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array:24 [ "pii" => "S1579212917301970" "issn" => "15792129" "doi" => "10.1016/j.arbr.2017.06.001" "estado" => "S300" "fechaPublicacion" => "2017-08-01" "aid" => "1608" "copyright" => "SEPAR" "copyrightAnyo" => "2017" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2017;53:443-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 4989 "formatos" => array:3 [ "EPUB" => 188 "HTML" => 2839 "PDF" => 1962 ] ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0300289617300923" "issn" => "03002896" "doi" => "10.1016/j.arbres.2017.04.002" "estado" => "S300" "fechaPublicacion" => "2017-08-01" "aid" => "1608" "copyright" => "SEPAR" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Arch Bronconeumol. 2017;53:443-9" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 22861 "formatos" => array:3 [ "EPUB" => 187 "HTML" => 18511 "PDF" => 4163 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Consenso sobre el solapamiento de asma y EPOC (ACO) entre la Guía española de la EPOC (GesEPOC) y la Guía Española para el Manejo del Asma (GEMA)" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "443" "paginaFinal" => "449" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Consensus on the Asthma-COPD Overlap Syndrome (ACOS) Between the Spanish COPD Guidelines (GesEPOC) and the Spanish Guidelines on the Management of Asthma (GEMA)" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2092 "Ancho" => 1583 "Tamanyo" => 133822 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Confirmación diagnóstica de ACO (solapamiento asma y EPOC).</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleBold">*</span> Mantenida tras tratamiento con GCI/LABA (6 meses). En algunos casos además tras ciclo de glucocorticoides orales (15 días).</p> <p id="spar9035" class="elsevierStyleSimplePara elsevierViewall">ACO: solapamiento asma y EPOC; céls: células; GCI: glucocorticoides inhalados; LABA: agonista β<span class="elsevierStyleInf">2</span> adrenérgico de acción larga; Paq: paquetes; PBD: prueba broncodilatadora.</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Fuente: Reproducido con permiso de la European Respiratory Society<span class="elsevierStyleSup">©</span>: Eur Respir J 2017; 49: 1700068 <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1183/13993003.00068-2017">doi:10.1183/13993003.00068-2017</span>.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Vicente Plaza, Francisco Álvarez, Myriam Calle, Ciro Casanova, Borja G. 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"apellidos" => "Cosío" ] 5 => array:2 [ "nombre" => "Antolín" "apellidos" => "López-Viña" ] 6 => array:2 [ "nombre" => "Luís" "apellidos" => "Pérez de Llano" ] 7 => array:2 [ "nombre" => "Santiago" "apellidos" => "Quirce" ] 8 => array:2 [ "nombre" => "Miguel" "apellidos" => "Román-Rodríguez" ] 9 => array:2 [ "nombre" => "Juan José" "apellidos" => "Soler-Cataluña" ] 10 => array:2 [ "nombre" => "Marc" "apellidos" => "Miravitlles" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1579212917301970" "doi" => "10.1016/j.arbr.2017.06.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917301970?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289617300923?idApp=UINPBA00003Z" "url" => "/03002896/0000005300000008/v1_201707280103/S0300289617300923/v1_201707280103/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S157921291730229X" "issn" => "15792129" "doi" => "10.1016/j.arbr.2016.12.019" "estado" => "S300" "fechaPublicacion" => "2017-08-01" "aid" => "1557" "copyright" => "SEPAR" "documento" => "article" "crossmark" => 1 "subdocumento" => "sco" "cita" => "Arch Bronconeumol. 2017;53:450" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1796 "formatos" => array:3 [ "EPUB" => 191 "HTML" => 1149 "PDF" => 456 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical image</span>" "titulo" => "Chagas Disease: An Important Cause of Megaesophagus in Latin America" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:1 [ "paginaInicial" => "450" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La enfermedad de Chagas: una causa importante del megaesófago en América Latina" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1504 "Ancho" => 1500 "Tamanyo" => 330732 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A chest radiograph (A) shows mediastinal widening with an air-fluid level, compatible with megaesophagus. 