What is the stepwise approach for managing Chronic Obstructive Pulmonary Disease (COPD) exacerbations according to the Rome classification?

Rome Classification for COPD Exacerbation Management

I must clarify that the evidence provided does not describe a "Rome classification" for COPD exacerbations. The European Respiratory Society Task Force guidelines describe a severity-based approach that stratifies COPD exacerbations into categories determining the appropriate site of care and management intensity, but this is not termed the "Rome classification." 1

Severity-Based Stratification and Management Approach

Initial Severity Assessment

The key decision point is determining whether the exacerbation is mild (suitable for home management) versus severe (requiring hospital evaluation or ICU admission). 1

Critical indicators of severe exacerbation requiring immediate hospital evaluation include: 1

• Loss of alertness (most significant parameter)
• Severe dyspnea at rest
• Combination of concerning clinical conditions
• Respiratory acidosis or significant hypercapnia
• Inability to manage at home

When severity is uncertain, default to hospital assessment to avoid missing life-threatening presentations. 1, 2

Mild Exacerbations: Home Management

For mild exacerbations, initiate or increase bronchodilator therapy with β2-agonists and/or anticholinergics, adjusting both dose and frequency. 1, 2

The four primary goals are: 1

• Treat bacterial infection if present (indicated by purulent sputum)
• Remove excess secretions
• Increase maximum airflow
• Improve respiratory muscle strength

Prescribe antibiotics (amoxicillin or tetracycline as first-line) when bacterial infection is suspected based on purulent sputum production. 1, 2

Severe Exacerbations: Hospital Management

Hospital management focuses on evaluating severity including life-threatening conditions, identifying the exacerbation cause, providing controlled oxygenation, and returning the patient to their best previous condition. 1

Oxygen Therapy

Provide controlled oxygen therapy targeting SpO2 of 88-92%, as excessive oxygen can worsen hypercapnia and respiratory acidosis in COPD patients. 1, 3

• Measure arterial blood gases within 60 minutes if initially acidotic or hypercapnic 1
• Recheck blood gases if clinical deterioration occurs 1
• A pH below 7.26 predicts poor outcomes 1

Bronchodilator Therapy

Administer nebulized bronchodilators immediately upon arrival: salbutamol 2.5-5 mg or terbutaline 5-10 mg, or ipratropium bromide 0.25-0.5 mg. 1

• For severe exacerbations or poor response, combine both β-agonist and anticholinergic agents 1
• Drive nebulizers with compressed air (not oxygen) if PaCO2 is elevated or respiratory acidosis present 1
• Continue oxygen via nasal prongs at 1-2 L/min during nebulization to prevent desaturation 1
• Continue nebulized therapy for 24-48 hours until clinical improvement 1, 2

Systemic Corticosteroids

Administer prednisolone 30 mg/day orally (or hydrocortisone 100 mg IV if oral route unavailable) for 7-14 days in severe exacerbations. 1, 2

• Discontinue after the acute episode unless proven effective when clinically stable 1
• Response during acute exacerbation does not automatically indicate need for long-term inhaled corticosteroids 1

Antibiotics

Use the same indications as outpatient management: prescribe when purulent sputum suggests bacterial infection. 1

• First-line: amoxicillin or tetracycline 1
• Second-line for severe exacerbations or treatment failure: broad-spectrum cephalosporin or newer macrolides 1
• Atypical pathogens (Chlamydia pneumoniae) occasionally implicated 1

Methylxanthines

Consider intravenous aminophylline (0.5 mg/kg/hour continuous infusion) only if the patient fails to respond to initial bronchodilator therapy. 1

• Monitor daily theophylline blood levels 1
• Evidence for effectiveness in acute exacerbations is limited 1

Very Severe/Life-Threatening Exacerbations: ICU Management

Direct ICU admission is indicated for very severe, life-threatening episodes. 1

Consider non-invasive ventilation (NIV) for patients with severe respiratory acidosis who fail initial medical therapy. 2

Common Pitfalls

• Never delay hospital evaluation when severity is uncertain 2
• Avoid sedatives, which worsen respiratory depression 2
• Do not power nebulizers with oxygen in hypercapnic patients—use compressed air 1
• Remember to evaluate for conditions mimicking COPD exacerbation: pneumonia, pulmonary embolism, heart failure, pneumothorax 2

Discharge Planning

Before discharge: 2

• Continue nebulized bronchodilators for 24-48 hours until improvement
• Transition to usual inhaler therapy 24-48 hours before discharge
• Measure FEV1 to establish new baseline
• Check arterial blood gases on room air in patients who presented with respiratory failure