array:23 [
  "pii" => "S1579212906605764"
  "issn" => "15792129"
  "doi" => "10.1016/S1579-2129(06)60576-4"
  "estado" => "S300"
  "fechaPublicacion" => "2006-10-01"
  "aid" => "60576"
  "copyright" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR)"
  "copyrightAnyo" => "2006"
  "documento" => "article"
  "crossmark" => 0
  "subdocumento" => "fla"
  "cita" => "Arch Bronconeumol. 2006;42:501-8"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 1973
    "formatos" => array:3 [
      "EPUB" => 91
      "HTML" => 1278
      "PDF" => 604
    ]
  ]
  "itemSiguiente" => array:18 [
    "pii" => "S1579212906605776"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(06)60577-6"
    "estado" => "S300"
    "fechaPublicacion" => "2006-10-01"
    "aid" => "60577"
    "copyright" => "Sociedad Española de Neumología y Cirugía Torácica (SEPAR)"
    "documento" => "article"
    "crossmark" => 0
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2006;42:509-15"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2987
      "formatos" => array:3 [
        "EPUB" => 87
        "HTML" => 2143
        "PDF" => 757
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
      "titulo" => "Determination of Maximal Diaphragm Strength in Chronic Obstructive Pulmonary Disease&#58; Cervical Magnetic Stimulation Versus Traditional Sniff Maneuver"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "509"
          "paginaFinal" => "515"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Juana Mart&#237;nez-Llorens, Carlos Coronell, Alba Ram&#237;rez-Sarmiento, Mauricio Orozco-Levi, Josep M&#46; Espadaler, Juan Bautista G&#225;ldiz, Joaquim Gea"
          "autores" => array:8 [
            0 => array:3 [
              "preGrado" => "Dra&#46;"
              "nombre" => "Juana"
              "apellidos" => "Mart&#237;nez-Llorens"
            ]
            1 => array:2 [
              "nombre" => "Carlos"
              "apellidos" => "Coronell"
            ]
            2 => array:2 [
              "nombre" => "Alba"
              "apellidos" => "Ram&#237;rez-Sarmiento"
            ]
            3 => array:2 [
              "nombre" => "Mauricio"
              "apellidos" => "Orozco-Levi"
            ]
            4 => array:2 [
              "nombre" => "Josep M&#46;"
              "apellidos" => "Espadaler"
            ]
            5 => array:2 [
              "nombre" => "Juan Bautista"
              "apellidos" => "G&#225;ldiz"
            ]
            6 => array:2 [
              "nombre" => "Joaquim"
              "apellidos" => "Gea"
            ]
            7 => array:1 [
              "colaborador" => "on behalf of the ENIGMA COPD study group"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212906605776?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004200000010/v1_201305150229/S1579212906605776/v1_201305150229/en/main.assets"
  ]
  "itemAnterior" => array:18 [
    "pii" => "S1579212906605752"
    "issn" => "15792129"
    "doi" => "10.1016/S1579-2129(06)60575-2"
    "estado" => "S300"
    "fechaPublicacion" => "2006-10-01"
    "aid" => "60575"
    "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. 2006;42:492-500"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 3532
      "formatos" => array:3 [
        "EPUB" => 91
        "HTML" => 2883
        "PDF" => 558
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
      "titulo" => "Blood Uric Acid Levels in Patients With Sleep-Disordered Breathing"
      "tienePdf" => "en"
      "tieneTextoCompleto" => 0
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "492"
          "paginaFinal" => "500"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Ar&#225;nzazu Ruiz Garc&#237;a, &#193;ngeles S&#225;nchez Armengol, Estefan&#237;a Luque Crespo, Domingo Garc&#237;a Aguilar, Auxiliadora Romero Falc&#246;n, Carmen Carmona Bernal, Francisco Capote"
          "autores" => array:7 [
            0 => array:3 [
              "preGrado" => "Dra&#46;"
              "nombre" => "Ar&#225;nzazu Ruiz"
              "apellidos" => "Garc&#237;a"
            ]
            1 => array:2 [
              "nombre" => "&#193;ngeles S&#225;nchez"
              "apellidos" => "Armengol"
            ]
            2 => array:2 [
              "nombre" => "Estefan&#237;a Luque"
              "apellidos" => "Crespo"
            ]
            3 => array:2 [
              "nombre" => "Domingo Garc&#237;a"
              "apellidos" => "Aguilar"
            ]
            4 => array:2 [
              "nombre" => "Auxiliadora Romero"
              "apellidos" => "Falc&#246;n"
            ]
            5 => array:2 [
              "nombre" => "Carmen Carmona"
              "apellidos" => "Bernal"
            ]
            6 => array:2 [
              "nombre" => "Francisco"
              "apellidos" => "Capote"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212906605752?idApp=UINPBA00003Z"
    "url" => "/15792129/0000004200000010/v1_201305150229/S1579212906605752/v1_201305150229/en/main.assets"
  ]
  "en" => array:14 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Original Articles</span>"
    "titulo" => "Effectiveness of a Specific Program for Patients With Chronic Obstructive Pulmonary Disease and Frequent Exacerbations"
    "tieneTextoCompleto" => 0
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "501"
        "paginaFinal" => "508"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Juan Jos&#233; Soler, Miguel &#193;ngel Mart&#237;nez-Garc&#237;a, Pilar Rom&#225;n, Rosa Orero, Susana Terrazas, Amparo Mart&#237;nez-Pechu&#225;n"
        "autores" => array:6 [
          0 => array:5 [
            "preGrado" => "Dr&#46;"
            "nombre" => "Juan Jos&#233;"
            "apellidos" => "Soler"
            "email" => array:1 [
              0 => "jjsoler&#64;telefonica&#46;net"
            ]
            "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"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Miguel &#193;ngel"
            "apellidos" => "Mart&#237;nez-Garc&#237;a"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Pilar"
            "apellidos" => "Rom&#225;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Rosa"
            "apellidos" => "Orero"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Susana"
            "apellidos" => "Terrazas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Amparo"
            "apellidos" => "Mart&#237;nez-Pechu&#225;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Unidad de Neumolog&#237;a&#44; Servicio de Medicina Inferna&#44; Hospital General de Requena&#44; Requena&#44; Valencia&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "aff1"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Medicina Interna&#44; Hospital General de Requena&#44; Requena&#44; Valencia&#44; Spain"
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "aff2"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#42;"
            "correspondencia" => "Correspondence&#58; Dr&#46; J&#46;J&#46; Soler&#46; Unidad de Neumolog&#237;a&#46; Servicio de Medicina Intema&#46; Hospital General de Requena&#46; Paraje Casablanca&#44; s&#47;n&#46; 46430 Requena&#46; Valencia&#46; Espa&#241;a"