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"apellidos" => "Cosío" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "Antolín" "apellidos" => "López-Viña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 6 => array:3 [ "nombre" => "Luís" "apellidos" => "Pérez de Llano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 7 => array:3 [ "nombre" => "Santiago" "apellidos" => "Quirce" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 8 => array:3 [ "nombre" => "Miguel" "apellidos" => "Román-Rodríguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 9 => array:3 [ "nombre" => "Juan José" "apellidos" => "Soler-Cataluña" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 10 => array:3 [ "nombre" => "Marc" "apellidos" => "Miravitlles" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">k</span>" "identificador" => "aff0055" ] ] ] ] "afiliaciones" => array:11 [ 0 => array:3 [ "entidad" => "Servei de Pneumologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Virgen del Rocío, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Clínico San Carlos, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, CIBERES, Palma de Mallorca, Illes Balears, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Alergología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Centro de Salud de Son Pisà, Palma de Mallorca, Illes Balears, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Arnau de Vilanova, Valencia, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Servei de Pneumologia, Hospital Universitari Vall d’Hebron, Barcelona, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Consenso sobre el solapamiento de asma y EPOC (ACO) entre la Guía española de la EPOC (GesEPOC) y la Guía Española para el Manejo del Asma (GEMA)" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2092 "Ancho" => 1583 "Tamanyo" => 136989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diagnostic confirmation of asthma–COPD overlap.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">*Persistent after treatment with ICS/LABA (6 months). In some cases also after a cycle of oral corticosteroids (15 days).</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ACO: asthma–COPD overlap; c: cells; ICS: inhaled corticosteroids; LABA: long-acting β<span class="elsevierStyleInf">2</span>-agonist; PBD: post-bronchodilator; p-y: pack-years.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission of the European Respiratory Society ©: Eur Respir J 2017;49:1700068, <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1183/13993003.00068-2017">doi:10.1183/13993003.00068-2017</span>.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Asthma and chronic obstructive pulmonary disease (COPD) are different chronic respiratory diseases, but the prevalence of both is high, causing some patients to present both entities concomitantly. The Spanish COPD guidelines (GesEPOC)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> were the first to recognize this phenotype,<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">2</span></a> calling it the mixed COPD–asthma phenotype, but since then it has received several names, the most widely recognized nowadays being asthma–COPD overlap, or simply the acronym ACO. From the time it was identified, the notion of overlap has generated considerable debate, and some issues, particularly surrounding concept and diagnosis, remain unclear. Despite the rapprochement of opinions between asthma and COPD experts,<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">3</span></a> no uniform criteria are available to define ACO in patients with a previous diagnosis of asthma or COPD. Thus ACO might be defined as an evolving process for which new scientific evidence is still needed to reach definitive conclusions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently, inconsistencies in approaches to ACO proposed in the Spanish reference guidelines for asthma (Spanish Guidelines for the Management of Asthma [GEMA])<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> and for COPD (GesEPOC)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> have been pointed out in the different scientific respiratory medicine fora.<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">5</span></a> For this reason, on the initiative of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), authors representing both guidelines formed a working group with the aim of reaching consensus on a common definition.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Method</span><p id="par0015" class="elsevierStylePara elsevierViewall">This Spanish consensus on ACO was executed by the asthma and COPD special interest groups on the initiative of the SEPAR. The coordinators of GEMA and GesEPOC (VP and MM) convened a group of specialists who were involved in drawing up these guidelines, along with a representative from primary care (MRR) who has experience in ACO.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Firstly, the topics of the consensus were defined: concept and definition, epidemiology, diagnostic confirmation, and treatment. Each topic was reviewed by 2 experts, one GEMA representative and one GesEPOC representative. The most important points in each of the sections were discussed in an in-person meeting, and criteria and a diagnostic algorithm for ACO were agreed upon.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Subsequently, the coordinators prepared a questionnaire in which the key points of the proposal were submitted for consensus. The questionnaire, which was reviewed by the whole group, consisted of 20 questions, statements or claims, and was completed online on the SEPAR website (<a href="http://www.separ.es/">www.separ.es</a>).