array:24 [
  "pii" => "S1579212915001846"
  "issn" => "15792129"
  "doi" => "10.1016/j.arbr.2015.04.027"
  "estado" => "S300"
  "fechaPublicacion" => "2015-08-01"
  "aid" => "1187"
  "copyright" => "SEPAR"
  "copyrightAnyo" => "2014"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "pgl"
  "cita" => "Arch Bronconeumol. 2015;51:384-95"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 8955
    "formatos" => array:3 [
      "EPUB" => 192
      "HTML" => 7136
      "PDF" => 1627
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0300289615001568"
      "issn" => "03002896"
      "doi" => "10.1016/j.arbres.2015.04.011"
      "estado" => "S300"
      "fechaPublicacion" => "2015-08-01"
      "aid" => "1187"
      "copyright" => "SEPAR"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "pgl"
      "cita" => "Arch Bronconeumol. 2015;51:384-95"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 9953
        "formatos" => array:3 [
          "EPUB" => 158
          "HTML" => 7305
          "PDF" => 2490
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Normativa SEPAR</span>"
        "titulo" => "Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "384"
            "paginaFinal" => "395"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0020"
            "etiqueta" => "Figura 4"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr4.jpeg"
                "Alto" => 1765
                "Ancho" => 2412
                "Tamanyo" => 145111
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Selecci&#243;n de ensayos cl&#237;nicos controlados que han utilizado pruebas a una potencia constante de intensidad alta para medir el efecto de intervenciones sobre los m&#250;sculos de las extremidades inferiores&#46;Potencia&#58; intensidad a la que se hizo la prueba como porcentaje de la W<span class="elsevierStyleItalic">R</span><span class="elsevierStyleInf">max</span>&#46; L&#237;nea vertical&#58; m&#237;nima diferencia cl&#237;nicamente relevante&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Esther Barreiro, V&#237;ctor Bustamante, Pilar Cejudo, Juan B&#46; G&#225;ldiz, Joaquim Gea, Pilar de Lucas, Juana Mart&#237;nez-Llorens, Francisco Ortega, Luis Puente-Maestu, Josep Roca, Jos&#233; Miguel Rodr&#237;guez Gonz&#225;lez-Moro"
            "autores" => array:11 [
              0 => array:2 [
                "nombre" => "Esther"
                "apellidos" => "Barreiro"
              ]
              1 => array:2 [
                "nombre" => "V&#237;ctor"
                "apellidos" => "Bustamante"
              ]
              2 => array:2 [
                "nombre" => "Pilar"
                "apellidos" => "Cejudo"
              ]
              3 => array:2 [
                "nombre" => "Juan B&#46;"
                "apellidos" => "G&#225;ldiz"
              ]
              4 => array:2 [
                "nombre" => "Joaquim"
                "apellidos" => "Gea"
              ]
              5 => array:2 [
                "nombre" => "Pilar"
                "apellidos" => "de Lucas"
              ]
              6 => array:2 [
                "nombre" => "Juana"
                "apellidos" => "Mart&#237;nez-Llorens"
              ]
              7 => array:2 [
                "nombre" => "Francisco"
                "apellidos" => "Ortega"
              ]
              8 => array:2 [
                "nombre" => "Luis"
                "apellidos" => "Puente-Maestu"
              ]
              9 => array:2 [
                "nombre" => "Josep"
                "apellidos" => "Roca"
              ]
              10 => array:2 [
                "nombre" => "Jos&#233; Miguel"
                "apellidos" => "Rodr&#237;guez Gonz&#225;lez-Moro"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1579212915001846"
          "doi" => "10.1016/j.arbr.2015.04.027"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915001846?idApp=UINPBA00003Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289615001568?idApp=UINPBA00003Z"
      "url" => "/03002896/0000005100000008/v2_201511200118/S0300289615001568/v2_201511200118/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S157921291500107X"
    "issn" => "15792129"
    "doi" => "10.1016/j.arbr.2015.04.014"
    "estado" => "S300"
    "fechaPublicacion" => "2015-08-01"
    "aid" => "1078"
    "copyright" => "SEPAR"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2015;51:396-402"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2516
      "formatos" => array:3 [
        "EPUB" => 139
        "HTML" => 1837
        "PDF" => 540
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
      "titulo" => "The Role of Pulmonology in the National Health System Chronicity Strategy"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "396"
          "paginaFinal" => "402"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "El papel de la neumolog&#237;a ante la Estrategia de cronicidad del Sistema Nacional de Salud"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1341
              "Ancho" => 1658
              "Tamanyo" => 129226
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Conceptual model for the care of patients with chronic diseases &#40;chronic care model&#41; proposed by Wagner&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Juan Jos&#233; Soler-Catalu&#241;a, Fernando S&#225;nchez Toril, M&#46; Carmen Aguar Benito"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Juan Jos&#233;"
              "apellidos" => "Soler-Catalu&#241;a"
            ]
            1 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "S&#225;nchez Toril"
            ]
            2 => array:2 [
              "nombre" => "M&#46; Carmen"
              "apellidos" => "Aguar Benito"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0300289614004384"
        "doi" => "10.1016/j.arbres.2014.10.007"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289614004384?idApp=UINPBA00003Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500107X?idApp=UINPBA00003Z"
    "url" => "/15792129/0000005100000008/v2_201511200100/S157921291500107X/v2_201511200100/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S157921291500141X"
    "issn" => "15792129"
    "doi" => "10.1016/j.arbr.2015.05.004"
    "estado" => "S300"
    "fechaPublicacion" => "2015-08-01"
    "aid" => "1031"
    "copyright" => "SEPAR"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2015;51:379-83"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2541
      "formatos" => array:3 [
        "EPUB" => 138
        "HTML" => 1891
        "PDF" => 512
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Characteristics of Candidates for Lung Transplantation Due to Chronic Obstructive Pulmonary Disease and Alpha-1 Antitrypsin Deficiency Emphysema"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "379"
          "paginaFinal" => "383"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Caracter&#237;sticas de la poblaci&#243;n candidata a trasplante pulmonar por enfermedad pulmonar obstructiva cr&#243;nica y por enfisema secundario a d&#233;ficit de alfa 1 antitripsina"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Fig&#46; 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 3783
              "Ancho" => 1659
              "Tamanyo" => 210738
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Error bars for the clinical variables according to the transplant period&#58; &#40;a&#41; PO<span class="elsevierStyleInf">2</span> values&#59; &#40;b&#41; FEV1&#37; values&#59; &#40;c&#41; 6-minute walk test values&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Daniela Giacoboni, Miriam Barrecheguren, Cristina Esquinas, Esther Rodr&#237;guez, Cristina Berastegui, Manuel L&#243;pez-Meseguer, V&#237;ctor Monforte, Carlos Bravo, Pietro Pirina, Marc Miravitlles, Antonio Rom&#225;n"
          "autores" => array:11 [
            0 => array:2 [
              "nombre" => "Daniela"
              "apellidos" => "Giacoboni"
            ]
            1 => array:2 [
              "nombre" => "Miriam"
              "apellidos" => "Barrecheguren"
            ]
            2 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Esquinas"
            ]
            3 => array:2 [
              "nombre" => "Esther"
              "apellidos" => "Rodr&#237;guez"
            ]
            4 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Berastegui"
            ]
            5 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "L&#243;pez-Meseguer"
            ]
            6 => array:2 [
              "nombre" => "V&#237;ctor"
              "apellidos" => "Monforte"
            ]
            7 => array:2 [
              "nombre" => "Carlos"
              "apellidos" => "Bravo"
            ]
            8 => array:2 [
              "nombre" => "Pietro"
              "apellidos" => "Pirina"
            ]
            9 => array:2 [
              "nombre" => "Marc"
              "apellidos" => "Miravitlles"
            ]
            10 => array:2 [
              "nombre" => "Antonio"
              "apellidos" => "Rom&#225;n"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0300289614003299"
        "doi" => "10.1016/j.arbres.2014.08.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289614003299?idApp=UINPBA00003Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500141X?idApp=UINPBA00003Z"
    "url" => "/15792129/0000005100000008/v2_201511200100/S157921291500141X/v2_201511200100/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Recommendations of SEPAR</span>"
    "titulo" => "Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "384"
        "paginaFinal" => "395"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Esther Barreiro, V&#237;ctor Bustamante, Pilar Cejudo, Juan B&#46; G&#225;ldiz, Joaquim Gea, Pilar de Lucas, Juana Mart&#237;nez-Llorens, Francisco Ortega, Luis Puente-Maestu, Josep Roca, Jos&#233; Miguel Rodr&#237;guez Gonz&#225;lez-Moro"
        "autores" => array:11 [
          0 => array:4 [
            "nombre" => "Esther"
            "apellidos" => "Barreiro"
            "email" => array:1 [
              0 => "ebarreiro&#64;imim&#46;es"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "V&#237;ctor"
            "apellidos" => "Bustamante"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Pilar"
            "apellidos" => "Cejudo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Juan B&#46;"
            "apellidos" => "G&#225;ldiz"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Joaquim"
            "apellidos" => "Gea"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Pilar"
            "apellidos" => "de Lucas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Juana"
            "apellidos" => "Mart&#237;nez-Llorens"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "Francisco"
            "apellidos" => "Ortega"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "Luis"
            "apellidos" => "Puente-Maestu"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          9 => array:3 [
            "nombre" => "Josep"
            "apellidos" => "Roca"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
            ]
          ]
          10 => array:3 [
            "nombre" => "Jos&#233; Miguel"
            "apellidos" => "Rodr&#237;guez Gonz&#225;lez-Moro"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:7 [
          0 => array:3 [
            "entidad" => "Servei de Pneumologia&#44; Unitat de Recerca en M&#250;scul i Aparell Respiratori &#40;URMAR&#41;&#44; IMIM-Hospital del Mar&#44; CEXS&#44; Universitat Pompeu Fabra&#44; Parc de Recerca Biom&#232;dica de Barcelona &#40;PRBB&#41;&#44; Barcelona&#44; Espa&#241;a"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "CIBER de Enfermedades Respiratorias &#40;CIBERES&#41;&#44; Instituto de Salud Carlos III&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Hospital Universitario Basurto&#44; Osakidetza&#44; Departamento de Medicina&#44; Universidad del Pa&#237;s Vasco&#44; Bilbao&#44; Espa&#241;a"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Unidad M&#233;dico-Quir&#250;rgica de Enfermedades Respiratorias&#44; Hospital Universitario Virgen del Roc&#237;o&#44; Sevilla&#44; Espa&#241;a"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Servicio de Neumolog&#237;a y Unidad de Investigaci&#243;n&#44; Hospital de Cruces&#44; Universidad del Pa&#237;s Vasco&#44; Barakaldo&#44; Espa&#241;a"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Servicio de Neumolog&#237;a&#44; Hospital General Gregorio Mara&#241;&#243;n&#44; Universidad Complutense de Madrid&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servei de Pneumologia&#44; Hospital Cl&#237;nic de Barcelona&#44; Barcelona&#44; Espa&#241;a"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1248
            "Ancho" => 3214
            "Tamanyo" => 246423
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Etiological factors involved in limb muscle dysfunction in COPD patients&#46; The factors have deleterious effects on lower limb muscle function and mass&#44; causing the scales to completely tip toward the negative side &#40;left tray&#41;&#46; &#40;B&#41; In the lower limb muscles&#44; the actions of the etiological factors are mediated by several biological mechanisms&#44; with deleterious effects on muscle function&#44; mass and structure&#46; The scales are completely tipped to the left&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">These guidelines discuss the latest findings on muscle dysfunction in patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; and examine the general problem&#44; etiology&#44; diagnosis&#44; evaluation&#44; and treatment&#46; To that end&#44; the expert authors have summarized the most recent publications on the various aspects of the topic&#44; and the Grading of Recommendations Assessment&#44; Development&#44; and Evaluation &#40;GRADE&#41; scale has been used to make recommendations on the grade of evidence for the various proposals discussed in this document&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">1</span></a> Due to space constraints&#44; an extended version expanding on these guidelines has been made available online&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology&#44; Pathophysiology and Implications for Patients</span><p id="par0010" class="elsevierStylePara elsevierViewall">Muscles in any part of the body have 2 main functional properties&#58; strength&#44; the maximum expression of their ability to contract&#59; and endurance&#44; the ability to maintain less than maximum strength over time&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">2</span></a> Strength depends mainly on muscle mass&#44; while endurance is determined by the aerobic capacity of the muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">3</span></a> Strength and endurance in different muscle groups can be measured in routine clinical practice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Muscle dysfunction is defined as the inability of a muscle to perform its task&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">2</span></a> as a result of loss of strength or endurance&#44; or both&#46; Dysfunction of the respiratory muscles or the muscles of the limbs &#40;also known as peripheral muscles&#41; is common in respiratory diseases&#46; Patients with limb muscle dysfunction lose their independence&#44; which adversely affects their quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">4&#44;5</span></a> COPD is probably the respiratory disease in which muscle dysfunction has been studied in most depth&#44; and it has been established that up to one third of COPD patients&#44; even in the early stages of the disease&#44; have a loss of muscle function in their limbs &#40;25&#37; less strength than control subjects&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">4</span></a> Respiratory muscle dysfunction is seen in advanced COPD patients&#44; whose diaphragmatic strength is between 20&#37; and 30&#37; of that of control subjects&#46;<a class="elsevierStyleCrossRefs" href="#bib0860"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently show that COPD patients have muscle dysfunction&#44; irrespective of the severity of their pulmonary obstruction&#46; Evidence GRADE 1A&#46;</span></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Muscle Dysfunction Pathophysiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">Research over the last 20 years has revealed that several factors and mechanisms are involved in the multifactorial etiology of muscle dysfunction in COPD patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Limb Muscle Dysfunction &#40;Quadriceps&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">As indicated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; cigarette smoke&#44; genetic and epigenetic alterations&#44; metabolic disorders &#40;including vitamin D and testosterone deficiencies&#41;&#44; drugs &#40;corticosteroids&#41;&#44; comorbidities&#44; exacerbations&#44; systemic inflammation&#44; malnutrition&#44; physical inactivity&#44; and aging are some of the factors involved in limb muscle dysfunction in COPD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;3</span></a> The biological events implicated in limb muscle dysfunction most notably include a series of structural changes&#44;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#8211;11</span></a> oxidative stress&#44;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#44;11&#44;12</span></a> chronic hypoxia&#44; hypercapnia and acidosis&#44; and structural and mitochondrial changes<a class="elsevierStyleCrossRefs" href="#bib0895"><span class="elsevierStyleSup">13&#44;14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Other mechanisms&#44; such as proteolysis&#44; apoptosis&#44; autophagy&#44; and epigenetics&#44; are also involved in the physiopathology of limb muscle dysfunction in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#44;15&#8211;19</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently point to biological mechanisms and factors involved in the development of muscle dysfunction in COPD patients&#46; Evidence GRADE 1A&#46;</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Respiratory Muscle Dysfunction</span><p id="par0040" class="elsevierStylePara elsevierViewall">The major factors involved in the respiratory muscle dysfunction of COPD are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#46; The most important of these are mechanical factors&#44; but there are also factors that induce positive adaptation&#44; which gives the respiratory muscles of these patients certain endurance<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">3&#44;20</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Adaptive biological phenomena have also been found in the diaphragm&#44; counteracting the potential deleterious effects&#59; these phenomena include shortening of the sarcomere length&#44; increased myoglobin content and higher proportions of fatigue-resistant fibers and capillary contacts&#44; increased mitochondrial density&#44; and improved aerobic muscle potential<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">3&#44;21&#8211;25</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; In COPD&#44; the final muscle phenotype will be a result of the balance between the adaptive factors and mechanisms&#44; and those involved in muscle function&#44; as well as between stable disease and exacerbations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; In advanced COPD however&#44; biological mechanisms<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">8&#44;9&#44;15&#8211;19&#44;26</span></a> identical to those described in limb muscle dysfunction affect the diaphragm&#44; prevailing over the adaptive mechanisms &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently point to biological mechanisms and factors involved in the development of muscle dysfunction in COPD patients&#46; Evidence GRADE 1A&#46;</span></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Evaluation of Respiratory Muscles&#58; Voluntary and Involuntary Maneuvers &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Evaluating Respiratory Muscle Strength&#58; Volitional Tests of Respiratory Muscle Strength</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Non-Invasive Testing</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Spirometry</span><p id="par0050" class="elsevierStylePara elsevierViewall">Forced spirometry&#44;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> although non-specific&#44; can detect a decline in forced vital capacity &#40;FVC&#41; that can be indicative of a non-obstructive ventilatory defect&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">28</span></a> A FVC decrease of greater than 25&#37; between spirometries performed in the sitting and supine positions&#44; or FVC less than 75&#37; of the predicted values in the supine position&#44; with normal values in the sitting position&#44; indicate diaphragmatic weakness&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Measuring Pressure at the Mouth</span><p id="par0055" class="elsevierStylePara elsevierViewall">Maximum pressures generated at the mouth&#44; whether inspiratory &#40;MIP&#41; or expiratory &#40;MEP&#41;&#44; are more specific for assessing respiratory muscle strength&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> These tests are generally static maneuvers &#40;without airflow&#41;&#44; performed using mouthpieces that can be occluded&#44; with a small leak to prevent glottic closure and to reduce the use of the buccal muscles&#46; MIP &#91;usually determined from residual volume &#40;RV&#41;&#93; is a measure of the strength of all the inspiratory muscles&#44; while MEP &#91;normally determined from total lung capacity &#40;TLC&#41;&#93; basically expresses the strength of the expiratory muscles in the abdomen<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; As for all voluntary maneuvers&#44; the patient needs to be encouraged verbally&#44; and three acceptable maneuvers should be obtained&#44; with a variation of less than 20&#37;&#46; Reference values for the healthy Mediterranean population are available&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">30</span></a> MIP values greater than 80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O can also exclude severe muscle dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Sniff Nasal Inspiratory Pressure &#40;SNIP&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nasal pressure is determined during maximal nasal inhalation &#40;SNIP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;31&#44;32</span></a> This is a natural&#44; dynamic maneuver&#44; carried out with the patient in a sitting position&#44; with one nostril blocked&#46; It is usually measured from functional residual capacity &#40;FRC&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;31&#44;32</span></a> using the highest value from at least 10 maneuvers&#46; Inspiratory muscle dysfunction can be ruled out if values are higher than &#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or &#8722;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Invasive Testing</span><p id="par0065" class="elsevierStylePara elsevierViewall">A good expression of the pleural pressure generated by activation of the inspiratory muscles can be obtained from the esophageal pressure determined by placing a pressure catheter in the mid-third of the esophagus during forced inhalation &#40;<span class="elsevierStyleItalic">sniff</span>Pesmax&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;33</span></a> Inspiratory muscle dysfunction can be ruled out if S<span class="elsevierStyleItalic">niff</span>Pesmax values are higher than &#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or &#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Diaphragmatic strength or transdiaphragmatic pressure &#40;Pdi&#41; can also be determined by measuring the difference between gastric and esophageal pressure&#44; estimated by placing 2 catheters connected to pressure transducers &#40;one in the esophagus and the other in the gastric cavity&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleItalic">Sniff</span>Pdi values lower than 75<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or 53<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women suggest diaphragmatic dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">34</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that volitional testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Non-Volitional Tests of Respiratory Muscle Strength &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">External stimulation techniques&#44; using phrenic nerve stimulators generating electric or magnetic fields &#40;Pdi<span class="elsevierStyleItalic">twitch</span>&#41;&#44; have been developed to avoid false positives&#46; Normal Pdi<span class="elsevierStyleItalic">twitch</span> values are about 20&#37;&#8211;30&#37; of the <span class="elsevierStyleItalic">sniff</span>Pdi&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;34</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that non-volitional testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evaluating Respiratory Muscle Endurance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Pressure&#8211;time product &#40;PTP&#41; is calculated by integrating the respiratory pressure measured at the mouth&#44; esophagus or Pdi over time &#40;cm H<span class="elsevierStyleInf">2</span>O&#47;min&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> Maximal sustainable ventilation &#40;MSV&#41; is expressed as a fraction of maximal voluntary ventilation &#40;MVV&#41;&#59; normal values are between 60&#37; and 80&#37; of the MVV&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> MSV is a measure of respiratory muscle endurance and the function of other elements of the rib cage&#46;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">35</span></a> Inspiratory or expiratory threshold loading tests are more specific&#46; There are two types&#58; incremental&#44; measuring the sustained maximal pressure &#40;SMIP and SMEP&#44; depending on whether inspiratory or expiratory&#41;&#44; and constant submaximal loading &#40;percentage of SMIP or MIP for inspiratory&#44; and SMEP or MEP for expiratory&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1010"><span class="elsevierStyleSup">36&#8211;39</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that endurance testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evaluation of Limb Muscles&#58; Volitional and Non-Volitional Testing</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">General Evaluation of Limb Muscles &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Evaluating Muscle Mass &#40;MM&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Initial calculations are based on systems determining body compartments&#44; such as the Matiegka method&#44;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">40</span></a> which takes body weight &#40;W&#41; as the sum of 4 components&#58; O&#44; skeletal weight&#59; D&#44; skin and subcutaneous adipose tissue weight&#59; M&#44; skeletal muscle weight&#59; and R&#44; remaining weight&#46; Skinfold anthropometry requires several measurements&#44; including height&#44; length and width of the limb&#44; folds and calculated body surface area&#44; but this technique generally overestimates the fat-free mass&#44; compared to other methods&#46;<a class="elsevierStyleCrossRef" href="#bib1035"><span class="elsevierStyleSup">41</span></a> Technological advances have led to complex and even invasive systems&#44; such as deuterium dilution&#44;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">40</span></a> considered the gold standard&#46; Although its use is limited to research centers&#44; it has been used to validate a series of more commonly used measurements&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall"></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bioimpedance Analysis &#40;BIA&#41; or Bioelectric Impedance</span><p id="par0105" class="elsevierStylePara elsevierViewall">This method is based on the principle that the electrical conductivity of a fat-free mass &#40;comparable to the MM&#41; is greater than that of fat&#46;<a class="elsevierStyleCrossRef" href="#bib1040"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Dual-Energy X-Ray Absorptiometry &#40;DEXA&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">DEXA is an imaging technique used for estimating total-body and regional skeletal muscle mass&#46; It also can be used for quantifying lean soft tissue&#44; fat and bone mineral density&#46;<a class="elsevierStyleCrossRef" href="#bib1045"><span class="elsevierStyleSup">43</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that the different tests for quantifying muscle mass in COPD patients are useful and provide reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Local MM Study Techniques</span><p id="par0120" class="elsevierStylePara elsevierViewall">Although measuring thigh circumference is simple and cheap&#44; it is not a good measure of local muscle