Rome Criteria Reclassify Most Hospitalized COPD Exacerbations

Roughly 3 in 4 patients hospitalized for chronic obstructive pulmonary disease (COPD) exacerbations did not meet Rome criteria for a severe event in pooled data from 7 studies, although hospitalization typically earns that label automatically. The proposed tiered testing bundle now aims to help emergency teams determine what is driving these episodes, according to experts who spoke at the 2026 Global Initiative for Chronic Obstructive Lung Disease (GOLD) International COPD Conference.

Speakers argued that grading severity by care delivered, not bedside measurements, can distort treatment, trial results, and cost.

Why the Current Exacerbation Definition Falls Short

Leonardo M. Fabbri, MD, FERS, of the University of Ferrara in Italy, said the GOLD definition used through 2022—an acute worsening of respiratory symptoms that results in additional therapy—ignored timing, classified severity after the fact by resources used, and gave limited attention to conditions that mimic exacerbation, such as pneumonia, cardiac events, and pulmonary embolism. An international panel developed the Rome proposal in 2021 to address those limits.¹

“A novel approach was needed because precise, practical, and objective point of care definition and severity assessment for acute medical events are needed by clinicians and researchers if they are to effectively diagnose them at the point of contact, assess the prognosis, and implement precision treatment,” Fabbri said.

He cautioned that grading an episode is not the same as grading the patient. Behind the acute exacerbation phase, the patient could have stable or decompensated chronic diseases contributing to the severity, he explained. His group is now developing a test bundle to characterize patient complexity.

What Hospital Data Show About Rome Severity

The Rome proposal grades severity using dyspnea on a visual scale, respiratory rate, heart rate, oxygen saturation, C-reactive protein (CRP), and blood gases when available, explained Bartolome R. Celli, MD, a professor of medicine at Harvard Medical School and director of the COPD Center at Brigham and Women’s Hospital.² Moderate events exceed at least 3 thresholds, he said, and severe events involve elevated carbon dioxide with acidosis.

Celli summarized 7 studies from various countries that retrospectively applied Rome criteria to 10,478 hospitalized patients.³ Under the GOLD definition used through 2022, any exacerbation requiring hospitalization was classified as severe, but retrospectively applying the Rome criteria showed that was often not the case. Overall, 28% of events were mild, 48% moderate, and 24% severe.

Treatment, however, barely varied. Antibiotics went to 85% of patients with mild events, 98% with moderate events, and 88% with severe events, and systemic corticosteroids to 92%, 93%, and 96%, respectively.³

“You know, over 80% of patients get this, whether they were mild, moderate, or severe,” Celli said. “I propose to you that this needs to change if we're able to classify the severity at the point of care.”

A Canadian cohort of 481 patients showed that 8% of those with mild events returned to the hospital within a month, compared with 17% of those with moderate or severe events,⁴ which has important implications for health care cost, Celli pointed out.

Celli argued that severity should be set at first contact, the same way most other diseases would for acute events. He used the examples of sepsis, pneumonia, and myocardial infarction, which all have objective criteria to define the severity of the episode at the point of care.

“We cannot continue defining the severity of an episode with how it was managed, because that has tremendous variability among societies, health care, and individual doctors or health care providers that see the patient,” Celli said.

Which Tests Belong in the Emergency Department Bundle

Carlos A. Camargo, MD, DrPH, a professor of emergency medicine and medicine at Harvard Medical School and of epidemiology at the Harvard T.H. Chan School of Public Health, presented a bundle developed by 17 international experts through a 4-round modified Delphi process, modeled on approaches used for sepsis, myocardial infarction, and stroke. The recommendations are under review for publication.

“The idea that you would treat simply the COPD exacerbation is an idea whose time has come and gone. We really need to look more holistically,” Camargo said. “We in the United States see a much broader array of exacerbations, specifically many more mild exacerbations,” he said, so Rome severity determines how far testing should escalate.

Everyone would receive a viral swab to test for any viral infection that might have triggered the exacerbation, but for mild exacerbations, nothing more was recommended. For moderate to severe events, first-line tests include C-reactive protein, a complete blood count with differential, blood urea nitrogen and creatinine, electrolytes, glucose, N-terminal pro–B-type natriuretic peptide, an electrocardiogram, and a chest X-ray. Selected patients may receive second-line tests, such as arterial blood gas (ABG), ultrasound, chest CT, troponin, or D-dimer, with hemoglobin A_1c later in hospitalization and spirometry 4 to 6 weeks after discharge.

As part of creating the list, the panel of experts weighed how feasible some of the tests are in practice. For instance, critical care specialists favored routine ABG testing, but Camargo said emergency clinicians would not adopt it, which moved it to be a second-line for selected patients. “If there’s 1 item in the list that people don’t want to do, and it’s hard to justify that it really makes a difference on a lot of people, it’s going to throw out the whole project,” he said.

Camargo said the bundle must fit local capacity.

“Now, all this would have to be adapted to local resources. I don’t think we should be asking a small rural hospital to be doing all this testing that we would do at the Brigham or Mass General,” he said.

References

1. Celli BR, Fabbri LM, Aaron SD, et al. An updated definition and severity classification of COPD exacerbations: the Rome proposal. Am J Respir Crit Care Med. 2021;204(11):1251-1258. doi:10.1164/rccm.202108-1819PP
2. Celli BR, Fabbri LM, Criner GJ, Papi A, Torres A, Agustí A. The ROME COPD exacerbation proposal works! Time to move forward. Am J Respir Crit Care Med. 2026;212(2):294-296. doi:10.1164/rccm.202505-1162VP
3. Reumkens C, Endres A, Simons SO, Savelkoul PHM, Sprooten RTM, Franssen FME. Application of the Rome severity classification of COPD exacerbations in a real-world cohort of hospitalised patients. ERJ Open Res. 2023;9(3):00569-2022. doi:10.1183/23120541.00569-2022
4. Saint-Pierre MD, Neder JA. Revisiting acute exacerbations of chronic obstructive pulmonary disease: insights from applying the Rome proposal in a North American academic hospital. Int J Chron Obstruct Pulmon Dis. 2026:21:614290. doi:10.2147/COPD.S614290.