British guidelines for the management of chronic obstructive pulmonary disease (COPD) were first published in 1997.¹ Over the subsequent 6 years there has been an enormous increase in our understanding of the underlying causes and mechanisms of acute exacerbations of COPD,^2–4 as well as the realisation that, in addition to being a major cause of morbidity and mortality, acute exacerbations place an enormous burden on healthcare resources.

COPD is the third largest cause of respiratory death in the UK after pneumonia and cancer, causing over 30 000 deaths per year. Age adjusted emergency admission rates for COPD in the UK rose by more than 50% between 1991 and 2000, and about one quarter of all hospital inpatient bed days used for treating acute respiratory disease are for COPD,⁵ amounting to nearly one million hospital bed days per year.⁶

With such a significant proportion of inpatient resources being consumed by acute exacerbations of COPD, understanding how well and effectively they are managed in hospital becomes a matter of much more than academic interest. In order to obtain information …