array:23 [
  "pii" => "S1579212907601360"
  "issn" => "15792129"
  "doi" => "10.1016/S1579-2129(07)60136-0"
  "estado" => "S300"
  "fechaPublicacion" => "2007-01-01"
  "aid" => "60136"
  "copyright" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR)"
  "copyrightAnyo" => "2007"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Arch Bronconeumol. 2007;43:599-604"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 2465
    "formatos" => array:3 [
      "EPUB" => 94
      "HTML" => 1492
      "PDF" => 879
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1579212907601372"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(07)60137-2"
    "estado" => "S300"
    "fechaPublicacion" => "2007-01-01"
    "aid" => "60137"
    "copyright" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR)"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2007;43:605-10"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2102
      "formatos" => array:3 [
        "EPUB" => 81
        "HTML" => 1394
        "PDF" => 627
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
      "titulo" => "Cost&#8211;Effectiveness and Degree of Satisfaction With Home Sleep Monitoring in Patients With Symptoms of Sleep Apnea"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "605"
          "paginaFinal" => "610"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Bernab&#233; Jurado G&#225;mez, Javier Redel Montero, Luis Mu&#241;oz Cabrera, Mari Carmen Fern&#225;ndez Mar&#237;n, Elisa Mu&#241;oz Gom&#225;riz, Miguel &#193;ngel Mart&#237;n P&#233;rez, Andr&#233;s Cosano Povedano"
          "autores" => array:7 [
            0 => array:2 [
              "nombre" => "Bernab&#233; Jurado"
              "apellidos" => "G&#225;mez"
            ]
            1 => array:2 [
              "nombre" => "Javier Redel"
              "apellidos" => "Montero"
            ]
            2 => array:2 [
              "nombre" => "Luis Mu&#241;oz"
              "apellidos" => "Cabrera"
            ]
            3 => array:2 [
              "nombre" => "Mari Carmen Fern&#225;ndez"
              "apellidos" => "Mar&#237;n"
            ]
            4 => array:2 [
              "nombre" => "Elisa Mu&#241;oz"
              "apellidos" => "Gom&#225;riz"
            ]
            5 => array:2 [
              "nombre" => "Miguel &#193;ngel Mart&#237;n"
              "apellidos" => "P&#233;rez"
            ]
            6 => array:2 [
              "nombre" => "Andr&#233;s Cosano"
              "apellidos" => "Povedano"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212907601372?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004300000011/v1_201305150302/S1579212907601372/v1_201305150302/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1579212907601359"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(07)60135-9"
    "estado" => "S300"
    "fechaPublicacion" => "2007-01-01"
    "aid" => "60135"
    "copyright" => "Sociedad Espa&#241;ola de Neumolog&#237;a y Cirug&#237;a Tor&#225;cica &#40;SEPAR&#41;"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2007;43:594-8"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 1987
      "formatos" => array:3 [
        "EPUB" => 82
        "HTML" => 1322
        "PDF" => 583
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
      "titulo" => "Bronchogenic Carcinoma 2000-2001&#58; Characteristics and Overall Survival"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "594"
          "paginaFinal" => "598"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Graciliano Estrada Trigueros, Lorena Comeche, &#193;ngel L&#243;pez Encuentra, Javier Montoro Zulueta, Fulgencio Gonz&#225;lez Garrido, Francisco Colina"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Graciliano Estrada"
              "apellidos" => "Trigueros"
            ]
            1 => array:2 [
              "nombre" => "Lorena"
              "apellidos" => "Comeche"
            ]
            2 => array:2 [
              "nombre" => "&#193;ngel L&#243;pez"
              "apellidos" => "Encuentra"
            ]
            3 => array:2 [
              "nombre" => "Javier Montoro"
              "apellidos" => "Zulueta"
            ]
            4 => array:2 [
              "nombre" => "Fulgencio Gonz&#225;lez"
              "apellidos" => "Garrido"
            ]
            5 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Colina"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212907601359?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004300000011/v1_201305150302/S1579212907601359/v1_201305150302/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
    "titulo" => "Benefits of a Home-Based Pulmonary Rehabilitation Program for Patients With Severe Chronic Obstructive Pulmonary Disease"
    "tieneTextoCompleto" => 0
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "599"
        "paginaFinal" => "604"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Vanessa Regiane Resqueti, Amaia Gorostiza, Juan B&#46; Gladis, Elena L&#243;pez de Santa Mar&#237;a, Pere Casan Clar&#224;, Rosa G&#252;ell Rous"
        "autores" => array:6 [
          0 => array:3 [
            "nombre" => "Vanessa Regiane"
            "apellidos" => "Resqueti"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Amaia"
            "apellidos" => "Gorostiza"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Juan B&#46;"
            "apellidos" => "Gladis"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Elena L&#243;pez"
            "apellidos" => "de Santa Mar&#237;a"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Pere Casan"
            "apellidos" => "Clar&#224;"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          5 => array:4 [
            "nombre" => "Rosa G&#252;ell"
            "apellidos" => "Rous"
            "email" => array:1 [
              0 => "vanessaresqueti&#64;hotmail&#46;com"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor1"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Hospital de la Santa Creu i de Sant Pau&#44; Facultad de Medicina&#44; Universidad Aut&#243;noma de Barcelona&#44; Barcelona&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff1"
          ]
          1 => array:3 [
