This PRAXIS Nexus article was written by Scott Cerreta, BS, RRT, Director of Education for the COPD Foundation. In this post, you will find:
- The background of the COPD Foundation Pocket Consultant Guide (PCG)
- Organization of the PCG
- A comparison of the PCG and GOLD
- Frequently Asked Questions
- A note from Dr. Byron Thomashow, one of the authors of the PCG
The COPD Foundation Pocket Consultant Guide (PCG) for the Diagnosis and Management of COPD was designed to be a practical tool to assist practicing clinicians in managing the diagnosis and treatment of individuals with COPD at the bedside. The PCG is designed to aid in identifying patients for whom spirometry should be performed, how patients should be classified based on spirometry, what additional assessments should be performed and when and how these diagnostic evaluations should influence therapy.
The PCG also features a handy up-to-date list of the common medications used to treat COPD. The cards are 4” x 6” tri-folded 6 panel cards that store easily in your pocket. With the PCG mobile app for Apple iOS, health care professionals fill in a symptoms assessment, spirometry results and exacerbation history for each patient in order to access a therapy chart. The chart becomes smart and highlights further testing and/or therapy, based on the inputted patient information. The chart also stresses the importance of smoking cessation, vaccinations, exercise, pulmonary rehabilitation, testing for Alpha-1 and evaluating co-morbid conditions.
The content of the Pocket Consultant Guide have been created by well recognized thought leaders in COPD including Dr. Byron Thomashow, Dr. David Mannino, Dr. Stephen Rennard, Dr. James Crapo, Dr. MeiLan Han, Dr. Ravi Kalhan, Dr. Barbara Yawn, Scott Cerreta and many more.
The target audience for the PCG is primary care physicians and other health care professionals that deliver clinical care. The PCG is small, portable and perfect as a bedside tool. You get access to the information needed to make clinical decisions and prescribe common treatments. What you don’t get is the lengthy explanation of the evidence and research for why these recommendations are made. Those tools are important and serve as a desk reference, not a bedside tool.
The PCG is based on recognizing seven severity domains: spirometry, symptoms, exacerbations, oxygen requirements, and the presence of emphysema, chronic bronchitis, and co-morbidities. A therapy chart (now only available in the app) organizes the seven severity domains and the treatment options. The latest card version of the PCG, updated November 2016, replaced the therapy chart with two new algorithms, Management of COPD and Management of Asthma and COPD Overlap Syndrome (ACOS). The update also includes updated medications approved in the past year and information for assessing exacerbations and lung cancer screening.
Organization of the PCG by Panels:
Panel 1 – New. This panel features the algorithm for COPD management. It contains very clear and precise instructions.
BOTH COLORS OF PCG CARDS
Panel 2 – Updated with new information. The Therapy Chart and information on who gets spirometry has been removed. This panel now features Spirometry Grades, Spirometry chart, the Seven Severity Domains and a new section on assessing exacerbations and lung cancer screening.
BOTH COLORS OF PCG CARDS
Panel 3 and 4 – Updated. Medication tables list the common drugs for treatment of COPD. There were 3 new drugs added since the last update and a few other cosmetic changes have been made to this panel. These two panels are the only difference between the PCG orange cards and the PCG blue cards. Orange cards list the drugs in trade name and the blue cards list the drugs in generic names.
BLUE PCG CARDS – GENERIC NAMES
ORANGE PCG CARDS – TRADE NAMES
Panel 5 – No changes. This panel features the COPD Assessment Test (CAT). This instrument is used to determine severity of symptoms.
Panel 6 – Updated with new information. The mMRC Breathlessness Scale remains unchanged. The ACOS algorithm is new and replaced the smoking cessation advice box.
BOTH COLORS OF PCG CARDS
PCG card Update in November 2016:
This is the most significant change we have made to the PCG since launch of version 4.0 in March of 2013. This version is now marked as v7.0, updated November 2016. The major challenge with the PCG card is space. Since it is a tool designed for bedside use, all the information must be crammed into a 4x6 inch pocket card. When new features are added other things must go. However, they are not gone forever! You can get access to these items in the PCG app.
