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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma and chronic obstructive pulmonary disease &#40;COPD&#41; are the two most common obstructive airway diseases &#40;asthma affects more than 300 million people worldwide<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">1</span></a> and more than 250 million people have COPD<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">2</span></a>&#41;&#46; The incidence of both entities is increasing&#46; The high prevalence and morbidity of these diseases also generates high healthcare costs &#40;in Spain&#44; 2&#37; of public health resources are spent on asthma and 2&#46;5&#37; on COPD&#41;&#46; The third most common airway disease&#44; bronchiectasis&#44; also carries a heavy healthcare burden&#44; with an estimated mean cost per exacerbation of around &#8364;5&#44;350&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Although the pathophysiological and clinical features of asthma&#44; COPD&#44; and bronchiectasis differ&#44; they can coexist in the same patient in the form of overlap syndromes&#44; either by chance &#40;as all these diseases are very prevalent&#41;&#44; or perhaps because they are connected in some way&#46; There is growing evidence of the existence of a clinical phenotype&#44; COPD and bronchiectasis&#44; that presents with its own clinical characteristics&#46; However&#44; studies have failed to demonstrate a causal association between these diseases&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#8211;7</span></a> and even less scientific evidence is available on the relationship between asthma and bronchiectasis&#46; Although bronchiectasis appears to be linked with more severe asthma&#44; the impact of bronchiectasis on the progress of asthma&#44; the possible pathophysiological mechanism that could explain this association&#44; and any causal relationship between these entities<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a> remain to be clarified&#46; Some authors believe that because COPD&#44; asthma&#44; and bronchiectasis share certain risk factors&#44; etiological features&#44; and pathophysiological pathways&#44; COPD and asthma could be responsible for the development of bronchiectasis in susceptible individuals&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">7</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Bronchiectasis is the consequence of a complex vicious circle of infection&#44; inflammation&#44; and mucociliary damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">9&#44;10</span></a> Failure to resolve the inflammation-infection binomial leads to chronicity&#44; with a cycle of destruction and repair of the bronchial wall that causes irreversible injuries&#46; This mechanism is intensified periodically during exacerbations&#44; possibly accelerating disease progression&#46; Many of these factors have also been observed in COPD&#44; triggered or magnified by tobacco smoke and other toxic gases&#46; It is not surprising&#44; therefore&#44; that according to some studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#44;5</span></a> between 30&#37; and 50&#37; of patients with moderate-severe COPD have bronchiectasis&#46; Patients with both COPD and bronchiectasis tend to be mainly men&#44; older&#44; and with a greater accumulated smoking index&#46; They also have more respiratory symptoms &#40;increased hypersecretion&#44; more purulent sputum&#44; and worse dyspnea&#41;&#44; poorer lung function&#44; more airway colonization by potentially pathogenic microorganisms &#40;especially <span class="elsevierStyleItalic">Pseudomonas aeruginosa</span> &#91;<span class="elsevierStyleItalic">P&#46; aeruginosa</span>&#93;&#41;&#44; more serious and more frequent exacerbations&#44; and higher mortality rates&#46;<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">4&#8211;7&#44;11&#44;12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">SEPAR bronchiectasis guidelines recommend performing a high-resolution CT scan to rule out bronchiectasis in patients with moderate-severe COPD with multiple exacerbations and&#47;or repeated isolation of potentially pathogenic microorganisms in respiratory samples &#40;or <span class="elsevierStyleItalic">P&#46; aeruginosa</span> on a single occasion&#41; in a clinically stable phase&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since the 1990s&#44; we have known that asthma and bronchiectasis coexist in a high percentage of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">13</span></a> but it is only now&#44; probably in the light of results in COPD&#44; that interest in this phenomenon has been rekindled&#44; and efforts are being directed at determining the characteristics of these patients and the possible prognostic and therapeutic implications of this combination&#46; Most studies that have attempted to determine the prevalence of bronchiectasis in asthma patients are retrospective or cross-sectional&#59; they use different methodologies&#59; high-resolution computed tomography is not always performed in all patients<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">14</span></a>&#59; and they have other important biases&#44; such as the inclusion of smokers<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">15</span></a> and patients with allergic bronchopulmonary aspergillosis<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">16</span></a> or other diseases causing bronchiectasis&#46; For all these reasons&#44; the reported incidence of bronchiectasis varies greatly&#44; from 2&#37; to 80&#37; of cases&#46; However&#44; higher quality studies report a prevalence of bronchiectasis in patients with severe asthma of around 25&#37;&#8211;30&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">17</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">A recent study by our group&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">18</span></a> designed to analyze the association between asthma and bronchiectasis while avoiding the biases of previous studies&#44; prospectively included 398 patients&#44; non-smokers with uncontrolled moderate or severe asthma&#44; followed up in a specialized high-complexity SEPAR-accredited asthma unit&#46; All study subjects underwent high-resolution computed tomography&#46; In total&#44; 28&#46;4&#37; had bronchiectasis &#40;20&#46;6&#37; with moderate asthma vs 33&#46;6&#37; with severe asthma&#44; <span class="elsevierStyleItalic">P</span>&#60;0&#46;001&#41;&#46; Asthma patients with bronchiectasis &#40;compared to those without bronchiectasis&#41; were older&#44; had poorer lung function and lower levels of FeNO&#44; and a greater percentage had severe asthma&#44; chronic expectoration&#44; purulent sputum and exacerbations&#44; more emergency room visits&#44; and a higher use of antibiotics&#46; The presence of bronchiectasis was associated with more severe asthma&#44; chronic expectoration&#44; at least 1 previous episode of pneumonia&#44; and lower levels of FeNO &#40;at a cut-off point of 20&#46;5<span class="elsevierStyleHsp" style=""></span>ppb&#41;&#46; All this suggests that these are a special type of patients&#44; with their own particular characteristics&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">There is still a long way to go and many questions must be answered about inflammatory airway diseases before we understand the complex causative pathophysiological processes&#44; their correlation&#44; and the clinical&#44; prognostic&#44; and therapeutic implications of bronchiectasis in patients with asthma or COPD&#46; These diseases remain a challenge for the treating physician&#44; even more so in the era of personalized medicine&#46;</p></span>"
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Editorial
Bronchiectasis in COPD and Asthma. More Than Just a Coincidence
Bronquiectasias en EPOC y asma. ¿Algo más que una casualidad?
Alicia Padilla-Galoa,
Corresponding author
aliciapadillagalo@gmail.com

Corresponding author.
, Casilda Olveira Fusterb
a Unidad de Neumología, Agencia Sanitaria Costa del Sol, Marbella, Málaga, Spain
b Servicio de Neumología, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Regional Universitario de Málaga/Universidad de Málaga, Málaga, Spain

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