Rome severity criteria identifies poor outcomes in COPD exacerbation
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Key takeaways:
- Mortality occurred in more patients with severe vs. mild COPD exacerbation based on Rome severity classification.
- ICU admittance and mechanical ventilation were reported more in the severe group.
Based off of the Rome severity classification for COPD exacerbations, more hospitalized patients with severe vs. mild exacerbation received mechanical ventilation and died over 3 years, according to results published in CHEST.
To determine if a patient has mild, moderate or severe exacerbation, the Rome severity classification considers several variables, according to researchers.
“Given the integration of five parameters (dyspnea, respiratory rate, heart rate, oxygen saturation and serum C-reactive protein [CRP]), it is possible to distinguish between mild and moderate cases of [exacerbation of] COPD,” Ernesto Crisafulli, MD, PhD, associate professor in the department of medicine at University of Verona in Italy, and colleagues wrote. “For severe episodes of [exacerbation of] COPD, there must be the presence of hypercapnia with respiratory acidosis.”
In a retrospective analysis, Crisafulli and colleagues evaluated 347 patients (median age, 72 years; 81% men) hospitalized with exacerbation of COPD to validate the severity classification from the Rome proposal outlined above by finding out if it could identify patients at risk for 6-month, 1-year, 2-year and 3-year all-cause mortality.
Researchers also assessed hospitalization duration, noninvasive/invasive mechanical ventilation use, ICU admission and all-cause in-hospital mortality between severity classifications.
Based on Rome severity grades, 135 (median age, 73 years; 73% men) patients had mild exacerbation of COPD, 107 (median age, 73 years; 85% men) had moderate exacerbation of COPD and 105 (median age, 71 years; 87% men) had severe exacerbation of COPD.
Mortality
An assessment of all-cause 1-year mortality revealed a significantly higher percentage of death in the severe vs. mild group (25% vs. 13%), as well as a significantly shorter mean survival time (307 days vs. 342 days).
Researchers continued to see a significant difference in survival at 1 year between the mild and severe classification groups (P = .027) and significant differences among the three classifications (P = .032) through Kaplan-Meier curves.
Similar to the above findings, significantly more patients classified as severe vs. mild died at 6 months (17% vs. 5%), 2 years (35% vs. 18%) and 3 years (46% vs. 30%). Mean survival time at each of these periods was also significantly shorter in the severe vs. mild group (6 months, 164 days vs. 176 days; 2 years, 562 days vs. 645 days; 3 years, 778 days vs. 927 days).
Between the mild and moderate exacerbation groups, more patients in the moderate group died at 6 months (15% vs. 5%) and 3 years (46% vs. 30%), according to researchers.
Following in accordance with these findings, researchers observed a significant difference in survival at 3 years between the mild and severe groups (P = .008), the mild and moderate groups (P = .012) and the three classifications (P = .004) based on Kaplan-Meier curves.
Additional outcomes
Median hospitalization duration was 9 days in the severe classification group, which was significantly longer than the duration of 7 days observed in the mild and moderate classification groups, according to researchers.
Further, more patients classified with severe vs. mild or moderate exacerbation required noninvasive mechanical ventilation (70% vs. 6% vs. 13%), invasive mechanical ventilation (12% vs. 2% vs. 1%) and ICU admittance (43% vs. 3% vs. 6%).
Researchers observed three outcomes that did not significantly differ between the three exacerbation classifications: In-hospital mortality, new episodes of exacerbation of COPD and 30-day readmission for exacerbation of COPD.
Between patients in the mild classification and patients in the severe classification, the risk for 1-year mortality was greater for those with severe exacerbation of COPD (HR = 1.99; 95% CI, 1.49-2.65) based on multivariable Cox regression analysis. Researchers also found a heightened 1-year mortality risk among those with moderate exacerbation vs. mild exacerbation (HR = 1.47; 95% CI, 1.1-1.97).
Several patient characteristics raised the risk for death in the total study population including older age (≥ 80 years), long-term oxygen therapy and previous exacerbation of COPD episodes.
In contrast, the risk for death declined with a BMI between 25 kg/m2 and 29 kg/m2 vs. a BMI between 18 kg/m2 and 24 kg/m2, according to researchers.
“Our study validates the severity classification of the Rome proposal in a cohort of hospitalized patients with [exacerbation of] COPD, showing that it is possible to distinguish patients with an intermediate-term worse prognosis (severe),” Crisafulli and colleagues wrote. “Therefore, any effort in managing these patients should be preferred and planned.”
Despite validation of the Rome criteria, the patient population included in this study was limited and should be more diverse in future testing, Min Hyung Ryu, PhD, postdoctoral fellow, and Craig P. Hersh, MD, MPH, physician at the Channing Division of Network Medicine at Brigham and Women’s Hospital, wrote in an accompanying editorial.
“Future studies will need to determine whether the Rome proposal is applicable in the management of [exacerbation of] COPD in outpatients and in a more diverse group of patients,” Ryu and Hersh wrote. “Sex differences have been reported in both exacerbation frequency and [exacerbation of] COPD outcomes, which highlights the importance of future sex-stratified analyses.”