          ]
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2005-08-28"
    "fechaAceptado" => "2006-02-07"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec154187"
          "palabras" => array:4 [
            0 => "Chronic obstructive pulmonary disease"
            1 => "Exacerbations"
            2 => "Hospitalization"
            3 => "Education"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec154188"
          "palabras" => array:4 [
            0 => "Enfermedad pulmonar obstructive cr&#243;nica"
            1 => "Exacerbaciones"
            2 => "Hospitalizaci&#243;n"
            3 => "Educaci&#243;n"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:1 [
        "resumen" => "<span class="elsevierStyleSectionTitle">Objective</span><p class="elsevierStyleSimplePara elsevierViewall">Patients with chronic obstructive pulmonary disease &#40;CQPD&#41; and a history of frequent exacerbations are a target population of particular interest from both a clinical and an economic standpoint&#46; The objective of this study was to evaluate the effectiveness of a program designed specifically to manage patients in this subgroup&#46;</p> <span class="elsevierStyleSectionTitle">Patients and methods</span><p class="elsevierStyleSimplePara elsevierViewall">This was a 1-year randomized controlled trial designed to compare the effectiveness of a specific program &#40;SP&#41; with that of conventional management &#40;CM&#41; in a group of patients with a high frequency of exacerbations &#40;3 or more per year&#41;&#46; Within-group and between-group comparisons were carried out for a number of variables related to the patients&#39; medical care&#44; dyspnea&#44; health-related quality of life &#40;HRQL&#41;&#44; inhaler technique&#44; and pulmonary function&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p class="elsevierStyleSimplePara elsevierViewall">A total of 26 patients were enrolled in the study &#40;all men&#41;&#46; The mean &#40;SD&#41; age was 73 &#40;8&#41; years&#44; and mean forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; expressed as a percentage of the reference value was 43&#37; &#40;15&#37;&#41;&#46; Exacerbations requiring hospital care &#40;emergency department visits and&#47;or admission&#41; decreased in both groups&#58; by 24&#46;4&#37; &#40;<span class="elsevierStyleItalic">P</span> not significant&#41; in the CM group and 44&#46;1&#37; &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;061&#41; in the SP group&#46; Hospital admissions decreased 73&#46;3&#37; in the SP group and increased 22&#37; in the CM group &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#41;&#46; While length of hospital stay decreased 773&#37; in the SP group&#44; this figure almost doubled in the CM group &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;014&#41;&#46; Dyspnea&#44; HRQL&#44; and inhaler technique improved in both groups&#46; FEV<span class="elsevierStyleInf">1</span> fell by 46 mL&#47;year in the CM group and increased 10 mL&#47;year in the SP group &#40;<span class="elsevierStyleItalic">P</span> not significant&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p class="elsevierStyleSimplePara elsevierViewall">The use of a simple program to manage selected patients with a history of frequent exacerbations produces a significant reduction in the number of hospital admissions&#44; an improvement in HRQL&#44; and may improve prognosis&#46;</p>"
      ]
      "es" => array:1 [
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivo</span><p class="elsevierStyleSimplePara elsevierViewall">Los pacientes con enfermedad pulmonar obstructiva cr&#243;nica que presentan frecuentes agudizaciones &#40;AEPOC&#41; constituyen una poblaci&#243;n diana de especial inter&#233;s&#44; tanto desde el pnnto de vista cl&#237;nico como econ&#243;mico&#46; El objetivo del estudio es evaluar la eficacia de un programa espec&#237;fico &#40;PE&#41; dirigido a este subgrupo de enfermos&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes y m&#233;todos</span><p class="elsevierStyleSimplePara elsevierViewall">Se ha realizado un estudio prospectivo&#44; aleatorizado y controlado de un a&#241;o de durati&#243;n&#44; en el que se ha comparado la eficacia del PE frente al tratamiento conventional &#40;TC&#41; en un grupo de pacientes con exacerbaciones frecuentes &#40;3 o m&#225;s AEPOC al a&#241;o&#41;&#46; Se efectuaron comparaciones intragrupo e intergrupo en diversos par&#225;metros asistenciales&#44; disnea&#44; calidad de vida relacionada con la salud &#40;CVRS&#41;&#44; t&#233;cnica inhalatoria y funci&#243;n pulmonar&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p class="elsevierStyleSimplePara elsevierViewall">Se incluy&#243; en el estudio a 26 pacientes &#40;todos varones&#41;&#44; con una edad media &#40;&#177; desviaci&#243;n est&#225;ndar&#41; de 73 &#177; 8 a&#241;os y volumen espiratorio forzado en el primer segundo&#44; en porcentaje del valor de referencia&#44; del 43 &#177; 15&#37;&#46; Las exacerbaciones que precisaron atenci&#243;n hospitalaria &#40;visitas a urgencias y&#47;u hospitalizaciones&#41; disminuyeron en ambos grupos&#58; un 24&#44;4&#37; &#40;p &#61; no significativo&#41; en el grupo TC y un 44&#44;1&#37; &#40;p &#61; 0&#44;061&#41; en el grupo PE&#46; Las hospitalizaciones se redujeron un 73&#44;3&#37; en el grupo de interventi&#243;n&#44; mientras que se incrementaron un 22&#37; en el TC &#40;p &#60; 0&#44;001&#41;&#46; Los d&#237;as de hospitalizaci&#243;n disminuyeron un 77&#44;3&#37; en el PE&#44; mientras que aumentaron casi el doble para el TC &#40;p &#61; 0&#44;014&#41;&#46; La disnea&#44; la CVRS y la t&#233;cnica inhalatoria mejoraron en ambos grupos&#46; El volumen espiratorio forzado en el primer segundo present&#243; un descenso de 46 ml&#47;a&#241;o en grupo TC&#44; mientras que se increment&#243; 10 ml&#47;a&#241;o para el grupo PE &#40;p &#61; no significative&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p class="elsevierStyleSimplePara elsevierViewall">El empleo de un programa sencillo&#44; dirigido a pacientes seleccionados con exacerbaciones frecuentes&#44; comporta una reducci&#243;n significativa del n&#250;mero de las hospitalizaciones&#44; mayor CVRS y quiz&#225; mejor pron&#243;stko&#46;</p>"
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "REFERENCES"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:32 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "TAR Seemungal"
                            1 => "GC Donaldson"
                            2 => "EA Paul"
                            3 => "JC Bestall"
                            4 => "DJ Jeffries"
                            5 => "JA Wedzicha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.157.5.9709032"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "1998"
                        "volumen" => "157"
                        "paginaInicial" => "1418"
