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the concept of phenotype has been used to identify groups of patients who share attributes that distinguish them from others&#44; making up clinical subgroups&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">3</span></a> A good example of this idea of phenotype is chronic obstructive pulmonary disease &#40;COPD&#41;&#44; a disease in which the underlying genes are unknown &#40;with the exception of alpha-1 antitrypsin deficiency&#41;&#46; Since phenotype differentiation has clinical implications&#44; the term &#8220;clinical phenotype&#8221; has been proposed&#44; which is defined as &#8220;a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes &#40;symptoms&#44; exacerbations&#44; response to therapy&#44; rate of disease progression&#44; or death&#41;&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The term COPD came into use around 50 years ago<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">5</span></a> and initially included 2 entities&#44; 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they have been included in some clinical guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">10</span></a> The most widely accepted phenotypes are&#58; emphysema&#44; chronic bronchitis&#44; frequent exacerbator&#44; and asthma-COPD overlap syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">3&#44;4&#44;8&#8211;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The growing wealth of data on the differences between biomass smoke-related COPD&#44; particularly wood smoke&#44; and tobacco smoke-related COPD<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">11&#44;12</span></a> has led experts to propose biomass COPD as an additional phenotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;14</span></a> This proposal is controversial&#44; and warrants a review of the existing information on these differences and the applicability of the term phenotype in the presence of risk factors that could be considered different&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this review&#44; we discuss the differences between wood smoke-related COPD &#40;W-COPD&#41; and tobacco smoke-related COPD &#40;T-COPD&#41;&#46; We have used the general term T-COPD&#44; although a more accurate name would be cigarette smoke COPD&#44; as this smoke contains an additional number of chemical products apart from those derived from burning tobacco&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">15&#44;16</span></a> Since the role of these chemicals cannot be clearly separated from the role of tobacco in the pathogenesis of COPD&#44; we will use the generic term T-COPD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For this review&#44; we searched the Medline&#44; LILACS and Cochrane databases&#44; using the terms biomass&#44; biomass fuels&#44; wood&#44; wood smoke&#44; indoor air pollution&#44; respiratory diseases&#44; chronic bronchitis and chronic obstructive pulmonary disease&#44; and the connectors AND&#47;OR&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Exposure to Wood Smoke as a Risk Factor for Chronic Obstructive Pulmonary Disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">Around 40&#37; of the world&#39;s population&#44; particularly in developing countries&#44; still use solid fuel&#44; whether coal or biomass &#40;wood&#44; vegetable remains and dung&#41;&#44; to cook or heat their homes&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">17&#44;18</span></a> In some countries&#44; these fuels are the main source of energy for over 70&#37; of the rural population&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">17&#44;18</span></a> In countries where migration from rural areas to cities is high&#44; the population of urban dwellers over the age of 40 years frequently has a significant history of exposure to biomass combustibles&#46; One example is Colombia&#44; where 39&#37; of the population over 40 years of age living in the 5 main cities had cooked with wood for more than 10 years before relocating&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">19</span></a> In 2010&#44; indoor air pollution from solid fuels was the third risk factor for death throughout the world &#40;3&#46;5 million deaths a year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">20</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A growing number of studies support the hypothesis that exposure to solid fuels&#44; including wood&#44; is a risk factor for respiratory diseases&#44; including acute respiratory disease in children&#44; COPD&#44; chronic bronchitis&#44; airflow obstruction&#44; bronchial hyperreactivity&#44; asthma&#44; tuberculosis and lung cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">21&#8211;39</span></a> Our group has documented the association between exposure to wood smoke for over 10 years and asthma in the population &#62;40 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">39</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Three systematic reviews and meta-analyses confirm that individuals chronically exposed to solid fuels at home have a higher risk of developing COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">36&#8211;38</span></a> In the case of wood smoke&#44; the risk of COPD increases significantly with the length of exposure &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> and with simultaneous exposure to tobacco smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;41</span></a> Although the risk is consistently greater in women&#44; a populational study &#40;<span class="elsevierStyleItalic">n</span>&#61;5539&#41; showed that&#44; after adjusting for age&#44; smoking&#44; educational level and occupational exposure&#44; men exposed to wood smoke for more than 10 years had a higher risk of COPD &#40;odds ratio &#91;OR&#93; women&#58; 1&#46;84&#59; OR men&#58; 1&#46;53&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> Exposure to wood smoke has also been described as a risk factor for COPD in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Air pollution in the home due to burning solid fuels is thought to be the main worldwide risk factor for COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">42&#44;43</span></a> although the prevalence of biomass-related COPD has not been precisely defined&#46; The PREPOCOL study found a prevalence of 6&#46;7&#37; for W-COPD compared to 7&#46;8&#37; for T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Some populational studies&#44; however&#44; found no association between exposure to biomass fuels and COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">44&#44;45</span></a> Most of the cohorts evaluated in these studies lived near sea level&#44; where cooking is usually done outdoors or with better ventilation&#46; In contrast&#44; many of the studies which document this association were performed in areas situated at high or intermediary altitudes&#44; where&#44; due to low temperatures&#44; cooking is done all year round inside poorly ventilated homes as it occurs in winter in regions that have seasons&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although exposure to wood smoke has been associated with respiratory diseases other than COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">24&#44;46&#8211;48</span></a> this review focuses on the differences between W-COPD and T-COPD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although the risk of COPD has been proven for all types of solid fuels&#44; studies which best characterize COPD due to this type of exposure have focused on COPD caused by inhalation of wood smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">11&#8211;14&#44;24&#44;32&#44;34&#44;47&#44;49</span></a> Several studies show that W-COPD has both significant differences and similarities with T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;62</span></a> The main differences are described below and summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Demographic Differences</span><p id="par0075" class="elsevierStylePara elsevierViewall">W-COPD is more common in women&#44; who are more often involved in the task of preparing food&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">11</span></a> Women with W-COPD are consistently reported to be shorter in height&#44; with a higher body mass index &#40;BMI&#41; than women with T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a> Since most women with W-COPD are of a rural origin&#44; and most of those with T-COPD are from urban conglomerations&#44; differences in height and BMI may be due to ethnic and environmental reasons that require investigation&#46; Moreover&#44; women with W-COPD are older&#44; suggesting that patients with this type of exposure need more time to develop the disease or are diagnosed later&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;49&#8211;51&#44;55&#44;56</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Differences</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although several studies have shown that the frequency of respiratory symptoms &#40;cough&#44; expectoration&#44; and dyspnea&#41; and chronic bronchitis is high in subjects exposed to biomass smoke&#44;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">36&#44;38</span></a> studies comparing W-COPD and T-COPD do not consistently find significant differences&#46; Some studies show that W-COPD symptoms are more frequent or have more impact<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;49&#44;62</span></a> but others do not&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">51&#44;53&#44;56</span></a> With regard to the physical examination&#44; Gonz&#225;lez-Garc&#237;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> found more frequent rhonchus and wheezing in W-COPD&#46; Functional and tomographic findings&#44; described below&#44; document greater bronchial compromise&#44; backing up studies which show more frequent cough&#44; expectoration&#44; rhonchus and wheezing in W-COPD&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Differences in Quality of Life</span><p id="par0085" class="elsevierStylePara elsevierViewall">A study of 138 women with COPD showed that&#44; among women with the same degree of obstruction&#44; those with W-COPD had a poorer health status &#40;poorer quality of life and worse dyspnea&#41; than those with T-COPD&#44; with no differences in comorbidities &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">62</span></a> Furthermore&#44; Camp et al&#46;&#44; using the Saint George&#39;s Hospital Questionnaire&#44; found worse symptoms and more compromised activity indices