mass&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> Alternatives include computed tomography &#40;CT&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> magnetic resonance imaging &#40;MRI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">45</span></a> and ultrasound&#44;<a class="elsevierStyleCrossRef" href="#bib1060"><span class="elsevierStyleSup">46</span></a> particularly for measuring quadriceps size&#46; In COPD&#44; the amount of local MM measured by these techniques has been correlated with parameters as diverse as muscle strength<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">47</span></a> and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> Muscle biopsy is a morphological technique that provides data on the structural and biochemical properties of the muscles&#44;<a class="elsevierStyleCrossRef" href="#bib1070"><span class="elsevierStyleSup">48</span></a> but its invasive nature means that use is essentially limited to research studies&#44; even when fine needle microbiopsies are obtained&#46;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">47</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Numerous studies consistently show that obtaining a muscle biopsy from COPD patients is highly useful and provides reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Physical Activity</span><p id="par0130" class="elsevierStylePara elsevierViewall">Physical activity can be measured by questionnaires or&#44; more reliably&#44; by accelerometers that record activities performed by a subject over a prolonged period&#46;<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Exercise Testing</span><p id="par0135" class="elsevierStylePara elsevierViewall">Both the walk test and ergometry are discussed in detail in the specific section of these guidelines&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Electromyography &#40;EMG&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">EMG consists of recording the electrical activity of muscles at rest and during both voluntary and externally stimulated contraction<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">50&#8211;53</span></a> &#40;see below&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that physical activity&#44; exercise capacity and electromyography are useful and provide reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limb Muscle Function Testing</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Voluntary Maneuvers</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Handgrip Dynamometry</span><p id="par0150" class="elsevierStylePara elsevierViewall">This is a simple measurement&#44; carried out with various types of dynamometers&#46; It is widely used and is recognized as a prognostic factor in COPD&#46;<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">54</span></a> Reference values are available for different populations&#46;<a class="elsevierStyleCrossRefs" href="#bib1105"><span class="elsevierStyleSup">55&#44;56</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Maximal Isometric Contraction of the Quadriceps Femoris &#40;Q-MVC&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">This procedure is normally performed with the patient in a sitting position&#44; with hips and knees bent at an angle of 90&#176;&#46; Quadriceps extension is measured with the leg fixed at the ankle&#44; connected to a dynamometer&#46;<a class="elsevierStyleCrossRef" href="#bib1115"><span class="elsevierStyleSup">57</span></a> Reference values are available&#46;<a class="elsevierStyleCrossRef" href="#bib1120"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Test of Endurance Time at 10&#37; of the Q-MVC</span><p id="par0160" class="elsevierStylePara elsevierViewall">This endurance test<a class="elsevierStyleCrossRef" href="#bib1125"><span class="elsevierStyleSup">59</span></a> is based on claudication after exercise involving cycles of contractions against a load equivalent to 10&#37; of the Q-MVC &#40;cycles of 2<span class="elsevierStyleHsp" style=""></span>s quadriceps contraction and 3<span class="elsevierStyleHsp" style=""></span>s of relaxation&#41;&#46; Other maneuvers&#44; more specific for estimating endurance&#44; are used for measuring pairs of forces &#40;torque&#41; in N<span class="elsevierStyleHsp" style=""></span>m &#40;Newtons<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>meter&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1130"><span class="elsevierStyleSup">60</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that tests for evaluating contraction function and muscle mass in COPD patients are very useful and provide reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Involuntary Maneuvers</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Supramaximal Quadriceps Twitch Force &#40;QTw&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">This technique is based on the electrical or magnetic stimulation of the femoral nerve in a single stimulus&#44; or &#8220;twitch&#8221;&#44; measuring the force generated after quadriceps activation&#46;<a class="elsevierStyleCrossRefs" href="#bib1135"><span class="elsevierStyleSup">61&#44;62</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that involuntary maneuver tests for the evaluation of muscle function in COPD patients are useful and provide reliable and comparable inter-individual measurements over time&#46; However&#44; their use has not been extended to routine clinical practice&#46; Evidence&#58; GRADE 1B&#46;</span></p></span></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Evaluation of Exercise Tolerance&#58; The 6-Minute Walk Test</span><p id="par0180" class="elsevierStylePara elsevierViewall">The 6-minute walk test is a simple exercise protocol measuring the distance walked quickly by the patient on a hard&#44; flat surface over a period of 6<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">63</span></a> Several other tests are used in the field &#40;stair-climbing&#44; Bruce&#44; 12-minute walk&#44; incremental walk&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">63&#8211;65</span></a> but the 6-minute walk is the most popular&#44; and is the most simple exercise test used as a reference in COPD and other diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#8211;72</span></a> It is highly standardized&#44;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">63&#44;73&#44;74</span></a> is reasonably reproducible&#44;<a class="elsevierStyleCrossRef" href="#bib1205"><span class="elsevierStyleSup">75</span></a> and is valuable for measuring the effects of different interventions in many chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">76&#8211;81</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The 6-minute walk is a high-intensity sustainable submaximal exercise<a class="elsevierStyleCrossRef" href="#bib1240"><span class="elsevierStyleSup">82</span></a> used for the overall and comprehensive evaluation of various physical functions &#40;cardiac&#44; respiratory&#44; peripheral oxygen transport&#44; muscle bioenergetics and neuromuscular integration&#41; that determine the patient&#39;s aerobic capacity&#46; Some studies<a class="elsevierStyleCrossRefs" href="#bib1240"><span class="elsevierStyleSup">82&#44;83</span></a> suggest that exercise intensity during the test is an indication of the patient&#39;s maximal sustainable power output over time &#40;critical power&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1250"><span class="elsevierStyleSup">84</span></a> This would explain the high predictive value of this test for mortality<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">76&#44;79&#44;80</span></a> and its valuable role in the clinical decision-making process&#46;<a class="elsevierStyleCrossRefs" href="#bib1205"><span class="elsevierStyleSup">75&#44;78&#44;81</span></a></p><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Indications</span><p id="par0190" class="elsevierStylePara elsevierViewall">Evaluation of the functional status of patients with different chronic diseases&#44; such as COPD&#44; asthma&#44; obesity&#44; interstitial lung diseases&#44; pulmonary hypertension and various cardiovascular diseases<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#8211;72</span></a> and measurement of the effect of interventions&#44; such as training&#44; lung transplantation&#44; lung parenchyma resection&#44; and pharmacological treatments for pulmonary hypertension&#44; COPD and heart failure were done&#46;<a class="elsevierStyleCrossRefs" href="#bib1215"><span class="elsevierStyleSup">77&#44;78</span></a> Although this is a very safe exercise protocol&#44; since the patients themselves determine the speed of the walk&#44; it should not be performed in patients with unstable angina&#44; recent myocardial infarction &#40;within 1 month&#41;&#44; tachycardia of over 120<span class="elsevierStyleHsp" style=""></span>bpm&#44; or high blood pressure spikes&#46; Safety measures and training by professionals are essential for any form of exercise testing&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">63</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Variables</span><p id="par0195" class="elsevierStylePara elsevierViewall">The variables measured in the test are the following&#58; &#40;i&#41; distance walked expressed in meters&#59; &#40;ii&#41; heart rate and oxygen saturation measured by pulse oximetry at the beginning and end of the test&#59; and &#40;iii&#41; symptoms&#44; dyspnea &#40;Borg scale&#41; and discomfort in the lower limbs at the beginning and end of the walk&#46; The walk test should be performed twice&#44; with approximately 1<span class="elsevierStyleHsp" style=""></span>h between assessments&#59; the longest distance walked should be used&#46; If the patient requires oxygen therapy&#44; the test should be performed with the prescribed oxygen regimen in place&#46;</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Interpretation of Results</span><p id="par0200" class="elsevierStylePara elsevierViewall">For comparison of the results obtained before and after an intervention&#44; the minimum clinically important difference&#44; set at 25&#8211;30<span class="elsevierStyleHsp" style=""></span>m&#44; must be identified after an intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#44;69&#44;70&#44;85</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Although results in terms of distance walked are usually interpreted as absolute values &#40;meters&#41;&#44; reference values are also used&#44; such as those of Enright et al&#46;<a class="elsevierStyleCrossRef" href="#bib1260"><span class="elsevierStyleSup">86</span></a> In short&#44; the 6-minute walk test is highly recommendable in clinical practice as a simple exercise test for evaluating functional status and the effect of certain interventions in patients with chronic respiratory and cardiac diseases&#46; The simplicity&#44; safety&#44; reproducibility and high predictive value of the test make it a simple reference protocol for studying aerobic capacity in clinical practice&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that the 6-minute walk test is very useful and provides highly reliable and comparable inter-individual measurements over time&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Evaluation of Exercise Tolerance&#58; Cycloergometry</span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Incremental Exercise Testing</span><p id="par0215" class="elsevierStylePara elsevierViewall">Incremental exercise testing can be used for evaluating the sub-maximal and maximal response&#44; and can often help identify the mechanisms underlying exercise intolerance&#46;<a class="elsevierStyleCrossRefs" href="#bib1265"><span class="elsevierStyleSup">87&#8211;90</span></a> It can also be used to adapt interventions for exercise intolerance to the source of the limitation&#44;<a class="elsevierStyleCrossRefs" href="#bib1275"><span class="elsevierStyleSup">89&#8211;98</span></a> and for ruling out other medical interventions &#40;such as physical training&#41; that may be a risk factor&#44; thus increasing patient safety&#46;<a class="elsevierStyleCrossRefs" href="#bib1265"><span class="elsevierStyleSup">87&#44;99</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The procedure is highly standardized&#46;<a class="elsevierStyleCrossRefs" href="#bib1150"><span class="elsevierStyleSup">64&#44;87</span></a> Cycle ergometry is the most commonly used test&#44; because it is cheap and compact&#44; and the work rate can be accurately determined&#46; Most patients can perform the test without practicing first&#46;<a class="elsevierStyleCrossRefs" href="#bib1150"><span class="elsevierStyleSup">64&#44;87&#44;100</span></a></p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Variables</span><p id="par0225" class="elsevierStylePara elsevierViewall">Most currently available software programs can generate large numbers of variables&#44; but the most commonly used in clinical studies are maximum oxygen consumption &#40;V&#729;O2max&#41; and maximum work rate &#40;<span class="elsevierStyleItalic">WR</span>max&#41;&#44; both of which are symptom-limited&#46; V&#729;O2max is a highly reproducible variable&#44; with coefficients of variation ranging from 3&#37; to 7&#37;&#44; when maximum work rate criteria are reached&#46;<a class="elsevierStyleCrossRefs" href="#bib1335"><span class="elsevierStyleSup">101&#8211;103</span></a> Consistent measurements have been obtained in multicenter clinical studies when appropriate quality controls are in place&#46;<a class="elsevierStyleCrossRefs" href="#bib1350"><span class="elsevierStyleSup">104&#44;105</span></a> Moreover&#44; in cardiac patients at least&#44; improved V&#729;O2max after interventions leads to improved survival&#46;<a class="elsevierStyleCrossRef" href="#bib1360"><span class="elsevierStyleSup">106</span></a>V&#729;O2max is sensitive to both pharmacological and non-pharmacological interventions&#44; and in particular to muscle training&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">11&#44;107&#8211;111</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The advantage of maximum work rate &#40;<span class="elsevierStyleItalic">WR</span>max&#41; over V&#729;O2max is that it can be determined without the need for a metabolic cart&#46; It should be remembered that&#44; unlike V&#729;O2max&#44; W<span class="elsevierStyleItalic">R</span>max depends on the rate of the previous incremental protocol &#40;&#916;<span class="elsevierStyleItalic">WR</span>&#47;&#916;<span class="elsevierStyleItalic">t</span>&#41;&#44; so it cannot be equated with the V&#729;O2max&#46; Moreover&#44; exactly the same protocol must be used before and after the intervention or exposure&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">112</span></a></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">High-Intensity Constant-Power Tests</span><p id="par0235" class="elsevierStylePara elsevierViewall">Although moderate-intensity constant-power tests can be performed to characterize the kinetics of the response of the oxygen transport system&#44; these tests require complex analysis&#44; so their use is limited to research studies&#46; In contrast&#44; high-intensity constant-power &#40;HICP&#41; tests have been used widely in studies for assessing interventions targeting the muscles&#46; The variable that defines exercise tolerance is time until the patient can no longer continue &#40;Tlim&#44; expressed in seconds&#41;&#46; Tlim has been shown in multicenter trials to be reproducible<a class="elsevierStyleCrossRefs" href="#bib1355"><span class="elsevierStyleSup">105&#44;113</span></a> and consistent<a class="elsevierStyleCrossRef" href="#bib1355"><span class="elsevierStyleSup">105</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The clinically important difference for these tests is in the order of 100<span class="elsevierStyleHsp" style=""></span>s &#40;95&#37; confidence interval&#58; 50&#8211;150<span class="elsevierStyleHsp" style=""></span>s&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1395"><span class="elsevierStyleSup">113</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that cycle ergometry is very useful and provides highly reliable and comparable inter-individual measurements over time&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Muscle Training in COPD Muscle Dysfunction</span><p id="par0245" class="elsevierStylePara elsevierViewall">Muscle training&#44; a fundamental component of Pulmonary Rehabilitation &#40;PR&#41; programs&#44; has been widely shown to be effective for improving exercise tolerance&#44; muscle strength&#44; dyspnea&#44; fatigue&#44; and quality of life&#46; Hence&#44; it is an essential intervention in the treatment of muscle dysfunction in COPD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;114</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">In patients with chronic respiratory disease&#44; general muscle training must be aimed at improving both the aerobic limitations and muscle dysfunction often seen in these diseases&#46; Choice of training type will not only depend on the needs of the patient and planned objectives&#44; but also to a large extent on the resources available in the rehabilitation clinic&#46;<a class="elsevierStyleCrossRefs" href="#bib1405"><span class="elsevierStyleSup">115&#44;116</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that muscle training is the best treatment for muscle dysfunction in COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Types of Training</span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Aerobic or Endurance Training</span><p id="par0260" class="elsevierStylePara elsevierViewall">This is the type of training most often used in PR&#44; and the evidence for recommendation is the highest &#40;Grade 1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;114&#44;117&#44;118</span></a> Aerobic exercise is a submaximal exercise involving the large muscle groups&#44; sustained for a prolonged length of time&#46; In COPD patients&#44; aerobic training not only achieves better cardiovascular adaptation&#44; it also improves limb muscle function&#46; This leads to increased muscle endurance&#44; with adaptive phenomena in the bioenergetics of the quadriceps<a class="elsevierStyleCrossRefs" href="#bib1425"><span class="elsevierStyleSup">119&#44;120</span></a> and skeletal muscles&#46;<a class="elsevierStyleCrossRef" href="#bib1435"><span class="elsevierStyleSup">121</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Cycloergometry and treadmill training are the most common aerobic exercises prescribed in PR&#44; especially in outpatient and inpatient rehabilitation programs&#46; Training intensity is very important when prescribing exercise therapy&#46; An intensity of around 60&#37;&#8211;80&#37; of the maximal exercise capacity &#40;previously evaluated with cardiopulmonary exercise testing&#41; for a minimum of 8 weeks<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> is recommended for achieving a substantial benefit&#44; while 12 weeks is considered the optimal duration<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Longer exercise programs can achieve greater&#44; longer-lasting effects&#44; particularly on quality of life indices&#46;<a class="elsevierStyleCrossRef" href="#bib1440"><span class="elsevierStyleSup">122</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that aerobic endurance muscle training is one of the best treatments for muscle dysfunction and restoring exercise capacity in COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Interval Training</span><p id="par0275" class="elsevierStylePara elsevierViewall">This is a modification of standard aerobic training&#44; in which short periods &#40;1&#8211;2<span class="elsevierStyleHsp" style=""></span>min duration&#41; of high-intensity exercise &#40;80&#37;&#8211;120&#37; maximum capacity&#41; are regularly alternated with similar periods of rest or lower intensity exercise&#46; In this way&#44; patients achieve high levels of output&#44; but with less dyspnea and fatigue&#46; The benefits are equivalent to those of conventional aerobic training&#46;<a class="elsevierStyleCrossRefs" href="#bib1435"><span class="elsevierStyleSup">121&#44;123&#44;124</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that interval training is one of the best treatments for muscle dysfunction and restoring exercise capacity in more severe COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Strength Training</span><p id="par0285" class="elsevierStylePara elsevierViewall">Following the &#8220;specificity principle&#8221;&#44; muscle strength training is potentially better for increasing the strength and mass of the exercised muscle than conventional aerobic training&#46;<a class="elsevierStyleCrossRef" href="#bib1455"><span class="elsevierStyleSup">125</span></a> Available evidence supports the use of strength training in combination with general aerobic training &#40;1A&#41;&#44; since this achieves further increases in limb muscle strength&#46;<a class="elsevierStyleCrossRefs" href="#bib1400"><span class="elsevierStyleSup">114&#44;118</span></a> In PR&#44; this type of exercise is often applied with weight-lifting exercises for the lower and upper limbs&#44; performed on gym apparatus with heavy loads&#44; equivalent to 70&#37;&#8211;85&#37; of the maximum weight lifted by the individual in a previous single maneuver &#40;or one repetition maximum testing&#44; 1 RM&#41;&#44; with few repetitions&#44;<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> in 2&#8211;3 sessions per week for 8&#8211;12 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib1400"><span class="elsevierStyleSup">114&#44;118</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that muscle strength training is one of the best treatments for muscle dysfunction and restoring exercise capacity in more severe COPD patients&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Other Types of Training</span><p id="par0295" class="elsevierStylePara elsevierViewall">Very promising alternatives for limb muscle training in PR programs include transcutaneous electrical nerve stimulation &#40;TENS&#41;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;126&#44;127</span></a> and electromagnetic stimulation&#44;<a class="elsevierStyleCrossRef" href="#bib1470"><span class="elsevierStyleSup">128</span></a> which is better tolerated but less well studied&#46;</p><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Respiratory Muscle Training</span><p id="par0300" class="elsevierStylePara elsevierViewall">Inspiratory muscle training &#40;IMT&#41; has been shown to improve muscle strength and endurance in COPD patients&#44; with benefits in dyspnea&#44; functional capacity and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib1475"><span class="elsevierStyleSup">129</span></a> The efficacy of specific expiratory muscle training with abdominal muscle exercises remains in doubt&#46; In general&#44; IMT should be performed twice a day&#44; at an intensity of at least 30&#37; of the MIP and in sessions lasting about 15<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> IMT is indicated mainly in patients with respiratory muscle dysfunction&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that respiratory muscle training may be of benefit in COPD patients with significant respiratory muscle dysfunction&#44; in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1B&#46;</span></p></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Other Non-Training-Based Treatments for Muscle Dysfunction</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Nutritional Supplements and Hormone Treatment</span><p id="par0310" class="elsevierStylePara elsevierViewall">Nutritional disorders are found in 20&#37;&#8211;40&#37; of patients with severe respiratory disease&#46; The causes appear to be multifactorial&#44; and include imbalance between energy intake and output&#44; hypoxemia&#44; and the systemic inflammatory component often observed with this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib1480"><span class="elsevierStyleSup">130&#8211;132</span></a> Results from the use of high-energy nutritional supplements in these patients &#40;anabolic steroids and growth hormones&#44; antioxidants and other protein compounds&#41; have been contradictory as regards weight gain and&#44; in particular&#44; their impact on functional recovery&#46;</p><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Nutritional Supplements</span><p id="par0315" class="elsevierStylePara elsevierViewall">Nutritional supplements are commonly used in COPD patients&#44; but there is very little evidence to support this approach&#46; While some authors have reported weight gain and increased fat-free mass&#44; along with improvements in exercise tolerance&#44; these data are not supported by other studies&#46; The most recent Cochrane review<a class="elsevierStyleCrossRef" href="#bib1495"><span class="elsevierStyleSup">133</span></a> includes a meta-analysis of 17 randomized clinical trials&#44;<a class="elsevierStyleCrossRefs" href="#bib1500"><span class="elsevierStyleSup">134&#8211;148</span></a> performed mainly in undernourished patients&#44; that provide little evidence that patients receiving nutritional supplements show improvements in weight&#44; fat-free mass&#44; respiratory muscle strength and distance walked during the 6-minute walk test&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2B&#46;</span></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Anabolic Steroids</span><p id="par0325" class="elsevierStylePara elsevierViewall">Androgen deficiency&#44; often associated with loss of muscle mass&#44; occurs in up to 40&#37; of COPD patients&#46;<a class="elsevierStyleCrossRef" href="#bib1575"><span class="elsevierStyleSup">149</span></a> Administration of anabolic steroids has been associated with weight gain and increased muscle mass&#44; supporting the use of these products as adjuvant treatment in rehabilitation programs&#46; However&#44; the results have not been sufficiently corroborated&#44; and this approach is not recommended by ERS&#47;ATS rehabilitation guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> Several published studies have shown that despite weight gain and increased fat-free mass&#44; no improvements were reported in lung function parameters&#44; exercise tolerance or respiratory &#40;MIP&#41; or limb &#40;handgrip strength&#41; muscle function&#46;<a class="elsevierStyleCrossRefs" href="#bib1545"><span class="elsevierStyleSup">143&#44;150&#8211;155</span></a> However&#44; the meta-analysis included not only treatment with androgenic derivatives&#44; but also a study on growth hormone and another on ghrelin &#40;a growth hormone secretagogue&#41;&#44; as well as other studies that may or may not have included training&#44; with no subgroup analyses&#46; All these factors limit the interpretation of the above-mentioned meta-analysis&#46; In reality&#44; the combination of nutritional or androgenic supplements with muscle training has led to increases in weight&#44; fat-free muscle mass&#44; MIP&#44; quadriceps force&#44; maximum work load and exercise endurance time&#46;<a class="elsevierStyleCrossRef" href="#bib1610"><span class="elsevierStyleSup">156</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2B&#46;</span></p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Growth Hormone and Ghrelin</span><p id="par0335" class="elsevierStylePara elsevierViewall">The use of recombinant human growth hormone &#40;GH&#41; has also been studied in malnourished COPD patients&#44; in rehabilitation programs&#44; but results have been inconclusive&#46;<a class="elsevierStyleCrossRefs" href="#bib1580"><span class="elsevierStyleSup">150&#44;157</span></a> More recently&#44; the use of ghrelin has been studied in these patients&#44; also in the rehabilitation setting&#46; Ghrelin is polypeptide hormone that acts by binding to GH-stimulating hypothalamic receptors&#44; stimulating secretion of GH&#46; It also stimulates the release of orexigenic factors&#44; increasing appetite&#46;<a class="elsevierStyleCrossRef" href="#bib1620"><span class="elsevierStyleSup">158</span></a> Paradoxically&#44; malnourished COPD patients may have elevated ghrelin levels&#46;<a class="elsevierStyleCrossRef" href="#bib1625"><span class="elsevierStyleSup">159</span></a> Results published to date on the exogenous administration of this substance are inconclusive&#46;<a class="elsevierStyleCrossRefs" href="#bib1630"><span class="elsevierStyleSup">160&#8211;162</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46;</span> Evidence GRADE 2C&#46;</p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Other Nutrients</span><p id="par0345" class="elsevierStylePara elsevierViewall">The ability of other products to improve the muscle and physical function of COPD patients&#44; including antioxidants&#44; vitamins<a class="elsevierStyleCrossRef" href="#bib1625"><span class="elsevierStyleSup">159</span></a> and high-calorie compounds&#44; has been investigated&#46; However studies are generally isolated and uncontrolled&#44; or conducted in small numbers of patients&#44; and results are difficult to reproduce&#46;<a class="elsevierStyleCrossRefs" href="#bib1645"><span class="elsevierStyleSup">163&#44;164</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46;</span> Evidence GRADE 2C&#46;</p></span></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Non-Pharmacological Treatments&#58; Non-Invasive Ventilation and Heliox</span><p id="par0355" class="elsevierStylePara elsevierViewall">It is well known that non-invasive mechanical ventilation &#40;NIV&#41; allows the respiratory muscles to rest&#44; explaining improved lung function&#44; evidenced by increased MIP&#44; Pdimax and pressure-time product&#46; A few studies have even associated the use of NIV with better limb muscle function&#44; demonstrated by increased quadriceps strength and endurance&#46;<a class="elsevierStyleCrossRef" href="#bib1655"><span class="elsevierStyleSup">165</span></a> This is probably a consequence of improved oxygen supply to the peripheral muscles&#44; as a result of the reduction in work-of-breathing&#46;<a class="elsevierStyleCrossRef" href="#bib1660"><span class="elsevierStyleSup">166</span></a> This same mechanism has been cited to explain the effect of breathing heliox &#40;a mixture of helium and oxygen&#41; on limb muscle function&#46; A recent Cochrane review&#44; based on a meta-analysis of 6 clinical trials evaluating the results of NIV during a physical exercise program&#44; concluded that the slight differences in exercise capacity and tolerance were inconsistent&#46; In line with the latest consensus recommendations from the ERS&#47;ATS&#44; the use of NIV during muscle training is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> This intervention should be limited to hypercapnic patients on night-time NIV programs&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies consistently show that the benefits outweigh the risks of treatment administration&#46; Research in the future may contribute to improved understanding in this area&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2A</span></p></span></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Conclusions</span><p id="par0365" class="elsevierStylePara elsevierViewall">In summary&#44; good respiratory and limb muscle function is essential for sustaining life and an acceptable quality of life&#46; Muscle function is affected in many respiratory diseases and may lead to problems for the patient&#39;s social life and for maintaining an adequate level of ventilation&#46; Muscle function can and must be evaluated in these patients&#44; so that the appropriate therapeutic measures can be implemented&#46; In view of the current evidence&#44; muscle training&#44; with or without nutritional supplements&#44; is clearly the best therapeutic strategy for increasing muscle mass and function and improving quality of life in COPD patients&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:18 [