</p><p id="par0030" class="elsevierStylePara elsevierViewall">A large group of experts in the area of asthma and/or COPD were invited to participate and were given a copy of the draft consensus document. A total of 44 specialists completed the opinion survey, based partly on the Delphi method.<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">6,7</span></a> Of these, 29 were respiratory medicine experts, 5 allergologists, 5 primary care physicians, and 5 internal medicine physicians.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The respondents had to score their degree of agreement or disagreement with the wording of the question or statement on a 1–7 Likert scale, in such a way that 1 represented the greatest disagreement with the wording, moving progressively to 7, which represented the greatest agreement. Agreement on the question or statement was consensual when the median score was 6 or 7, and disagreement was consensual when the median was 1 or 2. A median of between 3 and 5 signified a neutral opinion, neither agreement nor disagreement. Participants completed the survey in a first round of questions; in a second round, only questions which did not achieve consensual agreement or disagreement in the first round were addressed. Mean values and standard deviation for the results, percentage of agreement and the percentage of responses with a score of 6 or 7 are shown.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Concept and Definition</span><p id="par0040" class="elsevierStylePara elsevierViewall">It is unknown if the overlapping clinical characteristics of COPD and asthma are due to the presence of 2 common diseases in the same patient, or if, in contrast, there is a common underlying pathogenic element. Longitudinal studies recognize childhood asthma as an independent risk factor for developing COPD, particularly when it coincides with smoking.<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">8</span></a> However, more than 100 genes that usually code for a lymphocyte T helper (Th2) immunoinflammatory signal and that have been linked with greater reversibility in bronchodilator tests, peripheral eosinophilia, and better response to treatment with inhaled corticosteroids (ICS), have been identified in patients with well-characterized COPD and no history of asthma.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">9</span></a> Despite these findings, insufficient evidence is available to claim a common origin, so the best description of the situation of these patients is overlapping asthma and COPD. Thus, the ACO patient group would include both smokers with asthma who develop persistent airflow obstruction, and COPD patients with characteristics of asthma.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">10</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">In general terms, this group of ACO patients has more symptoms, worse quality of life, and greater risk of exacerbations than patients with COPD, although their survival is longer.<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">11–15</span></a> Response to treatment with ICS in ACO has also been shown to be halfway between the sensitivity to corticosteroids shown by Th2-high asthmatic phenotypes and the resistance to corticosteroids shown by a large proportion of the COPD phenotypes.<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">14</span></a> Differences in clinical outcomes and response to treatment of the asthma and COPD components of ACO require different approaches.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This GesEPOC-GEMA consensus document defines ACO as the presence of persistent airflow limitation in a smoker or former smoker who presents characteristics of asthma. This definition requires the concomitant presence of 3 basic elements: (1) persistent airflow limitation over time, essential to confirm the presence of permanent obstruction that does not change spontaneously or after treatment; (2) accumulated history of smoking (current or past) as a principal risk factor; (3) typical characteristics of asthma, including clinical, biological and functional manifestations.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Epidemiology</span><p id="par0055" class="elsevierStylePara elsevierViewall">The prevalence of ACO in the general population ranges between 1.6% and 4.5%,<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10,12–16</span></a> in COPD patients between 12.1% and 55.2%,<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10,12–16</span></a> and in patients with asthma, between 13.3% and 61%.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">17,18</span></a> These wide variations reflect the type of population analyzed (analyses of databases or clinical studies), the different criteria used for the identification of ACO, and the definition of asthma and COPD.</p><p id="par0060" class="elsevierStylePara elsevierViewall">In a recently published metaanalysis<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">19</span></a> that included 19 studies, the prevalence of ACO among patients with a COPD diagnosis was 27% in population studies and 28% in studies performed in hospital patients. In other recent studies, prevalence ranges from 11% to 25%, depending on the definition.