                        "paginaFinal" => "1422"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9603117"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Impacto asistencial hospitalario de la EPOC&#46; Peso espec&#237;fico del paciente con EPOC de alto consumo sanitario"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "JJ Soler"
                            1 => "L S&#225;nchez"
                            2 => "M Latorre"
                            3 => "J Alamar"
                            4 => "P Rom&#225;n"
                            5 => "M Perpi&#241;&#225;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2001"
                        "volumen" => "37"
                        "paginaInicial" => "375"
                        "paginaFinal" => "381"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11674937"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Costes de la EPOC en Espa&#241;a&#46; Estimaci&#243;n a partir de un estudio epidemiol&#243;gico poblacional"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "JF Masa"
                            1 => "V Sobradillo"
                            2 => "C Villasante"
                            3 => "CA Jim&#233;nez-Ruiz"
                            4 => "L Fem&#225;ndez-Fau"
                            5 => "JL Viejo"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2004"
                        "volumen" => "40"
                        "paginaInicial" => "72"
                        "paginaFinal" => "79"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14746730"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "JJ Soler-Catalu&#241;a"
                            1 => "MA Mart&#237;nez-Garc&#237;a"
                            2 => "P Rom&#225;n"
                            3 => "E Salcedo"
                            4 => "M Navarro"
                            5 => "R Ochando"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2005.040527"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2005"
                        "volumen" => "60"
                        "paginaInicial" => "925"
                        "paginaFinal" => "931"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16055622"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Treatment of chronic obstructive pulmonary disease and its exacerbations in general practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "M Miravitlles"
                            1 => "C Mayordomo"
                            2 => "M Art&#233;s"
                            3 => "L S&#225;nchez-Agudo"
                            4 => "F Nicolau"
                            5 => "JL Seg&#250;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "1999"
                        "volumen" => "93"
                        "paginaInicial" => "173"
                        "paginaFinal" => "179"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10464874"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1130634308759464"
                          "estado" => "S300"
                          "issn" => "11306343"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomised&#44; double blind&#44; placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease&#59; the ISOLDE trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "PS Burge"
                            1 => "PMA Calverley"
                            2 => "PW Jones"
                            3 => "S Spencer"
                            4 => "JA Anderson"
                            5 => "TK Maslen"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2000"
                        "volumen" => "320"
                        "paginaInicial" => "1297"
                        "paginaFinal" => "1303"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10807619"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk factors of emergency care and admissions in COPD patients with high consumption of health resources"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "JJ Soler"
                            1 => "L S&#225;nchez"
                            2 => "P Rom&#225;n"
                            3 => "MA Mart&#237;nez"
                            4 => "M Perpi&#241;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Resp Med"
                        "fecha" => "2004"
                        "volumen" => "98"
                        "paginaInicial" => "318"
                        "paginaFinal" => "329"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "GC Donaldson"
                            1 => "TAR Seemungal"
                            2 => "A Bhowmik"
                            3 => "JA Wedzicha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2002"
                        "volumen" => "57"
                        "paginaInicial" => "847"
                        "paginaFinal" => "852"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12324669"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of salmeterol xinafoate in the treatment of COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "DA Mahler"
                            1 => "JF Donohue"
                            2 => "RA Barbee"
                            3 => "MD Goldman"
                            4 => "NJ Gross"
                            5 => "ME Wisniewski"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1999"
                        "volumen" => "115"
                        "paginaInicial" => "957"
                        "paginaFinal" => "965"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10208192"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "V Brusasco"
                            1 => "R Hodder"
                            2 => "M Miravitlles"
                            3 => "L Korducki"
                            4 => "L Towse"
                            5 => "S Kesten"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2003"
                        "volumen" => "58"
                        "paginaInicial" => "399"
                        "paginaFinal" => "404"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12728159"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P Calverley"
                            1 => "R Pauwels"
                            2 => "J Vestbo"
                            3 => "P Jones"
                            4 => "N Pride"
                            5 => "A Gulsivik"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(03)12459-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2003"
                        "volumen" => "361"
                        "paginaInicial" => "449"
                        "paginaFinal" => "456"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12583942"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib12"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Efficacy of oral long-term N-acetylcysteine in chronic broncopulmonary disease&#58; a meta-analysis of published double-blind&#44; placebo-controlled trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "EM Grandjean"
                            1 => "P Berthet"
                            2 => "R Ruffmann"
                            3 => "P Leuenberger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0149-2918(00)88479-9"
