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y cl&#237;nicos &#40;grado de disnea medido por la escala modificada del Medical Research Council &#91;mMRC&#93; y agudizaciones&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Realizamos un estudio observacional de la cohorte de pacientes en seguimiento en la consulta monogr&#225;fica de EPOC del Servicio de Neumolog&#237;a del Hospital Universitario de La Princesa de Madrid &#40;Espa&#241;a&#41;&#46; El objetivo primario del estudio fue caracterizar a estos pacientes seg&#250;n la nueva clasificaci&#243;n de riesgo&#44; con evaluaci&#243;n de la adecuaci&#243;n de la intervenci&#243;n asistencial y el tratamiento en funci&#243;n de las recomendaciones propuestas por GesEPOC 2017&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Llevamos a cabo un an&#225;lisis estad&#237;stico descriptivo &#40;frecuencias relativas y absolutas&#59; medias y desviaciones t&#237;picas dependiendo del tipo de variable&#41; con el paquete estad&#237;stico IBM SPSS Statistics versi&#243;n 22&#46;0&#46; &#40;IBM&#44; EE&#46; UU&#46;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Nuestra cohorte estaba formada por un total de 430 pacientes&#46; De estos&#44; 144 &#40;33&#44;5&#37;&#41; cumpl&#237;an criterios de bajo riesgo y 286 &#40;66&#44;5&#37;&#41; se clasificaron como de alto riesgo&#46; En 57 &#40;19&#44;9&#37;&#41; de los de alto riesgo estaban presentes los 3 criterios y en 33 &#40;11&#44;5&#37;&#41; se cumpl&#237;a un &#250;nico criterio&#46; El criterio de alto riesgo m&#225;s frecuente fue tener un grado de disnea &#8805; 2 mMRC&#44; presente en un 76&#44;2&#37; de los pacientes&#46; Del total&#44; 12 &#40;4&#44;2&#37;&#41; eran de alto riesgo por cumplir como &#250;nico criterio un grado de disnea &#8805; 2 mMRC&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas&#44; y la distribuci&#243;n por fenotipo cl&#237;nico&#44; seg&#250;n el nivel de riesgo&#44; se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; En nuestra cohorte no se encontraron diferencias entre ambos grupos por edad&#44; sexo ni comorbilidades de forma estad&#237;sticamente significativa&#46; El 100&#37; de los pacientes de alto riesgo estaban clasificados en funci&#243;n del fenotipo cl&#237;nico&#44; siendo el fenotipo cl&#237;nico agudizador el m&#225;s frecuente &#40;50&#44;3&#37;&#41; y el fenotipo mixto el menos frecuente &#40;8&#44;7&#37;&#41;&#44; en concordancia con lo publicado en estudios previos<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5-7</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Los pacientes de alto riesgo presentaron mayor n&#250;mero de agudizaciones&#44; m&#225;s disnea y peor funci&#243;n pulmonar que los de bajo riesgo de forma significativa &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; tal como era de esperar&#46; Adem&#225;s&#44; estos pacientes presentaban un nivel de gravedad mayor evaluado por los &#237;ndices BODE y BODEx &#40;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;3 y 3&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8&#44; respectivamente&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Con relaci&#243;n al tratamiento por nivel de riesgo&#44; la mayor&#237;a de los pacientes de alto riesgo se encontraban en tratamiento con tripe terapia &#40;antimuscar&#237;nico de acci&#243;n larga&#47;&#946;-2 adren&#233;rgico de acci&#243;n larga&#47;corticoides inhalados &#91;LAMA&#47;LABA&#47;CI&#93;&#41; sin diferencias entre agudizador bronqu&#237;tico cr&#243;nico vs&#46; agudizador enfisematoso &#40;66&#44;1&#37; vs&#46; 67&#44;1&#37;&#41;&#44; similar a lo descrito en series m&#225;s amplias publicadas<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; Un 62&#44;4&#37; de los pacientes de alto riesgo no agudizadores tambi&#233;n se encontraba en tratamiento con triple terapia&#46; As&#237; mismo&#44; pese a que en los de bajo riesgo la opci&#243;n m&#225;s utilizada fue la doble broncodilataci&#243;n&#44; un 27&#44;1&#37; de los pacientes manten&#237;an tratamiento con triple