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estimated at 328<span class="elsevierStyleHsp" style=""></span>615<span class="elsevierStyleHsp" style=""></span>000 individuals worldwide&#46; Currently this disease is the third cause of death&#44; after ischemic heart disease and cerebrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Data from the 2007 EPI-SCAN study indicate that the prevalence of COPD in Spain is 10&#46;2&#37; &#40;15&#46;1&#37; in men and 5&#46;7&#37; in women&#41; of the population aged between 40 and 80 years&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a> The rate of underdiagnosis can be as high as 73&#37;&#44; although this varies widely depending on geographical region&#44; and distribution among the sexes is uneven&#44; with 1&#46;27 times more women being underdiagnosed than men &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain&#44; population aging&#44; which affects women more than men due to their greater longevity&#44; and the massive surge in smoking among women during the 1970s have led to an increase in smoking-related diseases particularly in middle-aged women&#44; and with it not only an increase in prevalence&#44; but also in associated morbidity and mortality&#46; According to a U&#46;S&#46; study&#44; the rate of mortality associated with COPD in women rose 5-fold in that country between 1971 and 2000&#44; and in 2000&#44; the number of deaths due to COPD in women &#40;59<span class="elsevierStyleHsp" style=""></span>936&#41; overtook that of men &#40;59<span class="elsevierStyleHsp" style=""></span>118&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite these data&#44; COPD is still considered mainly a &#8220;man&#39;s disease&#8221;&#44; causing a diagnostic bias that contributes to underdiagnosis in women&#46; Two similar studies&#44; one conducted in the U&#46;S&#46; and Canada<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">8</span></a> and the other in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a> concluded that diagnosis of COPD was biased according to the sex of the patient&#46; The results showed that men have a 1&#46;5-fold chance of receiving a provisional diagnosis of COPD&#44; a bias that is significantly reduced when abnormal spirometry results are available&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Risk Factors</span><p id="par0030" class="elsevierStylePara elsevierViewall">The main risk factor for developing COPD is smoking &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Numerous studies have evaluated the hypothesis that women are more susceptible to the toxic effects of tobacco than men&#46; A study published in 1997 that included 13<span class="elsevierStyleHsp" style=""></span>987 individuals from 2 populations in Denmark<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">10</span></a> concluded that smoking has a greater impact on the deterioration of lung function in women than in men&#44; a result that corroborated earlier findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">11&#44;12</span></a> Later&#44; Sorheim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">13</span></a> observed that in a group of COPD patients aged under 60 years&#44; women who smoked less &#40;&#60;20 pack-years&#41; had lower absolute and percentage values for forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; than men&#59; while women with a smoking history of more than 25&#8211;30 pack-years had similar figures to men &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Greater susceptibility to tobacco may be determined by anatomical &#40;smaller airways&#41;&#44; genetic and hormonal factors&#44; and this difference may manifest already in childhood&#44; since girls undergo greater lung function deterioration than boys when exposed to smoke or environmental pollution&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">14</span></a> Foreman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> analyzed the data from 2500 individuals included in the Genetic Epidemiology of COPD &#40;COPDGene&#41; study&#44; and concluded that women and African Americans may be more susceptible to the toxic effects of smoking&#44; since they experience more severe disease forms with earlier onset&#46; The results of this study also indicate that a maternal history of smoking or respiratory diseases were also significantly associated with earlier and more severe forms of COPD&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In biological terms&#44; studies conducted in animals confirm that females may be more susceptible to the deleterious effects of smoking&#46; Estrogens and other related compounds may increase the expression of the cytochrome P450 &#40;CYP&#41; enzyme&#44; which is directly involved in the metabolism of some of the components of tobacco smoke&#44; such as polycyclic aromatic hydrocarbons&#46; Bioactivation of these compounds by CYP produces reactive substances that are highly toxic to the lung and potentially carcinogenic&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Other risk factors for the development of COPD&#44; in addition to smoking&#44; include <span class="elsevierStyleItalic">environmental pollution</span>&#44; which is increasing in developed countries&#44; and <span class="elsevierStyleItalic">occupational exposure</span> to organic dusts&#44; coal&#44; heavy metals&#44; textiles&#44; tin&#44; ceramics&#44; and glass&#46; One etiological factor that is growing in importance is exposure to <span class="elsevierStyleItalic">smoke from biomass combustion</span>&#44; which primarily affects women in rural areas and&#47;or in developing countries&#44; who cook in poorly ventilated environments where concentrations of material particles in room air are higher than the recommended levels&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Published data emerging mainly from Latin American cohorts in Mexico and Colombia<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">19&#44;20</span></a> suggest that the clinical presentation of COPD caused by this exposure has a greater component of chronic bronchitis and less emphysema&#44; while survival rates are similar to those of women with COPD caused by smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Presentation</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dyspnea</span> is one of the characteristic symptoms of COPD and one of the main prognostic factors determining survival and quality of life of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">22</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">According