        0 => array:3 [
          "identificador" => "xres580682"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec597178"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xpalclavsec597177"
          "titulo" => "Abbreviations"
        ]
        3 => array:3 [
          "identificador" => "xres580681"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "xpalclavsec597179"
          "titulo" => "Palabras clave"
        ]
        5 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        6 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology&#44; Pathophysiology and Implications for Patients"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Muscle Dysfunction Pathophysiology"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Limb Muscle Dysfunction &#40;Quadriceps&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Respiratory Muscle Dysfunction"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Evaluation of Respiratory Muscles&#58; Voluntary and Involuntary Maneuvers &#40;Table 1&#41;"
          "secciones" => array:3 [
            0 => array:3 [
              "identificador" => "sec0035"
              "titulo" => "Evaluating Respiratory Muscle Strength&#58; Volitional Tests of Respiratory Muscle Strength"
              "secciones" => array:2 [
                0 => array:3 [
                  "identificador" => "sec0040"
                  "titulo" => "Non-Invasive Testing"
                  "secciones" => array:3 [
                    0 => array:2 [
                      "identificador" => "sec0045"
                      "titulo" => "Spirometry"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0050"
                      "titulo" => "Measuring Pressure at the Mouth"
                    ]
                    2 => array:2 [
                      "identificador" => "sec0055"
                      "titulo" => "Sniff Nasal Inspiratory Pressure &#40;SNIP&#41;"
                    ]
                  ]
                ]
                1 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Invasive Testing"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Non-Volitional Tests of Respiratory Muscle Strength &#40;Table 1&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Evaluating Respiratory Muscle Endurance &#40;Table 1&#41;"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0075"
          "titulo" => "Evaluation of Limb Muscles&#58; Volitional and Non-Volitional Testing"
          "secciones" => array:1 [
            0 => array:3 [
              "identificador" => "sec0080"
              "titulo" => "General Evaluation of Limb Muscles &#40;Fig&#46; 3&#41;"
              "secciones" => array:7 [
                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Evaluating Muscle Mass &#40;MM&#41;"
                ]
                1 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Bioimpedance Analysis &#40;BIA&#41; or Bioelectric Impedance"
                ]
                2 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Dual-Energy X-Ray Absorptiometry &#40;DEXA&#41;"
                ]
                3 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Local MM Study Techniques"
                ]
                4 => array:2 [
                  "identificador" => "sec0105"
                  "titulo" => "Physical Activity"
                ]
                5 => array:2 [
                  "identificador" => "sec0110"
                  "titulo" => "Exercise Testing"
                ]
                6 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Electromyography &#40;EMG&#41;"
                ]
              ]
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0120"
          "titulo" => "Limb Muscle Function Testing"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0125"
              "titulo" => "Voluntary Maneuvers"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0130"
                  "titulo" => "Handgrip Dynamometry"
                ]
                1 => array:2 [
                  "identificador" => "sec0135"
                  "titulo" => "Maximal Isometric Contraction of the Quadriceps Femoris &#40;Q-MVC&#41;"
                ]
                2 => array:2 [
                  "identificador" => "sec0140"
                  "titulo" => "Test of Endurance Time at 10&#37; of the Q-MVC"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "sec0145"
              "titulo" => "Involuntary Maneuvers"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0150"
                  "titulo" => "Supramaximal Quadriceps Twitch Force &#40;QTw&#41;"
                ]
              ]
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0155"
          "titulo" => "Evaluation of Exercise Tolerance&#58; The 6-Minute Walk Test"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Indications"
            ]
            1 => array:2 [
              "identificador" => "sec0165"
              "titulo" => "Variables"
            ]
            2 => array:2 [
              "identificador" => "sec0170"
              "titulo" => "Interpretation of Results"
            ]
          ]
        ]
        11 => array:3 [
          "identificador" => "sec0175"
          "titulo" => "Evaluation of Exercise Tolerance&#58; Cycloergometry"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0180"
              "titulo" => "Incremental Exercise Testing"
            ]
            1 => array:2 [
              "identificador" => "sec0185"
              "titulo" => "Variables"
            ]
            2 => array:2 [
              "identificador" => "sec0190"
              "titulo" => "High-Intensity Constant-Power Tests"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0195"
          "titulo" => "Muscle Training in COPD Muscle Dysfunction"
        ]
        13 => array:3 [
          "identificador" => "sec0200"
          "titulo" => "Types of Training"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0205"
              "titulo" => "Aerobic or Endurance Training"
            ]
            1 => array:2 [
              "identificador" => "sec0210"
              "titulo" => "Interval Training"
            ]
            2 => array:2 [
              "identificador" => "sec0215"
              "titulo" => "Strength Training"
            ]
          ]
        ]
        14 => array:3 [
          "identificador" => "sec0220"
          "titulo" => "Other Types of Training"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0225"
              "titulo" => "Respiratory Muscle Training"
            ]
          ]
        ]
        15 => array:3 [
          "identificador" => "sec0230"
          "titulo" => "Other Non-Training-Based Treatments for Muscle Dysfunction"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0235"
              "titulo" => "Nutritional Supplements and Hormone Treatment"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0240"
                  "titulo" => "Nutritional Supplements"
                ]
                1 => array:2 [
                  "identificador" => "sec0245"
                  "titulo" => "Anabolic Steroids"
                ]
                2 => array:2 [
                  "identificador" => "sec0250"
                  "titulo" => "Growth Hormone and Ghrelin"
                ]
                3 => array:2 [
                  "identificador" => "sec0255"
                  "titulo" => "Other Nutrients"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0260"
              "titulo" => "Non-Pharmacological Treatments&#58; Non-Invasive Ventilation and Heliox"
            ]
          ]
        ]
        16 => array:2 [
          "identificador" => "sec0265"
          "titulo" => "Conclusions"
        ]
        17 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec597178"
          "palabras" => array:3 [
            0 => "Chronic obstructive pulmonary disease"
            1 => "Muscle dysfunction"
            2 => "Spanish guidelines"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec597177"
          "palabras" => array:42 [
            0 => "ATP"
            1 => "ATS"
            2 => "BIA"
            3 => "COPD"
            4 => "CT"
            5 => "DEXA"
            6 => "EMG"
            7 => "ERS"
            8 => "FFM"
            9 => "FRC"
            10 => "FVC"
            11 => "GH"
            12 => "HICP"
            13 => "IMT"
            14 => "LLM"
            15 => "MD"
            16 => "MEP"
            17 => "MIP"
            18 => "MM"
            19 => "MR"
            20 => "MRI"
            21 => "MSV"
            22 => "MVIC"
            23 => "MVV"
            24 => "NIV"
            25 => "Pdi"
            26 => "Pdi<span class="elsevierStyleItalic">twitch</span>"
            27 => "PR"
            28 => "PTP"
            29 => "Q-MVC"
            30 => "QTw"
            31 => "RV"
            32 => "<span class="elsevierStyleItalic">Sniff</span>Pdi"
            33 => "SniffPesmax"
            34 => "SNIP"
            35 => "TENS"
            36 => "TLC"
            37 => "Tlim"
            38 => "ULM"
            39 => "VO2max"
            40 => "W<span class="elsevierStyleItalic">R</span>"
            41 => "W<span class="elsevierStyleItalic">R</span>max"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec597179"
          "palabras" => array:3 [
            0 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            1 => "Disfunci&#243;n muscular"
            2 => "Gu&#237;a espa&#241;ola"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">In patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; skeletal muscle dysfunction is a major comorbidity that negatively impacts their exercise capacity and quality of life&#46; In the current guidelines&#44; the most recent literature on the various aspects of COPD muscle dysfunction has been included&#46; The Grading of Recommendations&#44; Assessment&#44; Development&#44; and Evaluation &#40;GRADE&#41; scale has been used to make evidence-based recommendations on the different features&#46; Compared to a control population&#44; one third of COPD patients exhibited a 25&#37; decline in quadriceps muscle strength&#44; even at early stages of their disease&#46; Although both respiratory and limb muscles are altered&#44; the latter are usually more severely affected&#46; Numerous factors and biological mechanisms are involved in the etiology of COPD muscle dysfunction&#46; Several tests are proposed in order to diagnose and evaluate the degree of muscle dysfunction of both respiratory and limb muscles &#40;peripheral&#41;&#44; as well as to identify the patients&#8217; exercise capacity &#40;six-minute walking test and cycloergometry&#41;&#46; Currently available therapeutic strategies including the different training modalities and pharmacological and nutritional support are also described&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La disfunci&#243;n muscular de pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; constituye una de las comorbilidades m&#225;s importantes&#44; con repercusiones negativas en su capacidad de ejercicio y calidad de vida&#46; En la presente normativa se ha resumido la literatura publicada m&#225;s recientemente sobre los diferentes aspectos del tema y se ha utilizado tambi&#233;n la escala <span class="elsevierStyleItalic">Grading of Recommendations Assessment&#44; Development&#44; and Evaluation</span> &#40;GRADE&#41; de recomendaciones sobre el grado de evidencia de las diferentes propuestas de la normativa&#46; Respecto a una poblaci&#243;n control&#44; se estima que en un tercio de los pacientes EPOC la fuerza del cu&#225;driceps es un 25&#37; inferior incluso en estadios precoces de su enfermedad&#46; Aunque tanto los m&#250;sculos respiratorios como los de las extremidades est&#225;n alterados&#44; estos &#250;ltimos suelen verse mayormente afectados&#46; Diversos factores y mecanismos biol&#243;gicos est&#225;n involucrados en la disfunci&#243;n muscular de los pacientes&#46; Se proponen diversas pruebas para evaluar y diagnosticar el grado de afectaci&#243;n de los m&#250;sculos respiratorios y de las extremidades &#40;perif&#233;ricos&#41;&#44; as&#237; como identificar la capacidad de esfuerzo de los pacientes &#40;prueba de marcha de 6<span class="elsevierStyleHsp" style=""></span>min y cicloergometr&#237;a&#41;&#46; Se describen tambi&#233;n las posibles estrategias terap&#233;uticas vigentes que incluyen las diversas modalidades de entrenamiento y de soporte farmacol&#243;gico y nutricional&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Barreiro E&#44; Bustamante V&#44; Cejudo P&#44; G&#225;ldiz JB&#44; Gea J&#44; de Lucas P&#44; et al&#46; Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;384&#8211;395&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0380" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0275"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1248
            "Ancho" => 3214
            "Tamanyo" => 246423
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Etiological factors involved in limb muscle dysfunction in COPD patients&#46; The factors have deleterious effects on lower limb muscle function and mass&#44; causing the scales to completely tip toward the negative side &#40;left tray&#41;&#46; &#40;B&#41; In the lower limb muscles&#44; the actions of the etiological factors are mediated by several biological mechanisms&#44; with deleterious effects on muscle function&#44; mass and structure&#46; The scales are completely tipped to the left&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1216
            "Ancho" => 3315
            "Tamanyo" => 268371
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; In the respiratory muscles&#44; etiologic factors such as alterations in the chest geometry and mechanical overload can to some extent counteract &#40;training effect&#44; right tray of the scales&#41; the deleterious effects of the other etiologic factors of a more systematic nature &#40;left tray of the scales&#41;&#44; since these also contribute to limb muscle dysfunction&#46; &#40;B&#41; In the respiratory muscles&#44; several cell and molecular mechanisms have beneficial effects &#40;adaptive mechanisms&#44; right tray of the scales&#41;&#44; which counteract the deleterious effects of the deleterious effects of the other biological mechanisms &#40;left tray of the scales&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1470
            "Ancho" => 1694
            "Tamanyo" => 253555
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">List of the most commonly used tests in routine clinical practice for evaluating muscle mass and dysfunction&#46; Tests are classified as general or specific for evaluating muscle mass and function&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1765
            "Ancho" => 2471
            "Tamanyo" => 142820
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Selection of controlled clinical trials that used HICP for measuring the effect of interventions on lower limb muscles&#46; Power&#58; intensity at which the test was performed&#44; expressed as a percentage of <span class="elsevierStyleItalic">WR</span>max&#46; Vertical line&#46; Minimum clinically important difference&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#46; MIP&#44; maximum inspiratory pressure at the mouth &#40;static or M&#252;ller maneuver&#41;&#59; MEP&#44; maximum expiratory pressure at the mouth &#40;static or Valsalva maneuver&#41;&#59; SNIP&#44; sniff nasal inspiratory pressure &#40;dynamic sniff maneuver&#41;&#59; Pesmax&#44; maximum esophageal inspiratory pressure &#40;generally obtained during sniff maneuver&#41;&#59; Pdimax&#44; diaphragmatic pressure on inspiration &#40;generally obtained during sniff maneuver&#41;&#59; Pdimax <span class="elsevierStyleItalic">Twitch</span>&#44; transdiaphragmatic twitch pressure on inspiration&#44; induced by electrical or magnetic stimulation&#59; Q-MVC&#44; maximal voluntary isometric contraction of the quadriceps&#59; Qtw&#44; contraction induced by twitch of the quadriceps muscle&#59; MSV&#44; maximum sustainable ventilation&#59; MVV&#44; maximal voluntary ventilation&#59; SMIP&#44; sustained maximal inspiratory pressure with incremental threshold loads&#59; Tlim&#44; time limit or endurance time for submaximal constant loads &#40;generally percentage of SMIP or MIP for the inspiratory test or of SMEP or MEP for the expiratory test&#44; and percentage of Q-MVC &#40;generally 10&#37;&#41; for the quadriceps&#59; SMEP&#44; sustained maximal expiratory pressure with incremental threshold loads&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Functional property&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Muscle group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test&#47;Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Volitional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathological values&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">References&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="11" align="left" valign="top">Strength</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Non-specific</td><td class="td" title="table-entry  " align="left" valign="top">Forced spirometryPlethysmography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#62;80&#37;TLC&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;29</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Forced spirometry sitting to supine position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FVC sitting position and &#60;75&#37; pred&#46; supineReduction &#62;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;30</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Inspiratory</td><td class="td" title="table-entry  " align="left" valign="top">MIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80 pred&#46; or &#60;65&#37; pred&#46; or suspected if &#60;&#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;31</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SNIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suspected if&#58;Men&#58; &#60;&#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;32&#44;33</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pesmax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suspected if&#58;Men&#58; &#60;&#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;34</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pdimax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Men&#58; &#60;&#8722;75<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;50<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;35</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pdimax <span class="elsevierStyleItalic">Twitch</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Men&#58; &#60;&#8722;60 to 50<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;40 to 35<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;35</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Expiratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46; or &#60;65&#37; pred&#46; or suspected if &#60;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;31</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Upper limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Handgrip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1105">55&#44;56&#44;57</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Lower limbs &#40;quadriceps&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Q-MVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1120">58&#44;59</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">QTw&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1140">62&#44;63</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Endurance</td><td class="td" title="table-entry  " align="left" valign="top">Non-specific&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;60&#37;&#8211;80&#37; of MVV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;36</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Inspiratory</td><td class="td" title="table-entry  " align="left" valign="top">SMIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1015">37&#44;38</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Inspiratory tlim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1015">37&#44;38</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Expiratory</td><td class="td" title="table-entry  " align="left" valign="top">SMEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1025">39&#44;40</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Inspiratory tlim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1025">39&#44;40</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Quadriceps</td><td class="td" title="table-entry  " align="left" valign="top">Tlim at &#37; QMCV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib1130">60</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pair of forces &#40;torque&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib1135">61</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947510.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Types of Tests to Evaluate&#47;Assess the Strength and Endurance Components of Muscle Function&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grades&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Excellent effort with excellent repeatability &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good effort with good repeatability &#40;5&#8211;10 cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fair effort with fair repeatability &#40;10&#8211;20 cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Only one good maneuver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor maneuvers or poor repeatability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947508.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Proposed Scale &#40;John Moxham&#46; Test of Respiratory Muscle Strength&#46; <span class="elsevierStyleItalic">UptoDate</span> 2013&#41; for Evaluating Patient Collaboration and Cooperation in Performing Maximum Pressure Maneuvers of Respiratory Muscles at the Mouth &#40;MIP and MEP&#41;&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aerobic&#47;Endurance training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improve aerobic capacity&#46; Improve limb muscle function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Overload large upper and lower limb muscle groups&#46; Increase muscle strength and endurance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;4 days&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;3 days&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;4 series of 6&#8211;12 repetitions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Intensity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#37;&#8211;80&#37; of W<span class="elsevierStyleItalic">R</span>max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#37;&#8211;85&#37; of 1 RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#8211;12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#8211;12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947509.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Practical Recommendations for Aerobic and Strength Training in COPD&#46;</p>"
        ]
      ]
      7 => array:5 [
        "identificador" => "upi0005"
        "tipo" => "MULTIMEDIAECOMPONENTE"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "Ecomponente" => array:2 [
          "fichero" => "mmc1.pdf"
          "ficheroTamanyo" => 429663
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:166 [
            0 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE guidelines&#58; 1&#46; Introduction &#8211; GRADE evidence profiles and summary of findings tables"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinepi.2010.04.026"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An official American Thoracic Society&#47;European Respiratory Society statement&#58; update on limb muscle dysfunction in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201402-0373ST"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology of muscle dysfunction in COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prevalence of quadriceps weakness in COPD and the relationship with disease severity"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00104909"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.062026"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidative stress and respiratory muscle dysfunction in severe chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200407-887OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cellular adaptations in the diaphragm in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199712183372503"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidised proteins and superoxide anion production in the diaphragm of severe COPD patients"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00072008"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does oxidative stress modulate limb muscle atrophy in severe COPD patients&#63;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00137211"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Muscle fibre type shifting in the vastus lateralis of patients with COPD is associated with disease severity&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2007.078980"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.154.2.8756820"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The mechanisms of cachexia underlying muscle dysfunction in COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cigarette smoke-induced oxidative stress&#58; a role in chronic obstructive pulmonary disease skeletal muscle dysfunction"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200908-1220OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cigarette smoke-induced oxidative stress in skeletal muscles of mice"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resp.2012.02.001"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0905"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic endurance exercise induces quadriceps nitrosative stress in patients with severe COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2008.105163"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0910"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Inflammatory cells and apoptosis in respiratory and limb muscles of patients with COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0915"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do epigenetic events take place in the vastus lateralis of patients with mild chronic obstructive pulmonary disease&#63;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0102296"
