COPD is uniquely situated as a chronic disease at the beginning of the 21st century; it is not only an established major cause of mortality and morbidity but is increasing in prevalence despite current medical interventions. In addition COPD is not a stable disease but its natural history is punctuated by periods of acute deterioration or exacerbations. Exacerbations generate considerable additional morbidity and mortality, and directly affect patients' quality of life. However, despite significant advances in understanding and treating this disease, exacerbations continue to be the major cause of COPD-associated hospitalization, and provision for their management incurs considerable health care costs. This review will consider the current management of COPD exacerbations and how new clinical strategies may improve outcome of these important clinical events.