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">10,20,21</span></a> In Spain, the results of the recent CHAIN study, which included 831 patients with COPD from 36 university hospitals, showed a prevalence of ACO (using the specific major and minor modified GesEPOC criteria) of 15%.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">22</span></a> Another 2 observational studies conducted in Spanish populations of 3125 and 331 COPD patients found prevalences of 15.9%<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> and 12.1%,<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> respectively. These results are similar to those of the COPDGene study, which reported 13%,<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> and the MAJORICA study (population cohort of the Balearic Islands), which reported 18.3%.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the results of the main studies that have evaluated ACO prevalence.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">In short, although the prevalence of ACO varies widely depending on the source and the criteria used to define the syndrome, it seems to lie between 1.6% and 4.5% in the general adult population and between 15% and 25% in the adult population with chronic airflow obstruction.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Diagnostic Confirmation</span><p id="par0070" class="elsevierStylePara elsevierViewall">ACO diagnosis will be confirmed according to the following stepwise evaluation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>):<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Presence of chronic persistent airflow limitation (FEV<span class="elsevierStyleInf">1</span>/FVC post-bronchodilator <70%) in a patient ≥35 years, smoker or former smoker, with a smoking history of at least 10 pack-years.<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">1</span></a> In recently diagnosed patients, this criterion will be reevaluated after treatment with a long-acting β<span class="elsevierStyleInf">2</span>-agonist (LABA) and ICS and follow-up of at least 6 months; in some cases, it is also recommendable to administer a short course (15 days) of oral corticosteroids. Reversal of spirometric obstruction after these treatments will rule out the diagnosis of ACO in favor of a diagnosis of asthma.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0080" class="elsevierStylePara elsevierViewall">Diagnosis of current asthma.<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> Must include: (a) <span class="elsevierStyleItalic">history and/or symptoms causing clinical suspicion</span>: family history of asthma or personal history of asthma in childhood or personal history of atopy (sensitization to certain allergens), with respiratory symptoms (wheezing, cough, chest tightness) of variable course, on occasions in the form of a dyspneic crisis also of variable intensity, or inflammation of the upper airway (rhinosinusitis with or without nasal polyposis); and (b) <span class="elsevierStyleItalic">objective diagnostic confirmation</span>, with reversibility of obstruction of spirometric flows measure by spirometry or positive bronchodilator response (≥12% and ≥200<span class="elsevierStyleHsp" style=""></span>ml), or a diurnal variability of peak expiratory flow (PEF) ≥20%, or exhaled fractional exhaled nitric oxide (FE<span class="elsevierStyleInf">NO</span>) ≥50<span class="elsevierStyleHsp" style=""></span>ppb.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0085" class="elsevierStylePara elsevierViewall">If a diagnosis of asthma cannot be established, the ACO diagnosis will be confirmed if the bronchodilator response is very positive (≥15% and ≥400<span class="elsevierStyleHsp" style=""></span>ml), or if eosinophils are observed in blood (≥300<span class="elsevierStyleHsp" style=""></span>eosinophils/μl), or both. These characteristics, while not diagnostic of asthma in themselves, point toward the existence of a Th2-high inflammatory pattern, which allows a smoker with chronic airflow obstruction to be classified as ACO.<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">26</span></a></p></li></ul></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">In this way, the concept of ACO would encompass patients with a real asthma/COPD overlap, since they share both diagnoses, and to an even greater extent, patients with COPD with asthmatic features defined by an eosinophilic inflammatory component and/or great reversibility of the airflow obstruction.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Treatment</span><p id="par0095" class="elsevierStylePara elsevierViewall">Treatment objectives are also those common to both asthma and COPD individually: to prevent exacerbations, to achieve and maintain acceptable control of symptoms, and to reduce bronchial obstruction.</p><p id="par0100" class="elsevierStylePara elsevierViewall">ICS are the treatment of choice in asthma,<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">4</span></a> and patients with COPD and high Th2 expression respond to this treatment.