in women with W-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Differences in Lung Function</span><p id="par0090" class="elsevierStylePara elsevierViewall">Compared with T-COPD&#44; obstruction in W-COPD is milder&#44; both overall and after adjusting for age&#44;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;51&#44;56</span></a> and the decline in forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; is smaller and more homogeneous than in T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">50</span></a> Some studies show that carbon dioxide arterial pressure &#40;PaCO<span class="elsevierStyleInf">2</span>&#41; is higher &#40;lower ventilation&#41; and oxygen arterial pressure &#40;PaO<span class="elsevierStyleInf">2</span>&#41; and oxygen arterial saturation &#40;SaO<span class="elsevierStyleInf">2</span>&#41; are lower in W-COPD than in T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;49&#44;50&#44;56</span></a> The lower oxygenation rates observed in W-COPD may be explained in part by hypoventilation&#46; It remains to be determined whether this behavior is related with a higher BMI in these patients&#44; most of whom are women over 50 years of age&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Normal or mildly altered diffusing capacity &#40;DL<span class="elsevierStyleInf">CO</span>&#41; and DL<span class="elsevierStyleInf">CO</span>&#47;alveolar volume &#40;DL<span class="elsevierStyleInf">CO</span>&#47;VA&#41; ratio are consistently observed in W-COPD compared to T-COPD&#44; in which these parameters are significantly reduced&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">49&#44;54</span></a> This finding correlates with the lower grade of emphysema found on computed tomography &#40;CT&#41; in patients with W-COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;54&#44;59</span></a> and occurs at all levels of COPD severity &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> Mildly reduced DL<span class="elsevierStyleInf">CO</span> with normal DL<span class="elsevierStyleInf">CO</span>&#47;VA in women with W-COPD has been described in cases with significantly compromised small airways with little emphysema &#40;pseudophysiological emphysema&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">63</span></a> Compromised diffusion correlates better with reduced FEV<span class="elsevierStyleInf">1</span> in women with T-COPD than in those with W-COPD&#44; underpinning the greater contribution of emphysema to airflow obstruction in T-COPD &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Women with W-COPD have greater bronchial hyperreactivity than women with T-COPD &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> Further research is needed to determine if this correlates with the higher frequency of the asthma-COPD overlap phenotype observed in biomass-related COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">5</span></a> Taking into account the predominant role that inhaled corticosteroids may have in patients with asthma-COPD overlap syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">9&#44;10</span></a> these medications can be presumed to have a different impact on W-COPD than on T-COPD&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Differences in Exercise Tolerance</span><p id="par0105" class="elsevierStylePara elsevierViewall">Some studies which included the 6-minute walking test found no significant differences in distances walked between patients with W-COPD and T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;56&#44;62</span></a> Camp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">13</span></a> reported lower arterial oxygen saturation measured by pulse oximetry &#40;SpO<span class="elsevierStyleInf">2</span>&#41; at the end of the test in women with W-COPD&#44; but this was not reported in other studies&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Tomography and Histological Differences</span><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with W-COPD have consistently less emphysema and more airway changes &#40;bronchial thickening and fibrosis&#44; bronchiectasis&#44; and atelectasis&#41; than patients with T-COPD on both chest radiographs and histological studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;51&#44;52&#44;54&#44;59</span></a> These morphological differences can be related with a less compromised DL<span class="elsevierStyleInf">CO</span> and probably with the findings of greater bronchial hyperreactivity<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> and more frequent asthma phenotype in W-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Differences in Pulmonary Hypertension</span><p id="par0115" class="elsevierStylePara elsevierViewall">A recent study found that pulmonary hypertension on echocardiography was more common in patients with W-COPD than in those with T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">60</span></a> In a previous study&#44; our group&#44; on the basis of radiographical evaluations&#44; suggested the same in patients with severe COPD&#44;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> and Sandoval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">61</span></a> showed a high rate of PH among individuals exposed to wood smoke compared to those with T-COPD&#46; The origin of PH in W-COPD patients does not appear to be related solely with hypoxic pulmonary vasoconstriction&#44; but also to direct effects caused by the inhaled substances or indirect inflammatory-mediated effects&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Differences in the Incidence of Bronchial Anthracofibrosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">The incidence of bronchial anthracofibrosis and its severity in individuals exposed to wood smoke or tobacco smoke has not been evaluated in prospective studies&#44; and no differences are known&#46; However&#44; anthracofibrosis is commonly encountered in the airway of subjects exposed to wood smoke&#44; sometimes accompanied by bronchial stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">65&#8211;67</span></a> A significant proportion of these patients show documented airway obstruction<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">65</span></a> possibly aggravated by their central airway stenosis&#46; It is currently impossible to ascertain if bronchial anthracofibrosis is yet another feature of W-COPD that appears more commonly and in a more severe form than in T-COPD&#44; or if it is a specific entity accompanied by obstruction&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Differences in Meaningful Clinical Outcomes</span><p id="par0125" class="elsevierStylePara elsevierViewall">After adjusting for age&#44; sex&#44; and disease severity&#44; no differences were found in survival between W-COPD and T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">56&#44;57</span></a> Nor were differences identified in exacerbation rates between the 2 groups&#44;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a> but it should be noted that no prospective data are available on this aspect&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Differences in the Distribution of Clinical Phenotypes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Golpe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a> evaluated the frequency of clinical phenotypes defined by the Spanish COPD guidelines<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">10</span></a> in patients with COPD caused by biomass or tobacco smoke&#46; Similarly to the findings discussed above&#44; they found a greater frequency of emphysema phenotype in T-COPD&#46; The asthma-COPD overlap phenotype was more common in biomass COPD&#44; but the difference disappeared after adjusting for sex&#46; No difference was found in the frequencies of chronic bronchitis or exacerbator phenotypes&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Possible Reasons for Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke</span><p id="par0135" class="elsevierStylePara elsevierViewall">It is reasonable to expect that the greater airway inflammatory involvement and the lower rate of emphysema in W-COPD compared to T-COPD have an etiological&#44; pathogenic and physiopathological basis&#46; However&#44; very little data are available to explain the reasons for these differences&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The composition of wood smoke&#44; which contains hundreds of chemical compounds and particulates&#41; is just as complex<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">23&#44;68</span></a> as that of cigarette smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">15&#44;16</span></a> Wood combustion is generally incomplete&#44; generating greater concentrations of certain substances such as CO&#44; benzene&#44; and polycyclic hydrocarbons&#44; such as benzopyrene&#44; compared to cigarette smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">23</span></a> Practically 100&#37; of the particulated material in cigarette smoke is less than 2&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;m in size&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">69</span></a> This proportion is nearer 90&#37; in wood smoke<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">68</span></a>&#59; the remaining 10&#37; of particles are between 2&#46;5 and 10<span class="elsevierStyleHsp" style=""></span>&#956;m in size&#46; The role of this distribution of particle size in the greater airway compromise and more common development of anthracofibrosis in W-COPD has not been determined&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Silva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">70</span></a> recently reviewed pathogenic mechanisms involved in biomass COPD&#46; As in T-COPD&#44; many of these mechanisms are related with inflammatory activation and oxidative stress&#44; whereas no obvious significant differences in the mechanisms involved in the generation of respiratory injury in W-COPD were identified&#46; Although the lower rate or absence of emphysema in W-COPD might suggest less proteolytic activity against exposure to biomass smoke&#44; a recent study found no differences in this respect when comparing exposure to biomass smoke and to cigarette smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">64</span></a> Some authors have suggested that differences between W-COPD and T-COPD may be determined in part by differences in the characteristics of exposure&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">11</span></a> but research is needed to support this view&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In