                      "Revista" => array:7 [
                        "tituloSerie" => "Clin Ther"
                        "fecha" => "2000"
                        "volumen" => "22"
                        "paginaInicial" => "209"
                        "paginaFinal" => "221"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10743980"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1130634308728083"
                          "estado" => "S300"
                          "issn" => "11306343"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib13"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Results at 1 year of outpatient multidisciplinary rehabilitation&#58; a randomised controlled trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "TL Griffiths"
                            1 => "ML Burr"
                            2 => "IA Campbell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2000"
                        "volumen" => "355"
                        "paginaInicial" => "362"
                        "paginaFinal" => "368"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10665556"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib14"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Relation between influenza vaccination and outpatient visits&#44; hospitalization and mortality in elderly persons with chronic lung disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "KL Nichol"
                            1 => "L Baken"
                            2 => "A Nelson"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Intern Med"
                        "fecha" => "1999"
                        "volumen" => "130"
                        "paginaInicial" => "397"
                        "paginaFinal" => "403"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10068413"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib15"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Reduction of hospital utilization in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J Bourbeau"
                            1 => "M Julien"
                            2 => "F Maltais"
                            3 => "M Rouleau"
                            4 => "A Beaupr&#233;"
                            5 => "R Begin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2003"
                        "volumen" => "163"
                        "paginaInicial" => "585"
                        "paginaFinal" => "591"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12622605"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib16"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Self-management education for patients with chronic obstructive pulmonary disease&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "E Monninkhof"
                            1 => "P van der Valk"
                            2 => "J van der Palen"
                            3 => "C van Herwaarden"
                            4 => "MR Partridge"
                            5 => "G Ziehlhuis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2003"
                        "volumen" => "58"
                        "paginaInicial" => "394"
                        "paginaFinal" => "398"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12728158"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib17"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Toward a consensus definition for COPD exacerbation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "R Rodr&#237;guez-Roisin"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2000"
                        "volumen" => "117"
                        "paginaInicial" => "398S"
                        "paginaFinal" => "401S"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10843984"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib18"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:1 [
                  "host" => array:1 [
                    0 => array:1 [
                      "LibroEditado" => array:2 [
                        "titulo" => "Controlando la EPOC"
                        "serieFecha" => "2001"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib19"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Comparison of clinical dyspnea ratings and psychophysical measurements of respiratory sensation in obstructive airway disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "DA Mahler"
                            1 => "RA Rosiello"
                            2 => "A Harver"
                            3 => "T Lentine"
                            4 => "JF Govern"
                            5 => "JA Daubenspeck"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Am Rev Respir Dis"
                        "fecha" => "1987"
                        "volumen" => "165"
                        "paginaInicial" => "1229"
                        "paginaFinal" => "1233"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib20"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Validity and reliability of the St&#46; George&#39;s Respiratory Questionnaire after adaptation to a different language and culture&#58; the Spanish example"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M Ferrer"
                            1 => "J Alonso"
                            2 => "L Prieto"
                            3 => "V Plaza"
                            4 => "E Mons&#243;"
                            5 => "R Marrades"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "1996"
                        "volumen" => "9"
                        "paginaInicial" => "1160"
                        "paginaFinal" => "1166"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8804932"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib21"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A new method of classifying prognostic comorbidity in longitudinal studies&#58; development and validation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "ME Charlson"
                            1 => "P Pompei"
                            2 => "KL Ales"
                            3 => "CRI MacKenzie"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Chronic Dis"
                        "fecha" => "1987"
                        "volumen" => "40"
                        "paginaInicial" => "373"
                        "paginaFinal" => "383"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3558716"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib22"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normativa para la pr&#225;clica 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 Gonz&#225;lez"
                            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"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib23"
              "etiqueta" => "23"
              "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" => true
                          "autores" => array:6 [
                            0 => "J Roca"
                            1 => "J Sanchis"
                            2 => "A Agust&#237;-Vidal"
                            3 => "F Segarra"
