An Updated Definition and Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbations: The Rome Proposal

Abstract

AT A GLANCE COMMENTARYScientific knowledge on the subject: Precise and practical definitions for acute medical events are needed if clinicians are to effectively diagnose and manage patients, provide prognostic information, and implement precision medicine. The current definition of a chronic obstructive pulmonary disease exacerbation (ECOPD) is subjective and based solely on worsening of respiratory symptoms. Further, severity is classified post hoc by the healthcare resource used to treat the event. These shortcomings support the need to revise the ECOPD definition.What this study adds to the field: The Rome proposal for an updated definition of ECOPD addresses many of the shortcomings of older definitions. Based on extensive literature review and using Delphi methodology, it specifies the timespan within which worsening of symptoms define an ECOPD. Second, to the subjective worsening of symptoms it adds a series of clinical variables that are objectively measurable and readily available: dyspnea, oxygen saturation, respiratory rate, heart rate, C-reactive protein and, if needed, arterial blood gases. Third, based on agreed thresholds, it integrates these variables into three mutually exclusive severity categories that can be used to classify the exacerbation severity at initial patient contact. This proposal aims to facilitate and improve clinical care, research, and health services planning.

The Development of a COPD Exacerbation Recognition Tool (CERT) to Help Patients Recognize When to Seek Medical Advice

“…This finding fits with clinical practice, since physicians typically enquire about 2 or more symptoms, as in: “Has your cough or breathlessness got worse?”. The time course of worsening was not addressed in this study, but a very recent consensus document suggested ≤14 days worsening 13 and consideration should be made of including this in the instructions to the patients. It is important to recognize that the CERT is not a diagnostic instrument and does not set criteria for the presence of an exacerbation.…”

“…12 Whilst conceptually useful, this definition lacks operational specificity, although very recently a time period of ≤14 days of symptoms has been suggested. 13 A patient-reported diary card for COPD exacerbations (the EXAcerbations of COPD Tool [EXACT]) has been developed and validated, 14,15 but it contains 14 items, which may make it too large and complex for use as a simple guide for patients.…”

“NEWS2” as an Objective Assessment of Hospitalised COPD Exacerbation Severity

“…1 This is unsatisfactory given the need to identify those at greatest risk of the poorest outcomes such as the need for NIV and death. Whilst there has been a recent proposal to provide an objective classification of COPD exacerbation severity, 5 this requires validation and it is likely that a large proportion of hospitalised events would fall into the “moderate” category.…”

“…1 A recent consensus paper has attempted to provide an objective assessment of exacerbation severity but this “Rome” proposal requires validation. 5 Despite clear clinical need to better guide monitoring and treatment decisions, there is no accepted way to further risk-stratify hospitalised COPD exacerbations. Complicating any such assessment, the acuity of an exacerbation presentation represents a composite of the severity of the underlying COPD, the severity of the exacerbation insult, and the presence and severity of any co-morbidities.…”

International Differences in the Frequency of Chronic Obstructive Pulmonary Disease Exacerbations Reported in Three Clinical Trials

“…attempts at defining these events more rigorously may help reduce the extent of these international differences (20). The reason for these international differences merits further study.…”