summary&#44; the physiopathological mechanisms involved in W-COPD remain unclear&#44; but it seems that inflammatory activation in the airway is different&#44; and of a greater magnitude&#44; and that proteolytic activity induces less emphysema&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Chronic Obstructive Pulmonary Disease due to Wood Smoke&#58; A New Chronic Obstructive Pulmonary Disease Phenotype or a Different Entity&#63;</span><p id="par0155" class="elsevierStylePara elsevierViewall">The evidence consistently supports differences between W-COPD and T-COPD with respect to greater inflammatory airway compromise and a much lower or absent degree of emphysema in the former&#46; The etiological factors&#44; wood smoke and cigarette smoke&#44; can be grouped under the heading of noxious particles or gases&#44; but they are also different&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">23</span></a> so it is reasonable to propose that W-COPD be considered a distinct disease&#44; rather than a new COPD phenotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;14</span></a> Additionally&#44; recognition that exposure to wood smoke may be associated with radiological&#44; functional and histological manifestations that differ from those described under the definition of COPD&#44; such as pulmonary infiltrates&#44; restrictive patterns and particulate deposits in the lung&#44;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">24&#44;46&#8211;48</span></a> may be taken as yet another argument for separating it into a different nosological entity&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Even if it can be agreed&#44; using the present definition&#44; to describe obstructive disease caused by exposure to wood smoke as COPD&#44; W-COPD could still not be considered a different clinical phenotype&#44; since its clinical&#44; functional&#44; histological and radiological differences do not lead to differences in meaningful outcomes&#44; such as exacerbations and mortality&#44; as proposed in the definition of clinical phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">4</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">From a nosological point of view&#44; the model of respiratory disease caused by wood smoke leads us to question the definition of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">71</span></a> COPD has been defined as a non-specific functional characteristic &#40;irreversible airflow limitation &#91;post-bronchodilator obstruction&#93;&#41; in the presence of an imprecise exposure &#40;noxious particles or gases&#41;&#44; in the absence of a single etiological factor or a highly specific or pathognomonic feature&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">72</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">If a single etiological factor or a highly-specific defining pathological trait is present&#44; the identification of clinical phenotypes is a valid approach to achieve the goal of designing individualized patient management&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">3&#44;9</span></a> If the etiological factor of a disease is not identified&#44; or is not unique&#44; as in the case of COPD &#40;noxious particles or gases&#41;&#44; and the disease is defined by a non-specific trait&#44; the different characteristics and outcomes of a group may represent a distinct&#44; separate entity&#44; rather than another phenotype expression&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Irrespective of whether W-COPD is considered a new phenotype or a distinct entity&#44; the most important consideration is how it affects prognosis and treatment&#46; It can be presumed that the physiopathological mechanisms of W-COPD are different&#44; and that a different approach to treatment may needed&#46; In view of the predominating airway compromise&#44; anti-inflammatories&#44; such as inhaled corticosteroids&#44; can be expected to play a more important role&#46; Further research is required on the physiopathological mechanisms and treatment of disease caused by wood smoke&#46; Better understanding of these differences could be applied to the considerable number of cases of COPD unrelated with cigarette or wood smoke&#44;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">73&#44;44</span></a> and disorders due to occupational and environmental air pollution which are classified under COPD could be better characterized&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The term COPD has been unquestionably important&#46; On the road toward personalized treatment&#44; beyond the stage in which phenotyping has a central role&#44; differentiation by etiological or causative agent remains essential&#46;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">71&#44;74</span></a> The idea of COPD as a syndrome which encompasses diverse specific entities is growing&#44; and it appears to be time to rethink the definition of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">W-COPD differs from T-COPD&#46; The causative factor &#40;wood smoke&#41; and the characteristics of exposure are also different&#44; and this might mean that the physiopathological mechanisms and&#47;or its severity differ in some respect&#44; explaining the greater inflammatory airway compromise and the lack of emphysema that are features of W-COPD&#46; Therapeutic options would therefore also differ&#44; and a greater role would be given to anti-inflammatories&#44; such as inhaled corticosteroids&#46; From this standpoint&#44; W-COPD is better understood as a distinct disease rather than a COPD phenotype&#44; bringing into question the accuracy of COPD definitions&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of Interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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          "identificador" => "xres698491"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
            ]
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        1 => array:2 [
          "identificador" => "xpalclavsec708244"
          "titulo" => "Keywords"
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          "identificador" => "xres698492"
          "titulo" => "Resumen"
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            0 => array:1 [
              "identificador" => "abst0010"
            ]
          ]
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        3 => array:2 [
          "identificador" => "xpalclavsec708243"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Exposure to Wood Smoke as a Risk Factor for Chronic Obstructive Pulmonary Disease"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke"
          "secciones" => array:10 [
            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Demographic Differences"
            ]
            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Clinical Differences"
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Differences in Quality of Life"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Differences in Lung Function"
            ]
            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Differences in Exercise Tolerance"
            ]
            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Tomography and Histological Differences"
            ]
            6 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Differences in Pulmonary Hypertension"
            ]
            7 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Differences in the Incidence of Bronchial Anthracofibrosis"
            ]
            8 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Differences in Meaningful Clinical Outcomes"
            ]
            9 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Differences in the Distribution of Clinical Phenotypes"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Possible Reasons for Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke"
        ]
        8 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Chronic Obstructive Pulmonary Disease due to Wood Smoke&#58; A New Chronic Obstructive Pulmonary Disease Phenotype or a Different Entity&#63;"
        ]
        9 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Conclusions"
        ]
        10 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conflict of Interests"
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        11 => array:1 [
          "titulo" => "References"
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      ]
    ]
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    "tienePdf" => true
    "fechaRecibido" => "2015-11-09"
    "fechaAceptado" => "2016-04-04"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
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          "palabras" => array:4 [
            0 => "Chronic obstructive pulmonary disease"
            1 => "Wood smoke"
            2 => "Phenotype"
            3 => "Biomass"
          ]
        ]
      ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec708243"
          "palabras" => array:4 [
            0 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            1 => "Humo de le&#241;a"
            2 => "Fenotipo"