                            4 => "D Nuvajas"
                            5 => "R Rodr&#237;guez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "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"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib24"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Normativa sobre la gasometr&#237;a arterial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Grupo de Trabajo de la SEPAR para la pr&#225;ctica de la gasometr&#237;a arterial"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:7 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "1998"
                        "volumen" => "34"
                        "paginaInicial" => "142"
                        "paginaFinal" => "153"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9611639"
                            "web" => "Medline"
                          ]
                        ]
                        "itemHostRev" => array:3 [
                          "pii" => "S1130634309724651"
                          "estado" => "S300"
                          "issn" => "11306343"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib25"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The cost and efficacy of home care for patients with chronic lung disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M Bergner"
                            1 => "LD Hudson"
                            2 => "DA Conrad"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Med Care"
                        "fecha" => "1988"
                        "volumen" => "26"
                        "paginaInicial" => "566"
                        "paginaFinal" => "579"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/3379988"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib26"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment&#44; disability and handicap due to chronic airflow limitation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P Littlejohns"
                            1 => "CM Baveystock"
                            2 => "H Parnell"
                            3 => "PW Jones"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "1991"
                        "volumen" => "46"
                        "paginaInicial" => "559"
                        "paginaFinal" => "564"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1926024"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib27"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Respi-care&#58; an innovative home care program for the patient with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "MC Haggerty"
                            1 => "R Stockdale-Woolley"
                            2 => "S Nair"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "1991"
                        "volumen" => "100"
                        "paginaInicial" => "607"
                        "paginaFinal" => "612"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1889241"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib28"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Case management may reduce length of hospital stay in patients with recurrent admissions for chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "PJ Poole"
                            1 => "B Chase"
                            2 => "A Frankel"
                            3 => "P Black"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respirology"
                        "fecha" => "2001"
                        "volumen" => "6"
                        "paginaInicial" => "37"
                        "paginaFinal" => "42"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11264761"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib29"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluaci&#243;n de un programa de hospitalizaci&#243;n domiciliaria en pacientes con EPOC agudizada"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S D&#237;az"
                            1 => "F Gonz&#225;lez"
                            2 => "MA G&#243;mez"
                            3 => "S Mayoralas"
                            4 => "I Mart&#237;n"
                            5 => "C Villasante"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2005"
                        "volumen" => "41"
                        "paginaInicial" => "5"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15676129"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib30"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The St&#46; George&#39;s Respiratory Questionnaire"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "PW Jones"
                            1 => "FH Quirk"
                            2 => "CM Baveystock"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "1991"
                        "volumen" => "85"
                        "paginaInicial" => "25"
                        "paginaFinal" => "31"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1759018"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib31"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "TM Wilkinson"
                            1 => "GC Donaldson"
                            2 => "JR Hurst"
                            3 => "TA Seemungal"
                            4 => "JA Wedzicha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200310-1443OC"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2004"
                        "volumen" => "169"
                        "paginaInicial" => "1298"
                        "paginaFinal" => "1303"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14990395"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib32"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation &#40;EFRAM study&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "J Garc&#237;a-Aymerich"
                            1 => "E Barreiro"
                            2 => "E Farrero"
                            3 => "RM Marrades"
                            4 => "J Morera"
                            5 => "JM Ant&#243;"
                            6 => "the EFRAM investigators"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2000"
                        "volumen" => "16"
                        "paginaInicial" => "1037"
                        "paginaFinal" => "1042"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11292102"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000004200000010/v1_201305150229/S1579212906605764/v1_201305150229/en/main.assets"
  "Apartado" => null
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000004200000010/v1_201305150229/S1579212906605764/v1_201305150229/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212906605764?idApp=UINPBA00003Z"
]
Share
Journal Information
Vol. 42. Issue 10.
Pages 501-508 (October 2006)
Share
Share
Download PDF
More article options
Vol. 42. Issue 10.
Pages 501-508 (October 2006)
Original Articles
Full text access
Effectiveness of a Specific Program for Patients With Chronic Obstructive Pulmonary Disease and Frequent Exacerbations
Visits
4050
Juan José Solera,
Corresponding author
jjsoler@telefonica.net