terapia&#46; El porcentaje de pacientes EPOC de bajo riesgo en nuestra serie que recibe tratamiento con triple terapia no puede justificarse en su totalidad por la frecuencia del fenotipo mixto &#40;9&#44;7&#37; de los pacientes&#41;&#46; Como se observa en otros estudios&#44; este alto n&#250;mero se relacionar&#237;a con pacientes sobretratados<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En cuanto al tratamiento no farmacol&#243;gico&#44; en nuestra cohorte un 61&#44;2&#37; de los pacientes de alto riesgo estaban incluidos en un programa de rehabilitaci&#243;n pulmonar&#44; el 46&#44;9&#37; ten&#237;a oxigenoterapia cr&#243;nica domiciliaria y el 22&#44;2&#37; oxigenoterapia port&#225;til&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En consideraci&#243;n al estudio diagn&#243;stico&#44; al 94&#44;4&#37; de los pacientes de bajo riesgo y al 93&#44;7&#37; de los de alto riesgo se les realiz&#243; espirometr&#237;a con prueba broncodilatadora para el diagn&#243;stico y en el 100&#37; se evalu&#243; la saturaci&#243;n arterial de ox&#237;geno&#46; Por el contrario&#44; la medici&#243;n de alfa 1 antitripsina no se encontraba solicitada en la gran mayor&#237;a de los pacientes &#40;23&#44;3&#37; en los de bajo riesgo y 25&#44;9&#37; en los de alto riesgo&#41;&#46; En lo que respecta a otras pruebas complementarias m&#225;s espec&#237;ficas&#44; se realiz&#243; tomograf&#237;a computarizada de t&#243;rax a un 99&#44;6&#37;&#44; test de la marcha a un 80&#44;4&#37;&#44; vol&#250;menes pulmonares a un 87&#44;1&#37; y capacidad de difusi&#243;n a un 81&#44;5&#37; de los pacientes de alto riesgo&#46; La realizaci&#243;n de las pruebas diagn&#243;sticas en nuestros pacientes se adecuaba a las recomendaciones que establece GesEPOC 2017&#44; salvo en el cribado del d&#233;ficit de alfa 1 antitripsina&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Una de las limitaciones de nuestro estudio es que todos los pacientes pertenec&#237;an a una cohorte hospitalaria de un &#250;nico centro&#44; por lo que no es superponible a la poblaci&#243;n general con EPOC&#44; ya que estos pacientes pueden presentar m&#225;s comorbilidades y otros condicionantes asociados al alto riesgo&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la mayor parte de los pacientes en seguimiento en nuestra consulta monogr&#225;fica son de alto riesgo y fenotipo cl&#237;nico agudizador&#46; El manejo de los pacientes llevado a cabo se adec&#250;a a las recomendaciones propuestas por GesEPOC 2017&#44; si bien existen importantes aspectos a mejorar como el cribado de alfa 1 antitripsina y la adhesi&#243;n a las recomendaciones de tratamiento farmacol&#243;gico&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#46;&#176; de agudizaciones&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">189 &#40;66&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fenotipo cl&#237;nico&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No agudizador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">130 &#40;90&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">117 &#40;81&#44;5&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mixto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">14 &#40;9&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Agudizador enfisema&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79 &#40;27&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Agudizador bronqu&#237;tico cr&#243;nico&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65 &#40;22&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Adecuación del nivel de intervención en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) según la estratificación de riesgo propuesta por la Guía española de la EPOC (GesEPOC) versión 2017
Adjusting the Level of Intervention in Patients with Chronic Obstructive Pulmonary Disease According to the Risk Stratification Proposed by the Spanish COPD Guidelines (GesEPOC) Version 2017
Marta Erro Iribarrena,b,
Corresponding author
martaerro@gmail.com

Autor para correspondencia.