            3 => "Biomasa"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Around 40&#37; of the world&#39;s population continue using solid fuel&#44; including wood&#44; for cooking or heating their homes&#46; Chronic exposure to wood smoke is a risk factor for developing chronic obstructive pulmonary disease &#40;COPD&#41;&#46; In some regions of the world&#44; this can be a more important cause of COPD than exposure to tobacco smoke from cigarettes&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Significant differences between COPD associated with wood smoke &#40;W-COPD&#41; and that caused by smoking &#40;S-COPD&#41; have led some authors to suggest that W-COPD should be considered a new COPD phenotype&#46; We present a review of the differences between W-COPD and S-COPD&#46; On the premise that wood smoke and tobacco smoke are not the same and the physiopathological mechanisms they induce may differ&#44; we have analyzed whether W-COPD can be considered as another COPD phenotype or a distinct nosological entity&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Alrededor del 40&#37; de la poblaci&#243;n mundial sigue utilizando combustibles s&#243;lidos&#44; entre ellos la le&#241;a&#44; para cocinar o calentar sus hogares&#46; La exposici&#243;n cr&#243;nica al humo de le&#241;a es un factor de riesgo para el desarrollo de enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#46; En algunas zonas del mundo este factor puede ser m&#225;s importante que la exposici&#243;n al humo de tabaco&#44; generalmente inhalado como humo de cigarrillo&#44; como causa de EPOC&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se han descrito diferencias significativas entre la EPOC relacionada con humo de le&#241;a &#40;EPOC-L&#41; y la EPOC causada por humo de tabaco &#40;EPOC-T&#41; que han llevado a plantear por algunos autores que la EPOC-L pueda ser considerada un nuevo fenotipo de la EPOC&#46; Presentamos una revisi&#243;n de las diferencias entre la EPOC-L y la EPOC-T&#46; Basados en que el humo de la le&#241;a y el humo del tabaco no son iguales&#44; y que podr&#237;an inducir mecanismos fisiopatol&#243;gicos en alg&#250;n punto diferentes&#44; hacemos un an&#225;lisis acerca de si la EPOC-L debe considerarse un fenotipo diferente de la EPOC o una entidad nosol&#243;gica distinta&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Torres-Duque CA&#44; Garc&#237;a-Rodriguez MC&#44; Gonz&#225;lez-Garc&#237;a M&#46; Enfermedad pulmonar obstructiva cr&#243;nica por humo de le&#241;a&#58; &#191;un fenotipo diferente o una entidad distinta&#63;&#46; Arch Bronconeumol&#46; 2016&#59;52&#58;425&#8211;431&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of COPD by years of exposure to wood smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> The prevalence of COPD in individuals exposed to wood smoke increases significantly as the duration of exposure lengthens&#46; NK&#58; not known &#40;individuals exposed to wood smoke who did not report years of exposure&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Quality of life in COPD by wood smoke or tobacco smoke exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">62</span></a> In W-COPD&#44; overall quality of life scores &#40;SGRQ&#41; and all individual domain scores are poorer&#46; SGRQ&#58; Saint George&#39;s Hospital Respiratory Questionnaire&#46;</p>"
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      2 => array:7 [
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        "etiqueta" => "Fig&#46; 3"
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        "mostrarFloat" => true
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        "figura" => array:1 [
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; DL<span class="elsevierStyleInf">CO</span> &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> &#40;B&#41; DL<span class="elsevierStyleInf">CO</span>&#47;VA &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> In T-COPD&#44; DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;VA are more heavily compromised&#46; DL<span class="elsevierStyleInf">CO</span>&#47;VA is normal in W-COPD at all levels of severity&#46; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; VA&#58; alveolar volume&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Correlation between FEV<span class="elsevierStyleInf">1</span> &#40;&#37;&#41; and DL<span class="elsevierStyleInf">CO</span> by exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> Greater correlation is observed between FEV<span class="elsevierStyleInf">1</span> and DL<span class="elsevierStyleInf">CO</span> in T-COPD &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#44; <span class="elsevierStyleItalic">r</span>&#61;0&#46;599&#41; than in W-COPD &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;014&#44; <span class="elsevierStyleItalic">r</span>&#61;0&#46;320&#41;&#46; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#46;</p>"
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        "etiqueta" => "Fig&#46; 5"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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            "imagen" => "gr5.jpeg"
            "Alto" => 1192
            "Ancho" => 1461
            "Tamanyo" => 50140
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Bronchial hyperreactivity evaluated by PC<span class="elsevierStyleInf">20</span> by exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> White circles&#58; W-COPD&#59; black circles&#58; T-COPD&#46; PC20 geometric mean&#58; W-COPD versus T-COPD&#58; 0&#46;39 &#40;0&#46;06&#8211;5&#46;13&#41; versus 1&#46;24 &#40;0&#46;34&#8211;9&#46;39&#41;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;028&#46; PC20&#58; methacholine concentration causing &#8805;20&#37; reduction in FEV<span class="elsevierStyleInf">1</span>&#46;</p>"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#59; FVC&#58; forced vital capacity&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; carbon dioxide arterial pressure&#59; PaO<span class="elsevierStyleInf">2</span>&#58; oxygen arterial pressure&#59; SaO<span class="elsevierStyleInf">2</span>&#58; oxygen saturation&#59; VA&#58; alveolar volume&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "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">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">W-COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">T-COPD&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  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Demographic data</span><a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Clinical characteristics</span><a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">38&#44;49</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cough and expectoration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic bronchitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rhonchus and wheezing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Lung function tests</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher &#40;some studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lower&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Obstruction &#40;FEV1&#8722;FEV1&#47;FVC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reduced FEV1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchial hyperreactivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;VA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or mildly reduced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More reduced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Radiography</span>-<span class="elsevierStyleItalic">tomography</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;47&#44;49&#44;51&#44;54&#44;59</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon and mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common and more severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchial thickening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchiectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atelectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Histology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anthracosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Airway fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thickening of arteriole intima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Outcomes and clinical phenotypes</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;51&#44;56&#44;61&#44;62</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar or symptoms and activities more compromised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar or symptoms and activities less compromised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar after adjusting for age<br>Less after adjusting for age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exacerbator phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asthma-COPD overlap phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Differences Between W-COPD and T-COPD&#46;</p>"
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Is Chronic Obstructive Pulmonary Disease Caused by Wood Smoke a Different Phenotype or a Different Entity?
Enfermedad pulmonar obstructiva crónica por humo de leña: ¿un fenotipo diferente o una entidad distinta?
Carlos A. Torres-Duquea,
Corresponding author
ctorres@neumologica.org

Corresponding author.
, María Carmen García-Rodriguezb, Mauricio González-Garcíaa
a Fundación Neumológica Colombiana, Universidad de La Sabana, Bogotá, Colombia
b Fundación Neumológica Colombiana, Bogotá, Colombia
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; DL<span class="elsevierStyleInf">CO</span> &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> &#40;B&#41; DL<span class="elsevierStyleInf">CO</span>&#47;VA &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> In T-COPD&#44; DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;VA are more heavily compromised&#46; DL<span class="elsevierStyleInf">CO</span>&#47;VA is normal in W-COPD at all levels of severity&#46; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; VA&#58; alveolar volume&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">A phenotype is a set of observable characteristics in an individual resulting from the interaction between their genotype and the environment&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">1&#44;2</span></a> These characteristics are not only physical traits but also biochemical and functional characteristics&#46; Genotype refers to an individual&#39;s genetic make-up &#40;combination of genes&#41;&#46; The manner in which the information contained in the genes &#40;genotype&#41; translates to observable characteristics &#40;phenotype&#41; depends on different factors&#44; the most important of which are how dominant the gene is and how it interacts with the environment&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In the clinical setting&#44; the concept of phenotype has been used to identify groups of patients who share attributes that distinguish them from others&#44; making up clinical subgroups&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">3</span></a> A good example of this idea of phenotype is chronic obstructive pulmonary disease &#40;COPD&#41;&#44; a disease in which the underlying genes are unknown &#40;with the exception of alpha-1 antitrypsin deficiency&#41;&#46; Since phenotype differentiation has clinical implications&#44; the term &#8220;clinical phenotype&#8221; has been proposed&#44; which is defined as &#8220;a single or combination of disease attributes that describe differences between individuals with COPD as they relate to clinically meaningful outcomes &#40;symptoms&#44; exacerbations&#44; response to therapy&#44; rate of disease progression&#44; or death&#41;&#46;&#8221;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The term COPD came into use around 50 years ago<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">5</span></a> and initially included 2 entities&#44; chronic bronchitis and emphysema&#44; which shared a common