<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">9</span></a> Thus, all patients with ACO should receive ICS. A notable increase in the risk of developing pneumonia has been observed with the use of ICS in patients with COPD, particularly at high doses.<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">27</span></a> It is unknown if the risk in the ACO patient is similar, so it seems reasonable to assume that the minimum clinically effective dose should be administered. Monotherapy with LABA is contraindicated in asthma, and monotherapy with ICS is contraindicated in COPD. The initial treatment of ACO, then, will be a combination of ICS/LABA. However, very few studies have evaluated the efficacy of these combinations in this setting,<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">28,29</span></a> and none have compared them against each other. Consequently, no recommendations can be established regarding the combination of choice.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Tiotropium reduces the risk of COPD<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">30</span></a> and asthma exacerbations in patients who do not achieve sufficient control with a combination of ICS/LABA.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">31</span></a> It has also been shown to improve lung function in asthmatics with persistent bronchial obstruction despite treatment with a combination of ICS/LABA, although the impact on symptoms and on quality of life does not appear to be clinically significant.<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">31</span></a> Consequently, the addition of tiotropium to a combination of ICS/LABA should be considered if exacerbations and/or significant symptoms persist. No experience has been published on the use in asthma of other long-acting muscarinic agonists (LAMA) that are effective in COPD, such as aclidinium, umeclidium, or glycopyrronium.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Other complementary treatments, such as smoking cessation, respiratory rehabilitation, nasal anti-inflammatories, and oxygen therapy, should also be considered, if indicated.</p><p id="par0115" class="elsevierStylePara elsevierViewall">No solid evidence is currently available to recommend the use of biologics in the treatment of ACO, although their use is recommended in some cases of severe asthma. However, some studies have shown promising results with some of these drugs.<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">32–34</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Consensus Opinion Survey</span><p id="par0120" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> lists the results of the analysis of the responses of the participants after the 2 rounds. In the first round, a wide consensus was achieved in 16 of the 20 questions. However, the 4 questions which did not achieve consensus in the first round also failed to achieve consensus in the second.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">The interpretation of the results of the survey shows that the ACO consensus received a widely positive overall evaluation from the respondents (practically 80% for question 19). The evaluation of this consensus was clearly better than that received by other recent guidelines, especially with regard to conceptual and therapeutic aspects. On the other hand, neither agreement nor disagreement (rejection of the statement) was reached for the proposal to consider a COPD patient with ≥300<span class="elsevierStyleHsp" style=""></span>eosinophils/μl in blood as ACO. This indicates that, while it is widely agreed that a very positive bronchodilator test is an asthmatic feature in a COPD patient,<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">35</span></a> and consequently can be considered a criterion for ACO,<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">35,36</span></a> raised eosinophilia is not usually perceived as a marker of Th2 inflammation. However, the authors of the consensus agreed to include it in the algorithm as it identifies patients who respond well to ICS.<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">37</span></a> Prospective clinical studies are currently ongoing that will help define more precisely the role of eosinophilia in the diagnosis of ACO.</p><p id="par0130" class="elsevierStylePara elsevierViewall">In our opinion, this consensus is a step forward, not only because agreement was reached, but also because the general opinion is that it is an improvement on the previous documents of our respective guidelines. In view of the current evidence, we consider that this consensus offers a rational overview of the problem and a simple, pragmatic diagnostic confirmation, applicable in all of the healthcare levels of our setting, fulfilling the objectives that we set out before undertaking this task.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">This consensus has been funded by a grant from the <span class="elsevierStyleGrantSponsor" id="gs1">Integrated Asthma and COPD Research Program</span> and <span class="elsevierStyleGrantSponsor" id="gs2">Areas of the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR)</span>.