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GOLD COPD

Exacerbation severity (Rome proposal) and ED management, spirometric grade and A/B/E group, and initial and follow-up inhaler therapy, per the GOLD 2026 report.

Rome severity criteria

Arterial blood gas (optional)

Symptoms and red flags

Symptoms (for antibiotics)
Clinical findings

Severity

–
    Moderate = at least 3 of the 5 criteria. Severe = moderate plus ABG showing hypoxemia (PaO₂ ≤ 60) and/or hypercapnia with acidosis (PaCO₂ > 45 and pH < 7.35).

    ED management

    Spirometry (post-bronchodilator)

    Symptoms

    Exacerbations in the past year

    Result

    –
    GOLD grades: 1 FEV₁ ≥ 80%; 2 50–79%; 3 30–49%; 4 < 30%. Groups: A low symptoms, B high symptoms (mMRC ≥ 2 or CAAT ≥ 10); A and B have no moderate or severe exacerbations. E ≥ 1 moderate or severe exacerbation in the past year (changed in GOLD 2026).

    Patient

    GOLD group

    Follow-up

    Main problem despite current therapy
    Exacerbations = ≥ 1 moderate or severe exacerbation on current therapy. If both, follow the exacerbation pathway. Biologics use the exacerbation counts from the Classification tab.

    Recommendation

    For every patient
    • Short-acting rescue bronchodilator
    • Smoking cessation
    • Vaccines: yearly influenza; COVID-19; PCV21 or PCV20; RSV (age ≥ 50 or chronic heart/lung disease); Tdap if not given in adolescence; zoster (age > 50)
    • Pulmonary rehabilitation for groups B and E
    • Check inhaler technique and adherence before escalating

    Sources

    1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of COPD, 2026 report (v1.3, 8 Dec 2025). goldcopd.org.
    2. Celli BR et al. An updated definition and severity classification of COPD exacerbations: the Rome proposal. Am J Respir Crit Care Med 2021;204:1251–8.

    Teaching and decision support only. It does not replace clinical judgment or your institution's protocol.