            "entidad" => "Hospital de Cruces&#44; Barakaldo&#44; Vizcaya&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff2"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#42;"
            "correspondencia" => "Correspondence&#58; Dra&#46; R&#46; G&#252;ell Rous&#46; &#193;rea de Rehabilitaci&#243;n-Departamento de Neumolog&#237;a&#46; Hospital de la Santa Creu i de Sant Pau&#46; Sant Antoni M&#46; Claret&#44; 167&#46; 08025 Barcelona&#46; Espa&#241;a"
          ]
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2006-09-25"
    "fechaAceptado" => "2007-03-20"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec154658"
          "palabras" => array:5 [
            0 => "Chronic obstructive pulmonary disease &#40;COPD&#41;"
            1 => "Pulmonary rehabilitation"
            2 => "domiciliary"
            3 => "Health-related quality of life"
            4 => "Exercise tolerance"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec154659"
          "palabras" => array:4 [
            0 => "Enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;"
            1 => "Rehabilitaci&#243;n respiratoria domiciliaria"
            2 => "Calidad de vida relacionada con la salud"
            3 => "Capacidad del ejercicio"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:1 [
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetive</span><p class="elsevierStyleSimplePara elsevierViewall">The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease &#40;COPD&#41; are uncertain&#46; We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p class="elsevierStyleSimplePara elsevierViewall">Patients with severe COPD &#40;stages III-IV&#44; classification of the Global Initiative for Chronic Obstructive Lung Disease&#41; and incapacitating dyspnea &#40;scores 3-5&#44; Medical Research Council &#91;MRC&#93; scale&#41; were randomized to a control or domiciliary rehabilitation group&#46; The 9-week supervised pulmonary rehabilitation program included educational sessions&#44; respiratory physiotherapy&#44; and muscle training in weekly sessions in the patient&#39;s home&#46; We assessed the following variables at baseline&#44; 9 weeks&#44; and 6 months&#58; lung function&#44; exercise tolerance &#40;3-minute walk test&#41;&#44; dyspnea &#40;MRC score&#41;&#44; and health-related quality of life with the Chronic Respiratory Questionnaire &#40;CRQ&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">Thirty-eight patients with a mean &#40;SD&#41; age of 68 &#40;6&#41; years were enrolled&#46; The mean MRC score was 4 &#40;0&#46;8&#41; and mean forced expiratory volume in 1 second was 29&#37; of reference&#46; Twenty-nine patients completed the study &#40;6 months&#41;&#46; Distance covered on the walk test increased significantly in the rehabilitation group &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;001&#41; and the difference was maintained at 6 months&#46; Dyspnea also improved significantly with rehabilitation &#40;<span class="elsevierStyleItalic">P</span>&#8804;&#46;05&#41;&#44; but the reduction was not evident at 6 months&#46; Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks&#58; dyspnea &#40;3&#46;1 &#91;0&#46;8&#93; vs 3&#46;6 &#91;0&#46;7&#93;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;02&#41; and fatigue &#40;3&#46;7 &#91;0&#46;8&#93; vs 4&#46;2 &#91;0&#46;9&#93;&#59; <span class="elsevierStyleItalic">P</span>&#61;&#46;002&#41;&#46; A clinically relevant but not statistically significant change in mastery over disease was detected &#40;from 4&#46;3 to 4&#46;9&#41;&#46; All improvements were maintained at 6 months&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months&#46;</p>"
      ]
      "es" => array:1 [
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p class="elsevierStyleSimplePara elsevierViewall">Los beneficios de la rehabilitaci&#243;n respiratoria domiciliaria &#40;RRD&#41; en pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; de grado grave-muy grave son controvertidos&#46; Nuestro objetivo ha sido evaluar la eficacia a corto y medio plazo de un programa de RRD en pacientes con EPOC grave&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p class="elsevierStyleSimplePara elsevierViewall">Se trata de un estudio prospectivo y aleatorizado en pacientes con EPOC grave &#40;estadios III y IV de la clasificaci&#243;n GOLD&#41; y disnea invalidante &#8212;&#59; puntuaci&#243;n de 3 a 5 en la escala del Medical Research Council &#40;MRC&#41;&#8212;&#44; distribuidos en grupo control y grupo RRD&#46; El programa de rehabilitaci&#243;n respiratoria fue de 9 semanas y consist&#237;a en educaci&#243;n&#44; fisioterapia respiratoria y entrenamiento muscular con supervisi&#243;n semanal en domicilio&#46; Evaluamos en situaci&#243;n basal&#44; a las 9 semanas y a los 6 meses la funci&#243;n pulmonar&#44; la capacidad de ejercicio &#40;prueba de la marcha de 3 min&#41;&#44; la disnea &#40;MRC&#41; y la calidad de vida relacionada con la salud&#44; determinada con el Chronic Respiratory Questionnaire &#40;CRQ&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">Participaron en el estudio 38 pacientes&#44; con una edad media &#177; desviaci&#243;n est&#225;ndar de 68 &#177; 6 a&#241;os &#40;puntuaci&#243;n MRC&#58; 4 &#177; 0&#44;8&#59; volumen espiratorio forzado en el primer segundo&#58; 29&#37; del valor de referencia&#41;&#44; y 29 completaron el seguimiento a los 6 meses&#46; En el grupo RRD se increment&#243; significativamente la distancia recorrida en la prueba de la marcha de 3 min &#40;p &#61; 0&#44;001&#41;&#44; resultado que se mantuvo a los 6 meses&#46; La disnea mejor&#243; significativamente tras la RRD &#40;p &#8804; 0&#44;05&#41;&#44; pero dicha mejor&#237;a desapareci&#243; a los 6 meses&#46; Se observ&#243; una mejor&#237;a cl&#237;nica y estad&#237;sticamente significativa en 2 dominios del CRQ&#44; el de disnea &#40;3&#44;1 &#177; 0&#44;8 frente a 3&#44;6 &#177; 0&#44;7&#59; p &#61; 0&#44;02&#41; y el de fatiga &#40;3&#44;7 &#177; 0&#44;8 frente a 4&#44;2 &#177; 0&#44;9&#59; p &#61; 0&#44;002&#41;&#44; y tan s&#243;lo cl&#237;nica &#40;4&#44;3 frente a 4&#44;9&#41; en el control de la enfermedad&#44; mejor&#237;as que se mantuvieron a los 6 meses&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">La RRD en pacientes con EPOC grave-muy grave y alta incapacidad funcional aporta beneficios en la calidad de vida relacionada con la salud y la capacidad de ejercicio&#44; que pueden mantenerse hasta los 6 meses&#46;</p>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara">The preliminary results of this study were first presented at the annual European Respiratory Society Congress&#44; September 2005 in Copenhagen&#44; Denmark&#46;</p>"