PCG app Update in December 2016:
The major advantage of the PCG app is that it is not space limited. While we continue to make changes to the cards, the app will be the place to find all useful items used in past versions of the card. In the latest app update (to be released soon) you will find a new tab at the bottom of the app called Algorithms. This is where you will find the new COPD and ACOS management algorithms and the information on assessing exacerbations and lung cancer screening. The Therapy Chart and information on who should receive spirometry testing remains in the app. In fact, the user input fields are still active. The health care professional can fill in a symptoms assessment, spirometry results and exacerbation history for each patient in order to highlight areas of the therapy chart. The app also includes the Impact of Smoking graphic, which was removed in version 4.0 due to space limitations. The other advantage of the app is the drug panel features a toggle switch to change back in forth between generic names and trade names. This is very handy at the bedside when having conversation with patients. If you use the app, you won’t need to carry the blue AND orange pocket cards when you need to remember and discuss both names of the drugs.
Compare and Contrast PCG vs GOLD:
First, let’s start with a comparison of format. This is the biggest difference between the two strategies. PCG format is described above. GOLD strategy comes in several formats itself.
GOLD Report: 139 pages, full-sized 8.5x11. Very well referenced for a deep understanding of the evidence body that guides their strategy. In fact, about half of the pages are reference material. Each chapter ends with a list of references. This is a desk reference for physicians and other prescribers. It is most often used by experts in the field of COPD and pulmonologists. Content is mostly text.
GOLD Pocket Guide: 42 pages, mid-sized 6x10. About half the size of the GOLD Report. It contains all the essential information and a list of references are found at the end of the booklet rather than the end of every chapter. It is most often used by primary care and other prescribers. Content is mostly text.
GOLD At-a-Glance: 10 pages, pocket sized 4x6. This is the smallest GOLD product and closest format to the PCG. It is their solution for Outpatient Management and provides the essential pieces required for outpatient treatment. It is most often used by clinic staff. Content is mostly charts and graphics with much less text and no references.
In summary, GOLD is best used as a desk reference. The PCG is best used at the bedside. Together, these two strategies will provide the health care professional with the best set of complete tools for COPD diagnosis and management in each situation.
Second, let’s discuss differences in the Spirometry Grades. GOLD uses 4 grades.
- GOLD 1 – Mild FEV1 is ≥80 %predicted
- GOLD 2 – Moderate FEV1 is 50-79 %predicted
- GOLD 3 – Severe FEV1 is 30-49 %predicted
- GOLD 4 – Very Severe FEV1 is <30 %predicted
The PCG uses 5 spirometry grades.
- SG 0 – Normal spirometry does not rule out emphysema, chronic bronchitis, asthma, or risk of developing either exacerbations or COPD.
- SG 1 – Mild FEV1 is >60 %predicted
- SG 2 – Moderate FEV1 is 30-60 %predicted
- SG 3 – Severe FEV1 is <30 %predicted
- SG U Undefined: FEV1/FVC ratio >0.7, FEV1 <80% predicted. This is consistent with restriction, muscle weakness, and other pathologies.
The PCG authors believe that severe and very severe classification has always been poorly understood and used by patients and professionals. Therefore, it is confusing to classify COPD as Severe or Very Severe as these two names are not well differentiated. The evidence also suggests that there is a weak recommendation for use of bronchodilators with an FEV1 >60%. Therefore the PCG is more closely aligned with the evidence and published COPD Guidelines from ATS and ERS. Lastly, in past years, GOLD used the categories Zero and Undefined. The PCG authors believe the evidence from COPDgene warrants the reintroduction of these two classifications. HRCT has shown that people with normal spirometry have simple forms of Chronic Bronchitis and/or emphysema. So, it is important to recognize that just because a person has normal spirometry it does not mean their lungs are physically normal. All it means is that the current state of the disease is not significant enough to affect overall lung function results...yet. This moment in that person’s life could very well be an early sign of active design where if untreated may result in significant changes in lung function over the next few years. If the patient is symptomatic and continues to complain about their symptoms this should not be ignored. They should be evaluated for other signs of illness using other diagnostic tests.