to several published studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">23&#44;24</span></a> women report higher grades of dyspnea than men&#44; measured according to the modified Medical Research Council &#40;mMRC&#41; scale&#44; even with similar airflow obstruction and less exposure to tobacco&#46; A study published by De Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a> shows that in women&#44; but not in men&#44; the best predictor of dyspnea is the central respiratory drive&#44; suggesting that other non-physiological factors&#44; such as anxiety or depression may be involved and should be systematically evaluated in these patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cough</span> and <span class="elsevierStyleItalic">chronic expectoration</span> are other symptoms that also characterize respiratory diseases and COPD in particular&#46; A study published in 2012 in 4500 COPD patients&#44; 740 of which were women&#44; concluded that female patients reported higher grades of dyspnea than males&#44; but less cough and expectoration&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> The results of the EPI-SCAN also found that women with COPD have comparatively less sputum production than men&#44; a factor that may be affected by social factors&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Wheezing</span> is more common in women with COPD than in men&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a> probably because they have more airway involvement and greater bronchial hyperreactivity&#44; which may be a reason for the high incidence of the mixed COPD-asthma phenotype among women smokers&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exercise capacity</span> is determined with a submaximal exertion test&#44; the 6-minute walk test &#40;6MWT&#41;&#44; and&#44; like dyspnea&#44; is another predictor of mortality in COPD patient&#46; Several studies have found that both male and female COPD patients have lower than expected exercise capacity&#44; and this parameter is more useful as a prognostic factor in men&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">30</span></a> It was initially thought that this limitation was due to respiratory dysfunction &#40;airflow resistance and pulmonary hyperinflation as an independent mortality factor both in men and in women<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a>&#41;&#44; although we now know that it is due in large part to differences in the use of oxygen by skeletal muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">32</span></a> In a study measuring the results of cardiopulmonary exercise tests performed on a cycle ergometer&#44; women with COPD showed lower peak anaerobic power and lower optimal velocity than men&#44; probably related with loss of lean muscle mass in the lower limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Several studies have shown significant differences in the <span class="elsevierStyleItalic">prevalence and distribution of emphysema</span> between men and women with COPD&#46; Mart&#237;nez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> of the National Emphysema Treatment Trial Research Group &#40;NETT&#41; included 1053 patients &#40;409 women&#41; undergoing screening for a lung volume reduction surgery program&#44; and compared clinical&#44; physiological&#44; radiological&#44; and histological data from a small subgroup of patients&#46; Comparatively&#44; women had smaller airway diameters with proportionately thicker walls&#59; emphysema was less extensive than in men&#44; and predominantly central in distribution&#46; Dransfield et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">35</span></a> found that&#44; irrespective of disease severity&#44; male COPD patients who were smokers or former smokers had greater areas of emphysema on radiography than women with the same disease&#46; However&#44; a study published by Hardin et al&#46; in 2016 concluded that women in 3 phenotype subgroups &#40;early-onset COPD&#44; severe emphysema&#44; and grade IV COPD according to Global Initiative for Obstructive Lung Diseases &#40;GOLD&#41; criteria&#41; had a comparable grade of emphysema to men&#44; despite a lower pack-year index&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">36</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nutritional status</span> is a basic clinical parameter that must be evaluated in COPD patients using body mass index &#40;BMI&#41; or fat-free mass index &#40;FFMI&#41; measured with bioimpedance&#46; A study published in 1999 showed that COPD-related mortality increased considerably when BMI was lower than 21&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a> Several subsequent papers indicate that nutritional changes are more prevalent in women with COPD than in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">24&#44;30</span></a> According to a study published in 2006&#44; a reduced FFMI in patients with normal BMI is closely related with the female sex&#44; so the complete and systematic evaluation of the nutritional status in women is recommended&#44; in view of its potential as a prognostic factor&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">38</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exacerbations</span> are episodes of clinical instability that cause significant deterioration in health-related quality of life among COPD patients&#44; affecting disease progression and increasing the risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">39</span></a> According to the available data&#44; women have a greater number of exacerbations&#44;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">24&#44;40&#44;41</span></a> but hospitalization rates are similar in both women and men&#44; and readmission and survival rates after exacerbation are better in women&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Concomitant Disease</span><p id="par0090" class="elsevierStylePara elsevierViewall">COPD is a complex disease with multisystem manifestations&#44; and is associated throughout its course with other diseases or comorbidities that complicate the health status and prognosis of these patients&#46; Some of the most common include cardiovascular diseases&#44; lung cancer&#44; osteoporosis&#44; diabetes mellitus&#44; and affective disorders &#40;anxiety and depression&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">According to the ECLIPSE study&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">41</span></a> cardiovascular diseases