      ]
      1 => array:1 [
        "nota" => "<p class="elsevierStyleNotepara">The study was partially funded by the Breathe Network &#40;Red Respira&#41; of the Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41;&#46;</p>"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Standards for the diagnosis and treatment of patients with COPD&#58; a summary of the ATS&#47;ERS position paper"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "BR Celli"
                            1 => "W MacNee"
                            2 => "ATS&#47;ERS Task Force"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2004"
                        "volumen" => "23"
                        "paginaInicial" => "932"
                        "paginaFinal" => "946"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15219010"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary rehabilitation and the BODE index in COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "CG Cote"
                            1 => "BR Celli"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.05.00045505"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "630"
                        "paginaFinal" => "636"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16204593"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary rehabilitation-1999"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "ATS Medical Section of the American Lung Association"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.159.5.ats2-99"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1999"
                        "volumen" => "159"
                        "paginaInicial" => "1666"
                        "paginaFinal" => "1682"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10228143"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "American Thoracic Society&#47;European Respiratory Society statement on pulmonary rehabilitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:5 [
                            0 => "L Nice"
                            1 => "CL Donner"
                            2 => "E Wouters"
                            3 => "R Zuwallack"
                            4 => "J Bourbeau"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200508-1211ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "173"
                        "paginaInicial" => "1390"
                        "paginaFinal" => "1413"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16760357"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long term effects of outpatient rehabilitation of COPD&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R Guell"
                            1 => "P Casan"
                            2 => "J Belda"
                            3 => "M Sangen&#237;s"
                            4 => "F Morante"
                            5 => "G Guyatt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "117"
                        "paginaInicial" => "976"
                        "paginaFinal" => "983"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10767227"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pulmonary rehabilitation and COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "AL Ries"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Sem Respir Crit Care Med"
                        "fecha" => "2005"
                        "volumen" => "26"
                        "paginaInicial" => "133"
                        "paginaFinal" => "141"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "PJ Wijkstra"
                            1 => "EM ten Vergert"
                            2 => "R van Altena"
                            3 => "V Otten"
                            4 => "J Kraan"
                            5 => "DS Postma"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1995"
                        "volumen" => "50"
                        "paginaInicial" => "824"
                        "paginaFinal" => "828"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7570431"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD&#46; A follow-up of 18 months"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "JH Strijbos"
                            1 => "DS Postma"
                            2 => "R van Altena"
                            3 => "F Gimeno"
                            4 => "GH Koeter"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1996"
                        "volumen" => "109"
                        "paginaInicial" => "366"
                        "paginaFinal" => "372"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8620707"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomized controlled trial of pulmonary rehabilitation in severe chronic obstructive pulmonary disease patients&#44; stratified with the MRC dyspnoea scale"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "JA Wedzicha"
                            1 => "JC Bestall"
                            2 => "R Garrod"
                            3 => "R Garnham"
                            4 => "EA Paul"
                            5 => "PW Jones"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Repir J"
                        "fecha" => "1998"
                        "volumen" => "12"
                        "paginaInicial" => "363"
                        "paginaFinal" => "369"
                        "itemHostRev" => array:3 [
                          "pii" => "S002577530901450X"
                          "estado" => "S300"
                          "issn" => "00257753"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Results of a home-based training program for patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "MTE Hern&#225;ndez"
                            1 => "TM Rubio"
                            2 => "FO Ruiz"