, Tamara Alonso Péreza,b, Joan B. Sorianoa,b, Julio Ancochea Bermúdeza,b
a Servicio de Neumología, Hospital Universitario de la Princesa, Madrid, España
b Instituto de Investigación Sanitaria de la Princesa, Madrid, España
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&#40;IBM&#44; EE&#46; UU&#46;&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Nuestra cohorte estaba formada por un total de 430 pacientes&#46; De estos&#44; 144 &#40;33&#44;5&#37;&#41; cumpl&#237;an criterios de bajo riesgo y 286 &#40;66&#44;5&#37;&#41; se clasificaron como de alto riesgo&#46; En 57 &#40;19&#44;9&#37;&#41; de los de alto riesgo estaban presentes los 3 criterios y en 33 &#40;11&#44;5&#37;&#41; se cumpl&#237;a un &#250;nico criterio&#46; El criterio de alto riesgo m&#225;s frecuente fue tener un grado de disnea &#8805; 2 mMRC&#44; presente en un 76&#44;2&#37; de los pacientes&#46; Del total&#44; 12 &#40;4&#44;2&#37;&#41; eran de alto riesgo por cumplir como &#250;nico criterio un grado de disnea &#8805; 2 mMRC&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Las caracter&#237;sticas demogr&#225;ficas y cl&#237;nicas&#44; y la distribuci&#243;n por fenotipo cl&#237;nico&#44; seg&#250;n el nivel de riesgo&#44; se muestran en la <a class="elsevierStyleCrossRef" href="#tbl0005">tabla 1</a>&#46; En nuestra cohorte no se encontraron diferencias entre ambos grupos por edad&#44; sexo ni comorbilidades de forma estad&#237;sticamente significativa&#46; El 100&#37; de los pacientes de alto riesgo estaban clasificados en funci&#243;n del fenotipo cl&#237;nico&#44; siendo el fenotipo cl&#237;nico agudizador el m&#225;s frecuente &#40;50&#44;3&#37;&#41; y el fenotipo mixto el menos frecuente &#40;8&#44;7&#37;&#41;&#44; en concordancia con lo publicado en estudios previos<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">5-7</span></a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Los pacientes de alto riesgo presentaron mayor n&#250;mero de agudizaciones&#44; m&#225;s disnea y peor funci&#243;n pulmonar que los de bajo riesgo de forma significativa &#40;p &#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&#41;&#44; tal como era de esperar&#46; Adem&#225;s&#44; estos pacientes presentaban un nivel de gravedad mayor evaluado por los &#237;ndices BODE y BODEx &#40;4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>2&#44;3 y 3&#44;9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>1&#44;8&#44; respectivamente&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Con relaci&#243;n al tratamiento por nivel de riesgo&#44; la mayor&#237;a de los pacientes de alto riesgo se encontraban en tratamiento con tripe terapia &#40;antimuscar&#237;nico de acci&#243;n larga&#47;&#946;-2 adren&#233;rgico de acci&#243;n larga&#47;corticoides inhalados &#91;LAMA&#47;LABA&#47;CI&#93;&#41; sin diferencias entre agudizador bronqu&#237;tico cr&#243;nico vs&#46; agudizador enfisematoso &#40;66&#44;1&#37; vs&#46; 67&#44;1&#37;&#41;&#44; similar a lo descrito en series m&#225;s amplias publicadas<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a>&#46; Un 62&#44;4&#37; de los pacientes de alto riesgo no agudizadores tambi&#233;n se encontraba en tratamiento con triple terapia&#46; As&#237; mismo&#44; pese a que en los de bajo riesgo la opci&#243;n m&#225;s utilizada fue la doble broncodilataci&#243;n&#44; un 27&#44;1&#37; de los pacientes manten&#237;an tratamiento con triple terapia&#46; El porcentaje de pacientes EPOC de bajo riesgo en nuestra serie que recibe tratamiento con triple terapia no puede justificarse en su totalidad por la frecuencia del fenotipo mixto &#40;9&#44;7&#37; de los pacientes&#41;&#46; Como se observa en otros estudios&#44; este alto n&#250;mero se relacionar&#237;a con pacientes sobretratados<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">En