Editorial
COPD: The Hunt for the Right Classification
EPOC: en busca de la clasificación ideal
Francisco Ortega Ruiz
, Eduardo Márquez Martín, José Luis López-Campos
Corresponding author
Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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"francisco.ortega.sspa@juntadeandalucia.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Eduardo Márquez" "apellidos" => "Martín" ] 2 => array:2 [ "nombre" => "José Luis" "apellidos" => "López-Campos" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "EPOC: en busca de la clasificación ideal" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It is becoming clear that chronic obstructive pulmonary disease (COPD) is a multidimensional entity, and for this reason limiting its evaluation to functional changes does not address the full complexity of the disease. This realization has given rise to various proposals for classification that combine different parameters or “outcomes” in an attempt to qualify and/or quantify the degree of involvement and to assist in clinical decision-making.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">The task of classification involves grouping elements of information according to common attributes or properties. Defining a classification system, therefore, involves deciding, on the one hand, on which attributes the elements of the groups should be based, and on the other, how these attributes should be organized. With a good classification system, it should be possible to make an accurate qualitative identification of the patient and quantitatively assess their disease in order to adopt the most individualized therapeutic approach possible. It should have adequate predictive capacity and prognostic value, and it must be fast, practical and easy to use, and reduce the need for additional tests to a minimum.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Publication of the Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) guidelines, particularly the version which appeared in 2011, represented a significant change in the COPD diagnostic approach, clinical evaluation, and therapeutic strategy.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a> One of the main changes of the GOLD 2011 guidelines was to propose a multidimensional clinical assessment of the patient that went beyond the single-dimension approach of previous editions, which were based primarily on spirometric findings. Under the new system, 2 variables – severity of airflow limitation and frequency of exacerbations – are used to evaluate both the impact of symptoms on the patient's state of health and the risk of future adverse events.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Nevertheless, studies pointing out contradictions began to appear soon after publication of the new stratification system. Compared to previous classifications, the new GOLD system revealed an irregular distribution of patients. Of course, results depend on the study population, but even so, the new GOLD tended to polarize patients, with shifts towards groups A and D.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4–8</span></a> These results are confirmed in the paper published in this edition of <span class="elsevierStyleSmallCaps">Archivos de Bronconeumología</span>.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> In the PUMA study, the authors compared the prevalence and distribution of COPD stages defined by the GOLD recommendations with those of the Latin American Thorax Association (ALAT)<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a> in a primary care population. Using the latter system, patient distribution is bell-shaped, and a larger number of patients fall in the intermediate or “moderate” areas, while with the GOLD criteria, the distribution is U-shaped, with clusters of patients at the extremes.</p><p id="par0025" class="elsevierStylePara elsevierViewall">It is logical that discrepancies will be found when comparing 2 different systems. Lack of standardization in the distribution of severity between 2 classifications is mainly due to different cut-off points, and highlighting the limited concordance between the 2 does not imply the superiority of one system over another.</p><p id="par0030" class="elsevierStylePara elsevierViewall">More worrying are the other limitations demonstrated by the GOLD classification. Some studies revealed the surprising fact that mortality was significantly greater among subjects in group B (low risk, more symptoms) than in group C (high risk, fewer symptoms), at least in the short term.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">6,7</span></a> The difference in survival between groups B and C remained statistically significant after age and sex were included in the model. Moreover, a similar trend in hospital admissions was observed, with a greater risk of hospitalization in group B than in group C. If these findings are investigated further, the clinical outcomes appear to vary in groups C and D, depending on the criteria on which the classification is based. Thus, mortality appears to be higher when a low FEV<span class="elsevierStyleInf">1</span> is used to assign the patient to a group, but is far lower when the criteria is exacerbations.