                            3 => "H Riera"
                            4 => "RS Gil"
                            5 => "JC G&#243;mez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "118"
                        "paginaInicial" => "106"
                        "paginaFinal" => "114"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10893367"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "NR Anthonisen"
                            1 => "J Manfreda"
                            2 => "CPW Warren"
                            3 => "ES Hershfield"
                            4 => "GKM Harding"
                            5 => "NA Nelson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1987"
                        "volumen" => "106"
                        "paginaInicial" => "196"
                        "paginaFinal" => "204"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3492164"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normativa para la pr&#225;ctica de la espirometr&#237;a forzada"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "J Sanchis"
                            1 => "P Casan"
                            2 => "J Castillo"
                            3 => "N Gonzalez"
                            4 => "L Palenciano"
                            5 => "J Roca"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "1989"
                        "volumen" => "25"
                        "paginaInicial" => "132"
                        "paginaFinal" => "142"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Spirometric reference values for a mediterranean population"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "J Roca"
                            1 => "J Sanchis"
                            2 => "A Agust&#237;-Vidal"
                            3 => "R Rodr&#237;guez-Roisin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Bull Eur Physiopathol Respir"
                        "fecha" => "1986"
                        "volumen" => "22"
                        "paginaInicial" => "217"
                        "paginaFinal" => "224"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3730638"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Determinaci&#243;n de las presiones respiratorias est&#225;ticas m&#225;ximas&#46; Propuesta de procedimiento"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P Casan"
                            1 => "M Mayos"
                            2 => "J G&#225;ldiz"
                            3 => "J Giner"
                            4 => "JA Fiz"
                            5 => "JM Montserrat"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "1990"
                        "volumen" => "26"
                        "paginaInicial" => "223"
                        "paginaFinal" => "228"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Presiones respiratorias est&#225;ticas m&#225;ximas en adultos&#46; Valores de referencia en una poblaci&#243;n caucasiana mediterr&#225;nea"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P Morales"
                            1 => "J Sanchis"
                            2 => "PJ Cordero"
                            3 => "JL D&#237;ez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "1997"
                        "volumen" => "33"
                        "paginaInicial" => "213"
                        "paginaFinal" => "219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9254166"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:1 [
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:4 [
                        "titulo" => "Normativa sobre gasometr&#237;a arterial&#46; Recomendaciones SEPAR&#44; No&#46; 6"
                        "fecha" => "1987"
                        "editorial" => "Doyma"
                        "editorialLocalizacion" => "Barcelona"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of the distances covered during 3 and 6 min walking test"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "M Iriberri"
                            1 => "JB G&#225;ldiz"
                            2 => "A Gorostiza"
                            3 => "P Ansola"
                            4 => "C Jaca"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2002"
                        "volumen" => "96"
                        "paginaInicial" => "812"
                        "paginaFinal" => "816"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12412981"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Perceived exertion as an indicator of somatic stress"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "G Borg"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Scand J Rehab Med"
                        "fecha" => "1970"
                        "volumen" => "2"
                        "paginaInicial" => "92"
                        "paginaFinal" => "98"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Usefulness of the Medical Research Council &#40;MRC&#41; dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "JC Bestall"
                            1 => "EA Paul"
                            2 => "R Garrod"
                            3 => "R Garnham"
                            4 => "PW Jones"
                            5 => "JA Wedzicha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1999"
                        "volumen" => "54"
                        "paginaInicial" => "581"
                        "paginaFinal" => "586"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10377201"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quality of life in patients with chronic respiratory disease&#58; the Spanish version of the Chronic Respiratory Questionnaire &#40;CRQ&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R G&#252;ell"
                            1 => "P Casan"
                            2 => "M Sangenis"
                            3 => "F Morante"
                            4 => "J Belda"
                            5 => "GH Guyatt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "1998"
                        "volumen" => "11"
                        "paginaInicial" => "55"