risk factor &#40;smoking&#41; and a common functional change &#40;persistent airflow obstruction&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">6&#44;7</span></a> The most pure cases of these 2 entities had sufficiently different clinical characteristics to enable them to be separated into the 2 classic COPD phenotypes&#58; chronic bronchitis or &#8220;blue bloater&#8221; and emphysema or &#8220;pink puffer&#8221;&#46; However&#44; it was not known then that different phenotypes would eventually determine different therapeutic interventions and outcomes&#44; so little importance was given to the separation of the phenotypes&#44; and use of the generic term COPD expanded&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The concept of clinical phenotypes in COPD is now being revisited&#44; thanks to long-term follow-up of patient cohorts and technological advances&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">3&#44;4&#44;8&#44;9</span></a> Although the implications of separation by phenotypes are still debated&#44; they have been included in some clinical guidelines&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">10</span></a> The most widely accepted phenotypes are&#58; emphysema&#44; chronic bronchitis&#44; frequent exacerbator&#44; and asthma-COPD overlap syndrome&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">3&#44;4&#44;8&#8211;10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The growing wealth of data on the differences between biomass smoke-related COPD&#44; particularly wood smoke&#44; and tobacco smoke-related COPD<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">11&#44;12</span></a> has led experts to propose biomass COPD as an additional phenotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;14</span></a> This proposal is controversial&#44; and warrants a review of the existing information on these differences and the applicability of the term phenotype in the presence of risk factors that could be considered different&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this review&#44; we discuss the differences between wood smoke-related COPD &#40;W-COPD&#41; and tobacco smoke-related COPD &#40;T-COPD&#41;&#46; We have used the general term T-COPD&#44; although a more accurate name would be cigarette smoke COPD&#44; as this smoke contains an additional number of chemical products apart from those derived from burning tobacco&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">15&#44;16</span></a> Since the role of these chemicals cannot be clearly separated from the role of tobacco in the pathogenesis of COPD&#44; we will use the generic term T-COPD&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For this review&#44; we searched the Medline&#44; LILACS and Cochrane databases&#44; using the terms biomass&#44; biomass fuels&#44; wood&#44; wood smoke&#44; indoor air pollution&#44; respiratory diseases&#44; chronic bronchitis and chronic obstructive pulmonary disease&#44; and the connectors AND&#47;OR&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Exposure to Wood Smoke as a Risk Factor for Chronic Obstructive Pulmonary Disease</span><p id="par0040" class="elsevierStylePara elsevierViewall">Around 40&#37; of the world&#39;s population&#44; particularly in developing countries&#44; still use solid fuel&#44; whether coal or biomass &#40;wood&#44; vegetable remains and dung&#41;&#44; to cook or heat their homes&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">17&#44;18</span></a> In some countries&#44; these fuels are the main source of energy for over 70&#37; of the rural population&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">17&#44;18</span></a> In countries where migration from rural areas to cities is high&#44; the population of urban dwellers over the age of 40 years frequently has a significant history of exposure to biomass combustibles&#46; One example is Colombia&#44; where 39&#37; of the population over 40 years of age living in the 5 main cities had cooked with wood for more than 10 years before relocating&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">19</span></a> In 2010&#44; indoor air pollution from solid fuels was the third risk factor for death throughout the world &#40;3&#46;5 million deaths a year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">20</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">A growing number of studies support the hypothesis that exposure to solid fuels&#44; including wood&#44; is a risk factor for respiratory diseases&#44; including acute respiratory disease in children&#44; COPD&#44; chronic bronchitis&#44; airflow obstruction&#44; bronchial hyperreactivity&#44; asthma&#44; tuberculosis and lung cancer&#46;<a class="elsevierStyleCrossRefs" href="#bib0475"><span class="elsevierStyleSup">21&#8211;39</span></a> Our group has documented the association between exposure to wood smoke for over 10 years and asthma in the population &#62;40 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">39</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Three systematic reviews and meta-analyses confirm that individuals chronically exposed to solid fuels at home have a higher risk of developing COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">36&#8211;38</span></a> In the case of wood smoke&#44; the risk of COPD increases significantly with the length of exposure &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> and with simultaneous exposure to tobacco smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;41</span></a> Although the risk is consistently greater in women&#44; a populational study &#40;<span class="elsevierStyleItalic">n</span>&#61;5539&#41; showed that&#44; after adjusting for age&#44; smoking&#44; educational level and occupational exposure&#44; men exposed to wood smoke for more than 10 years had a higher risk of COPD &#40;odds ratio &#91;OR&#93; women&#58; 1&#46;84&#59; OR men&#58; 1&#46;53&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> Exposure to wood smoke has also been described as a risk factor for COPD in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Air pollution in the home due to burning solid fuels is thought to be the main worldwide risk factor for COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0580"><span class="elsevierStyleSup">42&#44;43</span></a> although the prevalence of biomass-related COPD has not been precisely defined&#46; The PREPOCOL study found a prevalence of 6&#46;7&#37; for W-COPD compared to 7&#46;8&#37; for T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Some populational studies&#44; however&#44; found no association between exposure to biomass fuels and COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0590"><span class="elsevierStyleSup">44&#44;45</span></a> Most of the cohorts evaluated in these studies lived near sea level&#44; where cooking is usually done outdoors or with better ventilation&#46; In contrast&#44; many of the studies which document this association were performed in areas situated at high or intermediary altitudes&#44; where&#44; due to low temperatures&#44; cooking is done all year round inside poorly ventilated homes as it occurs in winter in regions that have seasons&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Although exposure to wood smoke has been associated with respiratory diseases other than COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">24&#44;46&#8211;48</span></a> this review focuses on the differences between W-COPD and T-COPD&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke</span><p id="par0070" class="elsevierStylePara elsevierViewall">Although the risk of COPD has been proven for all types of solid fuels&#44; studies which best characterize COPD due to this type of exposure have focused on COPD caused by inhalation of wood smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0425"><span class="elsevierStyleSup">11&#8211;14&#44;24&#44;32&#44;34&#44;47&#44;49</span></a> Several studies show that W-COPD has both significant differences and similarities with T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;62</span></a> The main differences are described below and summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Demographic Differences</span><p id="par0075" class="elsevierStylePara elsevierViewall">W-COPD is more common in women&#44; who are more often involved in the task of preparing food&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">11</span></a> Women with W-COPD are consistently reported to be shorter in height&#44; with a higher body mass index &#40;BMI&#41; than women with T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a> Since most women with W-COPD are of a rural origin&#44; and most of those with T-COPD are from urban conglomerations&#44; differences in height and BMI may be due to ethnic and environmental reasons that require investigation&#46; Moreover&#44; women with W-COPD are older&#44; suggesting that patients with this type of exposure need more time to develop the disease or are diagnosed later&#46;<a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;49&#8211;51&#44;55&#44;56</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Clinical Differences</span><p id="par0080" class="elsevierStylePara elsevierViewall">Although several studies have shown that the frequency of respiratory symptoms &#40;cough&#44; expectoration&#44; and dyspnea&#41; and chronic bronchitis is high in subjects exposed to biomass smoke&#44;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">36&#44;38</span></a> studies comparing W-COPD and T-COPD do not consistently find significant differences&#46; Some studies show that W-COPD symptoms are more frequent or have more impact<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;49&#44;62</span></a> but others do not&#46;<a class="elsevierStyleCrossRefs" href="#bib0625"><span class="elsevierStyleSup">51&#44;53&#44;56</span></a> With regard to the physical examination&#44; Gonz&#225;lez-Garc&#237;a et al&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> found more frequent rhonchus and wheezing in W-COPD&#46; Functional and tomographic findings&#44; described below&#44; document greater bronchial compromise&#44; backing up studies which show more frequent cough&#44; expectoration&#44; rhonchus and wheezing in W-COPD&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Differences in Quality of Life</span><p id="par0085" class="elsevierStylePara elsevierViewall">A study of 138 women with COPD showed that&#44; among women with the same degree of obstruction&#44; those with W-COPD had a poorer health status &#40;poorer quality of life and worse dyspnea&#41; than those with