Application of the Rome severity classification of COPD exacerbations in a real-world cohort of hospitalised patients

ERJ Open Research · 6 authors, 6 centres

AI SUMMARY

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POPULATION364 COPD patients hospitalized with a severe exacerbation (ECOPD) at Maastricht University Medical Center, Netherlands (2011-2014)

INTERVENTIONApplication of the Rome severity classification (using dyspnea VAS, heart rate, respiratory rate, SpO2, CRP, and arterial blood gases)

COMPARISONTraditional severity classification (all hospitalized events considered severe) vs. Rome classification (mild, moderate, severe)

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TL;DR

This study applied the new Rome severity classification to 364 hospitalized COPD patients, finding that only 29.7% were classified as severe, while 56.0% were moderate and 14.3% were mild. In-hospital mortality was 13.9% for severe, 6.9% for moderate, and 3.8% for mild events. The Rome criteria can differentiate short-term mortality risk among hospitalized exacerbations, revealing significant clinical heterogeneity.

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**Background:** The traditional classification of COPD exacerbations (ECOPD) grades severity based on treatment setting and medication use, leading to heterogeneity among hospitalized patients. The Rome proposal uses six objective variables (dyspnea VAS ≥5, heart rate ≥95 bpm, respiratory rate ≥24 breaths/min, SpO2 <92% or a drop of ≥3%, CRP ≥10 mg/L, and arterial blood gas evidence of hypercapnia/acidosis) to classify events as mild, moderate, or severe. This study aimed to apply the Rome classification to a real-world cohort of hospitalized ECOPD patients and compare outcomes across severity groups.

**Methods:** This was a post-hoc analysis of 364 COPD patients admitted to the Department of Respiratory Medicine of Maastricht University Medical Center (MUMC) between June 1, 2011 and December 31, 2014. All patients had a severe ECOPD by traditional criteria (hospitalization). Demographics, vital signs, laboratory results, arterial blood gases, and disease characteristics were collected. Because no dyspnea VAS was available, all patients were assumed to have severe dyspnea (VAS ≥5). The Rome criteria were applied to classify patients as mild, moderate, or severe. In-hospital, 30-day, and 90-day all-cause mortality were compared. Statistical analyses included one-way ANOVA, Kruskal-Wallis, Chi-squared, and Fisher's exact tests with Bonferroni correction; p<0.05 was considered significant.

**Key Results:** According to the Rome classification, 52 (14.3%) patients had a mild ECOPD, 204 (56.0%) moderate, and 108 (29.7%) severe. In-hospital mortality was 3.8% (2/52) for mild, 6.9% (14/204) for moderate, and 13.9% (15/108) for severe events. 30-day mortality was 7.7% (4/52), 7.4% (15/204), and 17.6% (19/108), respectively. 90-day mortality was 7.7% (4/52), 13.7% (28/204), and 25.0% (27/108). Patients with severe ECOPD had significantly lower FEV1 (0.9±0.3 L vs. 1.2±0.5 L mild, p=0.004), lower FEV1% predicted (40.5±12.9% vs. 50.4±19.7% mild, p=0.004), lower DLCO/SB% predicted (40.8±15.1% vs. 47.7±19.1% mild, p=0.009), and more frequently required supplemental oxygen (63.7% vs. 34.8% mild, p<0.001). Heart rate, respiratory rate, and SpO2 were significantly worse in severe vs. mild groups (p<0.001). CRP was highest in moderate events (81.3±86.6 mg/L) vs. mild (20.0±33.4 mg/L) and severe (75.7±98.0 mg/L) (p<0.001). Arterial blood gas showed hypercapnia (PaCO2 >45 mmHg) in 94.4% of severe patients and acidosis (pH <7.35) in 100% of severe patients. Patients with mild ECOPD had the highest Charlson comorbidity index (2.65±1.6 vs. 2.08±1.3 moderate, p=0.035). Radiologic consolidation was more frequent in moderate (33.8%) and severe (30.6%) vs. mild (9.8%) (p=0.003).