Correspondence: Dr. J.J. Soler. Unidad de Neumología. Servicio de Medicina Intema. Hospital General de Requena. Paraje Casablanca, s/n. 46430 Requena. Valencia. España
, Miguel Ángel Martínez-Garcíaa, Pilar Románb, Rosa Orerob, Susana Terrazasb, Amparo Martínez-Pechuánb
a Unidad de Neumología, Servicio de Medicina Inferna, Hospital General de Requena, Requena, Valencia, Spain
b Servicio de Medicina Interna, Hospital General de Requena, Requena, Valencia, Spain
This item has received
Article information
Abstract
Bibliography
Download PDF
Statistics
Objective

Patients with chronic obstructive pulmonary disease (CQPD) and a history of frequent exacerbations are a target population of particular interest from both a clinical and an economic standpoint. The objective of this study was to evaluate the effectiveness of a program designed specifically to manage patients in this subgroup.

Patients and methods

This was a 1-year randomized controlled trial designed to compare the effectiveness of a specific program (SP) with that of conventional management (CM) in a group of patients with a high frequency of exacerbations (3 or more per year). Within-group and between-group comparisons were carried out for a number of variables related to the patients' medical care, dyspnea, health-related quality of life (HRQL), inhaler technique, and pulmonary function.

Results

A total of 26 patients were enrolled in the study (all men). The mean (SD) age was 73 (8) years, and mean forced expiratory volume in 1 second (FEV1) expressed as a percentage of the reference value was 43% (15%). Exacerbations requiring hospital care (emergency department visits and/or admission) decreased in both groups: by 24.4% (P not significant) in the CM group and 44.1% (P=.061) in the SP group. Hospital admissions decreased 73.3% in the SP group and increased 22% in the CM group (P<.001). While length of hospital stay decreased 773% in the SP group, this figure almost doubled in the CM group (P=.014). Dyspnea, HRQL, and inhaler technique improved in both groups. FEV1 fell by 46 mL/year in the CM group and increased 10 mL/year in the SP group (P not significant).

Conclusions

The use of a simple program to manage selected patients with a history of frequent exacerbations produces a significant reduction in the number of hospital admissions, an improvement in HRQL, and may improve prognosis.

Key words:
Chronic obstructive pulmonary disease
Exacerbations
Hospitalization
Education
Objetivo

Los pacientes con enfermedad pulmonar obstructiva crónica que presentan frecuentes agudizaciones (AEPOC) constituyen una población diana de especial interés, tanto desde el pnnto de vista clínico como económico. El objetivo del estudio es evaluar la eficacia de un programa específico (PE) dirigido a este subgrupo de enfermos.