are less prevalent in women with COPD&#44; while osteoporosis and affective disorders are more common in women than in men&#46; The results of the ECCO study<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a> indicate that there are significant sex-dependent differences in the comorbidities of these patients&#44; and these may be underestimated if the only method of quantification used is the Charlson index&#46; According to this study&#44; women with COPD have a lower prevalence of ischemic heart disease than men&#44; but a higher rate of heart failure&#44; osteoporosis&#44; and diabetes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anxiety and depression</span> are very common among COPD patients and have a significant impact on the disease because of their effect on symptom management&#44; quality of life&#44; and prognosis&#46; Studies in this area indicate that women have much higher rates of anxiety and depression&#44; even when disease involvement is moderate in terms of airflow obstruction and respiratory symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> Anxiety and depression in women with COPD is associated with a greater risk of exacerbation&#44; longer hospital stays&#44; persistent smoking habit&#44; less physical activity&#44; greater mortality&#44; and possibly poorer treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Osteoporosis</span> is one of the most important comorbidities associated with COPD&#44; with a prevalence of around 35&#37;&#46; It predominantly affects women&#44; particularly after menopause&#46; Factors such as age&#44; smoking&#44; and the use of systemic corticosteroids are involved in the development of osteoporosis in these patients and are associated with more severe forms of the disease and a poor nutritional status&#46; Clinical management of COPD patients&#44; then&#44; must include a bone scan and determination of bone mineralization markers&#44; so that early treatment with bisphosphonates&#44; calcium &#40;if dietary intake is insufficient&#41;&#44; and vitamin D supplements can be started if deficiencies are detected&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Prognosis</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Health-related quality of life</span> is a parameter directly associated with hospitalization&#44; use of healthcare resources&#44; response to treatment or mortality in COPD patients&#44; and can be evaluated with the Saint George&#39;s respiratory quality of life questionnaire &#40;SGRQ&#41;&#46; Health-related quality of life is poorer among women with COPD than men&#44; and women begin to experience symptoms at an earlier age and with less severe airflow obstruction&#46; In men&#44; parameters such as dyspnea&#44; exercise capacity&#44; degree of hyperinflation&#44; or comorbidities are significantly associated with the overall SGRQ score&#44; whereas in women only dyspnea and arterial oxygen tension are significantly correlated&#44; suggesting the need to find other factors for evaluation&#44; such as anxiety or depression&#44; that might explain the greater and earlier deterioration in quality of life among women&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Until relatively recently&#44; disease prognosis was evaluated purely on the basis of lung function involvement measured according to the predicted percentage of FEV<span class="elsevierStyleInf">1</span>&#46; This changed drastically with the introduction of multidimensional indexes&#44; such as BODE &#40;<span class="elsevierStyleItalic">Body mass index</span> &#91;BMI&#93;&#44; <span class="elsevierStyleItalic">Airflow obstruction</span>&#44; <span class="elsevierStyleItalic">Dyspnea</span>&#44; <span class="elsevierStyleItalic">Exercise capacity</span>&#41;&#44; which have greater prognostic value and better represent the heterogeneous nature of the disease<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> A study published in 2007 suggested that the proportional weight of each of the components of the BODE index varied between men and women&#44; and that in women the most important parameter was dyspnea grade according to the mMRC scale and BMI&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">30</span></a> Despite these variations&#44; BODE is an excellent predictor of mortality &#40;respiratory and all-cause&#41; in both sexes&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment</span><p id="par0120" class="elsevierStylePara elsevierViewall">Smoking is the major risk factor for COPD in the developed world&#44; so <span class="elsevierStyleItalic">smoking cessation</span> is the main intervention for delaying the progressive decline in lung function seen with this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">2</span></a> As mentioned above&#44; women appear to be more susceptible than men to the toxic effects of tobacco&#44; and some studies show that they are less likely to give up smoking&#44; and that their long-term cessation rate is lower than in men&#44; probably because they experience less symptomatic benefit after smoking cessation&#46; However&#44; according to the results of the Lung Health Study&#44; women who give up smoking definitively experience an improvement in lung function &#40;FEV<span class="elsevierStyleInf">1</span>&#41; 2&#46;5 times greater than that of men&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> Some of the most widely used drugs in smoking cessation&#44; such as bupropion and varenicline&#44; appear to be as effective in women as in men&#44; while nicotine replacement therapy is more effective in men&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Pharmacological treatment for COPD is based on <span class="elsevierStyleItalic">long-acting bronchodilators</span> administered via inhalation devices&#44; and a good inhalation technique is essential to ensure their efficacy&#46; A study published in 1994 found that inhalation technique was poorer among women than men in the same age group&#44; and errors in each of the inhalation procedures were observed&#46; Proper training in the use of these devices is essential to optimize treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">50</span></a> In the past&#44; few studies on the use of pharmacological agents in COPD were designed to evaluate efficacy by sex&#44; so the information available on the peculiarities of inhaled treatment in women is scant and occasionally contradictory&#46; In the TRISTAN study&#44; Vestbo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">51</span></a> reanalyzed the efficacy of