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0920"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidative stress&#44; redox signaling pathways&#44; and autophagy in cachectic muscles of male patients with advanced COPD and lung cancer"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.freeradbiomed.2014.11.006"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0925"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quadriceps muscle weakness and atrophy are associated with a differential epigenetic profile in advanced COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1042/CS20140428"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0930"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contractile properties of the human diaphragm during chronic hyperinflation"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199109263251304"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0935"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adaptation of the diaphragm and the vastus lateralis in mild-to-moderate COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.04.00020204"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0940"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subcellular adaptation of the human diaphragm in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0945"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.164.9.2011150"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0950"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mitochondrial electron transport chain function is enhanced in inspiratory muscles of patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200206-519OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0955"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0960"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0965"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0970"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0975"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0980"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0985"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0990"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0995"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib1000"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib1005"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib1010"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib1015"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib1020"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib1025"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib1030"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib1035"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib1040"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib1045"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib1050"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib1055"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib1060"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib1065"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib1070"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib1075"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib1080"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib1085"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib1090"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib1095"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib1100"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib1105"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib1110"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib1115"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib1120"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib1125"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib1130"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib1135"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib1140"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib1145"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib1150"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib1155"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib1160"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib1165"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib1170"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib1175"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib1180"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib1185"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib1190"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib1195"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib1200"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib1205"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib1210"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib1215"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib1220"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib1225"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib1230"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib1235"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib1240"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib1245"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib1250"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib1255"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib1260"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib1265"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib1270"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib1275"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib1280"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            90 => array:3 [
              "identificador" => "bib1285"
              "etiqueta" => "91"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            91 => array:3 [
              "identificador" => "bib1290"
              "etiqueta" => "92"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            92 => array:3 [
              "identificador" => "bib1295"
              "etiqueta" => "93"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            93 => array:3 [
              "identificador" => "bib1300"
              "etiqueta" => "94"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            94 => array:3 [
              "identificador" => "bib1305"
              "etiqueta" => "95"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            95 => array:3 [
              "identificador" => "bib1310"
              "etiqueta" => "96"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            96 => array:3 [
              "identificador" => "bib1315"
              "etiqueta" => "97"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            97 => array:3 [
              "identificador" => "bib1320"
              "etiqueta" => "98"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            98 => array:3 [
              "identificador" => "bib1325"
              "etiqueta" => "99"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            99 => array:3 [
              "identificador" => "bib1330"
              "etiqueta" => "100"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            100 => array:3 [
              "identificador" => "bib1335"
              "etiqueta" => "101"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            101 => array:3 [
              "identificador" => "bib1340"
              "etiqueta" => "102"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            102 => array:3 [
              "identificador" => "bib1345"
              "etiqueta" => "103"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            103 => array:3 [
              "identificador" => "bib1350"
              "etiqueta" => "104"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            104 => array:3 [
              "identificador" => "bib1355"
              "etiqueta" => "105"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            105 => array:3 [
              "identificador" => "bib1360"
              "etiqueta" => "106"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            106 => array:3 [
              "identificador" => "bib1365"
              "etiqueta" => "107"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            107 => array:3 [
              "identificador" => "bib1370"
              "etiqueta" => "108"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            108 => array:3 [
              "identificador" => "bib1375"
              "etiqueta" => "109"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            109 => array:3 [
              "identificador" => "bib1380"
              "etiqueta" => "110"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            110 => array:3 [
              "identificador" => "bib1385"
              "etiqueta" => "111"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            111 => array:3 [
              "identificador" => "bib1390"
              "etiqueta" => "112"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            112 => array:3 [
              "identificador" => "bib1395"
              "etiqueta" => "113"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            113 => array:3 [
              "identificador" => "bib1400"
              "etiqueta" => "114"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            114 => array:3 [
              "identificador" => "bib1405"
              "etiqueta" => "115"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            115 => array:3 [
              "identificador" => "bib1410"
              "etiqueta" => "116"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            116 => array:3 [
              "identificador" => "bib1415"
              "etiqueta" => "117"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            117 => array:3 [
              "identificador" => "bib1420"
              "etiqueta" => "118"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            118 => array:3 [
              "identificador" => "bib1425"
              "etiqueta" => "119"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            119 => array:3 [
              "identificador" => "bib1430"
              "etiqueta" => "120"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            120 => array:3 [
              "identificador" => "bib1435"
              "etiqueta" => "121"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            121 => array:3 [
              "identificador" => "bib1440"
              "etiqueta" => "122"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            122 => array:3 [
              "identificador" => "bib1445"
              "etiqueta" => "123"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            123 => array:3 [
              "identificador" => "bib1450"
              "etiqueta" => "124"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            124 => array:3 [
              "identificador" => "bib1455"
              "etiqueta" => "125"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            125 => array:3 [
              "identificador" => "bib1460"
              "etiqueta" => "126"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            126 => array:3 [
              "identificador" => "bib1465"
              "etiqueta" => "127"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            127 => array:3 [
              "identificador" => "bib1470"
              "etiqueta" => "128"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            128 => array:3 [
              "identificador" => "bib1475"
              "etiqueta" => "129"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            129 => array:3 [
              "identificador" => "bib1480"
              "etiqueta" => "130"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            130 => array:3 [
              "identificador" => "bib1485"
              "etiqueta" => "131"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            131 => array:3 [
              "identificador" => "bib1490"
              "etiqueta" => "132"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            132 => array:3 [
              "identificador" => "bib1495"
              "etiqueta" => "133"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            133 => array:3 [
              "identificador" => "bib1500"
              "etiqueta" => "134"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            134 => array:3 [
              "identificador" => "bib1505"
              "etiqueta" => "135"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            135 => array:3 [
              "identificador" => "bib1510"
              "etiqueta" => "136"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            136 => array:3 [
              "identificador" => "bib1515"
              "etiqueta" => "137"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            137 => array:3 [
              "identificador" => "bib1520"
              "etiqueta" => "138"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            138 => array:3 [
              "identificador" => "bib1525"
              "etiqueta" => "139"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            139 => array:3 [
              "identificador" => "bib1530"
              "etiqueta" => "140"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            140 => array:3 [
              "identificador" => "bib1535"
              "etiqueta" => "141"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            141 => array:3 [
              "identificador" => "bib1540"
              "etiqueta" => "142"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            142 => array:3 [
              "identificador" => "bib1545"
              "etiqueta" => "143"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            143 => array:3 [
              "identificador" => "bib1550"
              "etiqueta" => "144"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            144 => array:3 [
              "identificador" => "bib1555"
              "etiqueta" => "145"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            145 => array:3 [
              "identificador" => "bib1560"
              "etiqueta" => "146"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            146 => array:3 [
              "identificador" => "bib1565"
              "etiqueta" => "147"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            147 => array:3 [
              "identificador" => "bib1570"
              "etiqueta" => "148"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            148 => array:3 [
              "identificador" => "bib1575"
              "etiqueta" => "149"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            149 => array:3 [
              "identificador" => "bib1580"
              "etiqueta" => "150"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            150 => array:3 [
              "identificador" => "bib1585"
              "etiqueta" => "151"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            151 => array:3 [
              "identificador" => "bib1590"
              "etiqueta" => "152"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            152 => array:3 [
              "identificador" => "bib1595"
              "etiqueta" => "153"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            153 => array:3 [
              "identificador" => "bib1600"
              "etiqueta" => "154"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            154 => array:3 [
              "identificador" => "bib1605"
              "etiqueta" => "155"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            155 => array:3 [
              "identificador" => "bib1610"
              "etiqueta" => "156"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            156 => array:3 [
              "identificador" => "bib1615"
              "etiqueta" => "157"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            157 => array:3 [
              "identificador" => "bib1620"
              "etiqueta" => "158"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            158 => array:3 [
              "identificador" => "bib1625"
              "etiqueta" => "159"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            159 => array:3 [
              "identificador" => "bib1630"
              "etiqueta" => "160"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            160 => array:3 [
              "identificador" => "bib1635"
              "etiqueta" => "161"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            161 => array:3 [
              "identificador" => "bib1640"
              "etiqueta" => "162"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            162 => array:3 [
              "identificador" => "bib1645"
              "etiqueta" => "163"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            163 => array:3 [
              "identificador" => "bib1650"
              "etiqueta" => "164"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            164 => array:3 [
              "identificador" => "bib1655"
              "etiqueta" => "165"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            165 => array:3 [
              "identificador" => "bib1660"
              "etiqueta" => "166"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:3 [
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0370" class="elsevierStylePara elsevierViewall">The authors thank Ester Puig-Vilanova for her support and Anael Barber&#225;n-Garc&#237;a for her invaluable contribution to the review of the literature and incorporation of references&#46; They also thank Anna Salazar&#44; Mar&#237;a Cort&#233;s-Badia and Paula Bassaga&#241;as-&#210;dena for their collaboration in producing the list of abbreviations and references in the document&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000005100000008/v2_201511200100/S1579212915001846/v2_201511200100/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "9379"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Recommendations of SEPAR"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005100000008/v2_201511200100/S1579212915001846/v2_201511200100/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915001846?idApp=UINPBA00003Z"
]
Share
Journal Information

Statistics

Follow this link to access the full text of the article

Recommendations of SEPAR
Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease
Normativa SEPAR sobre disfunción muscular de los pacientes con enfermedad pulmonar obstructiva crónica
Esther Barreiroa,b,
Corresponding author
ebarreiro@imim.es

Corresponding author.
, Víctor Bustamantec, Pilar Cejudod, Juan B. Gáldizb,e, Joaquim Geaa,b, Pilar de Lucasf, Juana Martínez-Llorensa,b, Francisco Ortegab,d, Luis Puente-Maestuf, Josep Rocab,g, José Miguel Rodríguez González-Morof
a Servei de Pneumologia, Unitat de Recerca en Múscul i Aparell Respiratori (URMAR), IMIM-Hospital del Mar, CEXS, Universitat Pompeu Fabra, Parc de Recerca Biomèdica de Barcelona (PRBB), Barcelona, España
b CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
c Hospital Universitario Basurto, Osakidetza, Departamento de Medicina, Universidad del País Vasco, Bilbao, España
d Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío, Sevilla, España
e Servicio de Neumología y Unidad de Investigación, Hospital de Cruces, Universidad del País Vasco, Barakaldo, España
f Servicio de Neumología, Hospital General Gregorio Marañón, Universidad Complutense de Madrid, Madrid, España
g Servei de Pneumologia, Hospital Clínic de Barcelona, Barcelona, España
Read
16065
Times
was read the article
4435
Total PDF
11630
Total HTML
Share statistics
 array:24 [
  "pii" => "S1579212915001846"
  "issn" => "15792129"
  "doi" => "10.1016/j.arbr.2015.04.027"
  "estado" => "S300"
  "fechaPublicacion" => "2015-08-01"
  "aid" => "1187"
  "copyright" => "SEPAR"
  "copyrightAnyo" => "2014"
  "documento" => "article"
  "crossmark" => 1
  "subdocumento" => "pgl"
  "cita" => "Arch Bronconeumol. 2015;51:384-95"
  "abierto" => array:3 [
    "ES" => false
    "ES2" => false
    "LATM" => false
  ]
  "gratuito" => false
  "lecturas" => array:2 [
    "total" => 8955
    "formatos" => array:3 [
      "EPUB" => 192
      "HTML" => 7136
      "PDF" => 1627
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:19 [
      "pii" => "S0300289615001568"
      "issn" => "03002896"
      "doi" => "10.1016/j.arbres.2015.04.011"
      "estado" => "S300"
      "fechaPublicacion" => "2015-08-01"
      "aid" => "1187"
      "copyright" => "SEPAR"
      "documento" => "article"
      "crossmark" => 1
      "subdocumento" => "pgl"
      "cita" => "Arch Bronconeumol. 2015;51:384-95"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 9953
        "formatos" => array:3 [
          "EPUB" => 158
          "HTML" => 7305
          "PDF" => 2490
        ]
      ]
      "es" => array:13 [
        "idiomaDefecto" => true
        "cabecera" => "<span class="elsevierStyleTextfn">Normativa SEPAR</span>"
        "titulo" => "Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "tieneResumen" => array:2 [
          0 => "es"
          1 => "en"
        ]
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "384"
            "paginaFinal" => "395"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease"
          ]
        ]
        "contieneResumen" => array:2 [
          "es" => true
          "en" => true
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig0020"
            "etiqueta" => "Figura 4"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "gr4.jpeg"
                "Alto" => 1765
                "Ancho" => 2412
                "Tamanyo" => 145111
              ]
            ]
            "descripcion" => array:1 [
              "es" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Selecci&#243;n de ensayos cl&#237;nicos controlados que han utilizado pruebas a una potencia constante de intensidad alta para medir el efecto de intervenciones sobre los m&#250;sculos de las extremidades inferiores&#46;Potencia&#58; intensidad a la que se hizo la prueba como porcentaje de la W<span class="elsevierStyleItalic">R</span><span class="elsevierStyleInf">max</span>&#46; L&#237;nea vertical&#58; m&#237;nima diferencia cl&#237;nicamente relevante&#46;</p>"
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "Esther Barreiro, V&#237;ctor Bustamante, Pilar Cejudo, Juan B&#46; G&#225;ldiz, Joaquim Gea, Pilar de Lucas, Juana Mart&#237;nez-Llorens, Francisco Ortega, Luis Puente-Maestu, Josep Roca, Jos&#233; Miguel Rodr&#237;guez Gonz&#225;lez-Moro"
            "autores" => array:11 [
              0 => array:2 [
                "nombre" => "Esther"
                "apellidos" => "Barreiro"
              ]
              1 => array:2 [
                "nombre" => "V&#237;ctor"
                "apellidos" => "Bustamante"
              ]
              2 => array:2 [
                "nombre" => "Pilar"
                "apellidos" => "Cejudo"
              ]
              3 => array:2 [
                "nombre" => "Juan B&#46;"
                "apellidos" => "G&#225;ldiz"
              ]
              4 => array:2 [
                "nombre" => "Joaquim"
                "apellidos" => "Gea"
              ]
              5 => array:2 [
                "nombre" => "Pilar"
                "apellidos" => "de Lucas"
              ]
              6 => array:2 [
                "nombre" => "Juana"
                "apellidos" => "Mart&#237;nez-Llorens"
              ]
              7 => array:2 [
                "nombre" => "Francisco"
                "apellidos" => "Ortega"
              ]
              8 => array:2 [
                "nombre" => "Luis"
                "apellidos" => "Puente-Maestu"
              ]
              9 => array:2 [
                "nombre" => "Josep"
                "apellidos" => "Roca"
              ]
              10 => array:2 [
                "nombre" => "Jos&#233; Miguel"
                "apellidos" => "Rodr&#237;guez Gonz&#225;lez-Moro"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "S1579212915001846"
          "doi" => "10.1016/j.arbr.2015.04.027"
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => false
            "ES2" => false
            "LATM" => false
          ]
          "gratuito" => false
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915001846?idApp=UINPBA00003Z"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289615001568?idApp=UINPBA00003Z"
      "url" => "/03002896/0000005100000008/v2_201511200118/S0300289615001568/v2_201511200118/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S157921291500107X"
    "issn" => "15792129"
    "doi" => "10.1016/j.arbr.2015.04.014"
    "estado" => "S300"
    "fechaPublicacion" => "2015-08-01"
    "aid" => "1078"
    "copyright" => "SEPAR"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2015;51:396-402"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2516
      "formatos" => array:3 [
        "EPUB" => 139
        "HTML" => 1837
        "PDF" => 540
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>"
      "titulo" => "The Role of Pulmonology in the National Health System Chronicity Strategy"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "396"
          "paginaFinal" => "402"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "El papel de la neumolog&#237;a ante la Estrategia de cronicidad del Sistema Nacional de Salud"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0005"
          "etiqueta" => "Fig&#46; 1"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr1.jpeg"
              "Alto" => 1341
              "Ancho" => 1658
              "Tamanyo" => 129226
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Conceptual model for the care of patients with chronic diseases &#40;chronic care model&#41; proposed by Wagner&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">4</span></a></p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Juan Jos&#233; Soler-Catalu&#241;a, Fernando S&#225;nchez Toril, M&#46; Carmen Aguar Benito"
          "autores" => array:3 [
            0 => array:2 [
              "nombre" => "Juan Jos&#233;"
              "apellidos" => "Soler-Catalu&#241;a"
            ]
            1 => array:2 [
              "nombre" => "Fernando"
              "apellidos" => "S&#225;nchez Toril"
            ]
            2 => array:2 [
              "nombre" => "M&#46; Carmen"
              "apellidos" => "Aguar Benito"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0300289614004384"
        "doi" => "10.1016/j.arbres.2014.10.007"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289614004384?idApp=UINPBA00003Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500107X?idApp=UINPBA00003Z"
    "url" => "/15792129/0000005100000008/v2_201511200100/S157921291500107X/v2_201511200100/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S157921291500141X"
    "issn" => "15792129"
    "doi" => "10.1016/j.arbr.2015.05.004"
    "estado" => "S300"
    "fechaPublicacion" => "2015-08-01"
    "aid" => "1031"
    "copyright" => "SEPAR"
    "documento" => "article"
    "crossmark" => 1
    "subdocumento" => "fla"
    "cita" => "Arch Bronconeumol. 2015;51:379-83"
    "abierto" => array:3 [
      "ES" => false
      "ES2" => false
      "LATM" => false
    ]
    "gratuito" => false
    "lecturas" => array:2 [
      "total" => 2541
      "formatos" => array:3 [
        "EPUB" => 138
        "HTML" => 1891
        "PDF" => 512
      ]
    ]
    "en" => array:13 [
      "idiomaDefecto" => true
      "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
      "titulo" => "Characteristics of Candidates for Lung Transplantation Due to Chronic Obstructive Pulmonary Disease and Alpha-1 Antitrypsin Deficiency Emphysema"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "en"
        1 => "es"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "379"
          "paginaFinal" => "383"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Caracter&#237;sticas de la poblaci&#243;n candidata a trasplante pulmonar por enfermedad pulmonar obstructiva cr&#243;nica y por enfisema secundario a d&#233;ficit de alfa 1 antitripsina"
        ]
      ]
      "contieneResumen" => array:2 [
        "en" => true
        "es" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "resumenGrafico" => array:2 [
        "original" => 0
        "multimedia" => array:7 [
          "identificador" => "fig0010"
          "etiqueta" => "Fig&#46; 2"
          "tipo" => "MULTIMEDIAFIGURA"