T-COPD&#44; with no differences in comorbidities &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">62</span></a> Furthermore&#44; Camp et al&#46;&#44; using the Saint George&#39;s Hospital Questionnaire&#44; found worse symptoms and more compromised activity indices in women with W-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">13</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Differences in Lung Function</span><p id="par0090" class="elsevierStylePara elsevierViewall">Compared with T-COPD&#44; obstruction in W-COPD is milder&#44; both overall and after adjusting for age&#44;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;51&#44;56</span></a> and the decline in forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; is smaller and more homogeneous than in T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0620"><span class="elsevierStyleSup">50</span></a> Some studies show that carbon dioxide arterial pressure &#40;PaCO<span class="elsevierStyleInf">2</span>&#41; is higher &#40;lower ventilation&#41; and oxygen arterial pressure &#40;PaO<span class="elsevierStyleInf">2</span>&#41; and oxygen arterial saturation &#40;SaO<span class="elsevierStyleInf">2</span>&#41; are lower in W-COPD than in T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;49&#44;50&#44;56</span></a> The lower oxygenation rates observed in W-COPD may be explained in part by hypoventilation&#46; It remains to be determined whether this behavior is related with a higher BMI in these patients&#44; most of whom are women over 50 years of age&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Normal or mildly altered diffusing capacity &#40;DL<span class="elsevierStyleInf">CO</span>&#41; and DL<span class="elsevierStyleInf">CO</span>&#47;alveolar volume &#40;DL<span class="elsevierStyleInf">CO</span>&#47;VA&#41; ratio are consistently observed in W-COPD compared to T-COPD&#44; in which these parameters are significantly reduced&#46;<a class="elsevierStyleCrossRefs" href="#bib0615"><span class="elsevierStyleSup">49&#44;54</span></a> This finding correlates with the lower grade of emphysema found on computed tomography &#40;CT&#41; in patients with W-COPD&#44;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;54&#44;59</span></a> and occurs at all levels of COPD severity &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>A and B&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> Mildly reduced DL<span class="elsevierStyleInf">CO</span> with normal DL<span class="elsevierStyleInf">CO</span>&#47;VA in women with W-COPD has been described in cases with significantly compromised small airways with little emphysema &#40;pseudophysiological emphysema&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0685"><span class="elsevierStyleSup">63</span></a> Compromised diffusion correlates better with reduced FEV<span class="elsevierStyleInf">1</span> in women with T-COPD than in those with W-COPD&#44; underpinning the greater contribution of emphysema to airflow obstruction in T-COPD &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">Women with W-COPD have greater bronchial hyperreactivity than women with T-COPD &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> Further research is needed to determine if this correlates with the higher frequency of the asthma-COPD overlap phenotype observed in biomass-related COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">5</span></a> Taking into account the predominant role that inhaled corticosteroids may have in patients with asthma-COPD overlap syndrome&#44;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">9&#44;10</span></a> these medications can be presumed to have a different impact on W-COPD than on T-COPD&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Differences in Exercise Tolerance</span><p id="par0105" class="elsevierStylePara elsevierViewall">Some studies which included the 6-minute walking test found no significant differences in distances walked between patients with W-COPD and T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;56&#44;62</span></a> Camp et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">13</span></a> reported lower arterial oxygen saturation measured by pulse oximetry &#40;SpO<span class="elsevierStyleInf">2</span>&#41; at the end of the test in women with W-COPD&#44; but this was not reported in other studies&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Tomography and Histological Differences</span><p id="par0110" class="elsevierStylePara elsevierViewall">Patients with W-COPD have consistently less emphysema and more airway changes &#40;bronchial thickening and fibrosis&#44; bronchiectasis&#44; and atelectasis&#41; than patients with T-COPD on both chest radiographs and histological studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;51&#44;52&#44;54&#44;59</span></a> These morphological differences can be related with a less compromised DL<span class="elsevierStyleInf">CO</span> and probably with the findings of greater bronchial hyperreactivity<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> and more frequent asthma phenotype in W-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Differences in Pulmonary Hypertension</span><p id="par0115" class="elsevierStylePara elsevierViewall">A recent study found that pulmonary hypertension on echocardiography was more common in patients with W-COPD than in those with T-COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0670"><span class="elsevierStyleSup">60</span></a> In a previous study&#44; our group&#44; on the basis of radiographical evaluations&#44; suggested the same in patients with severe COPD&#44;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> and Sandoval et al&#46;<a class="elsevierStyleCrossRef" href="#bib0675"><span class="elsevierStyleSup">61</span></a> showed a high rate of PH among individuals exposed to wood smoke compared to those with T-COPD&#46; The origin of PH in W-COPD patients does not appear to be related solely with hypoxic pulmonary vasoconstriction&#44; but also to direct effects caused by the inhaled substances or indirect inflammatory-mediated effects&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">64</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Differences in the Incidence of Bronchial Anthracofibrosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">The incidence of bronchial anthracofibrosis and its severity in individuals exposed to wood smoke or tobacco smoke has not been evaluated in prospective studies&#44; and no differences are known&#46; However&#44; anthracofibrosis is commonly encountered in the airway of subjects exposed to wood smoke&#44; sometimes accompanied by bronchial stenosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0695"><span class="elsevierStyleSup">65&#8211;67</span></a> A significant proportion of these patients show documented airway obstruction<a class="elsevierStyleCrossRef" href="#bib0695"><span class="elsevierStyleSup">65</span></a> possibly aggravated by their central airway stenosis&#46; It is currently impossible to ascertain if bronchial anthracofibrosis is yet another feature of W-COPD that appears more commonly and in a more severe form than in T-COPD&#44; or if it is a specific entity accompanied by obstruction&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Differences in Meaningful Clinical Outcomes</span><p id="par0125" class="elsevierStylePara elsevierViewall">After adjusting for age&#44; sex&#44; and disease severity&#44; no differences were found in survival between W-COPD and T-COPD&#46;<a class="elsevierStyleCrossRefs" href="#bib0650"><span class="elsevierStyleSup">56&#44;57</span></a> Nor were differences identified in exacerbation rates between the 2 groups&#44;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a> but it should be noted that no prospective data are available on this aspect&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Differences in the Distribution of Clinical Phenotypes</span><p id="par0130" class="elsevierStylePara elsevierViewall">Golpe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a> evaluated the frequency of clinical phenotypes defined by the Spanish COPD guidelines<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">10</span></a> in patients with COPD caused by biomass or tobacco smoke&#46; Similarly to the findings discussed above&#44; they found a greater frequency of emphysema phenotype in T-COPD&#46; The asthma-COPD overlap phenotype was more common in biomass COPD&#44; but the difference disappeared after adjusting for sex&#46; No difference was found in the frequencies of chronic bronchitis or exacerbator phenotypes&#46;<a class="elsevierStyleCrossRef" href="#bib0625"><span class="elsevierStyleSup">51</span></a></p></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Possible Reasons for Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke</span><p id="par0135" class="elsevierStylePara elsevierViewall">It is reasonable to expect that the greater airway inflammatory involvement and the lower rate of emphysema in W-COPD compared to T-COPD have an etiological&#44; pathogenic and physiopathological basis&#46; However&#44; very little data are available to explain the reasons for these differences&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">The composition of wood smoke&#44; which contains hundreds of chemical compounds and particulates&#41; is just as complex<a class="elsevierStyleCrossRefs" href="#bib0485"><span class="elsevierStyleSup">23&#44;68</span></a> as that of cigarette smoke&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">15&#44;16</span></a> Wood combustion is generally incomplete&#44; generating greater concentrations of certain substances such as CO&#44; benzene&#44; and polycyclic hydrocarbons&#44; such as benzopyrene&#44; compared to cigarette smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">23</span></a> Practically 100&#37; of the particulated material in cigarette smoke is less than 2&#46;5<span class="elsevierStyleHsp" style=""></span>&#956;m in size&#46;<a class="elsevierStyleCrossRef" href="#bib0715"><span class="elsevierStyleSup">69</span></a> This proportion is nearer 90&#37; in wood smoke<a class="elsevierStyleCrossRef" href="#bib0710"><span class="elsevierStyleSup">68</span></a>&#59; the remaining 10&#37; of particles are between 2&#46;5 and 10<span class="elsevierStyleHsp" style=""></span>&#956;m in size&#46; The role of this distribution of particle size in the greater airway compromise and more common development of anthracofibrosis in W-COPD has not been determined&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Silva et al&#46;<a