the combination of salmeterol&#47;fluticasone on lung function &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#44; exacerbation rates and quality of life of COPD patients&#44; and found no differences between sexes&#46; However&#44; a more recent meta-analysis published by Soriano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">52</span></a> reported greater improvement in lung function in COPD patients in the first 6 months of treatment with inhaled corticosteroid in women &#40;this finding again supports the idea of greater bronchial hyperreactivity among women&#41;&#44; and in patients who had given up smoking&#46; The results of the UPLIFT study&#44; which evaluated the effects of tiotropium bromide on lung function&#44; quality of life&#44; and exacerbations&#44; found no significant differences according to sex&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">53</span></a> Although these studies contribute significant information with possibly therapeutic implications&#44; new studies are needed to draw a more accurate picture of the appropriate medical treatment of women with COPD&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Respiratory rehabilitation</span> has been shown to be a mainstay in the treatment of COPD&#44; since it improves dyspnea&#44; quality of life&#44; exercise tolerance&#44; and reduces exacerbations and the use of health resources&#46; Rehabilitation programs must combine peripheral muscle training with specific respiratory muscle training&#44; psychosocial&#47;behavioral education&#44; and nutritional interventions&#44; among others&#46; The minimum recommended duration of programs is 8 weeks or 20 sessions&#44; at a rate of 2&#8211;5<span class="elsevierStyleHsp" style=""></span>sessions&#47;week&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">39&#44;54</span></a> Studies that evaluate the response of COPD patients to pulmonary rehabilitation programs have found no significant differences in benefit with regard to sex&#44; but it must be mentioned that women obtain a much greater benefit in the initial months of physical training&#44; similar to the long-term effect&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">55</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Long-term home oxygen therapy</span> &#40;LTOT&#41; is indicated in patients with COPD and severe resting hypoxemia as it improves quality of life and survival&#44; but differences in the effect of this treatment between the sexes is not clearly defined&#46; Studies&#44; such as that of Miyamoto et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">56</span></a> found that women receiving LTOT had improved survival compared to men&#44; irrespective of the etiology of their respiratory failure&#46; These results were subsequently confirmed by Crockett et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">57</span></a> and Franklin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">58</span></a> In contrast&#44; a recently published study by Machado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">59</span></a> showed that among patients with COPD receiving LTOT&#44; survival is significantly lower in women&#44; in individuals with lower BMI&#44; and in those with higher grades of respiratory failure&#46; These conflicting results underline the need for new studies to evaluate the possible existence of a difference between sexes in response to LTOT&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Unfortunately&#44; we do not have any specific information on the effect of sex on the results of surgical &#40;lung volume reduction&#41; or endoscopic &#40;valves or coils&#41; treatment for reducing lung volume in patients with emphysema&#46; However&#44; given the unique characteristics of the clinical presentation of COPD in women&#44; differences in response to these treatments are only to be expected&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">COPD is a growing health issue among women&#46; Our priority is to design educational programs and training courses to emphasize the importance of COPD in the female sex and to help raise clinical suspicion and reduce underdiagnosis&#46; Similarly&#44; the therapeutic management of these patients must be optimized with better differential characterization and special attention to comorbidities such as osteoporosis&#44; anxiety or depression&#46;</p></span></span>"
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                        0 => array:2 [
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                          "autores" => array:6 [
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Special Article
Chronic Obstructive Pulmonary Disease in Women. Is it Different?
Enfermedad pulmonar obstructiva crónica en mujeres: ¿somos diferentes?
Tamara Alonsoa,
Corresponding author
marita-med@hotmail.com

Corresponding author.
, Patricia Sobradillob, Juan P. de Torresc
a Servicio de Neumología, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Madrid, Spain
b Servicio de Neumología, Hospital Universitario Araba, Vitoria-Gasteiz, Spain
c Servicio de Neumología, Clínica Universidad de Navarra, Pamplona, Spain
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estimated at 328<span class="elsevierStyleHsp" style=""></span>615<span class="elsevierStyleHsp" style=""></span>000 individuals worldwide&#46; Currently this disease is the third cause of death&#44; after ischemic heart disease and cerebrovascular disease&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Data from the 2007 EPI-SCAN study indicate that the prevalence of COPD in Spain is 10&#46;2&#37; &#40;15&#46;1&#37; in men and 5&#46;7&#37; in women&#41; of the population aged between 40 and 80 years&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">5</span></a> The rate of underdiagnosis can be as high as 73&#37;&#44; although this varies widely depending on geographical region&#44; and distribution among the sexes is uneven&#44; with 1&#46;27 times more women being underdiagnosed than men &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">In Spain&#44; population aging&#44; which affects women more than men due to their greater longevity&#44; and the massive surge in smoking among women during the 1970s have led to an increase in smoking-related diseases particularly in middle-aged women&#44; and with it not only an increase in prevalence&#44; but also in associated morbidity and mortality&#46; According to a U&#46;S&#46; study&#44; the rate of mortality associated with COPD in women rose 5-fold in that country