          "mostrarFloat" => true
          "mostrarDisplay" => false
          "figura" => array:1 [
            0 => array:4 [
              "imagen" => "gr2.jpeg"
              "Alto" => 3783
              "Ancho" => 1659
              "Tamanyo" => 210738
            ]
          ]
          "descripcion" => array:1 [
            "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Error bars for the clinical variables according to the transplant period&#58; &#40;a&#41; PO<span class="elsevierStyleInf">2</span> values&#59; &#40;b&#41; FEV1&#37; values&#59; &#40;c&#41; 6-minute walk test values&#46;</p>"
          ]
        ]
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Daniela Giacoboni, Miriam Barrecheguren, Cristina Esquinas, Esther Rodr&#237;guez, Cristina Berastegui, Manuel L&#243;pez-Meseguer, V&#237;ctor Monforte, Carlos Bravo, Pietro Pirina, Marc Miravitlles, Antonio Rom&#225;n"
          "autores" => array:11 [
            0 => array:2 [
              "nombre" => "Daniela"
              "apellidos" => "Giacoboni"
            ]
            1 => array:2 [
              "nombre" => "Miriam"
              "apellidos" => "Barrecheguren"
            ]
            2 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Esquinas"
            ]
            3 => array:2 [
              "nombre" => "Esther"
              "apellidos" => "Rodr&#237;guez"
            ]
            4 => array:2 [
              "nombre" => "Cristina"
              "apellidos" => "Berastegui"
            ]
            5 => array:2 [
              "nombre" => "Manuel"
              "apellidos" => "L&#243;pez-Meseguer"
            ]
            6 => array:2 [
              "nombre" => "V&#237;ctor"
              "apellidos" => "Monforte"
            ]
            7 => array:2 [
              "nombre" => "Carlos"
              "apellidos" => "Bravo"
            ]
            8 => array:2 [
              "nombre" => "Pietro"
              "apellidos" => "Pirina"
            ]
            9 => array:2 [
              "nombre" => "Marc"
              "apellidos" => "Miravitlles"
            ]
            10 => array:2 [
              "nombre" => "Antonio"
              "apellidos" => "Rom&#225;n"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "S0300289614003299"
        "doi" => "10.1016/j.arbres.2014.08.003"
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289614003299?idApp=UINPBA00003Z"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S157921291500141X?idApp=UINPBA00003Z"
    "url" => "/15792129/0000005100000008/v2_201511200100/S157921291500141X/v2_201511200100/en/main.assets"
  ]
  "en" => array:20 [
    "idiomaDefecto" => true
    "cabecera" => "<span class="elsevierStyleTextfn">Recommendations of SEPAR</span>"
    "titulo" => "Guidelines for the Evaluation and Treatment of Muscle Dysfunction in Patients With Chronic Obstructive Pulmonary Disease"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "384"
        "paginaFinal" => "395"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Esther Barreiro, V&#237;ctor Bustamante, Pilar Cejudo, Juan B&#46; G&#225;ldiz, Joaquim Gea, Pilar de Lucas, Juana Mart&#237;nez-Llorens, Francisco Ortega, Luis Puente-Maestu, Josep Roca, Jos&#233; Miguel Rodr&#237;guez Gonz&#225;lez-Moro"
        "autores" => array:11 [
          0 => array:4 [
            "nombre" => "Esther"
            "apellidos" => "Barreiro"
            "email" => array:1 [
              0 => "ebarreiro&#64;imim&#46;es"
            ]
            "referencia" => array:3 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              2 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor0005"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "V&#237;ctor"
            "apellidos" => "Bustamante"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "aff0015"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Pilar"
            "apellidos" => "Cejudo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Juan B&#46;"
            "apellidos" => "G&#225;ldiz"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">e</span>"
                "identificador" => "aff0025"
              ]
            ]
          ]
          4 => array:3 [
            "nombre" => "Joaquim"
            "apellidos" => "Gea"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          5 => array:3 [
            "nombre" => "Pilar"
            "apellidos" => "de Lucas"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          6 => array:3 [
            "nombre" => "Juana"
            "apellidos" => "Mart&#237;nez-Llorens"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "aff0005"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
            ]
          ]
          7 => array:3 [
            "nombre" => "Francisco"
            "apellidos" => "Ortega"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">d</span>"
                "identificador" => "aff0020"
              ]
            ]
          ]
          8 => array:3 [
            "nombre" => "Luis"
            "apellidos" => "Puente-Maestu"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
          9 => array:3 [
            "nombre" => "Josep"
            "apellidos" => "Roca"
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "aff0010"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">g</span>"
                "identificador" => "aff0035"
              ]
            ]
          ]
          10 => array:3 [
            "nombre" => "Jos&#233; Miguel"
            "apellidos" => "Rodr&#237;guez Gonz&#225;lez-Moro"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">f</span>"
                "identificador" => "aff0030"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:7 [
          0 => array:3 [
            "entidad" => "Servei de Pneumologia&#44; Unitat de Recerca en M&#250;scul i Aparell Respiratori &#40;URMAR&#41;&#44; IMIM-Hospital del Mar&#44; CEXS&#44; Universitat Pompeu Fabra&#44; Parc de Recerca Biom&#232;dica de Barcelona &#40;PRBB&#41;&#44; Barcelona&#44; Espa&#241;a"
            "etiqueta" => "a"
            "identificador" => "aff0005"
          ]
          1 => array:3 [
            "entidad" => "CIBER de Enfermedades Respiratorias &#40;CIBERES&#41;&#44; Instituto de Salud Carlos III&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "b"
            "identificador" => "aff0010"
          ]
          2 => array:3 [
            "entidad" => "Hospital Universitario Basurto&#44; Osakidetza&#44; Departamento de Medicina&#44; Universidad del Pa&#237;s Vasco&#44; Bilbao&#44; Espa&#241;a"
            "etiqueta" => "c"
            "identificador" => "aff0015"
          ]
          3 => array:3 [
            "entidad" => "Unidad M&#233;dico-Quir&#250;rgica de Enfermedades Respiratorias&#44; Hospital Universitario Virgen del Roc&#237;o&#44; Sevilla&#44; Espa&#241;a"
            "etiqueta" => "d"
            "identificador" => "aff0020"
          ]
          4 => array:3 [
            "entidad" => "Servicio de Neumolog&#237;a y Unidad de Investigaci&#243;n&#44; Hospital de Cruces&#44; Universidad del Pa&#237;s Vasco&#44; Barakaldo&#44; Espa&#241;a"
            "etiqueta" => "e"
            "identificador" => "aff0025"
          ]
          5 => array:3 [
            "entidad" => "Servicio de Neumolog&#237;a&#44; Hospital General Gregorio Mara&#241;&#243;n&#44; Universidad Complutense de Madrid&#44; Madrid&#44; Espa&#241;a"
            "etiqueta" => "f"
            "identificador" => "aff0030"
          ]
          6 => array:3 [
            "entidad" => "Servei de Pneumologia&#44; Hospital Cl&#237;nic de Barcelona&#44; Barcelona&#44; Espa&#241;a"
            "etiqueta" => "g"
            "identificador" => "aff0035"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica"
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1248
            "Ancho" => 3214
            "Tamanyo" => 246423
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Etiological factors involved in limb muscle dysfunction in COPD patients&#46; The factors have deleterious effects on lower limb muscle function and mass&#44; causing the scales to completely tip toward the negative side &#40;left tray&#41;&#46; &#40;B&#41; In the lower limb muscles&#44; the actions of the etiological factors are mediated by several biological mechanisms&#44; with deleterious effects on muscle function&#44; mass and structure&#46; The scales are completely tipped to the left&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">These guidelines discuss the latest findings on muscle dysfunction in patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; and examine the general problem&#44; etiology&#44; diagnosis&#44; evaluation&#44; and treatment&#46; To that end&#44; the expert authors have summarized the most recent publications on the various aspects of the topic&#44; and the Grading of Recommendations Assessment&#44; Development&#44; and Evaluation &#40;GRADE&#41; scale has been used to make recommendations on the grade of evidence for the various proposals discussed in this document&#46;<a class="elsevierStyleCrossRef" href="#bib0835"><span class="elsevierStyleSup">1</span></a> Due to space constraints&#44; an extended version expanding on these guidelines has been made available online&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology&#44; Pathophysiology and Implications for Patients</span><p id="par0010" class="elsevierStylePara elsevierViewall">Muscles in any part of the body have 2 main functional properties&#58; strength&#44; the maximum expression of their ability to contract&#59; and endurance&#44; the ability to maintain less than maximum strength over time&#46;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">2</span></a> Strength depends mainly on muscle mass&#44; while endurance is determined by the aerobic capacity of the muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0845"><span class="elsevierStyleSup">3</span></a> Strength and endurance in different muscle groups can be measured in routine clinical practice&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Muscle dysfunction is defined as the inability of a muscle to perform its task&#44;<a class="elsevierStyleCrossRef" href="#bib0840"><span class="elsevierStyleSup">2</span></a> as a result of loss of strength or endurance&#44; or both&#46; Dysfunction of the respiratory muscles or the muscles of the limbs &#40;also known as peripheral muscles&#41; is common in respiratory diseases&#46; Patients with limb muscle dysfunction lose their independence&#44; which adversely affects their quality of life&#46;<a class="elsevierStyleCrossRefs" href="#bib0850"><span class="elsevierStyleSup">4&#44;5</span></a> COPD is probably the respiratory disease in which muscle dysfunction has been studied in most depth&#44; and it has been established that up to one third of COPD patients&#44; even in the early stages of the disease&#44; have a loss of muscle function in their limbs &#40;25&#37; less strength than control subjects&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0850"><span class="elsevierStyleSup">4</span></a> Respiratory muscle dysfunction is seen in advanced COPD patients&#44; whose diaphragmatic strength is between 20&#37; and 30&#37; of that of control subjects&#46;<a class="elsevierStyleCrossRefs" href="#bib0860"><span class="elsevierStyleSup">6&#8211;8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently show that COPD patients have muscle dysfunction&#44; irrespective of the severity of their pulmonary obstruction&#46; Evidence GRADE 1A&#46;</span></p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Muscle Dysfunction Pathophysiology</span><p id="par0025" class="elsevierStylePara elsevierViewall">Research over the last 20 years has revealed that several factors and mechanisms are involved in the multifactorial etiology of muscle dysfunction in COPD patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Limb Muscle Dysfunction &#40;Quadriceps&#41;</span><p id="par0030" class="elsevierStylePara elsevierViewall">As indicated in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#44; cigarette smoke&#44; genetic and epigenetic alterations&#44; metabolic disorders &#40;including vitamin D and testosterone deficiencies&#41;&#44; drugs &#40;corticosteroids&#41;&#44; comorbidities&#44; exacerbations&#44; systemic inflammation&#44; malnutrition&#44; physical inactivity&#44; and aging are some of the factors involved in limb muscle dysfunction in COPD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;3</span></a> The biological events implicated in limb muscle dysfunction most notably include a series of structural changes&#44;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#8211;11</span></a> oxidative stress&#44;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#44;11&#44;12</span></a> chronic hypoxia&#44; hypercapnia and acidosis&#44; and structural and mitochondrial changes<a class="elsevierStyleCrossRefs" href="#bib0895"><span class="elsevierStyleSup">13&#44;14</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; Other mechanisms&#44; such as proteolysis&#44; apoptosis&#44; autophagy&#44; and epigenetics&#44; are also involved in the physiopathology of limb muscle dysfunction in these patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0875"><span class="elsevierStyleSup">9&#44;15&#8211;19</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently point to biological mechanisms and factors involved in the development of muscle dysfunction in COPD patients&#46; Evidence GRADE 1A&#46;</span></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Respiratory Muscle Dysfunction</span><p id="par0040" class="elsevierStylePara elsevierViewall">The major factors involved in the respiratory muscle dysfunction of COPD are shown in <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#46; The most important of these are mechanical factors&#44; but there are also factors that induce positive adaptation&#44; which gives the respiratory muscles of these patients certain endurance<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">3&#44;20</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>A&#41;&#46; Adaptive biological phenomena have also been found in the diaphragm&#44; counteracting the potential deleterious effects&#59; these phenomena include shortening of the sarcomere length&#44; increased myoglobin content and higher proportions of fatigue-resistant fibers and capillary contacts&#44; increased mitochondrial density&#44; and improved aerobic muscle potential<a class="elsevierStyleCrossRefs" href="#bib0845"><span class="elsevierStyleSup">3&#44;21&#8211;25</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; In COPD&#44; the final muscle phenotype will be a result of the balance between the adaptive factors and mechanisms&#44; and those involved in muscle function&#44; as well as between stable disease and exacerbations &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46; In advanced COPD however&#44; biological mechanisms<a class="elsevierStyleCrossRefs" href="#bib0870"><span class="elsevierStyleSup">8&#44;9&#44;15&#8211;19&#44;26</span></a> identical to those described in limb muscle dysfunction affect the diaphragm&#44; prevailing over the adaptive mechanisms &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>B&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Observational studies consistently point to biological mechanisms and factors involved in the development of muscle dysfunction in COPD patients&#46; Evidence GRADE 1A&#46;</span></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Evaluation of Respiratory Muscles&#58; Voluntary and Involuntary Maneuvers &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Evaluating Respiratory Muscle Strength&#58; Volitional Tests of Respiratory Muscle Strength</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Non-Invasive Testing</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Spirometry</span><p id="par0050" class="elsevierStylePara elsevierViewall">Forced spirometry&#44;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> although non-specific&#44; can detect a decline in forced vital capacity &#40;FVC&#41; that can be indicative of a non-obstructive ventilatory defect&#46;<a class="elsevierStyleCrossRef" href="#bib0970"><span class="elsevierStyleSup">28</span></a> A FVC decrease of greater than 25&#37; between spirometries performed in the sitting and supine positions&#44; or FVC less than 75&#37; of the predicted values in the supine position&#44; with normal values in the sitting position&#44; indicate diaphragmatic weakness&#46;<a class="elsevierStyleCrossRef" href="#bib0975"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Measuring Pressure at the Mouth</span><p id="par0055" class="elsevierStylePara elsevierViewall">Maximum pressures generated at the mouth&#44; whether inspiratory &#40;MIP&#41; or expiratory &#40;MEP&#41;&#44; are more specific for assessing respiratory muscle strength&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> These tests are generally static maneuvers &#40;without airflow&#41;&#44; performed using mouthpieces that can be occluded&#44; with a small leak to prevent glottic closure and to reduce the use of the buccal muscles&#46; MIP &#91;usually determined from residual volume &#40;RV&#41;&#93; is a measure of the strength of all the inspiratory muscles&#44; while MEP &#91;normally determined from total lung capacity &#40;TLC&#41;&#93; basically expresses the strength of the expiratory muscles in the abdomen<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; As for all voluntary maneuvers&#44; the patient needs to be encouraged verbally&#44; and three acceptable maneuvers should be obtained&#44; with a variation of less than 20&#37;&#46; Reference values for the healthy Mediterranean population are available&#46;<a class="elsevierStyleCrossRef" href="#bib0980"><span class="elsevierStyleSup">30</span></a> MIP values greater than 80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O can also exclude severe muscle dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Sniff Nasal Inspiratory Pressure &#40;SNIP&#41;</span><p id="par0060" class="elsevierStylePara elsevierViewall">Nasal pressure is determined during maximal nasal inhalation &#40;SNIP&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;31&#44;32</span></a> This is a natural&#44; dynamic maneuver&#44; carried out with the patient in a sitting position&#44; with one nostril blocked&#46; It is usually measured from functional residual capacity &#40;FRC&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;31&#44;32</span></a> using the highest value from at least 10 maneuvers&#46; Inspiratory muscle dysfunction can be ruled out if values are higher than &#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or &#8722;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Invasive Testing</span><p id="par0065" class="elsevierStylePara elsevierViewall">A good expression of the pleural pressure generated by activation of the inspiratory muscles can be obtained from the esophageal pressure determined by placing a pressure catheter in the mid-third of the esophagus during forced inhalation &#40;<span class="elsevierStyleItalic">sniff</span>Pesmax&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;33</span></a> Inspiratory muscle dysfunction can be ruled out if S<span class="elsevierStyleItalic">niff</span>Pesmax values are higher than &#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or &#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Diaphragmatic strength or transdiaphragmatic pressure &#40;Pdi&#41; can also be determined by measuring the difference between gastric and esophageal pressure&#44; estimated by placing 2 catheters connected to pressure transducers &#40;one in the esophagus and the other in the gastric cavity&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a><span class="elsevierStyleItalic">Sniff</span>Pdi values lower than 75<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in men or 53<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O in women suggest diaphragmatic dysfunction&#46;<a class="elsevierStyleCrossRef" href="#bib1000"><span class="elsevierStyleSup">34</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that volitional testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Non-Volitional Tests of Respiratory Muscle Strength &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0080" class="elsevierStylePara elsevierViewall">External stimulation techniques&#44; using phrenic nerve stimulators generating electric or magnetic fields &#40;Pdi<span class="elsevierStyleItalic">twitch</span>&#41;&#44; have been developed to avoid false positives&#46; Normal Pdi<span class="elsevierStyleItalic">twitch</span> values are about 20&#37;&#8211;30&#37; of the <span class="elsevierStyleItalic">sniff</span>Pdi&#46;<a class="elsevierStyleCrossRefs" href="#bib0965"><span class="elsevierStyleSup">27&#44;34</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that non-volitional testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Evaluating Respiratory Muscle Endurance &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;</span><p id="par0090" class="elsevierStylePara elsevierViewall">Pressure&#8211;time product &#40;PTP&#41; is calculated by integrating the respiratory pressure measured at the mouth&#44; esophagus or Pdi over time &#40;cm H<span class="elsevierStyleInf">2</span>O&#47;min&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> Maximal sustainable ventilation &#40;MSV&#41; is expressed as a fraction of maximal voluntary ventilation &#40;MVV&#41;&#59; normal values are between 60&#37; and 80&#37; of the MVV&#46;<a class="elsevierStyleCrossRef" href="#bib0965"><span class="elsevierStyleSup">27</span></a> MSV is a measure of respiratory muscle endurance and the function of other elements of the rib cage&#46;<a class="elsevierStyleCrossRef" href="#bib1005"><span class="elsevierStyleSup">35</span></a> Inspiratory or expiratory threshold loading tests are more specific&#46; There are two types&#58; incremental&#44; measuring the sustained maximal pressure &#40;SMIP and SMEP&#44; depending on whether inspiratory or expiratory&#41;&#44; and constant submaximal loading &#40;percentage of SMIP or MIP for inspiratory&#44; and SMEP or MEP for expiratory&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib1010"><span class="elsevierStyleSup">36&#8211;39</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that endurance testing for evaluating respiratory muscle function is useful and provides reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evaluation of Limb Muscles&#58; Volitional and Non-Volitional Testing</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">General Evaluation of Limb Muscles &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;</span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Evaluating Muscle Mass &#40;MM&#41;</span><p id="par0100" class="elsevierStylePara elsevierViewall">Initial calculations are based on systems determining body compartments&#44; such as the Matiegka method&#44;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">40</span></a> which takes body weight &#40;W&#41; as the sum of 4 components&#58; O&#44; skeletal weight&#59; D&#44; skin and subcutaneous adipose tissue weight&#59; M&#44; skeletal muscle weight&#59; and R&#44; remaining weight&#46; Skinfold anthropometry requires several measurements&#44; including height&#44; length and width of the limb&#44; folds and calculated body surface area&#44; but this technique generally overestimates the fat-free mass&#44; compared to other methods&#46;<a class="elsevierStyleCrossRef" href="#bib1035"><span class="elsevierStyleSup">41</span></a> Technological advances have led to complex and even invasive systems&#44; such as deuterium dilution&#44;<a class="elsevierStyleCrossRef" href="#bib1030"><span class="elsevierStyleSup">40</span></a> considered the gold standard&#46; Although its use is limited to research centers&#44; it has been used to validate a series of more commonly used measurements&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall"></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Bioimpedance Analysis &#40;BIA&#41; or Bioelectric Impedance</span><p id="par0105" class="elsevierStylePara elsevierViewall">This method is based on the principle that the electrical conductivity of a fat-free mass &#40;comparable to the MM&#41; is greater than that of fat&#46;<a class="elsevierStyleCrossRef" href="#bib1040"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Dual-Energy X-Ray Absorptiometry &#40;DEXA&#41;</span><p id="par0110" class="elsevierStylePara elsevierViewall">DEXA is an imaging technique used for estimating total-body and regional skeletal muscle mass&#46; It also can be used for quantifying lean soft tissue&#44; fat and bone mineral density&#46;<a class="elsevierStyleCrossRef" href="#bib1045"><span class="elsevierStyleSup">43</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that the different tests for quantifying muscle mass in COPD patients are useful and provide reliable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Local MM Study Techniques</span><p id="par0120" class="elsevierStylePara elsevierViewall">Although measuring thigh circumference is simple and cheap&#44; it is not a good measure of local muscle mass&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> Alternatives include computed tomography &#40;CT&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> magnetic resonance imaging &#40;MRI&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib1055"><span class="elsevierStyleSup">45</span></a> and ultrasound&#44;<a class="elsevierStyleCrossRef" href="#bib1060"><span class="elsevierStyleSup">46</span></a> particularly for measuring quadriceps size&#46; In COPD&#44; the amount of local MM measured by these techniques has been correlated with parameters as diverse as muscle strength<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">47</span></a> and mortality&#46;<a class="elsevierStyleCrossRef" href="#bib1050"><span class="elsevierStyleSup">44</span></a> Muscle biopsy is a morphological technique that provides data on the structural and biochemical properties of the muscles&#44;<a class="elsevierStyleCrossRef" href="#bib1070"><span class="elsevierStyleSup">48</span></a> but its invasive nature means that use is essentially limited to research studies&#44; even when fine needle microbiopsies are obtained&#46;<a class="elsevierStyleCrossRef" href="#bib1065"><span class="elsevierStyleSup">47</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Numerous studies consistently show that obtaining a muscle biopsy from COPD patients is highly useful and provides reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Physical Activity</span><p id="par0130" class="elsevierStylePara elsevierViewall">Physical activity can be measured by questionnaires or&#44; more reliably&#44; by accelerometers that record activities performed by a subject over a prolonged period&#46;<a class="elsevierStyleCrossRef" href="#bib1075"><span class="elsevierStyleSup">49</span></a></p></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Exercise Testing</span><p id="par0135" class="elsevierStylePara elsevierViewall">Both the walk test and ergometry are discussed in detail in the specific section of these guidelines&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Electromyography &#40;EMG&#41;</span><p id="par0140" class="elsevierStylePara elsevierViewall">EMG consists of recording the electrical activity of muscles at rest and during both voluntary and externally stimulated contraction<a class="elsevierStyleCrossRefs" href="#bib1080"><span class="elsevierStyleSup">50&#8211;53</span></a> &#40;see below&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that physical activity&#44; exercise capacity and electromyography are useful and provide reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Limb Muscle Function Testing</span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Voluntary Maneuvers</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Handgrip Dynamometry</span><p id="par0150" class="elsevierStylePara elsevierViewall">This is a simple measurement&#44; carried out with various types of dynamometers&#46; It is widely used and is recognized as a prognostic factor in COPD&#46;<a class="elsevierStyleCrossRef" href="#bib1100"><span class="elsevierStyleSup">54</span></a> Reference values are available for different populations&#46;<a class="elsevierStyleCrossRefs" href="#bib1105"><span class="elsevierStyleSup">55&#44;56</span></a></p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Maximal Isometric Contraction of the Quadriceps Femoris &#40;Q-MVC&#41;</span><p id="par0155" class="elsevierStylePara elsevierViewall">This procedure is normally performed with the patient in a sitting position&#44; with hips and knees bent at an angle of 90&#176;&#46; Quadriceps extension is measured with the leg fixed at the ankle&#44; connected to a dynamometer&#46;<a class="elsevierStyleCrossRef" href="#bib1115"><span class="elsevierStyleSup">57</span></a> Reference values are available&#46;<a