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> This diversity in the results within a single group casts serious doubts on the use of a standard therapeutic strategy for all of these patients in that group. In the PUMA study, where the ALAT stratification was used, BODE index scores increased as COPD worsened, a finding not observed with the GOLD criteria: BODE index, then, may be a better indirect method of estimating prognosis.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">To analyze the prognostic value of a classification system, prospective studies, as yet unavailable, are needed. In general, studies have subsequently applied the new stratification criteria to previously published cohorts, a technique subject to numerous biases. The new classification also involves new therapeutic strategies, and several years of clinical application are needed before a proper evaluation and assessment of its true prognostic impact can be made.</p><p id="par0040" class="elsevierStylePara elsevierViewall">An updated version of the GOLD guidelines has been published recently, which attempts to eliminate the discrepancies of the previous version by proposing a new patient classification and evaluation system.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> This, in short, involves separating the degrees of spirometric involvement of the “ABCD” groups and looking exclusively at symptoms and history of exacerbations. This clearly simplifies patient classification, although lung function is excluded from therapeutic decision-making, and the assessment becomes exclusively clinical. It seems that in less than 10 years, our focus has shifted: COPD was initially defined as a mere functional obstruction but now lung function is being sidelined, to the extent that its benefit in patient control and progress is being downplayed. Only time and comparative studies, which no doubt will be undertaken, will clarify the utility of this new proposal.</p><p id="par0045" class="elsevierStylePara elsevierViewall">With regard to the Spanish COPD guidelines (GesEPOC),<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> no prospective studies have compared the concordance of these classifications and their prognostic value with other recommendations. One of the strong points of the GesEPOC guidelines is that they recognize and emphasize the complexity of COPD by developing different profiles and promoting a multidimensional evaluation of the severity of the disease.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> In principle, it is a more complex classification based on the recognition of different phenotypes and levels of severity based on the BODE index. We do not know how far they have been adopted in our setting, but if we look at the results of the “COPD observatory”, a survey on COPD treatment guidelines sponsored by SEPAR, only 39.8% of respondents rated severity classification according to GesEPOC as easy or very easy; information was available on the 6-min walk test in 44.8% of cases, and on the CAT questionnaire in 51.7%, suggesting that GesEPOC use is not as widespread as might be hoped.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Designing a strategy that is easy to use in different healthcare situations and that encompasses the main aspects of a disease as complex as COPD seems to be far from easy. Only in recent years have we begun to understand the natural history of this disease.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a> Deeper insight into its course and its impact on clinical and biological parameters will give us the data we need to recommend useful strategies that come close to the real world situation in the clinic.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ruiz FO, Martín EM, López-Campos JL. EPOC: en busca de la clasificación ideal. Arch Bronconeumol. 2017;53:91–92.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <span class="elsevierStyleInterRef" id="intr0010" href="https://www.nice.org.uk/guidance/cg101/resources">https://www.nice.org.uk/guidance/cg101/resources</span> [accessed Sep 2016]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "NICE Guidelines (CG101). Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care (Partial Update)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "National Institute for Health and Care Excellence" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2010" "editorial" => "National Institute for Health and Care Excellence" "editorialLocalizacion" => "London" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0085" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Iniciativa GOLD 2011. ¿Cambio de paradigma?