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To describe prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure.Analysis of prospectively collected data.A multidisciplinary intensive care unit of an inner-city university hospital.Patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure from August 1995 through July 1998.Data were obtained concerning demographics, arterial blood gas, Acute Physiology and Chronic Health Evaluation (APACHE) II score, sepsis, mechanical ventilation, organ failure, complications, and hospital mortality rate. Fifty-nine percent of patients were male, 63% white, and 36% African-American; the mean age was 63.1 ± 8.9 yrs. Noninvasive mechanical ventilation was tried in 40% of patients and was successful in 54% of them. Invasive mechanical ventilation was required in 61% of the 250 admissions. Sepsis developed in 31% of patients, nonpulmonary organ failure in 20%, pneumothorax in 3%, and acute respiratory distress syndrome in 2%. Multiple organ failure developed in 31% of patients with sepsis compared with 3% without sepsis (p < .0001). Predicted and observed hospital mortality rates were 30% and 15%, respectively. Differences in age and arterial carbon dioxide and oxygen tensions between survivors and nonsurvivors were not significant. Arterial pH was lower in nonsurvivors than in survivors (7.21 vs. 7.25, p = .0408). The APACHE II-predicted mortality rate (p = .0001; odds ratio, 1.046; 95% confidence interval, 1.022–1.070) and number of organ failures (p < .0001; odds ratio, 5.524; 95% confidence interval, 3.041–10.031) were independent predictors of hospital outcome; invasive mechanical ventilation was not an independent predictor.Physiologic abnormalities at admission to an intensive care unit and development of nonrespiratory organ failure are important predictors of hospital outcome for critically ill patients with chronic obstructive pulmonary disease who have acute respiratory failure. Improved outcome would require prevention and appropriate treatment of sepsis and multiple organ failure.