**Clinical Implications:** The Rome classification reveals substantial heterogeneity among hospitalized ECOPD patients, with only about 30% meeting criteria for severe events. The classification differentiates short-term mortality risk, with severe events having the highest mortality. However, >10% of patients with mild or moderate events died within 90 days, suggesting that factors beyond the Rome criteria (e.g., comorbidities, social support) influence outcomes. The findings support the use of objective, readily measurable variables to stratify ECOPD severity, which could improve clinical decision-making, resource allocation, and interpretation of clinical trials. The Rome criteria may need refinement, particularly in distinguishing moderate from severe events, and additional parameters (e.g., comorbidities, imaging) could enhance predictive accuracy.

PICO

PPOPULATION

364 COPD patients hospitalized with a severe exacerbation (ECOPD) at Maastricht University Medical Center, Netherlands (2011-2014)

IINTERVENTION

Application of the Rome severity classification (using dyspnea VAS, heart rate, respiratory rate, SpO2, CRP, and arterial blood gases)

OOUTCOME

In-hospital, 30-day, and 90-day all-cause mortality; distribution across severity classes; clinical parameters

STUDY TYPE

cohort

SPECIALTY

pulmonology

SUMMARISED BY

AI pipeline

FIDELITY CHECK

100% · A

ORIGINAL PAPER

PMC10204729

Application of the Rome severity classification of COPD exacerbations in a real-world cohort of hospitalised patients

ERJ Open Research

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ABSTRACT

Background Recently, the Rome classification was proposed in which objective and readily measurable variables were integrated to mark exacerbations of COPD (ECOPD) severity. The aim of this study is to investigate the distribution of a real-world patient population with hospitalised ECOPD according to the current classification across the newly proposed severity classification. We assume that a significant proportion of hospitalised patients will have a mild or moderate event. Methods The Rome classification was applied to a cohort of 364 COPD patients hospitalised at the Department of Respiratory Medicine of Maastricht University Medical Center (MUMC) with a severe ECOPD. Differences in in-hospital, 30- and 90-day mortality were compared between mild, moderate and severe ECOPD according to the new classification. Moreover, data were stratified by the different severity classes and compared regarding general disease characteristics and clinical parameters. Results According to the Rome proposal, 52 (14.3%) patients had a mild ECOPD, 204 (56.0%) a moderate and 108 (29.7%) a severe ECOPD. In-hospital mortality in mild, moderate and severe events was 3.8%, 6.9% and 13.9%, respectively. Most clinical parameters indicated a significantly worse condition in patients classified in the severe group, compared to those in mild or moderate groups. Conclusion Most of the events, traditionally all classified as severe because of the hospitalisation, were classified as moderate, while almost 15% were mild. The results of this study provide insight into the heterogeneity of hospitalised ECOPD and show that the newly proposed Rome criteria can differentiate between events with different short-term mortality rates.

CITATION EXPORT

Carmen Reumkens, Adrian Endres, Sami O. Simons et al.. Application of the Rome severity classification of COPD exacerbations in a real-world cohort of hospitalised patients. ERJ Open Research. (2023). https://doi.org/10.1183/23120541.00569-2022

AUTHORS

6 · 6 CENTRES

Carmen Reumkens, Adrian Endres, Sami O. Simons, Paul H.M. Savelkoul, Roy T.M. Sprooten, Frits M.E. Franssen

1Department of Medical Microbiology, Infectious Diseases and Infection Prevention, School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands
2Department of Respiratory Medicine and Allergology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
3Department of Respiratory Medicine, NUTRIM, MUMC+, Maastricht, The Netherlands
4Department of Respiratory Medicine, MUMC+, Maastricht, The Netherlands
5Department of Research and Education, Ciro, Horn, The Netherlands
6These authors contributed equally