cuanto al tratamiento no farmacol&#243;gico&#44; en nuestra cohorte un 61&#44;2&#37; de los pacientes de alto riesgo estaban incluidos en un programa de rehabilitaci&#243;n pulmonar&#44; el 46&#44;9&#37; ten&#237;a oxigenoterapia cr&#243;nica domiciliaria y el 22&#44;2&#37; oxigenoterapia port&#225;til&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">En consideraci&#243;n al estudio diagn&#243;stico&#44; al 94&#44;4&#37; de los pacientes de bajo riesgo y al 93&#44;7&#37; de los de alto riesgo se les realiz&#243; espirometr&#237;a con prueba broncodilatadora para el diagn&#243;stico y en el 100&#37; se evalu&#243; la saturaci&#243;n arterial de ox&#237;geno&#46; Por el contrario&#44; la medici&#243;n de alfa 1 antitripsina no se encontraba solicitada en la gran mayor&#237;a de los pacientes &#40;23&#44;3&#37; en los de bajo riesgo y 25&#44;9&#37; en los de alto riesgo&#41;&#46; En lo que respecta a otras pruebas complementarias m&#225;s espec&#237;ficas&#44; se realiz&#243; tomograf&#237;a computarizada de t&#243;rax a un 99&#44;6&#37;&#44; test de la marcha a un 80&#44;4&#37;&#44; vol&#250;menes pulmonares a un 87&#44;1&#37; y capacidad de difusi&#243;n a un 81&#44;5&#37; de los pacientes de alto riesgo&#46; La realizaci&#243;n de las pruebas diagn&#243;sticas en nuestros pacientes se adecuaba a las recomendaciones que establece GesEPOC 2017&#44; salvo en el cribado del d&#233;ficit de alfa 1 antitripsina&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Una de las limitaciones de nuestro estudio es que todos los pacientes pertenec&#237;an a una cohorte hospitalaria de un &#250;nico centro&#44; por lo que no es superponible a la poblaci&#243;n general con EPOC&#44; ya que estos pacientes pueden presentar m&#225;s comorbilidades y otros condicionantes asociados al alto riesgo&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">En conclusi&#243;n&#44; la mayor parte de los pacientes en seguimiento en nuestra consulta monogr&#225;fica son de alto riesgo y fenotipo cl&#237;nico agudizador&#46; El manejo de los pacientes llevado a cabo se adec&#250;a a las recomendaciones propuestas por GesEPOC 2017&#44; si bien existen importantes aspectos a mejorar como el cribado de alfa 1 antitripsina y la adhesi&#243;n a las recomendaciones de tratamiento farmacol&#243;gico&#46;</p></span>"
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                  \t\t\t\t"><span class="elsevierStyleItalic">N&#46;&#176; de agudizaciones&#44; media</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">&#177;</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">DE</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">189 &#40;66&#44;1&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Fenotipo cl&#237;nico&#44; n &#40;&#37;&#41;</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#60;<span class="elsevierStyleHsp" style=""></span>0&#44;05&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>No agudizador&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">130 &#40;90&#44;3&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mixto&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Agudizador enfisema&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#8211;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">79 &#40;27&#44;6&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Agudizador bronqu&#237;tico cr&#243;nico&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">65 &#40;22&#44;7&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 03002896
Original language: Spanish
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2019 December 7 6 13
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Archivos de Bronconeumología

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