class="elsevierStyleCrossRef" href="#bib0720"><span class="elsevierStyleSup">70</span></a> recently reviewed pathogenic mechanisms involved in biomass COPD&#46; As in T-COPD&#44; many of these mechanisms are related with inflammatory activation and oxidative stress&#44; whereas no obvious significant differences in the mechanisms involved in the generation of respiratory injury in W-COPD were identified&#46; Although the lower rate or absence of emphysema in W-COPD might suggest less proteolytic activity against exposure to biomass smoke&#44; a recent study found no differences in this respect when comparing exposure to biomass smoke and to cigarette smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0690"><span class="elsevierStyleSup">64</span></a> Some authors have suggested that differences between W-COPD and T-COPD may be determined in part by differences in the characteristics of exposure&#44;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">11</span></a> but research is needed to support this view&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In summary&#44; the physiopathological mechanisms involved in W-COPD remain unclear&#44; but it seems that inflammatory activation in the airway is different&#44; and of a greater magnitude&#44; and that proteolytic activity induces less emphysema&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Chronic Obstructive Pulmonary Disease due to Wood Smoke&#58; A New Chronic Obstructive Pulmonary Disease Phenotype or a Different Entity&#63;</span><p id="par0155" class="elsevierStylePara elsevierViewall">The evidence consistently supports differences between W-COPD and T-COPD with respect to greater inflammatory airway compromise and a much lower or absent degree of emphysema in the former&#46; The etiological factors&#44; wood smoke and cigarette smoke&#44; can be grouped under the heading of noxious particles or gases&#44; but they are also different&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">23</span></a> so it is reasonable to propose that W-COPD be considered a distinct disease&#44; rather than a new COPD phenotype&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;14</span></a> Additionally&#44; recognition that exposure to wood smoke may be associated with radiological&#44; functional and histological manifestations that differ from those described under the definition of COPD&#44; such as pulmonary infiltrates&#44; restrictive patterns and particulate deposits in the lung&#44;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">24&#44;46&#8211;48</span></a> may be taken as yet another argument for separating it into a different nosological entity&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Even if it can be agreed&#44; using the present definition&#44; to describe obstructive disease caused by exposure to wood smoke as COPD&#44; W-COPD could still not be considered a different clinical phenotype&#44; since its clinical&#44; functional&#44; histological and radiological differences do not lead to differences in meaningful outcomes&#44; such as exacerbations and mortality&#44; as proposed in the definition of clinical phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">4</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">From a nosological point of view&#44; the model of respiratory disease caused by wood smoke leads us to question the definition of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0725"><span class="elsevierStyleSup">71</span></a> COPD has been defined as a non-specific functional characteristic &#40;irreversible airflow limitation &#91;post-bronchodilator obstruction&#93;&#41; in the presence of an imprecise exposure &#40;noxious particles or gases&#41;&#44; in the absence of a single etiological factor or a highly specific or pathognomonic feature&#46;<a class="elsevierStyleCrossRef" href="#bib0730"><span class="elsevierStyleSup">72</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">If a single etiological factor or a highly-specific defining pathological trait is present&#44; the identification of clinical phenotypes is a valid approach to achieve the goal of designing individualized patient management&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">3&#44;9</span></a> If the etiological factor of a disease is not identified&#44; or is not unique&#44; as in the case of COPD &#40;noxious particles or gases&#41;&#44; and the disease is defined by a non-specific trait&#44; the different characteristics and outcomes of a group may represent a distinct&#44; separate entity&#44; rather than another phenotype expression&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Irrespective of whether W-COPD is considered a new phenotype or a distinct entity&#44; the most important consideration is how it affects prognosis and treatment&#46; It can be presumed that the physiopathological mechanisms of W-COPD are different&#44; and that a different approach to treatment may needed&#46; In view of the predominating airway compromise&#44; anti-inflammatories&#44; such as inhaled corticosteroids&#44; can be expected to play a more important role&#46; Further research is required on the physiopathological mechanisms and treatment of disease caused by wood smoke&#46; Better understanding of these differences could be applied to the considerable number of cases of COPD unrelated with cigarette or wood smoke&#44;<a class="elsevierStyleCrossRefs" href="#bib0735"><span class="elsevierStyleSup">73&#44;44</span></a> and disorders due to occupational and environmental air pollution which are classified under COPD could be better characterized&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The term COPD has been unquestionably important&#46; On the road toward personalized treatment&#44; beyond the stage in which phenotyping has a central role&#44; differentiation by etiological or causative agent remains essential&#46;<a class="elsevierStyleCrossRefs" href="#bib0725"><span class="elsevierStyleSup">71&#44;74</span></a> The idea of COPD as a syndrome which encompasses diverse specific entities is growing&#44; and it appears to be time to rethink the definition of COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">W-COPD differs from T-COPD&#46; The causative factor &#40;wood smoke&#41; and the characteristics of exposure are also different&#44; and this might mean that the physiopathological mechanisms and&#47;or its severity differ in some respect&#44; explaining the greater inflammatory airway compromise and the lack of emphysema that are features of W-COPD&#46; Therapeutic options would therefore also differ&#44; and a greater role would be given to anti-inflammatories&#44; such as inhaled corticosteroids&#46; From this standpoint&#44; W-COPD is better understood as a distinct disease rather than a COPD phenotype&#44; bringing into question the accuracy of COPD definitions&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflict of Interests</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors state that they have no conflict of interests&#46;</p></span></span>"
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          "identificador" => "xres698491"
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          "identificador" => "xpalclavsec708244"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Exposure to Wood Smoke as a Risk Factor for Chronic Obstructive Pulmonary Disease"
        ]
        6 => array:3 [
          "identificador" => "sec0015"
          "titulo" => "Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke"
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            0 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Demographic Differences"
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            1 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Clinical Differences"
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            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Differences in Quality of Life"
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            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Differences in Lung Function"
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            4 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Differences in Exercise Tolerance"
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            5 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Tomography and Histological Differences"
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            6 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Differences in Pulmonary Hypertension"
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            7 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Differences in the Incidence of Bronchial Anthracofibrosis"
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            8 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Differences in Meaningful Clinical Outcomes"
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            9 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Differences in the Distribution of Clinical Phenotypes"
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        ]
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          "identificador" => "sec0070"
          "titulo" => "Possible Reasons for Differences Between Chronic Obstructive Pulmonary Disease due to Wood Smoke and Chronic Obstructive Pulmonary Disease due to Tobacco Smoke"
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        8 => array:2 [
          "identificador" => "sec0075"
          "titulo" => "Chronic Obstructive Pulmonary Disease due to Wood Smoke&#58; A New Chronic Obstructive Pulmonary Disease Phenotype or a Different Entity&#63;"
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          "identificador" => "sec0080"
          "titulo" => "Conclusions"
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    "fechaRecibido" => "2015-11-09"
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            0 => "Chronic obstructive pulmonary disease"
            1 => "Wood smoke"
            2 => "Phenotype"
            3 => "Biomass"
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          "identificador" => "xpalclavsec708243"
          "palabras" => array:4 [
            0 => "Enfermedad pulmonar obstructiva cr&#243;nica"
            1 => "Humo de le&#241;a"
            2 => "Fenotipo"