between 1971 and 2000&#44; and in 2000&#44; the number of deaths due to COPD in women &#40;59<span class="elsevierStyleHsp" style=""></span>936&#41; overtook that of men &#40;59<span class="elsevierStyleHsp" style=""></span>118&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite these data&#44; COPD is still considered mainly a &#8220;man&#39;s disease&#8221;&#44; causing a diagnostic bias that contributes to underdiagnosis in women&#46; Two similar studies&#44; one conducted in the U&#46;S&#46; and Canada<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">8</span></a> and the other in Spain&#44;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">9</span></a> concluded that diagnosis of COPD was biased according to the sex of the patient&#46; The results showed that men have a 1&#46;5-fold chance of receiving a provisional diagnosis of COPD&#44; a bias that is significantly reduced when abnormal spirometry results are available&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Risk Factors</span><p id="par0030" class="elsevierStylePara elsevierViewall">The main risk factor for developing COPD is smoking &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Numerous studies have evaluated the hypothesis that women are more susceptible to the toxic effects of tobacco than men&#46; A study published in 1997 that included 13<span class="elsevierStyleHsp" style=""></span>987 individuals from 2 populations in Denmark<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">10</span></a> concluded that smoking has a greater impact on the deterioration of lung function in women than in men&#44; a result that corroborated earlier findings&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">11&#44;12</span></a> Later&#44; Sorheim et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">13</span></a> observed that in a group of COPD patients aged under 60 years&#44; women who smoked less &#40;&#60;20 pack-years&#41; had lower absolute and percentage values for forced expiratory volume in 1 second &#40;FEV<span class="elsevierStyleInf">1</span>&#41; than men&#59; while women with a smoking history of more than 25&#8211;30 pack-years had similar figures to men &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Greater susceptibility to tobacco may be determined by anatomical &#40;smaller airways&#41;&#44; genetic and hormonal factors&#44; and this difference may manifest already in childhood&#44; since girls undergo greater lung function deterioration than boys when exposed to smoke or environmental pollution&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">14</span></a> Foreman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">15</span></a> analyzed the data from 2500 individuals included in the Genetic Epidemiology of COPD &#40;COPDGene&#41; study&#44; and concluded that women and African Americans may be more susceptible to the toxic effects of smoking&#44; since they experience more severe disease forms with earlier onset&#46; The results of this study also indicate that a maternal history of smoking or respiratory diseases were also significantly associated with earlier and more severe forms of COPD&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In biological terms&#44; studies conducted in animals confirm that females may be more susceptible to the deleterious effects of smoking&#46; Estrogens and other related compounds may increase the expression of the cytochrome P450 &#40;CYP&#41; enzyme&#44; which is directly involved in the metabolism of some of the components of tobacco smoke&#44; such as polycyclic aromatic hydrocarbons&#46; Bioactivation of these compounds by CYP produces reactive substances that are highly toxic to the lung and potentially carcinogenic&#46;<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">16&#44;17</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Other risk factors for the development of COPD&#44; in addition to smoking&#44; include <span class="elsevierStyleItalic">environmental pollution</span>&#44; which is increasing in developed countries&#44; and <span class="elsevierStyleItalic">occupational exposure</span> to organic dusts&#44; coal&#44; heavy metals&#44; textiles&#44; tin&#44; ceramics&#44; and glass&#46; One etiological factor that is growing in importance is exposure to <span class="elsevierStyleItalic">smoke from biomass combustion</span>&#44; which primarily affects women in rural areas and&#47;or in developing countries&#44; who cook in poorly ventilated environments where concentrations of material particles in room air are higher than the recommended levels&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">18</span></a> Published data emerging mainly from Latin American cohorts in Mexico and Colombia<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">19&#44;20</span></a> suggest that the clinical presentation of COPD caused by this exposure has a greater component of chronic bronchitis and less emphysema&#44; while survival rates are similar to those of women with COPD caused by smoking&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Clinical Presentation</span><p id="par0050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Dyspnea</span> is one of the characteristic symptoms of COPD and one of the main prognostic factors determining survival and quality of life of these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">22</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">According to several published studies&#44;<a class="elsevierStyleCrossRefs" href="#bib0410"><span class="elsevierStyleSup">23&#44;24</span></a> women report higher grades of dyspnea than men&#44; measured according to the modified Medical Research Council &#40;mMRC&#41; scale&#44; even with similar airflow obstruction and less exposure to tobacco&#46; A study published by De Torres et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">25</span></a> shows that in women&#44; but not in men&#44; the best predictor of dyspnea is the central respiratory drive&#44; suggesting that other non-physiological factors&#44; such as anxiety or depression may be involved and should be systematically evaluated in these patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Cough</span> and <span class="elsevierStyleItalic">chronic expectoration</span> are other symptoms that also characterize respiratory diseases and COPD in particular&#46; A study published in 2012 in 4500 COPD patients&#44; 740 of which were women&#44; concluded that female patients reported higher grades of dyspnea than males&#44; but less cough and