Third, let’s discuss differences in the Therapy Chart treatment strategy. Both strategies believe and present similar results and combinations in treatment. How they arrive at those results is what differs. Let’s start with similarities.
For both strategies, treatment is no longer dictated by spirometry alone. It is a combination of lung function, symptoms and exacerbation history. Both strategies recommend the same tools and cut-offs for determining lung function (post bronchodilator FEV1/FVC ratio below 0.70 determines presence of COPD and FEV1 %predicted determines the severity), symptoms (CAT scores and/or mMRC scores) and exacerbation history (frequency in past 12 months).
Both strategies believe that long-acting bronchodilators are first line therapy. Combinations of LABAs and LAMAs are second line therapy and Inhaled Corticosteroids (ICS) is often introduced in triple therapy and have a more prominent role for more severe COPD or those with frequent exacerbations. However, recent evidence has shown the role of ICS has become increasingly unclear and has raised the possibility that eosinophil percentage in blood could help determine role of ICS. This is very premature and therefore not part of any present suggestions for treatment, but the PCG does list this in a bullet point section.
The difference really boils down to the concept of the strategy. GOLD uses the ABCD box methodology. The PCG uses algorithms and a therapy chart where all seven Severity Domains should be evaluated in each patient.
In the GOLD box, advancing symptoms shifts to the right. More exacerbations and/or lower FEV1s shift upwards in the box. This concept is novel and an atypical approach to standard treatment strategies used in other disease management scenarios. This box is often described as confusing and difficult to follow. Another common complaint about the box is that the drug treatment combinations are determined by the box letter. For example, group A gets the least aggressive treatment recommendations. In group B, more recommendations are added. In group C, more are added and in group D, the most recommendations are added. What confuses people the most is that inhaled COPD drugs are used to treat symptoms. So, it does not make sense that a patient in group C (FEV1 <50% and/or 2 or more exacerbations) who is not complaining of symptoms would have more treatment recommendations than a patient in group B with frequent complaints of symptoms and higher CAT scores. If these drugs are used for symptom control, than doesn’t it make sense to add or remove those drugs based on the symptoms scales and patient complaints? The GOLD box strategy is often described as complicated or comprehensive. It does take more time to learn and often requires the busy practitioner to refer back to the GOLD Report for a list of all the options for each group.
The PCG uses a systematic approach to treatment recommendations based on the seven severity domains. As a patient complains of more symptoms and has increased measured symptoms scores, the recommendation is to change or add new treatment options from mono therapy to double therapy to triple therapy. It’s that simple. Special treatment options are also considered in special cases. These are pointed out in the Therapy Chart with special characters. The PCG therapy chart and algorithms define these clear paths. There are even cases where more severe symptoms, health limitations and exacerbations would warrant starting treatment with double therapy. The evidence clearly shows that combination therapy with a LABA/LAMA is more effective than using either agent alone with no increased risk of side effects. Furthermore, the PCG strategy is based on common strategies used in management of other diseases and familiar to busy primary care providers. The PCG strategy is often described as simple and practical.
Are these formal COPD guidelines?
No, neither the PCG or GOLD strategies for COPD Diagnosis and Management are formal guidelines. Despite many references and publications where the term “GOLD guideline” is used, this is inaccurate. Guidelines are very expensive to produce, extremely lengthy and often get updated about every ten years. ATS/ERS published COPD guidelines in 2004. Since, there has been official statement updates to these guidelines in the form of a Clinical Practice Guideline Consensus Statement from ATS/ERS/ACP/ACCP in 2007 then again in 2011 with seven recommendations for treatment of stable COPD.