            3 => "Biomasa"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Around 40&#37; of the world&#39;s population continue using solid fuel&#44; including wood&#44; for cooking or heating their homes&#46; Chronic exposure to wood smoke is a risk factor for developing chronic obstructive pulmonary disease &#40;COPD&#41;&#46; In some regions of the world&#44; this can be a more important cause of COPD than exposure to tobacco smoke from cigarettes&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Significant differences between COPD associated with wood smoke &#40;W-COPD&#41; and that caused by smoking &#40;S-COPD&#41; have led some authors to suggest that W-COPD should be considered a new COPD phenotype&#46; We present a review of the differences between W-COPD and S-COPD&#46; On the premise that wood smoke and tobacco smoke are not the same and the physiopathological mechanisms they induce may differ&#44; we have analyzed whether W-COPD can be considered as another COPD phenotype or a distinct nosological entity&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Alrededor del 40&#37; de la poblaci&#243;n mundial sigue utilizando combustibles s&#243;lidos&#44; entre ellos la le&#241;a&#44; para cocinar o calentar sus hogares&#46; La exposici&#243;n cr&#243;nica al humo de le&#241;a es un factor de riesgo para el desarrollo de enfermedad pulmonar obstructiva cr&#243;nica &#40;EPOC&#41;&#46; En algunas zonas del mundo este factor puede ser m&#225;s importante que la exposici&#243;n al humo de tabaco&#44; generalmente inhalado como humo de cigarrillo&#44; como causa de EPOC&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Se han descrito diferencias significativas entre la EPOC relacionada con humo de le&#241;a &#40;EPOC-L&#41; y la EPOC causada por humo de tabaco &#40;EPOC-T&#41; que han llevado a plantear por algunos autores que la EPOC-L pueda ser considerada un nuevo fenotipo de la EPOC&#46; Presentamos una revisi&#243;n de las diferencias entre la EPOC-L y la EPOC-T&#46; Basados en que el humo de la le&#241;a y el humo del tabaco no son iguales&#44; y que podr&#237;an inducir mecanismos fisiopatol&#243;gicos en alg&#250;n punto diferentes&#44; hacemos un an&#225;lisis acerca de si la EPOC-L debe considerarse un fenotipo diferente de la EPOC o una entidad nosol&#243;gica distinta&#46;</p></span>"
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      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Torres-Duque CA&#44; Garc&#237;a-Rodriguez MC&#44; Gonz&#225;lez-Garc&#237;a M&#46; Enfermedad pulmonar obstructiva cr&#243;nica por humo de le&#241;a&#58; &#191;un fenotipo diferente o una entidad distinta&#63;&#46; Arch Bronconeumol&#46; 2016&#59;52&#58;425&#8211;431&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Prevalence of COPD by years of exposure to wood smoke&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">40</span></a> The prevalence of COPD in individuals exposed to wood smoke increases significantly as the duration of exposure lengthens&#46; NK&#58; not known &#40;individuals exposed to wood smoke who did not report years of exposure&#41;&#46;</p>"
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Quality of life in COPD by wood smoke or tobacco smoke exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0680"><span class="elsevierStyleSup">62</span></a> In W-COPD&#44; overall quality of life scores &#40;SGRQ&#41; and all individual domain scores are poorer&#46; SGRQ&#58; Saint George&#39;s Hospital Respiratory Questionnaire&#46;</p>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">&#40;A&#41; DL<span class="elsevierStyleInf">CO</span> &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> &#40;B&#41; DL<span class="elsevierStyleInf">CO</span>&#47;VA &#40;&#37;&#41; by exposure and degree of obstruction&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> In T-COPD&#44; DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;VA are more heavily compromised&#46; DL<span class="elsevierStyleInf">CO</span>&#47;VA is normal in W-COPD at all levels of severity&#46; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; VA&#58; alveolar volume&#46;</p>"
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Correlation between FEV<span class="elsevierStyleInf">1</span> &#40;&#37;&#41; and DL<span class="elsevierStyleInf">CO</span> by exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0615"><span class="elsevierStyleSup">49</span></a> Greater correlation is observed between FEV<span class="elsevierStyleInf">1</span> and DL<span class="elsevierStyleInf">CO</span> in T-COPD &#40;<span class="elsevierStyleItalic">P</span>&#60;&#46;001&#44; <span class="elsevierStyleItalic">r</span>&#61;0&#46;599&#41; than in W-COPD &#40;<span class="elsevierStyleItalic">P</span>&#61;&#46;014&#44; <span class="elsevierStyleItalic">r</span>&#61;0&#46;320&#41;&#46; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Bronchial hyperreactivity evaluated by PC<span class="elsevierStyleInf">20</span> by exposure&#46;<a class="elsevierStyleCrossRef" href="#bib0645"><span class="elsevierStyleSup">55</span></a> White circles&#58; W-COPD&#59; black circles&#58; T-COPD&#46; PC20 geometric mean&#58; W-COPD versus T-COPD&#58; 0&#46;39 &#40;0&#46;06&#8211;5&#46;13&#41; versus 1&#46;24 &#40;0&#46;34&#8211;9&#46;39&#41;&#44; <span class="elsevierStyleItalic">P</span>&#61;&#46;028&#46; PC20&#58; methacholine concentration causing &#8805;20&#37; reduction in FEV<span class="elsevierStyleInf">1</span>&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#58; body mass index&#59; DL<span class="elsevierStyleInf">CO</span>&#58; carbon monoxide diffusing capacity&#59; FEV<span class="elsevierStyleInf">1</span>&#58; forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s&#59; FVC&#58; forced vital capacity&#59; PaCO<span class="elsevierStyleInf">2</span>&#58; carbon dioxide arterial pressure&#59; PaO<span class="elsevierStyleInf">2</span>&#58; oxygen arterial pressure&#59; SaO<span class="elsevierStyleInf">2</span>&#58; oxygen saturation&#59; VA&#58; alveolar volume&#46;</p>"
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                  <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">Characteristics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">W-COPD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">T-COPD&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  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Demographic data</span><a class="elsevierStyleCrossRefs" href="#bib0570"><span class="elsevierStyleSup">40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly women&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Predominantly men&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Height&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>BMI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Clinical characteristics</span><a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">38&#44;49</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Cough and expectoration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Very common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chronic bronchitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rhonchus and wheezing&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Lung function tests</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;40&#44;47&#44;49&#8211;51&#44;54&#8211;56</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaCO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher &#40;some studies&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>PaO<span class="elsevierStyleInf">2</span> and SaO<span class="elsevierStyleInf">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lower&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less low&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Obstruction &#40;FEV1&#8722;FEV1&#47;FVC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Reduced FEV1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchial hyperreactivity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Highest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lowest&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>DL<span class="elsevierStyleInf">CO</span> and DL<span class="elsevierStyleInf">CO</span>&#47;VA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal or mildly reduced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More reduced&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Radiography</span>-<span class="elsevierStyleItalic">tomography</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;47&#44;49&#44;51&#44;54&#44;59</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon and mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common and more severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchial thickening&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bronchiectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Atelectasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Histology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Mild&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More severe&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Anthracosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Airway fibrosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Thickening of arteriole intima&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Outcomes and clinical phenotypes</span><a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">13&#44;51&#44;56&#44;61&#44;62</span></a></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pulmonary hypertension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Quality of life&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar or symptoms and activities more compromised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar or symptoms and activities less compromised&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar after adjusting for age<br>Less after adjusting for age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Exacerbator phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Asthma-COPD overlap phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Less common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Emphysema phenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Uncommon&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">More common&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Differences Between W-COPD and T-COPD&#46;</p>"
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    ]
    "bibliografia" => array:2 [
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      "seccion" => array:1 [
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                  "host" => array:1 [
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            1 => array:3 [
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ISSN: 15792129
Original language: English
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