                        "paginaFinal" => "60"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9543270"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessing the minimal important difference in symptoms&#58; a comparison of two techniques"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "DA Redelmeier"
                            1 => "RS Goldstein"
                            2 => "GH Guyatt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Epidemiol"
                        "fecha" => "1996"
                        "volumen" => "49"
                        "paginaInicial" => "1215"
                        "paginaFinal" => "1219"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8892486"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Interpreting small differences in functional status&#58; the six minute walk test in chronic lung disease patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "DA Redelmeier"
                            1 => "AM Bayoumi"
                            2 => "RS Goldstein"
                            3 => "GH Guyatt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.155.4.9105067"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "155"
                        "paginaInicial" => "1278"
                        "paginaFinal" => "1282"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9105067"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Physical training fails to improve ventilatory muscle endurance in patients with chronic obstructive respiratory disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "MJ Belman"
                            1 => "BA Kendregan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1982"
                        "volumen" => "81"
                        "paginaInicial" => "440"
                        "paginaFinal" => "443"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7067509"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R Casaburi"
                            1 => "A Patessio"
                            2 => "F Ioli"
                            3 => "S Zanaboni"
                            4 => "CF Donner"
                            5 => "K Wasserman"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm/143.1.9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am Rev Respir Dis"
                        "fecha" => "1991"
                        "volumen" => "143"
                        "paginaInicial" => "9"
                        "paginaFinal" => "18"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1986689"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F Maltais"
                            1 => "P Leblanc"
                            2 => "J Jobin"
                            3 => "CH Berub&#233;"
                            4 => "J Bruneau"
                            5 => "L Carrier"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.155.2.9032194"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1997"
                        "volumen" => "155"
                        "paginaInicial" => "555"
                        "paginaFinal" => "561"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9032194"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multidisciplinary treatment of chronic pulmonary insufficiency&#58; I&#46; Physiologic aspects of rehabilitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "DP Agle"
                            1 => "GL Baum"
                            2 => "EH Chester"
                            3 => "M Wendt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Phychosom Med"
                        "fecha" => "1973"
                        "volumen" => "35"
                        "paginaInicial" => "41"
                        "paginaFinal" => "49"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "&#191;Cu&#225;l es el papel del entrenamiento de los m&#250;sculos inspiratorios en el tratamiento de la EPOC&#63;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "S Mota-Casals"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2005"
                        "volumen" => "41"
                        "paginaInicial" => "593"
                        "paginaFinal" => "595"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16324596"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Short and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "T Troosters"
                            1 => "R Grosselink"
                            2 => "M Decramer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Med"
                        "fecha" => "2000"
                        "volumen" => "109"
                        "paginaInicial" => "207"
                        "paginaFinal" => "212"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10974183"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib29"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Maintenance after pulmonary rehabilitation in chronic lung disease&#58; a randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "AL Ries"
                            1 => "TM Kaplan"
                            2 => "R Myers"
                            3 => "LM Prewitt"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200204-318OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2003"
                        "volumen" => "167"
                        "paginaInicial" => "880"
                        "paginaFinal" => "888"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12505859"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000004300000011/v1_201305150302/S1579212907601360/v1_201305150302/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000004300000011/v1_201305150302/S1579212907601360/v1_201305150302/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212907601360?idApp=UINPBA00003Z"
]
Share
Journal Information
Vol. 43. Issue 11.
Pages 599-604 (January 2007)
Share
Share
Download PDF
More article options
Vol. 43. Issue 11.
Pages 599-604 (January 2007)
Original Articles
Full text access
Benefits of a Home-Based Pulmonary Rehabilitation Program for Patients With Severe Chronic Obstructive Pulmonary Disease
Visits
4282
Vanessa Regiane Resquetia, Amaia Gorostizab, Juan B. Gladisb, Elena López de Santa Maríab, Pere Casan Claràa, Rosa Güell Rousa,
Corresponding author
vanessaresqueti@hotmail.com