class="elsevierStyleCrossRef" href="#bib1120"><span class="elsevierStyleSup">58</span></a></p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Test of Endurance Time at 10&#37; of the Q-MVC</span><p id="par0160" class="elsevierStylePara elsevierViewall">This endurance test<a class="elsevierStyleCrossRef" href="#bib1125"><span class="elsevierStyleSup">59</span></a> is based on claudication after exercise involving cycles of contractions against a load equivalent to 10&#37; of the Q-MVC &#40;cycles of 2<span class="elsevierStyleHsp" style=""></span>s quadriceps contraction and 3<span class="elsevierStyleHsp" style=""></span>s of relaxation&#41;&#46; Other maneuvers&#44; more specific for estimating endurance&#44; are used for measuring pairs of forces &#40;torque&#41; in N<span class="elsevierStyleHsp" style=""></span>m &#40;Newtons<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>meter&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1130"><span class="elsevierStyleSup">60</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that tests for evaluating contraction function and muscle mass in COPD patients are very useful and provide reliable and comparable inter-individual measurements over time&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Involuntary Maneuvers</span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Supramaximal Quadriceps Twitch Force &#40;QTw&#41;</span><p id="par0170" class="elsevierStylePara elsevierViewall">This technique is based on the electrical or magnetic stimulation of the femoral nerve in a single stimulus&#44; or &#8220;twitch&#8221;&#44; measuring the force generated after quadriceps activation&#46;<a class="elsevierStyleCrossRefs" href="#bib1135"><span class="elsevierStyleSup">61&#44;62</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that involuntary maneuver tests for the evaluation of muscle function in COPD patients are useful and provide reliable and comparable inter-individual measurements over time&#46; However&#44; their use has not been extended to routine clinical practice&#46; Evidence&#58; GRADE 1B&#46;</span></p></span></span></span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Evaluation of Exercise Tolerance&#58; The 6-Minute Walk Test</span><p id="par0180" class="elsevierStylePara elsevierViewall">The 6-minute walk test is a simple exercise protocol measuring the distance walked quickly by the patient on a hard&#44; flat surface over a period of 6<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">63</span></a> Several other tests are used in the field &#40;stair-climbing&#44; Bruce&#44; 12-minute walk&#44; incremental walk&#44; etc&#46;&#41;&#44;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">63&#8211;65</span></a> but the 6-minute walk is the most popular&#44; and is the most simple exercise test used as a reference in COPD and other diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#8211;72</span></a> It is highly standardized&#44;<a class="elsevierStyleCrossRefs" href="#bib1145"><span class="elsevierStyleSup">63&#44;73&#44;74</span></a> is reasonably reproducible&#44;<a class="elsevierStyleCrossRef" href="#bib1205"><span class="elsevierStyleSup">75</span></a> and is valuable for measuring the effects of different interventions in many chronic diseases&#46;<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">76&#8211;81</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The 6-minute walk is a high-intensity sustainable submaximal exercise<a class="elsevierStyleCrossRef" href="#bib1240"><span class="elsevierStyleSup">82</span></a> used for the overall and comprehensive evaluation of various physical functions &#40;cardiac&#44; respiratory&#44; peripheral oxygen transport&#44; muscle bioenergetics and neuromuscular integration&#41; that determine the patient&#39;s aerobic capacity&#46; Some studies<a class="elsevierStyleCrossRefs" href="#bib1240"><span class="elsevierStyleSup">82&#44;83</span></a> suggest that exercise intensity during the test is an indication of the patient&#39;s maximal sustainable power output over time &#40;critical power&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1250"><span class="elsevierStyleSup">84</span></a> This would explain the high predictive value of this test for mortality<a class="elsevierStyleCrossRefs" href="#bib1210"><span class="elsevierStyleSup">76&#44;79&#44;80</span></a> and its valuable role in the clinical decision-making process&#46;<a class="elsevierStyleCrossRefs" href="#bib1205"><span class="elsevierStyleSup">75&#44;78&#44;81</span></a></p><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">Indications</span><p id="par0190" class="elsevierStylePara elsevierViewall">Evaluation of the functional status of patients with different chronic diseases&#44; such as COPD&#44; asthma&#44; obesity&#44; interstitial lung diseases&#44; pulmonary hypertension and various cardiovascular diseases<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#8211;72</span></a> and measurement of the effect of interventions&#44; such as training&#44; lung transplantation&#44; lung parenchyma resection&#44; and pharmacological treatments for pulmonary hypertension&#44; COPD and heart failure were done&#46;<a class="elsevierStyleCrossRefs" href="#bib1215"><span class="elsevierStyleSup">77&#44;78</span></a> Although this is a very safe exercise protocol&#44; since the patients themselves determine the speed of the walk&#44; it should not be performed in patients with unstable angina&#44; recent myocardial infarction &#40;within 1 month&#41;&#44; tachycardia of over 120<span class="elsevierStyleHsp" style=""></span>bpm&#44; or high blood pressure spikes&#46; Safety measures and training by professionals are essential for any form of exercise testing&#46;<a class="elsevierStyleCrossRef" href="#bib1145"><span class="elsevierStyleSup">63</span></a></p></span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Variables</span><p id="par0195" class="elsevierStylePara elsevierViewall">The variables measured in the test are the following&#58; &#40;i&#41; distance walked expressed in meters&#59; &#40;ii&#41; heart rate and oxygen saturation measured by pulse oximetry at the beginning and end of the test&#59; and &#40;iii&#41; symptoms&#44; dyspnea &#40;Borg scale&#41; and discomfort in the lower limbs at the beginning and end of the walk&#46; The walk test should be performed twice&#44; with approximately 1<span class="elsevierStyleHsp" style=""></span>h between assessments&#59; the longest distance walked should be used&#46; If the patient requires oxygen therapy&#44; the test should be performed with the prescribed oxygen regimen in place&#46;</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Interpretation of Results</span><p id="par0200" class="elsevierStylePara elsevierViewall">For comparison of the results obtained before and after an intervention&#44; the minimum clinically important difference&#44; set at 25&#8211;30<span class="elsevierStyleHsp" style=""></span>m&#44; must be identified after an intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib1160"><span class="elsevierStyleSup">66&#44;69&#44;70&#44;85</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Although results in terms of distance walked are usually interpreted as absolute values &#40;meters&#41;&#44; reference values are also used&#44; such as those of Enright et al&#46;<a class="elsevierStyleCrossRef" href="#bib1260"><span class="elsevierStyleSup">86</span></a> In short&#44; the 6-minute walk test is highly recommendable in clinical practice as a simple exercise test for evaluating functional status and the effect of certain interventions in patients with chronic respiratory and cardiac diseases&#46; The simplicity&#44; safety&#44; reproducibility and high predictive value of the test make it a simple reference protocol for studying aerobic capacity in clinical practice&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that the 6-minute walk test is very useful and provides highly reliable and comparable inter-individual measurements over time&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Evaluation of Exercise Tolerance&#58; Cycloergometry</span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Incremental Exercise Testing</span><p id="par0215" class="elsevierStylePara elsevierViewall">Incremental exercise testing can be used for evaluating the sub-maximal and maximal response&#44; and can often help identify the mechanisms underlying exercise intolerance&#46;<a class="elsevierStyleCrossRefs" href="#bib1265"><span class="elsevierStyleSup">87&#8211;90</span></a> It can also be used to adapt interventions for exercise intolerance to the source of the limitation&#44;<a class="elsevierStyleCrossRefs" href="#bib1275"><span class="elsevierStyleSup">89&#8211;98</span></a> and for ruling out other medical interventions &#40;such as physical training&#41; that may be a risk factor&#44; thus increasing patient safety&#46;<a class="elsevierStyleCrossRefs" href="#bib1265"><span class="elsevierStyleSup">87&#44;99</span></a></p><p id="par0220" class="elsevierStylePara elsevierViewall">The procedure is highly standardized&#46;<a class="elsevierStyleCrossRefs" href="#bib1150"><span class="elsevierStyleSup">64&#44;87</span></a> Cycle ergometry is the most commonly used test&#44; because it is cheap and compact&#44; and the work rate can be accurately determined&#46; Most patients can perform the test without practicing first&#46;<a class="elsevierStyleCrossRefs" href="#bib1150"><span class="elsevierStyleSup">64&#44;87&#44;100</span></a></p></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">Variables</span><p id="par0225" class="elsevierStylePara elsevierViewall">Most currently available software programs can generate large numbers of variables&#44; but the most commonly used in clinical studies are maximum oxygen consumption &#40;V&#729;O2max&#41; and maximum work rate &#40;<span class="elsevierStyleItalic">WR</span>max&#41;&#44; both of which are symptom-limited&#46; V&#729;O2max is a highly reproducible variable&#44; with coefficients of variation ranging from 3&#37; to 7&#37;&#44; when maximum work rate criteria are reached&#46;<a class="elsevierStyleCrossRefs" href="#bib1335"><span class="elsevierStyleSup">101&#8211;103</span></a> Consistent measurements have been obtained in multicenter clinical studies when appropriate quality controls are in place&#46;<a class="elsevierStyleCrossRefs" href="#bib1350"><span class="elsevierStyleSup">104&#44;105</span></a> Moreover&#44; in cardiac patients at least&#44; improved V&#729;O2max after interventions leads to improved survival&#46;<a class="elsevierStyleCrossRef" href="#bib1360"><span class="elsevierStyleSup">106</span></a>V&#729;O2max is sensitive to both pharmacological and non-pharmacological interventions&#44; and in particular to muscle training&#46;<a class="elsevierStyleCrossRefs" href="#bib0885"><span class="elsevierStyleSup">11&#44;107&#8211;111</span></a></p><p id="par0230" class="elsevierStylePara elsevierViewall">The advantage of maximum work rate &#40;<span class="elsevierStyleItalic">WR</span>max&#41; over V&#729;O2max is that it can be determined without the need for a metabolic cart&#46; It should be remembered that&#44; unlike V&#729;O2max&#44; W<span class="elsevierStyleItalic">R</span>max depends on the rate of the previous incremental protocol &#40;&#916;<span class="elsevierStyleItalic">WR</span>&#47;&#916;<span class="elsevierStyleItalic">t</span>&#41;&#44; so it cannot be equated with the V&#729;O2max&#46; Moreover&#44; exactly the same protocol must be used before and after the intervention or exposure&#46;<a class="elsevierStyleCrossRef" href="#bib1390"><span class="elsevierStyleSup">112</span></a></p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">High-Intensity Constant-Power Tests</span><p id="par0235" class="elsevierStylePara elsevierViewall">Although moderate-intensity constant-power tests can be performed to characterize the kinetics of the response of the oxygen transport system&#44; these tests require complex analysis&#44; so their use is limited to research studies&#46; In contrast&#44; high-intensity constant-power &#40;HICP&#41; tests have been used widely in studies for assessing interventions targeting the muscles&#46; The variable that defines exercise tolerance is time until the patient can no longer continue &#40;Tlim&#44; expressed in seconds&#41;&#46; Tlim has been shown in multicenter trials to be reproducible<a class="elsevierStyleCrossRefs" href="#bib1355"><span class="elsevierStyleSup">105&#44;113</span></a> and consistent<a class="elsevierStyleCrossRef" href="#bib1355"><span class="elsevierStyleSup">105</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; The clinically important difference for these tests is in the order of 100<span class="elsevierStyleHsp" style=""></span>s &#40;95&#37; confidence interval&#58; 50&#8211;150<span class="elsevierStyleHsp" style=""></span>s&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib1395"><span class="elsevierStyleSup">113</span></a></p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that cycle ergometry is very useful and provides highly reliable and comparable inter-individual measurements over time&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Muscle Training in COPD Muscle Dysfunction</span><p id="par0245" class="elsevierStylePara elsevierViewall">Muscle training&#44; a fundamental component of Pulmonary Rehabilitation &#40;PR&#41; programs&#44; has been widely shown to be effective for improving exercise tolerance&#44; muscle strength&#44; dyspnea&#44; fatigue&#44; and quality of life&#46; Hence&#44; it is an essential intervention in the treatment of muscle dysfunction in COPD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;114</span></a></p><p id="par0250" class="elsevierStylePara elsevierViewall">In patients with chronic respiratory disease&#44; general muscle training must be aimed at improving both the aerobic limitations and muscle dysfunction often seen in these diseases&#46; Choice of training type will not only depend on the needs of the patient and planned objectives&#44; but also to a large extent on the resources available in the rehabilitation clinic&#46;<a class="elsevierStyleCrossRefs" href="#bib1405"><span class="elsevierStyleSup">115&#44;116</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that muscle training is the best treatment for muscle dysfunction in COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Types of Training</span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Aerobic or Endurance Training</span><p id="par0260" class="elsevierStylePara elsevierViewall">This is the type of training most often used in PR&#44; and the evidence for recommendation is the highest &#40;Grade 1A&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;114&#44;117&#44;118</span></a> Aerobic exercise is a submaximal exercise involving the large muscle groups&#44; sustained for a prolonged length of time&#46; In COPD patients&#44; aerobic training not only achieves better cardiovascular adaptation&#44; it also improves limb muscle function&#46; This leads to increased muscle endurance&#44; with adaptive phenomena in the bioenergetics of the quadriceps<a class="elsevierStyleCrossRefs" href="#bib1425"><span class="elsevierStyleSup">119&#44;120</span></a> and skeletal muscles&#46;<a class="elsevierStyleCrossRef" href="#bib1435"><span class="elsevierStyleSup">121</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">Cycloergometry and treadmill training are the most common aerobic exercises prescribed in PR&#44; especially in outpatient and inpatient rehabilitation programs&#46; Training intensity is very important when prescribing exercise therapy&#46; An intensity of around 60&#37;&#8211;80&#37; of the maximal exercise capacity &#40;previously evaluated with cardiopulmonary exercise testing&#41; for a minimum of 8 weeks<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> is recommended for achieving a substantial benefit&#44; while 12 weeks is considered the optimal duration<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; Longer exercise programs can achieve greater&#44; longer-lasting effects&#44; particularly on quality of life indices&#46;<a class="elsevierStyleCrossRef" href="#bib1440"><span class="elsevierStyleSup">122</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0270" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that aerobic endurance muscle training is one of the best treatments for muscle dysfunction and restoring exercise capacity in COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Interval Training</span><p id="par0275" class="elsevierStylePara elsevierViewall">This is a modification of standard aerobic training&#44; in which short periods &#40;1&#8211;2<span class="elsevierStyleHsp" style=""></span>min duration&#41; of high-intensity exercise &#40;80&#37;&#8211;120&#37; maximum capacity&#41; are regularly alternated with similar periods of rest or lower intensity exercise&#46; In this way&#44; patients achieve high levels of output&#44; but with less dyspnea and fatigue&#46; The benefits are equivalent to those of conventional aerobic training&#46;<a class="elsevierStyleCrossRefs" href="#bib1435"><span class="elsevierStyleSup">121&#44;123&#44;124</span></a></p><p id="par0280" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that interval training is one of the best treatments for muscle dysfunction and restoring exercise capacity in more severe COPD patients&#46; It is of benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">Strength Training</span><p id="par0285" class="elsevierStylePara elsevierViewall">Following the &#8220;specificity principle&#8221;&#44; muscle strength training is potentially better for increasing the strength and mass of the exercised muscle than conventional aerobic training&#46;<a class="elsevierStyleCrossRef" href="#bib1455"><span class="elsevierStyleSup">125</span></a> Available evidence supports the use of strength training in combination with general aerobic training &#40;1A&#41;&#44; since this achieves further increases in limb muscle strength&#46;<a class="elsevierStyleCrossRefs" href="#bib1400"><span class="elsevierStyleSup">114&#44;118</span></a> In PR&#44; this type of exercise is often applied with weight-lifting exercises for the lower and upper limbs&#44; performed on gym apparatus with heavy loads&#44; equivalent to 70&#37;&#8211;85&#37; of the maximum weight lifted by the individual in a previous single maneuver &#40;or one repetition maximum testing&#44; 1 RM&#41;&#44; with few repetitions&#44;<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> in 2&#8211;3 sessions per week for 8&#8211;12 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib1400"><span class="elsevierStyleSup">114&#44;118</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The different studies consistently show that muscle strength training is one of the best treatments for muscle dysfunction and restoring exercise capacity in more severe COPD patients&#46; It is of great benefit in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1A&#46;</span></p></span></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Other Types of Training</span><p id="par0295" class="elsevierStylePara elsevierViewall">Very promising alternatives for limb muscle training in PR programs include transcutaneous electrical nerve stimulation &#40;TENS&#41;<a class="elsevierStyleCrossRefs" href="#bib0840"><span class="elsevierStyleSup">2&#44;126&#44;127</span></a> and electromagnetic stimulation&#44;<a class="elsevierStyleCrossRef" href="#bib1470"><span class="elsevierStyleSup">128</span></a> which is better tolerated but less well studied&#46;</p><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Respiratory Muscle Training</span><p id="par0300" class="elsevierStylePara elsevierViewall">Inspiratory muscle training &#40;IMT&#41; has been shown to improve muscle strength and endurance in COPD patients&#44; with benefits in dyspnea&#44; functional capacity and quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib1475"><span class="elsevierStyleSup">129</span></a> The efficacy of specific expiratory muscle training with abdominal muscle exercises remains in doubt&#46; In general&#44; IMT should be performed twice a day&#44; at an intensity of at least 30&#37; of the MIP and in sessions lasting about 15<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRef" href="#bib1420"><span class="elsevierStyleSup">118</span></a> IMT is indicated mainly in patients with respiratory muscle dysfunction&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The various studies consistently show that respiratory muscle training may be of benefit in COPD patients with significant respiratory muscle dysfunction&#44; in routine clinical practice and in clinical studies&#46; Evidence&#58; GRADE 1B&#46;</span></p></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Other Non-Training-Based Treatments for Muscle Dysfunction</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">Nutritional Supplements and Hormone Treatment</span><p id="par0310" class="elsevierStylePara elsevierViewall">Nutritional disorders are found in 20&#37;&#8211;40&#37; of patients with severe respiratory disease&#46; The causes appear to be multifactorial&#44; and include imbalance between energy intake and output&#44; hypoxemia&#44; and the systemic inflammatory component often observed with this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib1480"><span class="elsevierStyleSup">130&#8211;132</span></a> Results from the use of high-energy nutritional supplements in these patients &#40;anabolic steroids and growth hormones&#44; antioxidants and other protein compounds&#41; have been contradictory as regards weight gain and&#44; in particular&#44; their impact on functional recovery&#46;</p><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Nutritional Supplements</span><p id="par0315" class="elsevierStylePara elsevierViewall">Nutritional supplements are commonly used in COPD patients&#44; but there is very little evidence to support this approach&#46; While some authors have reported weight gain and increased fat-free mass&#44; along with improvements in exercise tolerance&#44; these data are not supported by other studies&#46; The most recent Cochrane review<a class="elsevierStyleCrossRef" href="#bib1495"><span class="elsevierStyleSup">133</span></a> includes a meta-analysis of 17 randomized clinical trials&#44;<a class="elsevierStyleCrossRefs" href="#bib1500"><span class="elsevierStyleSup">134&#8211;148</span></a> performed mainly in undernourished patients&#44; that provide little evidence that patients receiving nutritional supplements show improvements in weight&#44; fat-free mass&#44; respiratory muscle strength and distance walked during the 6-minute walk test&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2B&#46;</span></p></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Anabolic Steroids</span><p id="par0325" class="elsevierStylePara elsevierViewall">Androgen deficiency&#44; often associated with loss of muscle mass&#44; occurs in up to 40&#37; of COPD patients&#46;<a class="elsevierStyleCrossRef" href="#bib1575"><span class="elsevierStyleSup">149</span></a> Administration of anabolic steroids has been associated with weight gain and increased muscle mass&#44; supporting the use of these products as adjuvant treatment in rehabilitation programs&#46; However&#44; the results have not been sufficiently corroborated&#44; and this approach is not recommended by ERS&#47;ATS rehabilitation guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> Several published studies have shown that despite weight gain and increased fat-free mass&#44; no improvements were reported in lung function parameters&#44; exercise tolerance or respiratory &#40;MIP&#41; or limb &#40;handgrip strength&#41; muscle function&#46;<a class="elsevierStyleCrossRefs" href="#bib1545"><span class="elsevierStyleSup">143&#44;150&#8211;155</span></a> However&#44; the meta-analysis included not only treatment with androgenic derivatives&#44; but also a study on growth hormone and another on ghrelin &#40;a growth hormone secretagogue&#41;&#44; as well as other studies that may or may not have included training&#44; with no subgroup analyses&#46; All these factors limit the interpretation of the above-mentioned meta-analysis&#46; In reality&#44; the combination of nutritional or androgenic supplements with muscle training has led to increases in weight&#44; fat-free muscle mass&#44; MIP&#44; quadriceps force&#44; maximum work load and exercise endurance time&#46;<a class="elsevierStyleCrossRef" href="#bib1610"><span class="elsevierStyleSup">156</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2B&#46;</span></p></span><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Growth Hormone and Ghrelin</span><p id="par0335" class="elsevierStylePara elsevierViewall">The use of recombinant human growth hormone &#40;GH&#41; has also been studied in malnourished COPD patients&#44; in rehabilitation programs&#44; but results have been inconclusive&#46;<a class="elsevierStyleCrossRefs" href="#bib1580"><span class="elsevierStyleSup">150&#44;157</span></a> More recently&#44; the use of ghrelin has been studied in these patients&#44; also in the rehabilitation setting&#46; Ghrelin is polypeptide hormone that acts by binding to GH-stimulating hypothalamic receptors&#44; stimulating secretion of GH&#46; It also stimulates the release of orexigenic factors&#44; increasing appetite&#46;<a class="elsevierStyleCrossRef" href="#bib1620"><span class="elsevierStyleSup">158</span></a> Paradoxically&#44; malnourished COPD patients may have elevated ghrelin levels&#46;<a class="elsevierStyleCrossRef" href="#bib1625"><span class="elsevierStyleSup">159</span></a> Results published to date on the exogenous administration of this substance are inconclusive&#46;<a class="elsevierStyleCrossRefs" href="#bib1630"><span class="elsevierStyleSup">160&#8211;162</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46;</span> Evidence GRADE 2C&#46;</p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Other Nutrients</span><p id="par0345" class="elsevierStylePara elsevierViewall">The ability of other products to improve the muscle and physical function of COPD patients&#44; including antioxidants&#44; vitamins<a class="elsevierStyleCrossRef" href="#bib1625"><span class="elsevierStyleSup">159</span></a> and high-calorie compounds&#44; has been investigated&#46; However studies are generally isolated and uncontrolled&#44; or conducted in small numbers of patients&#44; and results are difficult to reproduce&#46;<a class="elsevierStyleCrossRefs" href="#bib1645"><span class="elsevierStyleSup">163&#44;164</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies do not consistently show that the benefits outweigh the risks of treatment administration&#46; It is hoped that better quality research in the future will contribute to improved understanding in this area&#44; and provide more reliable results than those currently available&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46;</span> Evidence GRADE 2C&#46;</p></span></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Non-Pharmacological Treatments&#58; Non-Invasive Ventilation and Heliox</span><p id="par0355" class="elsevierStylePara elsevierViewall">It is well known that non-invasive mechanical ventilation &#40;NIV&#41; allows the respiratory muscles to rest&#44; explaining improved lung function&#44; evidenced by increased MIP&#44; Pdimax and pressure-time product&#46; A few studies have even associated the use of NIV with better limb muscle function&#44; demonstrated by increased quadriceps strength and endurance&#46;<a class="elsevierStyleCrossRef" href="#bib1655"><span class="elsevierStyleSup">165</span></a> This is probably a consequence of improved oxygen supply to the peripheral muscles&#44; as a result of the reduction in work-of-breathing&#46;<a class="elsevierStyleCrossRef" href="#bib1660"><span class="elsevierStyleSup">166</span></a> This same mechanism has been cited to explain the effect of breathing heliox &#40;a mixture of helium and oxygen&#41; on limb muscle function&#46; A recent Cochrane review&#44; based on a meta-analysis of 6 clinical trials evaluating the results of NIV during a physical exercise program&#44; concluded that the slight differences in exercise capacity and tolerance were inconsistent&#46; In line with the latest consensus recommendations from the ERS&#47;ATS&#44; the use of NIV during muscle training is not recommended&#46;<a class="elsevierStyleCrossRef" href="#bib1400"><span class="elsevierStyleSup">114</span></a> This intervention should be limited to hypercapnic patients on night-time NIV programs&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">The studies consistently show that the benefits outweigh the risks of treatment administration&#46; Research in the future may contribute to improved understanding in this area&#44; to help introduce this type of treatment into routine clinical practice for the management of COPD patients&#46; Evidence GRADE 2A</span></p></span></span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Conclusions</span><p id="par0365" class="elsevierStylePara elsevierViewall">In summary&#44; good respiratory and limb muscle function is essential for sustaining life and an acceptable quality of life&#46; Muscle function is affected in many respiratory diseases and may lead to problems for the patient&#39;s social life and for maintaining an adequate level of ventilation&#46; Muscle function can and must be evaluated in these patients&#44; so that the appropriate therapeutic measures can be implemented&#46; In view of the current evidence&#44; muscle training&#44; with or without nutritional supplements&#44; is clearly the best therapeutic strategy for increasing muscle mass and function and improving quality of life in COPD patients&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:18 [