expectoration&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a> The results of the EPI-SCAN also found that women with COPD have comparatively less sputum production than men&#44; a factor that may be affected by social factors&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">6</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Wheezing</span> is more common in women with COPD than in men&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">27</span></a> probably because they have more airway involvement and greater bronchial hyperreactivity&#44; which may be a reason for the high incidence of the mixed COPD-asthma phenotype among women smokers&#46;<a class="elsevierStyleCrossRefs" href="#bib0435"><span class="elsevierStyleSup">28&#44;29</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exercise capacity</span> is determined with a submaximal exertion test&#44; the 6-minute walk test &#40;6MWT&#41;&#44; and&#44; like dyspnea&#44; is another predictor of mortality in COPD patient&#46; Several studies have found that both male and female COPD patients have lower than expected exercise capacity&#44; and this parameter is more useful as a prognostic factor in men&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">30</span></a> It was initially thought that this limitation was due to respiratory dysfunction &#40;airflow resistance and pulmonary hyperinflation as an independent mortality factor both in men and in women<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a>&#41;&#44; although we now know that it is due in large part to differences in the use of oxygen by skeletal muscle&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">32</span></a> In a study measuring the results of cardiopulmonary exercise tests performed on a cycle ergometer&#44; women with COPD showed lower peak anaerobic power and lower optimal velocity than men&#44; probably related with loss of lean muscle mass in the lower limbs&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">33</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Several studies have shown significant differences in the <span class="elsevierStyleItalic">prevalence and distribution of emphysema</span> between men and women with COPD&#46; Mart&#237;nez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">34</span></a> of the National Emphysema Treatment Trial Research Group &#40;NETT&#41; included 1053 patients &#40;409 women&#41; undergoing screening for a lung volume reduction surgery program&#44; and compared clinical&#44; physiological&#44; radiological&#44; and histological data from a small subgroup of patients&#46; Comparatively&#44; women had smaller airway diameters with proportionately thicker walls&#59; emphysema was less extensive than in men&#44; and predominantly central in distribution&#46; Dransfield et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">35</span></a> found that&#44; irrespective of disease severity&#44; male COPD patients who were smokers or former smokers had greater areas of emphysema on radiography than women with the same disease&#46; However&#44; a study published by Hardin et al&#46; in 2016 concluded that women in 3 phenotype subgroups &#40;early-onset COPD&#44; severe emphysema&#44; and grade IV COPD according to Global Initiative for Obstructive Lung Diseases &#40;GOLD&#41; criteria&#41; had a comparable grade of emphysema to men&#44; despite a lower pack-year index&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">36</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Nutritional status</span> is a basic clinical parameter that must be evaluated in COPD patients using body mass index &#40;BMI&#41; or fat-free mass index &#40;FFMI&#41; measured with bioimpedance&#46; A study published in 1999 showed that COPD-related mortality increased considerably when BMI was lower than 21&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">37</span></a> Several subsequent papers indicate that nutritional changes are more prevalent in women with COPD than in men&#46;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">24&#44;30</span></a> According to a study published in 2006&#44; a reduced FFMI in patients with normal BMI is closely related with the female sex&#44; so the complete and systematic evaluation of the nutritional status in women is recommended&#44; in view of its potential as a prognostic factor&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">38</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Exacerbations</span> are episodes of clinical instability that cause significant deterioration in health-related quality of life among COPD patients&#44; affecting disease progression and increasing the risk of death&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">39</span></a> According to the available data&#44; women have a greater number of exacerbations&#44;<a class="elsevierStyleCrossRefs" href="#bib0415"><span class="elsevierStyleSup">24&#44;40&#44;41</span></a> but hospitalization rates are similar in both women and men&#44; and readmission and survival rates after exacerbation are better in women&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">42</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Concomitant Disease</span><p id="par0090" class="elsevierStylePara elsevierViewall">COPD is a complex disease with multisystem manifestations&#44; and is associated throughout its course with other diseases or comorbidities that complicate the health status and prognosis of these patients&#46; Some of the most common include cardiovascular diseases&#44; lung cancer&#44; osteoporosis&#44; diabetes mellitus&#44; and affective disorders &#40;anxiety and depression&#41;&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">According to the ECLIPSE study&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">41</span></a> cardiovascular diseases are less prevalent in women with COPD&#44; while osteoporosis and affective disorders are more common in women than in men&#46; The results of the ECCO study<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">43</span></a> indicate that there are significant sex-dependent differences in the comorbidities of these patients&#44; and these may be underestimated if the only method of quantification used is the Charlson index&#46; According to this study&#44; women with COPD have a lower prevalence of ischemic heart disease than men&#44; but a higher rate of heart failure&#44; osteoporosis&#44; and diabetes&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Anxiety and depression</span> are very common among COPD patients and