Correspondence: Dra. R. Güell Rous. Área de Rehabilitación-Departamento de Neumología. Hospital de la Santa Creu i de Sant Pau. Sant Antoni M. Claret, 167. 08025 Barcelona. España
a Hospital de la Santa Creu i de Sant Pau, Facultad de Medicina, Universidad Autónoma de Barcelona, Barcelona, Spain
b Hospital de Cruces, Barakaldo, Vizcaya, Spain
This item has received
Article information
Objetive

The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease (COPD) are uncertain. We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting.

Patients and methods

Patients with severe COPD (stages III-IV, classification of the Global Initiative for Chronic Obstructive Lung Disease) and incapacitating dyspnea (scores 3-5, Medical Research Council [MRC] scale) were randomized to a control or domiciliary rehabilitation group. The 9-week supervised pulmonary rehabilitation program included educational sessions, respiratory physiotherapy, and muscle training in weekly sessions in the patient's home. We assessed the following variables at baseline, 9 weeks, and 6 months: lung function, exercise tolerance (3-minute walk test), dyspnea (MRC score), and health-related quality of life with the Chronic Respiratory Questionnaire (CRQ).

Results

Thirty-eight patients with a mean (SD) age of 68 (6) years were enrolled. The mean MRC score was 4 (0.8) and mean forced expiratory volume in 1 second was 29% of reference. Twenty-nine patients completed the study (6 months). Distance covered on the walk test increased significantly in the rehabilitation group (P=.001) and the difference was maintained at 6 months. Dyspnea also improved significantly with rehabilitation (P≤.05), but the reduction was not evident at 6 months. Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks: dyspnea (3.1 [0.8] vs 3.6 [0.7]; P=.02) and fatigue (3.7 [0.8] vs 4.2 [0.9]; P=.002). A clinically relevant but not statistically significant change in mastery over disease was detected (from 4.3 to 4.9). All improvements were maintained at 6 months.

Conclusions

Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months.

Key words:
Chronic obstructive pulmonary disease (COPD)
Pulmonary rehabilitation
domiciliary
Health-related quality of life
Exercise tolerance
Objetivo

Los beneficios de la rehabilitación respiratoria domiciliaria (RRD) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) de grado grave-muy grave son controvertidos. Nuestro objetivo ha sido evaluar la eficacia a corto y medio plazo de un programa de RRD en pacientes con EPOC grave.