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "R. Rodríguez-Roisin" 1 => "A. Agustí" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2012.02.018" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2012" "volumen" => "48" "paginaInicial" => "286" "paginaFinal" => "289" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22537593" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0090" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Vestbo" 1 => "S.S. Hurd" 2 => "A.G. Agustí" 3 => "P.W. Jones" 4 => "C. Vogelmeier" 5 => "A. Anzueto" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201204-0596PP" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2013" "volumen" => "187" "paginaInicial" => "347" "paginaFinal" => "365" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22878278" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0095" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Distribution and prognostic validity of the new global initiative for chronic obstructive lung disease grading classification" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.B. Soriano" 1 => "I. Alfageme" 2 => "P. Almagro" 3 => "C. Casanova" 4 => "C. Esteban" 5 => "J.J. Soler-Cataluña" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-1053" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "143" "paginaInicial" => "694" "paginaFinal" => "702" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23187891" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0100" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comparison of 2011 and 2007 GOLD guidelines for predicting mortality and hospitalization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A. Johannessen" 1 => "R.M. Nilsen" 2 => "M. Storebø" 3 => "A. Gulsvik" 4 => "T. Eagan" 5 => "P. Bakke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201212-2276OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2013" "volumen" => "188" "paginaInicial" => "51" "paginaFinal" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23590268" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0105" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prediction of the clinical course of chronic obstructive pulmonary disease, using the new GOLD classification: a study of the general population" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Lange" 1 => "J.L. Marott" 2 => "J. Vestbo" 3 => "K.R. Olsen" 4 => "T.S. Ingebrigtsen" 5 => "M. Dahl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201207-1299OC" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2012" "volumen" => "186" "paginaInicial" => "975" "paginaFinal" => "981" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22997207" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0110" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Frequently asked questions (FAQs) about the GOLD 2011 assessment proposal of COPD: a comparative analysis of four different cohorts" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Agusti" 1 => "S. Hurd" 2 => "P. Jones" 3 => "L. Fabbri" 4 => "F. Martinez" 5 => "C. Vogelmeier" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00036513" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2013" "volumen" => "42" "paginaInicial" => "1391" "paginaFinal" => "1401" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23645406" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0115" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The distribution of COPD in UK general practice using the new GOLD classification" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J. Haughney" 1 => "K. Gruffydd-Jones" 2 => "J. Roberts" 3 => "A.J. Lee" 4 => "A. Hardwell" 5 => "L. McGarvey" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00065013" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2014" "volumen" => "43" "paginaInicial" => "993" "paginaFinal" => "1002" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24176990" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0120" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "[in press]" "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clasificación de los pacientes con EPOC según los sistemas de estadiaje ALAT y GOLD a partir de datos del estudio PUMA" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Montes de Oca" 1 => "M.V. López Varela" 2 => "M.E. Laucho Contreras" 3 => "A. Casas" 4 => "E. Schiavi" 5 => "A. Rey" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2016" ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0125" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía de práctica clínica de la enfermedad pulmonar obstructiva crónica (EPOC) ALAT-2014: preguntas y respuestas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Montes de Oca" 1 => "M.V. López Varela" 2 => "A. Acuña" 3 => "E. Schiavi" 4 => "M.A. Rey" 5 => "J. Jardim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.arbres.2014.11.017" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2015" "volumen" => "51" "paginaInicial" => "403" "paginaFinal" => "416" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25596991" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0130" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:3 [ "comentario" => "Available from: <span class="elsevierStyleInterRef" id="intr0015" href="http://goldcopd.org/">http://goldcopd.org</span> [accessed Nov 2016]" "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "From the global strategy for the diagnosis, management and prevention of COPD, global initiative for chronic obstructive lung disease (GOLD)" ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2017" ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0135" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía española de la EPOC (GesEPOC). Actualización 2014" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Miravitlles" 1 => "J.J. Soler-Cataluña" 2 => "M. Calle" 3 => "J. Molina" 4 => "P. Almagro" 5 => "J.A. Quintano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0300-2896(14)70070-5" "Revista" => array:7 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2014" "volumen" => "50" "numero" => "Suppl. 