have a significant impact on the disease because of their effect on symptom management&#44; quality of life&#44; and prognosis&#46; Studies in this area indicate that women have much higher rates of anxiety and depression&#44; even when disease involvement is moderate in terms of airflow obstruction and respiratory symptoms&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">44</span></a> Anxiety and depression in women with COPD is associated with a greater risk of exacerbation&#44; longer hospital stays&#44; persistent smoking habit&#44; less physical activity&#44; greater mortality&#44; and possibly poorer treatment adherence&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">26</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Osteoporosis</span> is one of the most important comorbidities associated with COPD&#44; with a prevalence of around 35&#37;&#46; It predominantly affects women&#44; particularly after menopause&#46; Factors such as age&#44; smoking&#44; and the use of systemic corticosteroids are involved in the development of osteoporosis in these patients and are associated with more severe forms of the disease and a poor nutritional status&#46; Clinical management of COPD patients&#44; then&#44; must include a bone scan and determination of bone mineralization markers&#44; so that early treatment with bisphosphonates&#44; calcium &#40;if dietary intake is insufficient&#41;&#44; and vitamin D supplements can be started if deficiencies are detected&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">45</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Prognosis</span><p id="par0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Health-related quality of life</span> is a parameter directly associated with hospitalization&#44; use of healthcare resources&#44; response to treatment or mortality in COPD patients&#44; and can be evaluated with the Saint George&#39;s respiratory quality of life questionnaire &#40;SGRQ&#41;&#46; Health-related quality of life is poorer among women with COPD than men&#44; and women begin to experience symptoms at an earlier age and with less severe airflow obstruction&#46; In men&#44; parameters such as dyspnea&#44; exercise capacity&#44; degree of hyperinflation&#44; or comorbidities are significantly associated with the overall SGRQ score&#44; whereas in women only dyspnea and arterial oxygen tension are significantly correlated&#44; suggesting the need to find other factors for evaluation&#44; such as anxiety or depression&#44; that might explain the greater and earlier deterioration in quality of life among women&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">46</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Until relatively recently&#44; disease prognosis was evaluated purely on the basis of lung function involvement measured according to the predicted percentage of FEV<span class="elsevierStyleInf">1</span>&#46; This changed drastically with the introduction of multidimensional indexes&#44; such as BODE &#40;<span class="elsevierStyleItalic">Body mass index</span> &#91;BMI&#93;&#44; <span class="elsevierStyleItalic">Airflow obstruction</span>&#44; <span class="elsevierStyleItalic">Dyspnea</span>&#44; <span class="elsevierStyleItalic">Exercise capacity</span>&#41;&#44; which have greater prognostic value and better represent the heterogeneous nature of the disease<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">47</span></a> A study published in 2007 suggested that the proportional weight of each of the components of the BODE index varied between men and women&#44; and that in women the most important parameter was dyspnea grade according to the mMRC scale and BMI&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">30</span></a> Despite these variations&#44; BODE is an excellent predictor of mortality &#40;respiratory and all-cause&#41; in both sexes&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">31</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment</span><p id="par0120" class="elsevierStylePara elsevierViewall">Smoking is the major risk factor for COPD in the developed world&#44; so <span class="elsevierStyleItalic">smoking cessation</span> is the main intervention for delaying the progressive decline in lung function seen with this disease&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">2</span></a> As mentioned above&#44; women appear to be more susceptible than men to the toxic effects of tobacco&#44; and some studies show that they are less likely to give up smoking&#44; and that their long-term cessation rate is lower than in men&#44; probably because they experience less symptomatic benefit after smoking cessation&#46; However&#44; according to the results of the Lung Health Study&#44; women who give up smoking definitively experience an improvement in lung function &#40;FEV<span class="elsevierStyleInf">1</span>&#41; 2&#46;5 times greater than that of men&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">48</span></a> Some of the most widely used drugs in smoking cessation&#44; such as bupropion and varenicline&#44; appear to be as effective in women as in men&#44; while nicotine replacement therapy is more effective in men&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">49</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Pharmacological treatment for COPD is based on <span class="elsevierStyleItalic">long-acting bronchodilators</span> administered via inhalation devices&#44; and a good inhalation technique is essential to ensure their efficacy&#46; A study published in 1994 found that inhalation technique was poorer among women than men in the same age group&#44; and errors in each of the inhalation procedures were observed&#46; Proper training in the use of these devices is essential to optimize treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">50</span></a> In the past&#44; few studies on the use of pharmacological agents in COPD were designed to evaluate efficacy by sex&#44; so the information available on the peculiarities of inhaled treatment in women is scant and occasionally contradictory&#46; In the TRISTAN study&#44; Vestbo et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">51</span></a> reanalyzed the efficacy of the combination of salmeterol&#47;fluticasone on lung function &#40;FEV<span class="elsevierStyleInf">1</span>&#41;&#44; exacerbation rates and quality of life of COPD patients&#44; and found no differences between sexes&#46; However&#44; a more recent meta-analysis published by Soriano et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">52</span></a> reported