Both the PCG and GOLD are classified as “strategies” for COPD diagnosis and management, which is based on the published formal guidelines and all the evidence published after that. Therefore, strategies are more timely in publication compared to formal guidelines. COPD strategies are written by a handful of experts in the field and become the resource most clinicians use for managing COPD. GOLD is updated annually and the PCG is updated biannually.
The PCG spirometry chart tightly conforms to the recommendation numbers 2 to 5 from the COPD Consensus Statement in 2011. This is the reason why the PCG uses a cutoff of 60% between Mild and Moderate COPD and differs from the GOLD spirometry chart. There is a weak recommendation and low-quality of evidence to support routine bronchodilator therapy for an FEV1 above 60%.
Our organization only wants to use one set of COPD strategies. Do you recommend using GOLD or the PCG?
YES! Think of these strategies as tools. There are different tools for different jobs. We recommend using a handful of GOLD Report and/or GOLD Pocket Guides as a desk reference for COPD experts. We recommend using the PCG for primary care practitioners and all other health care professional as a bedside tool. Together, these tools will provide a hospital system with the right references in the hands of the right people.
What are the available formats?
GOLD formats are described above. GOLD also has a companion mobile app. Let’s discuss the PCG format here. The PCG is available in print form as a 4x6 inch tri-folded 6 panel pocket card. The latest update is version 7.0, November 2016. The PCG cards are available in two colors. The only content differences between the two colors are the list of medications on panel 3 and 4. The orange cards list the drugs in trade names and the blue card lists the drugs in generic name. The PCG is also available in a mobile app for iOS Apple devices.
What is the cost?
Both GOLD and PCG strategies are copyright protected. Any reuse, reprint or electronic display of the content requires special permission. Both GOLD and the PCG require a purchase for use of its contents for commercial purposes which may include publications, studies, CME programs, PowerPoint presentations of any kind, etc.
A clear difference between GOLD and PCG is use of the printed materials ordered directly from each organization. GOLD charges a fee for all printed products and their mobile app to health care professionals, organizations and commercial groups.
The PCG cards and app are available at no cost to health care professionals and organizations. There is a fee for shipping the PCG cards and for commercial use of the cards. So, a healthcare system with 3000 employees that directly care for people with COPD, may find it cost prohibitive to supply GOLD products to all clinicians in the organization. However, careful consideration to supply GOLD materials to a handful of experts and PCG cards to all the other employees would serve as an effective method for supplying COPD management strategies to all employees that directly care for individuals with COPD in the most cost-effective way.
In closing, Dr. Byron Thomashow co-author of the PCG had these comments to share:
The COPD Foundation understands that this is a work in evolution and will continue to update as more information and more medications become available. The flow chart starts with a diagnosis of COPD confirmed by post bronchodilator obstruction, however it is clear that spirometry remains underutilized and that post bronchodilator testing is almost never performed in primary care. The COPD Foundation has been working with a group of investigators on an NIH case finding trial. The results have just been published.
A new approach for identifying patients with undiagnosed Chronic Obstructive Pulmonary Disease.
Martinez F, Mannino D, Klein Leidy N, Bacci ED, Barr RG, Bowler RP, Han MK, Houfek TF, Rennard S, Thomashow B, Walsh J, Yawn BP, for the high risk COPS screening study group. Am J Resp Crit Care Med Published on line October 2016.
The investigators have developed a new short 5 question screener called CAPTURE which combined with PEF (peak flow testing) appears to better define those who need spirometry. A large validation trial for CAPTURE in primary care is now being planned. If the validation study confirms the preliminary results future versions of the PCG could well start with CAPTURE.Thanks for taking the time to review this summary. We welcome any comments and questions that you may have about the Pocket Consultant Guide contents. Our PCG authors are a part of this community and will be contributing to the conversations and questions that you propose.