Objective: To review the evidence-based literature on the role of inhaled corticosteroids (ICS) in the management of chronic obstructive pulmonary disease (COPD) and to assess the utilization of ICS in patients admitted to hospital with exacerbations of COPD. Methods: A MEDLINE search with the terms "chronic obstructive pulmonary disease", "COPD management", "inhaled corticosteroids", and "inhaled steroids" was conducted for the period 1978 to 2003, to assess the published evidence for ICS therapy. A chart review of inpatients with a diagnosis of COPD exacerbation was conducted for the 13-month period January 1, 2000, to January 31, 2001. Results: The literature review identified some weaknesses in the published evidence. Patients have not always been treated optimally with bronchodilators, and different outcomes have been measured in different trials. Recent trials have shown a reduction in exacerbations, and there is probably a subpopulation that would benefit from ICS. A total of 103 patients (46 men and 57 women) were identified for the chart review. Fifty-one (50%) of these patients had a prescription for ICS. However, bronchodilator therapy was optimized for only 13 (27%) of 49 ICS users. Ex-smokers receiving specialist care were more likely to be receiving an ICS. They were also more likely to be receiving oral theophylline, although no other historical or clinical factor leading to institution of ICS therapy could be identified. Fluticasone (28 patients or 55% of those receiving ICS therapy) was the most frequently prescribed ICS. Spirometry results were documented for only 77 patients (75%). Conclusions: Although smoking cessation and initiation of home oxygen therapy are the only accepted evidence-based disease-modifying therapies for COPD, there has been a recent focus on adjuvant treatment with ICS as a disease-modifying therapy, in particular to prevent or reduce exacerbations. The literature review suggested that therapy for COPD should be encouraged and should adhere to recent national guidelines. Bronchodilation should be optimized - with focus on compliance, inhaler technique, and optimal therapy with short-acting anticholinergics, β2-agonists, or long-acting agents - before addition of ICS therapy is considered. Cost-effectiveness trials, along with consideration of advances in therapy, are necessary to identify the COPD patients most likely to benefit from ICS therapy.