1" "paginaInicial" => "1" "paginaFinal" => "16" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24507959" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0140" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "¿Qué ha supuesto la guía española de la EPOC (GesEPOC) y cómo puede mejorar?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M. Miravitlles" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0300-2896(16)30197-1" "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2016" "volumen" => "52" "paginaInicial" => "1" "paginaFinal" => "2" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27389766" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0145" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Arnedillo A, Calle M, de Lucas P, Monsó E, Soler JJ. Observatorio EPOC. Encuesta de opinión sobre la normativa de tratamiento de la EPOC. Sociedad Española de Neumología y Cirugía Torácica (SEPAR). <a href="http://www.separcontenidos.es/site/?q=node/363">http://www.separcontenidos.es/site/?q=node/363</a>" ] ] ] 14 => array:3 [ "identificador" => "bib0150" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The path to personalised medicine in COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "A. Agustí" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thoraxjnl-2014-205507" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2014" "volumen" => "69" "paginaInicial" => "857" "paginaFinal" => "864" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24781218" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000003/v1_201703240112/S1579212916303482/v1_201703240112/en/main.assets" "Apartado" => array:4 [ "identificador" => "46447" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000003/v1_201703240112/S1579212916303482/v1_201703240112/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916303482?idApp=UINPBA00003Z" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 39 | 18 | 57 |
| 2024 September | 33 | 13 | 46 |
| 2024 August | 71 | 35 | 106 |
| 2024 July | 41 | 28 | 69 |
| 2024 June | 52 | 25 | 77 |
| 2024 May | 77 | 31 | 108 |
| 2024 April | 41 | 29 | 70 |
| 2024 March | 44 | 18 | 62 |
| 2024 February | 29 | 19 | 48 |
| 2023 March | 9 | 2 | 11 |
| 2023 February | 24 | 21 | 45 |
| 2023 January | 24 | 25 | 49 |
| 2022 December | 43 | 23 | 66 |
| 2022 November | 44 | 24 | 68 |
| 2022 October | 49 | 28 | 77 |
| 2022 September | 18 | 27 | 45 |
| 2022 August | 37 | 38 | 75 |
| 2022 July | 30 | 33 | 63 |
| 2022 June | 17 | 31 | 48 |
| 2022 May | 30 | 26 | 56 |
| 2022 April | 39 | 24 | 63 |
| 2022 March | 41 | 35 | 76 |
| 2022 February | 34 | 27 | 61 |
| 2022 January | 36 | 29 | 65 |
| 2021 December | 37 | 44 | 81 |
| 2021 November | 31 | 41 | 72 |
| 2021 October | 37 | 52 | 89 |
| 2021 September | 40 | 47 | 87 |
| 2021 August | 39 | 35 | 74 |
| 2021 July | 27 | 24 | 51 |
| 2021 June | 38 | 40 | 78 |
| 2021 May | 34 | 46 | 80 |
| 2021 April | 105 | 109 | 214 |
| 2021 March | 43 | 21 | 64 |
| 2021 February | 20 | 26 | 46 |
| 2021 January | 33 | 10 | 43 |
| 2020 December | 30 | 26 | 56 |
| 2020 November | 33 | 19 | 52 |
| 2020 October | 24 | 20 | 44 |
| 2020 September | 22 | 11 | 33 |
| 2020 August | 24 | 16 | 40 |
| 2020 July | 29 | 21 | 50 |
| 2020 June | 12 | 12 | 24 |
| 2020 May | 28 | 9 | 37 |
| 2020 April | 26 | 23 | 49 |
| 2020 March | 25 | 8 | 33 |
| 2020 February | 47 | 15 | 62 |
| 2020 January | 26 | 15 | 41 |
| 2019 December | 25 | 12 | 37 |
| 2019 November | 29 | 25 | 54 |
| 2019 October | 27 | 16 | 43 |
| 2019 September | 19 | 11 | 30 |
| 2019 August | 31 | 11 | 42 |
| 2019 July | 24 | 19 | 43 |
| 2019 June | 19 | 10 | 29 |
| 2019 May | 33 | 15 | 48 |
| 2019 April | 36 | 22 | 58 |
| 2019 March | 38 | 13 | 51 |
| 2019 February | 26 | 13 | 39 |
| 2019 January | 20 | 9 | 29 |
| 2018 December | 28 | 18 | 46 |
| 2018 November | 75 | 15 | 90 |
| 2018 October | 107 | 17 | 124 |
| 2018 September | 54 | 14 | 68 |
| 2018 May | 33 | 1 | 34 |
| 2018 April | 44 | 5 | 49 |
| 2018 March | 63 | 6 | 69 |
| 2018 February | 76 | 8 | 84 |
| 2018 January | 148 | 7 | 155 |
| 2017 December | 52 | 6 | 58 |
| 2017 November | 18 | 8 | 26 |
| 2017 October | 19 | 6 | 25 |
| 2017 September | 23 | 5 | 28 |
| 2017 August | 23 | 11 | 34 |
| 2017 July | 19 | 15 | 34 |
| 2017 June | 36 | 19 | 55 |
| 2017 May | 1 | 1 | 2 |
| 2017 April | 2 | 0 | 2 |
| 2017 March | 0 | 2 | 2 |
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