PaO2 less than 60 mm Hg)	Decreases mortality risk	Hypercarbia	Titrate to PaO2 > 60 mm Hg or oxygen saturation ≥ 90 percent