greater improvement in lung function in COPD patients in the first 6 months of treatment with inhaled corticosteroid in women &#40;this finding again supports the idea of greater bronchial hyperreactivity among women&#41;&#44; and in patients who had given up smoking&#46; The results of the UPLIFT study&#44; which evaluated the effects of tiotropium bromide on lung function&#44; quality of life&#44; and exacerbations&#44; found no significant differences according to sex&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">53</span></a> Although these studies contribute significant information with possibly therapeutic implications&#44; new studies are needed to draw a more accurate picture of the appropriate medical treatment of women with COPD&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Respiratory rehabilitation</span> has been shown to be a mainstay in the treatment of COPD&#44; since it improves dyspnea&#44; quality of life&#44; exercise tolerance&#44; and reduces exacerbations and the use of health resources&#46; Rehabilitation programs must combine peripheral muscle training with specific respiratory muscle training&#44; psychosocial&#47;behavioral education&#44; and nutritional interventions&#44; among others&#46; The minimum recommended duration of programs is 8 weeks or 20 sessions&#44; at a rate of 2&#8211;5<span class="elsevierStyleHsp" style=""></span>sessions&#47;week&#46;<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">39&#44;54</span></a> Studies that evaluate the response of COPD patients to pulmonary rehabilitation programs have found no significant differences in benefit with regard to sex&#44; but it must be mentioned that women obtain a much greater benefit in the initial months of physical training&#44; similar to the long-term effect&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">55</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Long-term home oxygen therapy</span> &#40;LTOT&#41; is indicated in patients with COPD and severe resting hypoxemia as it improves quality of life and survival&#44; but differences in the effect of this treatment between the sexes is not clearly defined&#46; Studies&#44; such as that of Miyamoto et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">56</span></a> found that women receiving LTOT had improved survival compared to men&#44; irrespective of the etiology of their respiratory failure&#46; These results were subsequently confirmed by Crockett et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">57</span></a> and Franklin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">58</span></a> In contrast&#44; a recently published study by Machado et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">59</span></a> showed that among patients with COPD receiving LTOT&#44; survival is significantly lower in women&#44; in individuals with lower BMI&#44; and in those with higher grades of respiratory failure&#46; These conflicting results underline the need for new studies to evaluate the possible existence of a difference between sexes in response to LTOT&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Unfortunately&#44; we do not have any specific information on the effect of sex on the results of surgical &#40;lung volume reduction&#41; or endoscopic &#40;valves or coils&#41; treatment for reducing lung volume in patients with emphysema&#46; However&#44; given the unique characteristics of the clinical presentation of COPD in women&#44; differences in response to these treatments are only to be expected&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conclusions</span><p id="par0145" class="elsevierStylePara elsevierViewall">COPD is a growing health issue among women&#46; Our priority is to design educational programs and training courses to emphasize the importance of COPD in the female sex and to help raise clinical suspicion and reduce underdiagnosis&#46; Similarly&#44; the therapeutic management of these patients must be optimized with better differential characterization and special attention to comorbidities such as osteoporosis&#44; anxiety or depression&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Alonso T&#44; Sobradillo P&#44; de Torres JP&#46; Enfermedad pulmonar obstructiva cr&#243;nica en mujeres&#58; &#191;somos diferentes&#63; Arch Bronconeumol&#46; 2017&#59;53&#58;222&#8211;227&#46;</p>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Dose&#8211;response relationship between number of pack-years and predicted percentage of forced expiratory volume in first second after bronchodilation &#40;post-PBD FEV1&#37; predicted&#41; in female COPD subjects and male COPD subjects&#44; expressed by linear regression with 95&#37; confidence interval&#46;</p>"
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                      "titulo" => "Gu&#237;a Espa&#241;ola de la EPOC &#40;GesEPOC&#41;&#46; Tratamiento farmacol&#243;gico de la EPOC estable"
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                          "autores" => array:6 [
                            0 => "M&#46; Miravitlles"
                            1 => "J&#46;J&#46; Soler-Catalu&#241;a"
                            2 => "M&#46; Calle"
                            3 => "J&#46; Molina"
                            4 => "P&#46; Almagro"
                            5 => "J&#46;A&#46; Quintano"
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                      "doi" => "10.1016/j.arbres.2012.04.001"
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                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2012"
                        "volumen" => "48"
                        "paginaInicial" => "247"
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        "titulo" => "Acknowledgements"
        "texto" => "<p id="par0150" class="elsevierStylePara elsevierViewall">We would like thank Mar&#237;a Pilar Aus&#237;n &#40;Servicio de Neumolog&#237;a&#46; Hospital del Mar&#44; Barcelona&#41;&#44; JB Soriano &#40;Servicio de Neumolog&#237;a&#44; Hospital Universitario de La Princesa&#44; Instituto de Investigaci&#243;n Sanitaria Princesa &#91;IP&#93;&#44; Madrid&#41;&#44; and Julio Ancochea &#40;Servicio de Neumolog&#237;a&#44; Hospital Universitario de La Princesa&#44; Instituto de Investigaci&#243;n Sanitaria Princesa &#91;IP&#93;&#44; Madrid&#41; for their important contribution to this manuscript&#46;</p>"
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ISSN: 15792129
Original language: English
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