Pacientes y métodos

Se trata de un estudio prospectivo y aleatorizado en pacientes con EPOC grave (estadios III y IV de la clasificación GOLD) y disnea invalidante —; puntuación de 3 a 5 en la escala del Medical Research Council (MRC)—, distribuidos en grupo control y grupo RRD. El programa de rehabilitación respiratoria fue de 9 semanas y consistía en educación, fisioterapia respiratoria y entrenamiento muscular con supervisión semanal en domicilio. Evaluamos en situación basal, a las 9 semanas y a los 6 meses la función pulmonar, la capacidad de ejercicio (prueba de la marcha de 3 min), la disnea (MRC) y la calidad de vida relacionada con la salud, determinada con el Chronic Respiratory Questionnaire (CRQ).

Resultados

Participaron en el estudio 38 pacientes, con una edad media ± desviación estándar de 68 ± 6 años (puntuación MRC: 4 ± 0,8; volumen espiratorio forzado en el primer segundo: 29% del valor de referencia), y 29 completaron el seguimiento a los 6 meses. En el grupo RRD se incrementó significativamente la distancia recorrida en la prueba de la marcha de 3 min (p = 0,001), resultado que se mantuvo a los 6 meses. La disnea mejoró significativamente tras la RRD (p ≤ 0,05), pero dicha mejoría desapareció a los 6 meses. Se observó una mejoría clínica y estadísticamente significativa en 2 dominios del CRQ, el de disnea (3,1 ± 0,8 frente a 3,6 ± 0,7; p = 0,02) y el de fatiga (3,7 ± 0,8 frente a 4,2 ± 0,9; p = 0,002), y tan sólo clínica (4,3 frente a 4,9) en el control de la enfermedad, mejorías que se mantuvieron a los 6 meses.

Conclusiones

La RRD en pacientes con EPOC grave-muy grave y alta incapacidad funcional aporta beneficios en la calidad de vida relacionada con la salud y la capacidad de ejercicio, que pueden mantenerse hasta los 6 meses.