Pacientes y métodos

Se ha realizado un estudio prospectivo, aleatorizado y controlado de un año de duratión, en el que se ha comparado la eficacia del PE frente al tratamiento conventional (TC) en un grupo de pacientes con exacerbaciones frecuentes (3 o más AEPOC al año). Se efectuaron comparaciones intragrupo e intergrupo en diversos parámetros asistenciales, disnea, calidad de vida relacionada con la salud (CVRS), técnica inhalatoria y función pulmonar.

Resultados

Se incluyó en el estudio a 26 pacientes (todos varones), con una edad media (± desviación estándar) de 73 ± 8 años y volumen espiratorio forzado en el primer segundo, en porcentaje del valor de referencia, del 43 ± 15%. Las exacerbaciones que precisaron atención hospitalaria (visitas a urgencias y/u hospitalizaciones) disminuyeron en ambos grupos: un 24,4% (p = no significativo) en el grupo TC y un 44,1% (p = 0,061) en el grupo PE. Las hospitalizaciones se redujeron un 73,3% en el grupo de interventión, mientras que se incrementaron un 22% en el TC (p < 0,001). Los días de hospitalización disminuyeron un 77,3% en el PE, mientras que aumentaron casi el doble para el TC (p = 0,014). La disnea, la CVRS y la técnica inhalatoria mejoraron en ambos grupos. El volumen espiratorio forzado en el primer segundo presentó un descenso de 46 ml/año en grupo TC, mientras que se incrementó 10 ml/año para el grupo PE (p = no significative).

Conclusiones

El empleo de un programa sencillo, dirigido a pacientes seleccionados con exacerbaciones frecuentes, comporta una reducción significativa del número de las hospitalizaciones, mayor CVRS y quizá mejor pronóstko.