        0 => array:3 [
          "identificador" => "xres580682"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec597178"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xpalclavsec597177"
          "titulo" => "Abbreviations"
        ]
        3 => array:3 [
          "identificador" => "xres580681"
          "titulo" => "Resumen"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
        ]
        4 => array:2 [
          "identificador" => "xpalclavsec597179"
          "titulo" => "Palabras clave"
        ]
        5 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        6 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Epidemiology&#44; Pathophysiology and Implications for Patients"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Muscle Dysfunction Pathophysiology"
            ]
            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Limb Muscle Dysfunction &#40;Quadriceps&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Respiratory Muscle Dysfunction"
            ]
          ]
        ]
        7 => array:3 [
          "identificador" => "sec0030"
          "titulo" => "Evaluation of Respiratory Muscles&#58; Voluntary and Involuntary Maneuvers &#40;Table 1&#41;"
          "secciones" => array:3 [
            0 => array:3 [
              "identificador" => "sec0035"
              "titulo" => "Evaluating Respiratory Muscle Strength&#58; Volitional Tests of Respiratory Muscle Strength"
              "secciones" => array:2 [
                0 => array:3 [
                  "identificador" => "sec0040"
                  "titulo" => "Non-Invasive Testing"
                  "secciones" => array:3 [
                    0 => array:2 [
                      "identificador" => "sec0045"
                      "titulo" => "Spirometry"
                    ]
                    1 => array:2 [
                      "identificador" => "sec0050"
                      "titulo" => "Measuring Pressure at the Mouth"
                    ]
                    2 => array:2 [
                      "identificador" => "sec0055"
                      "titulo" => "Sniff Nasal Inspiratory Pressure &#40;SNIP&#41;"
                    ]
                  ]
                ]
                1 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Invasive Testing"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Non-Volitional Tests of Respiratory Muscle Strength &#40;Table 1&#41;"
            ]
            2 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Evaluating Respiratory Muscle Endurance &#40;Table 1&#41;"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0075"
          "titulo" => "Evaluation of Limb Muscles&#58; Volitional and Non-Volitional Testing"
          "secciones" => array:1 [
            0 => array:3 [
              "identificador" => "sec0080"
              "titulo" => "General Evaluation of Limb Muscles &#40;Fig&#46; 3&#41;"
              "secciones" => array:7 [
                0 => array:2 [
                  "identificador" => "sec0085"
                  "titulo" => "Evaluating Muscle Mass &#40;MM&#41;"
                ]
                1 => array:2 [
                  "identificador" => "sec0090"
                  "titulo" => "Bioimpedance Analysis &#40;BIA&#41; or Bioelectric Impedance"
                ]
                2 => array:2 [
                  "identificador" => "sec0095"
                  "titulo" => "Dual-Energy X-Ray Absorptiometry &#40;DEXA&#41;"
                ]
                3 => array:2 [
                  "identificador" => "sec0100"
                  "titulo" => "Local MM Study Techniques"
                ]
                4 => array:2 [
                  "identificador" => "sec0105"
                  "titulo" => "Physical Activity"
                ]
                5 => array:2 [
                  "identificador" => "sec0110"
                  "titulo" => "Exercise Testing"
                ]
                6 => array:2 [
                  "identificador" => "sec0115"
                  "titulo" => "Electromyography &#40;EMG&#41;"
                ]
              ]
            ]
          ]
        ]
        9 => array:3 [
          "identificador" => "sec0120"
          "titulo" => "Limb Muscle Function Testing"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0125"
              "titulo" => "Voluntary Maneuvers"
              "secciones" => array:3 [
                0 => array:2 [
                  "identificador" => "sec0130"
                  "titulo" => "Handgrip Dynamometry"
                ]
                1 => array:2 [
                  "identificador" => "sec0135"
                  "titulo" => "Maximal Isometric Contraction of the Quadriceps Femoris &#40;Q-MVC&#41;"
                ]
                2 => array:2 [
                  "identificador" => "sec0140"
                  "titulo" => "Test of Endurance Time at 10&#37; of the Q-MVC"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "sec0145"
              "titulo" => "Involuntary Maneuvers"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0150"
                  "titulo" => "Supramaximal Quadriceps Twitch Force &#40;QTw&#41;"
                ]
              ]
            ]
          ]
        ]
        10 => array:3 [
          "identificador" => "sec0155"
          "titulo" => "Evaluation of Exercise Tolerance&#58; The 6-Minute Walk Test"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0160"
              "titulo" => "Indications"
            ]
            1 => array:2 [
              "identificador" => "sec0165"
              "titulo" => "Variables"
            ]
            2 => array:2 [
              "identificador" => "sec0170"
              "titulo" => "Interpretation of Results"
            ]
          ]
        ]
        11 => array:3 [
          "identificador" => "sec0175"
          "titulo" => "Evaluation of Exercise Tolerance&#58; Cycloergometry"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0180"
              "titulo" => "Incremental Exercise Testing"
            ]
            1 => array:2 [
              "identificador" => "sec0185"
              "titulo" => "Variables"
            ]
            2 => array:2 [
              "identificador" => "sec0190"
              "titulo" => "High-Intensity Constant-Power Tests"
            ]
          ]
        ]
        12 => array:2 [
          "identificador" => "sec0195"
          "titulo" => "Muscle Training in COPD Muscle Dysfunction"
        ]
        13 => array:3 [
          "identificador" => "sec0200"
          "titulo" => "Types of Training"
          "secciones" => array:3 [
            0 => array:2 [
              "identificador" => "sec0205"
              "titulo" => "Aerobic or Endurance Training"
            ]
            1 => array:2 [
              "identificador" => "sec0210"
              "titulo" => "Interval Training"
            ]
            2 => array:2 [
              "identificador" => "sec0215"
              "titulo" => "Strength Training"
            ]
          ]
        ]
        14 => array:3 [
          "identificador" => "sec0220"
          "titulo" => "Other Types of Training"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0225"
              "titulo" => "Respiratory Muscle Training"
            ]
          ]
        ]
        15 => array:3 [
          "identificador" => "sec0230"
          "titulo" => "Other Non-Training-Based Treatments for Muscle Dysfunction"
          "secciones" => array:2 [
            0 => array:3 [
              "identificador" => "sec0235"
              "titulo" => "Nutritional Supplements and Hormone Treatment"
              "secciones" => array:4 [
                0 => array:2 [
                  "identificador" => "sec0240"
                  "titulo" => "Nutritional Supplements"
                ]
                1 => array:2 [
                  "identificador" => "sec0245"
                  "titulo" => "Anabolic Steroids"
                ]
                2 => array:2 [
                  "identificador" => "sec0250"
                  "titulo" => "Growth Hormone and Ghrelin"
                ]
                3 => array:2 [
                  "identificador" => "sec0255"
                  "titulo" => "Other Nutrients"
                ]
              ]
            ]
            1 => array:2 [
              "identificador" => "sec0260"
              "titulo" => "Non-Pharmacological Treatments&#58; Non-Invasive Ventilation and Heliox"
            ]
          ]
        ]
        16 => array:2 [
          "identificador" => "sec0265"
          "titulo" => "Conclusions"
        ]
        17 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:2 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec597178"
          "palabras" => array:3 [
            0 => "Chronic obstructive pulmonary disease"
            1 => "Muscle dysfunction"
            2 => "Spanish guidelines"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec597177"
          "palabras" => array:42 [
            0 => "ATP"
            1 => "ATS"
            2 => "BIA"
            3 => "COPD"
            4 => "CT"
            5 => "DEXA"
            6 => "EMG"
            7 => "ERS"
            8 => "FFM"
            9 => "FRC"
            10 => "FVC"
            11 => "GH"
            12 => "HICP"
            13 => "IMT"
            14 => "LLM"
            15 => "MD"
            16 => "MEP"
            17 => "MIP"
            18 => "MM"
            19 => "MR"
            20 => "MRI"
            21 => "MSV"
            22 => "MVIC"
            23 => "MVV"
            24 => "NIV"
            25 => "Pdi"
            26 => "Pdi<span class="elsevierStyleItalic">twitch</span>"
            27 => "PR"
            28 => "PTP"
            29 => "Q-MVC"
            30 => "QTw"
            31 => "RV"
            32 => "<span class="elsevierStyleItalic">Sniff</span>Pdi"
            33 => "SniffPesmax"
            34 => "SNIP"
            35 => "TENS"
            36 => "TLC"
            37 => "Tlim"
            38 => "ULM"
            39 => "VO2max"
            40 => "W<span class="elsevierStyleItalic">R</span>"
            41 => "W<span class="elsevierStyleItalic">R</span>max"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec597179"
          "palabras" => array:3 [
            0 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            1 => "Disfunci&#243;n muscular"
            2 => "Gu&#237;a espa&#241;ola"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">In patients with chronic obstructive pulmonary disease &#40;COPD&#41;&#44; skeletal muscle dysfunction is a major comorbidity that negatively impacts their exercise capacity and quality of life&#46; In the current guidelines&#44; the most recent literature on the various aspects of COPD muscle dysfunction has been included&#46; The Grading of Recommendations&#44; Assessment&#44; Development&#44; and Evaluation &#40;GRADE&#41; scale has been used to make evidence-based recommendations on the different features&#46; Compared to a control population&#44; one third of COPD patients exhibited a 25&#37; decline in quadriceps muscle strength&#44; even at early stages of their disease&#46; Although both respiratory and limb muscles are altered&#44; the latter are usually more severely affected&#46; Numerous factors and biological mechanisms are involved in the etiology of COPD muscle dysfunction&#46; Several tests are proposed in order to diagnose and evaluate the degree of muscle dysfunction of both respiratory and limb muscles &#40;peripheral&#41;&#44; as well as to identify the patients&#8217; exercise capacity &#40;six-minute walking test and cycloergometry&#41;&#46; Currently available therapeutic strategies including the different training modalities and pharmacological and nutritional support are also described&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La disfunci&#243;n muscular de pacientes con enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41; constituye una de las comorbilidades m&#225;s importantes&#44; con repercusiones negativas en su capacidad de ejercicio y calidad de vida&#46; En la presente normativa se ha resumido la literatura publicada m&#225;s recientemente sobre los diferentes aspectos del tema y se ha utilizado tambi&#233;n la escala <span class="elsevierStyleItalic">Grading of Recommendations Assessment&#44; Development&#44; and Evaluation</span> &#40;GRADE&#41; de recomendaciones sobre el grado de evidencia de las diferentes propuestas de la normativa&#46; Respecto a una poblaci&#243;n control&#44; se estima que en un tercio de los pacientes EPOC la fuerza del cu&#225;driceps es un 25&#37; inferior incluso en estadios precoces de su enfermedad&#46; Aunque tanto los m&#250;sculos respiratorios como los de las extremidades est&#225;n alterados&#44; estos &#250;ltimos suelen verse mayormente afectados&#46; Diversos factores y mecanismos biol&#243;gicos est&#225;n involucrados en la disfunci&#243;n muscular de los pacientes&#46; Se proponen diversas pruebas para evaluar y diagnosticar el grado de afectaci&#243;n de los m&#250;sculos respiratorios y de las extremidades &#40;perif&#233;ricos&#41;&#44; as&#237; como identificar la capacidad de esfuerzo de los pacientes &#40;prueba de marcha de 6<span class="elsevierStyleHsp" style=""></span>min y cicloergometr&#237;a&#41;&#46; Se describen tambi&#233;n las posibles estrategias terap&#233;uticas vigentes que incluyen las diversas modalidades de entrenamiento y de soporte farmacol&#243;gico y nutricional&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Barreiro E&#44; Bustamante V&#44; Cejudo P&#44; G&#225;ldiz JB&#44; Gea J&#44; de Lucas P&#44; et al&#46; Normativa SEPAR sobre disfunci&#243;n muscular de los pacientes con enfermedad pulmonar obstructiva cr&#243;nica&#46; Arch Bronconeumol&#46; 2015&#59;51&#58;384&#8211;395&#46;</p>"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0380" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0275"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:7 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 1248
            "Ancho" => 3214
            "Tamanyo" => 246423
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; Etiological factors involved in limb muscle dysfunction in COPD patients&#46; The factors have deleterious effects on lower limb muscle function and mass&#44; causing the scales to completely tip toward the negative side &#40;left tray&#41;&#46; &#40;B&#41; In the lower limb muscles&#44; the actions of the etiological factors are mediated by several biological mechanisms&#44; with deleterious effects on muscle function&#44; mass and structure&#46; The scales are completely tipped to the left&#46;</p>"
        ]
      ]
      1 => array:7 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1216
            "Ancho" => 3315
            "Tamanyo" => 268371
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; In the respiratory muscles&#44; etiologic factors such as alterations in the chest geometry and mechanical overload can to some extent counteract &#40;training effect&#44; right tray of the scales&#41; the deleterious effects of the other etiologic factors of a more systematic nature &#40;left tray of the scales&#41;&#44; since these also contribute to limb muscle dysfunction&#46; &#40;B&#41; In the respiratory muscles&#44; several cell and molecular mechanisms have beneficial effects &#40;adaptive mechanisms&#44; right tray of the scales&#41;&#44; which counteract the deleterious effects of the deleterious effects of the other biological mechanisms &#40;left tray of the scales&#41;&#46;</p>"
        ]
      ]
      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1470
            "Ancho" => 1694
            "Tamanyo" => 253555
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">List of the most commonly used tests in routine clinical practice for evaluating muscle mass and dysfunction&#46; Tests are classified as general or specific for evaluating muscle mass and function&#46;</p>"
        ]
      ]
      3 => array:7 [
        "identificador" => "fig0020"
        "etiqueta" => "Fig&#46; 4"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr4.jpeg"
            "Alto" => 1765
            "Ancho" => 2471
            "Tamanyo" => 142820
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Selection of controlled clinical trials that used HICP for measuring the effect of interventions on lower limb muscles&#46; Power&#58; intensity at which the test was performed&#44; expressed as a percentage of <span class="elsevierStyleItalic">WR</span>max&#46; Vertical line&#46; Minimum clinically important difference&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#46; MIP&#44; maximum inspiratory pressure at the mouth &#40;static or M&#252;ller maneuver&#41;&#59; MEP&#44; maximum expiratory pressure at the mouth &#40;static or Valsalva maneuver&#41;&#59; SNIP&#44; sniff nasal inspiratory pressure &#40;dynamic sniff maneuver&#41;&#59; Pesmax&#44; maximum esophageal inspiratory pressure &#40;generally obtained during sniff maneuver&#41;&#59; Pdimax&#44; diaphragmatic pressure on inspiration &#40;generally obtained during sniff maneuver&#41;&#59; Pdimax <span class="elsevierStyleItalic">Twitch</span>&#44; transdiaphragmatic twitch pressure on inspiration&#44; induced by electrical or magnetic stimulation&#59; Q-MVC&#44; maximal voluntary isometric contraction of the quadriceps&#59; Qtw&#44; contraction induced by twitch of the quadriceps muscle&#59; MSV&#44; maximum sustainable ventilation&#59; MVV&#44; maximal voluntary ventilation&#59; SMIP&#44; sustained maximal inspiratory pressure with incremental threshold loads&#59; Tlim&#44; time limit or endurance time for submaximal constant loads &#40;generally percentage of SMIP or MIP for the inspiratory test or of SMEP or MEP for the expiratory test&#44; and percentage of Q-MVC &#40;generally 10&#37;&#41; for the quadriceps&#59; SMEP&#44; sustained maximal expiratory pressure with incremental threshold loads&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Functional property&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Muscle group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Test&#47;Variable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Volitional&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pathological values&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">References&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " rowspan="11" align="left" valign="top">Strength</td><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Non-specific</td><td class="td" title="table-entry  " align="left" valign="top">Forced spirometryPlethysmography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FEV<span class="elsevierStyleInf">1</span>&#47;FVC&#62;80&#37;TLC&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;29</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Forced spirometry sitting to supine position&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">FVC sitting position and &#60;75&#37; pred&#46; supineReduction &#62;25&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;30</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="5" align="left" valign="top">Inspiratory</td><td class="td" title="table-entry  " align="left" valign="top">MIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80 pred&#46; or &#60;65&#37; pred&#46; or suspected if &#60;&#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;31</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">SNIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suspected if&#58;Men&#58; &#60;&#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;60<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;32&#44;33</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pesmax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Suspected if&#58;Men&#58; &#60;&#8722;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;70<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;34</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pdimax&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Men&#58; &#60;&#8722;75<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;50<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;35</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pdimax <span class="elsevierStyleItalic">Twitch</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Men&#58; &#60;&#8722;60 to 50<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>OWomen&#58; &#60;&#8722;40 to 35<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;35</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Expiratory&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46; or &#60;65&#37; pred&#46; or suspected if &#60;80<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;31</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Upper limbs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Handgrip&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1105">55&#44;56&#44;57</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Lower limbs &#40;quadriceps&#41;</td><td class="td" title="table-entry  " align="left" valign="top">Q-MVC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;80&#37; pred&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1120">58&#44;59</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">QTw&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1140">62&#44;63</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="7" align="left" valign="top">Endurance</td><td class="td" title="table-entry  " align="left" valign="top">Non-specific&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">MSV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#60;60&#37;&#8211;80&#37; of MVV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib0970">28&#44;36</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Inspiratory</td><td class="td" title="table-entry  " align="left" valign="top">SMIP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1015">37&#44;38</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Inspiratory tlim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1015">37&#44;38</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Expiratory</td><td class="td" title="table-entry  " align="left" valign="top">SMEP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1025">39&#44;40</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Inspiratory tlim&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRefs" href="#bib1025">39&#44;40</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " rowspan="2" align="left" valign="top">Quadriceps</td><td class="td" title="table-entry  " align="left" valign="top">Tlim at &#37; QMCV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib1130">60</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Pair of forces &#40;torque&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Not defined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><a class="elsevierStyleCrossRef" href="#bib1135">61</a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947510.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Types of Tests to Evaluate&#47;Assess the Strength and Endurance Components of Muscle Function&#46;</p>"
        ]
      ]
      5 => array:7 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Grades&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Excellent effort with excellent repeatability &#40;&#60;5<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Good effort with good repeatability &#40;5&#8211;10 cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fair effort with fair repeatability &#40;10&#8211;20 cm H<span class="elsevierStyleInf">2</span>O difference among maneuvers&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">D&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Only one good maneuver&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Poor maneuvers or poor repeatability&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947508.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Proposed Scale &#40;John Moxham&#46; Test of Respiratory Muscle Strength&#46; <span class="elsevierStyleItalic">UptoDate</span> 2013&#41; for Evaluating Patient Collaboration and Cooperation in Performing Maximum Pressure Maneuvers of Respiratory Muscles at the Mouth &#40;MIP and MEP&#41;&#46;</p>"
        ]
      ]
      6 => array:7 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "tabla" => array:1 [
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Aerobic&#47;Endurance training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strength training&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Objective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improve aerobic capacity&#46; Improve limb muscle function&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Overload large upper and lower limb muscle groups&#46; Increase muscle strength and endurance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#8211;4 days&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;3 days&#47;week&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mode&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;30<span class="elsevierStyleHsp" style=""></span>min&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2&#8211;4 series of 6&#8211;12 repetitions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Intensity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">60&#37;&#8211;80&#37; of W<span class="elsevierStyleItalic">R</span>max&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">70&#37;&#8211;85&#37; of 1 RM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Duration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#8211;12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">8&#8211;12 weeks&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab947509.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Practical Recommendations for Aerobic and Strength Training in COPD&#46;</p>"
        ]
      ]
      7 => array:5 [
        "identificador" => "upi0005"
        "tipo" => "MULTIMEDIAECOMPONENTE"
        "mostrarFloat" => false
        "mostrarDisplay" => true
        "Ecomponente" => array:2 [
          "fichero" => "mmc1.pdf"
          "ficheroTamanyo" => 429663
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:166 [
            0 => array:3 [
              "identificador" => "bib0835"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "GRADE guidelines&#58; 1&#46; Introduction &#8211; GRADE evidence profiles and summary of findings tables"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jclinepi.2010.04.026"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0840"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An official American Thoracic Society&#47;European Respiratory Society statement&#58; update on limb muscle dysfunction in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.201402-0373ST"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0845"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathophysiology of muscle dysfunction in COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0850"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The prevalence of quadriceps weakness in COPD and the relationship with disease severity"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00104909"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0855"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quadriceps strength predicts mortality in patients with moderate to severe chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.062026"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0860"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidative stress and respiratory muscle dysfunction in severe chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200407-887OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0865"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cellular adaptations in the diaphragm in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199712183372503"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0870"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidised proteins and superoxide anion production in the diaphragm of severe COPD patients"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00072008"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0875"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Does oxidative stress modulate limb muscle atrophy in severe COPD patients&#63;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00137211"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0880"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Muscle fibre type shifting in the vastus lateralis of patients with COPD is associated with disease severity&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2007.078980"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0885"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Skeletal muscle adaptation to endurance training in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.154.2.8756820"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0890"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The mechanisms of cachexia underlying muscle dysfunction in COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0895"