Palabras clave:
Enfermedad pulmonar obstructiva crónica (EPOC)
Rehabilitación respiratoria domiciliaria
Calidad de vida relacionada con la salud
Capacidad del ejercicio
Full text is only aviable in PDF
References
[1]
BR Celli, W MacNee, ATS/ERS Task Force.
Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper.
Eur Respir J, 23 (2004), pp. 932-946
[2]
CG Cote, BR Celli.
Pulmonary rehabilitation and the BODE index in COPD.
Eur Respir J, 26 (2005), pp. 630-636
[3]
ATS Medical Section of the American Lung Association.
Pulmonary rehabilitation-1999.
Am J Respir Crit Care Med, 159 (1999), pp. 1666-1682
[4]
L Nice, CL Donner, E Wouters, R Zuwallack, J Bourbeau, et al.
American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation.
Am J Respir Crit Care Med, 173 (2006), pp. 1390-1413
[5]
R Guell, P Casan, J Belda, M Sangenís, F Morante, G Guyatt, et al.
Long term effects of outpatient rehabilitation of COPD: a randomized trial.
Chest, 117 (2000), pp. 976-983
[6]
AL Ries.
Pulmonary rehabilitation and COPD.
Sem Respir Crit Care Med, 26 (2005), pp. 133-141
[7]
PJ Wijkstra, EM ten Vergert, R van Altena, V Otten, J Kraan, DS Postma, et al.
Long term benefits of rehabilitation at home on quality of life and exercise tolerance in patients with chronic obstructive pulmonary disease.
Thorax, 50 (1995), pp. 824-828
[8]
JH Strijbos, DS Postma, R van Altena, F Gimeno, GH Koeter.
A comparison between an outpatient hospital-based pulmonary rehabilitation program and a home-care pulmonary rehabilitation program in patients with COPD. A follow-up of 18 months.
Chest, 109 (1996), pp. 366-372
[9]
JA Wedzicha, JC Bestall, R Garrod, R Garnham, EA Paul, PW Jones.
Randomized controlled trial of pulmonary rehabilitation in severe chronic obstructive pulmonary disease patients, stratified with the MRC dyspnoea scale.
Eur Repir J, 12 (1998), pp. 363-369
[10]
MTE Hernández, TM Rubio, FO Ruiz, H Riera, RS Gil, JC Gómez.
Results of a home-based training program for patients with COPD.
Chest, 118 (2000), pp. 106-114
[11]
NR Anthonisen, J Manfreda, CPW Warren, ES Hershfield, GKM Harding, NA Nelson.
Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease.
Ann Intern Med, 106 (1987), pp. 196-204
[12]
J Sanchis, P Casan, J Castillo, N Gonzalez, L Palenciano, J Roca.
Normativa para la práctica de la espirometría forzada.
Arch Bronconeumol, 25 (1989), pp. 132-142
[13]
J Roca, J Sanchis, A Agustí-Vidal, R Rodríguez-Roisin.
Spirometric reference values for a mediterranean population.
Bull Eur Physiopathol Respir, 22 (1986), pp. 217-224
[14]
P Casan, M Mayos, J Gáldiz, J Giner, JA Fiz, JM Montserrat, et al.
Determinación de las presiones respiratorias estáticas máximas. Propuesta de procedimiento.
Arch Bronconeumol, 26 (1990), pp. 223-228
[15]
P Morales, J Sanchis, PJ Cordero, JL Díez.
Presiones respiratorias estáticas máximas en adultos. Valores de referencia en una población caucasiana mediterránea.
Arch Bronconeumol, 33 (1997), pp. 213-219
[16]
Normativa sobre gasometría arterial. Recomendaciones SEPAR, No. 6, Doyma, (1987),
[17]
M Iriberri, JB Gáldiz, A Gorostiza, P Ansola, C Jaca.
Comparison of the distances covered during 3 and 6 min walking test.
Respir Med, 96 (2002), pp. 812-816
[18]
G Borg.
Perceived exertion as an indicator of somatic stress.
Scand J Rehab Med, 2 (1970), pp. 92-98
[19]
JC Bestall, EA Paul, R Garrod, R Garnham, PW Jones, JA Wedzicha.
Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease.
Thorax, 54 (1999), pp. 581-586
[20]
R Güell, P Casan, M Sangenis, F Morante, J Belda, GH Guyatt.
Quality of life in patients with chronic respiratory disease: the Spanish version of the Chronic Respiratory Questionnaire (CRQ).
Eur Respir J, 11 (1998), pp. 55-60
[21]
DA Redelmeier, RS Goldstein, GH Guyatt.
Assessing the minimal important difference in symptoms: a comparison of two techniques.
J Clin Epidemiol, 49 (1996), pp. 1215-1219
[22]
DA Redelmeier, AM Bayoumi, RS Goldstein, GH Guyatt.
Interpreting small differences in functional status: the six minute walk test in chronic lung disease patients.
Am J Respir Crit Care Med, 155 (1997), pp. 1278-1282
[23]
MJ Belman, BA Kendregan.
Physical training fails to improve ventilatory muscle endurance in patients with chronic obstructive respiratory disease.
Chest, 81 (1982), pp. 440-443
[24]
R Casaburi, A Patessio, F Ioli, S Zanaboni, CF Donner, K Wasserman, et al.
Reductions in exercise lactic acidosis and ventilation as a result of exercise training in patients with obstructive lung disease.
Am Rev Respir Dis, 143 (1991), pp. 9-18
[25]
F Maltais, P Leblanc, J Jobin, CH Berubé, J Bruneau, L Carrier, et al.
Intensity of training and physiologic adaptation in patients with chronic obstructive pulmonary disease.
Am J Respir Crit Care Med, 155 (1997), pp. 555-561
[26]
DP Agle, GL Baum, EH Chester, M Wendt.
Multidisciplinary treatment of chronic pulmonary insufficiency: I. Physiologic aspects of rehabilitation.
Phychosom Med, 35 (1973), pp. 41-49
[27]
S Mota-Casals.
¿Cuál es el papel del entrenamiento de los músculos inspiratorios en el tratamiento de la EPOC?.
Arch Bronconeumol, 41 (2005), pp. 593-595
[28]
T Troosters, R Grosselink, M Decramer.
Short and long-term effects of outpatient rehabilitation in patients with chronic obstructive pulmonary disease: a randomized trial.
Am J Med, 109 (2000), pp. 207-212
[29]
AL Ries, TM Kaplan, R Myers, LM Prewitt.
Maintenance after pulmonary rehabilitation in chronic lung disease: a randomized trial.
Am J Respir Crit Care Med, 167 (2003), pp. 880-888

The preliminary results of this study were first presented at the annual European Respiratory Society Congress, September 2005 in Copenhagen, Denmark.

The study was partially funded by the Breathe Network (Red Respira) of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).

Copyright © 2007. Sociedad Española de Neumología y Cirugía Torácica (SEPAR)
Archivos de Bronconeumología
Article options
Tools

Are you a health professional able to prescribe or dispense drugs?