Chronic obstructive pulmonary disease (COPD) is the fifth commonest cause of death in North America and is the only leading cause of death that is increasing in prevalence. Early detection and prevention through smoking cessation are essential to stem this epidemic. Once COPD is diagnosed there is a compelling rationale for vaccination against influenza and possibly pneumococcal pneumonia, although proof of efficacy is lacking. If airways obstruction is present, inhaled quaternary anticholinergic bronchodilators or inhaled beta 2 agonists or both may be of benefit, the former agents showing fewer side effects and often greater efficacy in elderly patients. Theophylline may enhance the effect or increase the duration of the bronchodilatation produced by an inhaled agent and may offer added nonbronchodilatory effects such as improved respiratory muscle endurance and ventilatory stimulation. If significant airflow obstruction persists, an objectively monitored trial of oral steroid therapy is required. Limitation of activity despite optimum medical therapy may be alleviated in selected patients by a supervised exercise rehabilitation program. If hypoxemia is present supplemental oxygen therapy will improve the patient's survival and quality of life. Additional therapies, from respiratory stimulants to lung transplantation, remain under investigation.