              "etiqueta" => "13"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cigarette smoke-induced oxidative stress&#58; a role in chronic obstructive pulmonary disease skeletal muscle dysfunction"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200908-1220OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0900"
              "etiqueta" => "14"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cigarette smoke-induced oxidative stress in skeletal muscles of mice"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.resp.2012.02.001"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0905"
              "etiqueta" => "15"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic endurance exercise induces quadriceps nitrosative stress in patients with severe COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2008.105163"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0910"
              "etiqueta" => "16"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Inflammatory cells and apoptosis in respiratory and limb muscles of patients with COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0915"
              "etiqueta" => "17"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Do epigenetic events take place in the vastus lateralis of patients with mild chronic obstructive pulmonary disease&#63;"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1371/journal.pone.0102296"
                      "Revista" => array:5 [ …5]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0920"
              "etiqueta" => "18"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Oxidative stress&#44; redox signaling pathways&#44; and autophagy in cachectic muscles of male patients with advanced COPD and lung cancer"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.freeradbiomed.2014.11.006"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            18 => array:3 [
              "identificador" => "bib0925"
              "etiqueta" => "19"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Quadriceps muscle weakness and atrophy are associated with a differential epigenetic profile in advanced COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1042/CS20140428"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            19 => array:3 [
              "identificador" => "bib0930"
              "etiqueta" => "20"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contractile properties of the human diaphragm during chronic hyperinflation"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJM199109263251304"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            20 => array:3 [
              "identificador" => "bib0935"
              "etiqueta" => "21"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Adaptation of the diaphragm and the vastus lateralis in mild-to-moderate COPD"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.04.00020204"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            21 => array:3 [
              "identificador" => "bib0940"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subcellular adaptation of the human diaphragm in chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0945"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Injury of the human diaphragm associated with exertion and chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/ajrccm.164.9.2011150"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            23 => array:3 [
              "identificador" => "bib0950"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Mitochondrial electron transport chain function is enhanced in inspiratory muscles of patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [ …1]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200206-519OC"
                      "Revista" => array:6 [ …6]
                    ]
                  ]
                ]
              ]
            ]
            24 => array:3 [
              "identificador" => "bib0955"
              "etiqueta" => "25"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            25 => array:3 [
              "identificador" => "bib0960"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0965"
              "etiqueta" => "27"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            27 => array:3 [
              "identificador" => "bib0970"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            28 => array:3 [
              "identificador" => "bib0975"
              "etiqueta" => "29"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            29 => array:3 [
              "identificador" => "bib0980"
              "etiqueta" => "30"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            30 => array:3 [
              "identificador" => "bib0985"
              "etiqueta" => "31"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            31 => array:3 [
              "identificador" => "bib0990"
              "etiqueta" => "32"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            32 => array:3 [
              "identificador" => "bib0995"
              "etiqueta" => "33"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            33 => array:3 [
              "identificador" => "bib1000"
              "etiqueta" => "34"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            34 => array:3 [
              "identificador" => "bib1005"
              "etiqueta" => "35"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            35 => array:3 [
              "identificador" => "bib1010"
              "etiqueta" => "36"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib1015"
              "etiqueta" => "37"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            37 => array:3 [
              "identificador" => "bib1020"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib1025"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib1030"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib1035"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib1040"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib1045"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib1050"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib1055"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib1060"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib1065"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib1070"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib1075"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib1080"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib1085"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            51 => array:3 [
              "identificador" => "bib1090"
              "etiqueta" => "52"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            52 => array:3 [
              "identificador" => "bib1095"
              "etiqueta" => "53"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            53 => array:3 [
              "identificador" => "bib1100"
              "etiqueta" => "54"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            54 => array:3 [
              "identificador" => "bib1105"
              "etiqueta" => "55"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            55 => array:3 [
              "identificador" => "bib1110"
              "etiqueta" => "56"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            56 => array:3 [
              "identificador" => "bib1115"
              "etiqueta" => "57"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            57 => array:3 [
              "identificador" => "bib1120"
              "etiqueta" => "58"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            58 => array:3 [
              "identificador" => "bib1125"
              "etiqueta" => "59"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            59 => array:3 [
              "identificador" => "bib1130"
              "etiqueta" => "60"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            60 => array:3 [
              "identificador" => "bib1135"
              "etiqueta" => "61"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            61 => array:3 [
              "identificador" => "bib1140"
              "etiqueta" => "62"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            62 => array:3 [
              "identificador" => "bib1145"
              "etiqueta" => "63"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            63 => array:3 [
              "identificador" => "bib1150"
              "etiqueta" => "64"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            64 => array:3 [
              "identificador" => "bib1155"
              "etiqueta" => "65"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            65 => array:3 [
              "identificador" => "bib1160"
              "etiqueta" => "66"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            66 => array:3 [
              "identificador" => "bib1165"
              "etiqueta" => "67"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            67 => array:3 [
              "identificador" => "bib1170"
              "etiqueta" => "68"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            68 => array:3 [
              "identificador" => "bib1175"
              "etiqueta" => "69"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            69 => array:3 [
              "identificador" => "bib1180"
              "etiqueta" => "70"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            70 => array:3 [
              "identificador" => "bib1185"
              "etiqueta" => "71"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            71 => array:3 [
              "identificador" => "bib1190"
              "etiqueta" => "72"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            72 => array:3 [
              "identificador" => "bib1195"
              "etiqueta" => "73"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            73 => array:3 [
              "identificador" => "bib1200"
              "etiqueta" => "74"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            74 => array:3 [
              "identificador" => "bib1205"
              "etiqueta" => "75"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            75 => array:3 [
              "identificador" => "bib1210"
              "etiqueta" => "76"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            76 => array:3 [
              "identificador" => "bib1215"
              "etiqueta" => "77"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            77 => array:3 [
              "identificador" => "bib1220"
              "etiqueta" => "78"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            78 => array:3 [
              "identificador" => "bib1225"
              "etiqueta" => "79"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            79 => array:3 [
              "identificador" => "bib1230"
              "etiqueta" => "80"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            80 => array:3 [
              "identificador" => "bib1235"
              "etiqueta" => "81"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            81 => array:3 [
              "identificador" => "bib1240"
              "etiqueta" => "82"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            82 => array:3 [
              "identificador" => "bib1245"
              "etiqueta" => "83"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            83 => array:3 [
              "identificador" => "bib1250"
              "etiqueta" => "84"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            84 => array:3 [
              "identificador" => "bib1255"
              "etiqueta" => "85"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            85 => array:3 [
              "identificador" => "bib1260"
              "etiqueta" => "86"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            86 => array:3 [
              "identificador" => "bib1265"
              "etiqueta" => "87"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [ …1]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            87 => array:3 [
              "identificador" => "bib1270"
              "etiqueta" => "88"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            88 => array:3 [
              "identificador" => "bib1275"
              "etiqueta" => "89"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            89 => array:3 [
              "identificador" => "bib1280"
              "etiqueta" => "90"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            90 => array:3 [
              "identificador" => "bib1285"
              "etiqueta" => "91"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            91 => array:3 [
              "identificador" => "bib1290"
              "etiqueta" => "92"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            92 => array:3 [
              "identificador" => "bib1295"
              "etiqueta" => "93"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            93 => array:3 [
              "identificador" => "bib1300"
              "etiqueta" => "94"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            94 => array:3 [
              "identificador" => "bib1305"
              "etiqueta" => "95"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            95 => array:3 [
              "identificador" => "bib1310"
              "etiqueta" => "96"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            96 => array:3 [
              "identificador" => "bib1315"
              "etiqueta" => "97"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            97 => array:3 [
              "identificador" => "bib1320"
              "etiqueta" => "98"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            98 => array:3 [
              "identificador" => "bib1325"
              "etiqueta" => "99"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            99 => array:3 [
              "identificador" => "bib1330"
              "etiqueta" => "100"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            100 => array:3 [
              "identificador" => "bib1335"
              "etiqueta" => "101"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            101 => array:3 [
              "identificador" => "bib1340"
              "etiqueta" => "102"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            102 => array:3 [
              "identificador" => "bib1345"
              "etiqueta" => "103"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            103 => array:3 [
              "identificador" => "bib1350"
              "etiqueta" => "104"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            104 => array:3 [
              "identificador" => "bib1355"
              "etiqueta" => "105"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            105 => array:3 [
              "identificador" => "bib1360"
              "etiqueta" => "106"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            106 => array:3 [
              "identificador" => "bib1365"
              "etiqueta" => "107"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            107 => array:3 [
              "identificador" => "bib1370"
              "etiqueta" => "108"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            108 => array:3 [
              "identificador" => "bib1375"
              "etiqueta" => "109"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            109 => array:3 [
              "identificador" => "bib1380"
              "etiqueta" => "110"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            110 => array:3 [
              "identificador" => "bib1385"
              "etiqueta" => "111"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            111 => array:3 [
              "identificador" => "bib1390"
              "etiqueta" => "112"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            112 => array:3 [
              "identificador" => "bib1395"
              "etiqueta" => "113"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            113 => array:3 [
              "identificador" => "bib1400"
              "etiqueta" => "114"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            114 => array:3 [
              "identificador" => "bib1405"
              "etiqueta" => "115"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            115 => array:3 [
              "identificador" => "bib1410"
              "etiqueta" => "116"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            116 => array:3 [
              "identificador" => "bib1415"
              "etiqueta" => "117"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            117 => array:3 [
              "identificador" => "bib1420"
              "etiqueta" => "118"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            118 => array:3 [
              "identificador" => "bib1425"
              "etiqueta" => "119"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            119 => array:3 [
              "identificador" => "bib1430"
              "etiqueta" => "120"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            120 => array:3 [
              "identificador" => "bib1435"
              "etiqueta" => "121"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            121 => array:3 [
              "identificador" => "bib1440"
              "etiqueta" => "122"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            122 => array:3 [
              "identificador" => "bib1445"
              "etiqueta" => "123"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            123 => array:3 [
              "identificador" => "bib1450"
              "etiqueta" => "124"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            124 => array:3 [
              "identificador" => "bib1455"
              "etiqueta" => "125"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            125 => array:3 [
              "identificador" => "bib1460"
              "etiqueta" => "126"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            126 => array:3 [
              "identificador" => "bib1465"
              "etiqueta" => "127"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            127 => array:3 [
              "identificador" => "bib1470"
              "etiqueta" => "128"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            128 => array:3 [
              "identificador" => "bib1475"
              "etiqueta" => "129"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            129 => array:3 [
              "identificador" => "bib1480"
              "etiqueta" => "130"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            130 => array:3 [
              "identificador" => "bib1485"
              "etiqueta" => "131"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            131 => array:3 [
              "identificador" => "bib1490"
              "etiqueta" => "132"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            132 => array:3 [
              "identificador" => "bib1495"
              "etiqueta" => "133"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            133 => array:3 [
              "identificador" => "bib1500"
              "etiqueta" => "134"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            134 => array:3 [
              "identificador" => "bib1505"
              "etiqueta" => "135"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            135 => array:3 [
              "identificador" => "bib1510"
              "etiqueta" => "136"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            136 => array:3 [
              "identificador" => "bib1515"
              "etiqueta" => "137"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            137 => array:3 [
              "identificador" => "bib1520"
              "etiqueta" => "138"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            138 => array:3 [
              "identificador" => "bib1525"
              "etiqueta" => "139"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            139 => array:3 [
              "identificador" => "bib1530"
              "etiqueta" => "140"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            140 => array:3 [
              "identificador" => "bib1535"
              "etiqueta" => "141"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            141 => array:3 [
              "identificador" => "bib1540"
              "etiqueta" => "142"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            142 => array:3 [
              "identificador" => "bib1545"
              "etiqueta" => "143"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            143 => array:3 [
              "identificador" => "bib1550"
              "etiqueta" => "144"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            144 => array:3 [
              "identificador" => "bib1555"
              "etiqueta" => "145"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            145 => array:3 [
              "identificador" => "bib1560"
              "etiqueta" => "146"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            146 => array:3 [
              "identificador" => "bib1565"
              "etiqueta" => "147"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            147 => array:3 [
              "identificador" => "bib1570"
              "etiqueta" => "148"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            148 => array:3 [
              "identificador" => "bib1575"
              "etiqueta" => "149"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            149 => array:3 [
              "identificador" => "bib1580"
              "etiqueta" => "150"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            150 => array:3 [
              "identificador" => "bib1585"
              "etiqueta" => "151"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            151 => array:3 [
              "identificador" => "bib1590"
              "etiqueta" => "152"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            152 => array:3 [
              "identificador" => "bib1595"
              "etiqueta" => "153"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            153 => array:3 [
              "identificador" => "bib1600"
              "etiqueta" => "154"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            154 => array:3 [
              "identificador" => "bib1605"
              "etiqueta" => "155"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            155 => array:3 [
              "identificador" => "bib1610"
              "etiqueta" => "156"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            156 => array:3 [
              "identificador" => "bib1615"
              "etiqueta" => "157"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:1 [ …1]
                  ]
                ]
              ]
            ]
            157 => array:3 [
              "identificador" => "bib1620"
              "etiqueta" => "158"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            158 => array:3 [
              "identificador" => "bib1625"
              "etiqueta" => "159"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            159 => array:3 [
              "identificador" => "bib1630"
              "etiqueta" => "160"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            160 => array:3 [
              "identificador" => "bib1635"
              "etiqueta" => "161"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            161 => array:3 [
              "identificador" => "bib1640"
              "etiqueta" => "162"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            162 => array:3 [
              "identificador" => "bib1645"
              "etiqueta" => "163"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            163 => array:3 [
              "identificador" => "bib1650"
              "etiqueta" => "164"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            164 => array:3 [
              "identificador" => "bib1655"
              "etiqueta" => "165"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
            165 => array:3 [
              "identificador" => "bib1660"
              "etiqueta" => "166"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [ …2]
                  ]
                  "host" => array:1 [
                    0 => array:2 [ …2]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
    "agradecimientos" => array:1 [
      0 => array:3 [
        "titulo" => "Acknowledgments"
        "texto" => "<p id="par0370" class="elsevierStylePara elsevierViewall">The authors thank Ester Puig-Vilanova for her support and Anael Barber&#225;n-Garc&#237;a for her invaluable contribution to the review of the literature and incorporation of references&#46; They also thank Anna Salazar&#44; Mar&#237;a Cort&#233;s-Badia and Paula Bassaga&#241;as-&#210;dena for their collaboration in producing the list of abbreviations and references in the document&#46;</p>"
        "vista" => "all"
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/15792129/0000005100000008/v2_201511200100/S1579212915001846/v2_201511200100/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "9379"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Recommendations of SEPAR"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005100000008/v2_201511200100/S1579212915001846/v2_201511200100/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212915001846?idApp=UINPBA00003Z"
]
Article information
ISSN: 15792129
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 8 2 10
2024 October 125 74 199
2024 September 106 25 131
2024 August 80 60 140
2024 July 108 26 134
2024 June 71 57 128
2024 May 164 70 234
2024 April 87 72 159
2024 March 65 55 120
2024 February 36 91 127
2024 January 1 2 3
2023 May 1 0 1
2023 March 10 7 17
2023 February 43 52 95
2023 January 40 67 107
2022 December 62 57 119
2022 November 65 66 131
2022 October 79 102 181
2022 September 37 56 93
2022 August 54 69 123
2022 July 57 97 154
2022 June 52 77 129
2022 May 46 93 139
2022 April 53 77 130
2022 March 72 72 144
2022 February 48 95 143
2022 January 59 137 196
2021 December 47 64 111
2021 November 68 63 131
2021 October 73 76 149
2021 September 64 65 129
2021 August 51 76 127
2021 July 72 35 107
2021 June 85 75 160
2021 May 85 43 128
2021 April 212 81 293
2021 March 164 52 216
2021 February 135 50 185
2021 January 115 37 152
2020 December 87 40 127
2020 November 131 33 164
2020 October 121 47 168
2020 September 105 32 137
2020 August 115 33 148
2020 July 140 60 200
2020 June 271 38 309
2020 May 239 41 280
2020 April 209 48 257
2020 March 197 50 247
2020 February 242 41 283
2020 January 326 38 364
2019 December 226 45 271
2019 November 219 35 254
2019 October 242 40 282
2019 September 215 36 251
2019 August 155 47 202
2019 July 236 50 286
2019 June 202 31 233
2019 May 242 48 290
2019 April 240 69 309
2019 March 211 80 291
2019 February 192 80 272
2019 January 123 68 191
2018 December 99 36 135
2018 November 297 46 343
2018 October 650 61 711
2018 September 206 21 227
2018 May 51 1 52
2018 April 75 18 93
2018 March 144 21 165
2018 February 114 24 138
2018 January 562 16 578
2017 December 651 17 668
2017 November 128 25 153
2017 October 113 19 132
2017 September 64 33 97
2017 August 37 25 62
2017 July 39 27 66
2017 June 88 30 118
2017 May 76 30 106
2017 April 62 33 95
2017 March 79 60 139
2017 February 39 48 87
2017 January 32 24 56
2016 December 63 30 93
2016 November 88 45 133
2016 October 96 44 140
2016 September 113 72 185
2016 August 107 57 164
2016 July 65 63 128
2016 March 2 0 2
2016 February 1 0 1
2015 December 3 0 3
2015 October 0 4 4
Show all

Follow this link to access the full text of the article

Archivos de Bronconeumología

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