Palabras clave:
Enfermedad pulmonar obstructive crónica
Exacerbaciones
Hospitalización
Educación
Full text is only aviable in PDF
REFERENCES
[1]
TAR Seemungal, GC Donaldson, EA Paul, JC Bestall, DJ Jeffries, JA Wedzicha.
Effect of exacerbation on quality of life in patients with chronic obstructive pulmonary disease.
Am J Respir Crit Care Med, 157 (1998), pp. 1418-1422
[2]
JJ Soler, L Sánchez, M Latorre, J Alamar, P Román, M Perpiñá.
Impacto asistencial hospitalario de la EPOC. Peso específico del paciente con EPOC de alto consumo sanitario.
Arch Bronconeumol, 37 (2001), pp. 375-381
[3]
JF Masa, V Sobradillo, C Villasante, CA Jiménez-Ruiz, L Femández-Fau, JL Viejo, et al.
Costes de la EPOC en España. Estimación a partir de un estudio epidemiológico poblacional.
Arch Bronconeumol, 40 (2004), pp. 72-79
[4]
JJ Soler-Cataluña, MA Martínez-García, P Román, E Salcedo, M Navarro, R Ochando.
Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease.
Thorax, 60 (2005), pp. 925-931
[5]
M Miravitlles, C Mayordomo, M Artés, L Sánchez-Agudo, F Nicolau, JL Segú.
Treatment of chronic obstructive pulmonary disease and its exacerbations in general practice.
Respir Med, 93 (1999), pp. 173-179
[6]
PS Burge, PMA Calverley, PW Jones, S Spencer, JA Anderson, TK Maslen, et al.
Randomised, double blind, placebo controlled study of fluticasone propionate in patients with moderate to severe chronic obstructive pulmonary disease; the ISOLDE trial.
BMJ, 320 (2000), pp. 1297-1303
[7]
JJ Soler, L Sánchez, P Román, MA Martínez, M Perpiña.
Risk factors of emergency care and admissions in COPD patients with high consumption of health resources.
Resp Med, 98 (2004), pp. 318-329
[8]
GC Donaldson, TAR Seemungal, A Bhowmik, JA Wedzicha.
Relationship between exacerbation frequency and lung function decline in chronic obstructive pulmonary disease.
Thorax, 57 (2002), pp. 847-852
[9]
DA Mahler, JF Donohue, RA Barbee, MD Goldman, NJ Gross, ME Wisniewski, et al.
Efficacy of salmeterol xinafoate in the treatment of COPD.
Chest, 115 (1999), pp. 957-965
[10]
V Brusasco, R Hodder, M Miravitlles, L Korducki, L Towse, S Kesten, et al.
Health outcomes following treatment for six months with once daily tiotropium compared with twice daily salmeterol in patients with COPD.
Thorax, 58 (2003), pp. 399-404
[11]
P Calverley, R Pauwels, J Vestbo, P Jones, N Pride, A Gulsivik, et al.
Combined salmeterol and fluticasone in the treatment of chronic obstructive pulmonary disease: a randomised controlled trial.
[12]
EM Grandjean, P Berthet, R Ruffmann, P Leuenberger.
Efficacy of oral long-term N-acetylcysteine in chronic broncopulmonary disease: a meta-analysis of published double-blind, placebo-controlled trials.
[13]
TL Griffiths, ML Burr, IA Campbell.
Results at 1 year of outpatient multidisciplinary rehabilitation: a randomised controlled trial.
Lancet, 355 (2000), pp. 362-368
[14]
KL Nichol, L Baken, A Nelson.
Relation between influenza vaccination and outpatient visits, hospitalization and mortality in elderly persons with chronic lung disease.
Ann Intern Med, 130 (1999), pp. 397-403
[15]
J Bourbeau, M Julien, F Maltais, M Rouleau, A Beaupré, R Begin, et al.
Reduction of hospital utilization in patients with chronic obstructive pulmonary disease.
Arch Intern Med, 163 (2003), pp. 585-591
[16]
E Monninkhof, P van der Valk, J van der Palen, C van Herwaarden, MR Partridge, G Ziehlhuis.
Self-management education for patients with chronic obstructive pulmonary disease: a systematic review.
Thorax, 58 (2003), pp. 394-398
[17]
R Rodríguez-Roisin.
Toward a consensus definition for COPD exacerbation.
Chest, 117 (2000), pp. 398S-401S
[18]
Controlando la EPOC,
[19]
DA Mahler, RA Rosiello, A Harver, T Lentine, JF Govern, JA Daubenspeck.
Comparison of clinical dyspnea ratings and psychophysical measurements of respiratory sensation in obstructive airway disease.
Am Rev Respir Dis, 165 (1987), pp. 1229-1233
[20]
M Ferrer, J Alonso, L Prieto, V Plaza, E Monsó, R Marrades, et al.
Validity and reliability of the St. George's Respiratory Questionnaire after adaptation to a different language and culture: the Spanish example.
Eur Respir J, 9 (1996), pp. 1160-1166
[21]
ME Charlson, P Pompei, KL Ales, CRI MacKenzie.
A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.
J Chronic Dis, 40 (1987), pp. 373-383
[22]
J Sanchis, P Casan, J Castillo, N González, L Palenciano, J Roca.
Normativa para la práclica de la espirometría forzada.
Arch Bronconeumol, 25 (1989), pp. 132-142
[23]
J Roca, J Sanchis, A Agustí-Vidal, F Segarra, D Nuvajas, R Rodríguez, et al.
Spirometric reference values for a Mediterranean population.
Bull Eur Physiopathol Respir, 22 (1986), pp. 217-224
[24]
Grupo de Trabajo de la SEPAR para la práctica de la gasometría arterial.
Normativa sobre la gasometría arterial.
Arch Bronconeumol, 34 (1998), pp. 142-153
[25]
M Bergner, LD Hudson, DA Conrad.
The cost and efficacy of home care for patients with chronic lung disease.
Med Care, 26 (1988), pp. 566-579
[26]
P Littlejohns, CM Baveystock, H Parnell, PW Jones.
Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability and handicap due to chronic airflow limitation.
Thorax, 46 (1991), pp. 559-564
[27]
MC Haggerty, R Stockdale-Woolley, S Nair.
Respi-care: an innovative home care program for the patient with chronic obstructive pulmonary disease.
Chest, 100 (1991), pp. 607-612
[28]
PJ Poole, B Chase, A Frankel, P Black.
Case management may reduce length of hospital stay in patients with recurrent admissions for chronic obstructive pulmonary disease.
Respirology, 6 (2001), pp. 37-42
[29]
S Díaz, F González, MA Gómez, S Mayoralas, I Martín, C Villasante.
Evaluación de un programa de hospitalización domiciliaria en pacientes con EPOC agudizada.
Arch Bronconeumol, 41 (2005), pp. 5-10
[30]
PW Jones, FH Quirk, CM Baveystock.
The St. George's Respiratory Questionnaire.
Respir Med, 85 (1991), pp. 25-31
[31]
TM Wilkinson, GC Donaldson, JR Hurst, TA Seemungal, JA Wedzicha.
Early therapy improves outcomes of exacerbations of chronic obstructive pulmonary disease.
Am J Respir Crit Care Med, 169 (2004), pp. 1298-1303
[32]
J García-Aymerich, E Barreiro, E Farrero, RM Marrades, J Morera, JM Antó, the EFRAM investigators.
Patients hospitalized for COPD have a high prevalence of modifiable risk factors for exacerbation (EFRAM study).
Eur Respir J, 16 (2000), pp. 1037-1042
Copyright © 2006. 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?