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflict of Interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">The authors received no fees for their participation in this consensus. However:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">VP states that in the last 3 years he has received fees for participating as a speaker in meetings organized by Chiesi, Esteve, GlaxoSmithKline, Novartis, Orion and Pfizer, and as a consultant for ALK, MundiPharma, Orion and Teva. He has received economic assistance for attending congresses from AstraZeneca, Chiesi and Novartis, and grants for research projects from AstraZeneca, Chiesi and Menarini.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0150" class="elsevierStylePara elsevierViewall">FA states that in the last 3 years he has acted as a consultant and received assistance for attending congresses and fees for participating as a speaker in various meeting from AstraZeneca, Boehringer Ingelheim, Esteve, GlaxoSmithKline, Novartis, MundiPharma, Pfizer, Sandoz, Teva, and has received grants for research projects from Chiesi, GlaxoSmithKline, Menarini and Novartis.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0155" class="elsevierStylePara elsevierViewall">MC states that she has received assistance for attending congresses and fees for participating as a speaker in various meeting from GlaxoSmithKline, Novartis, and Pfizer, and has received grants for research projects from AstraZeneca and Menarini.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">CC states that in the last 3 years he has received fees for speaking engagements and/or scientific consultancy from AstraZeneca, Boehringer-Ingelheim, Gebro Pharma, GlaxoSmithKline, Laboratorios Esteve, Menarini, Novartis and Rovi.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">BGC states that in the last 3 years he has acted as a consultant, received assistance for attending congresses and received fees for participating as a speaker in various meeting from GlaxoSmithKline, Novartis, Chiesi, Boehringer-Ingelheim, Menarini and Pfizer.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">ALV states that in the last 3 years he has acted as a consultant, received assistance for attending congresses and received fees for participating as a speaker in various meeting from TEVA, GlaxoSmithKline, Novartis, MundiPharma, Chiesi, Boehringer-Ingelheim, and Pfizer.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">LPLL states that in the last 3 years he has received payment from Novartis, Astra, Boehringer Ingelheim, Teva, Sanofi, Sandoz, Zambón, Boehringer Ingelheim, Chiesi, Pfizer, Almirall, MundiPharma, Esteve and Ferrer for presentations at medical congresses, consultancy, and coordination or participation in clinical research projects. He has also been invited to attend national and international congresses by some of these laboratories.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">SQ states that in the last 3 years he has received fees for participating as a speaker in meetings organized by CAstraZeneca, Chiesi, GlaxoSmithKline, Novartis AND Leti, and as a consultant for ALK, MundiPharma and Teva.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">MRR states that in the last 3 years he has received fees for participating as a speaker in meetings sponsored by AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Menarini, MundiPharma, Novartis, Pfizer, Rovi and Teva, and has received grants for research projects from GlaxoSmithKline and AstraZeneca.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">JJSC has received fees for scientific consultancy and/or for speaking at conferences from AstraZeneca, Boehringer Ingelheim, Chiesi, Ferrer, GlaxoSmithKline, Laboratorios Esteve, Menarini, MundiPharma, Novartis and Rovi.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">MM has received fees for scientific consultancy and/or for speaking at conferences from AstraZeneca, Boehringer Ingelheim, CSL Behring, Grupo Ferrer, GlaxoSmithKline, Grifols, Laboratorios Esteve, Teva, Cipla, Menarini, Novartis and Gebro Pharma.</p></li></ul></p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres875354" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec863538" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres875355" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec863539" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Method" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Concept and Definition" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Epidemiology" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Diagnostic Confirmation" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Treatment" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Consensus Opinion Survey" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflict of Interests" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-02-09" "fechaAceptado" => "2017-04-01" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec863538" "palabras" => array:5 [ 0 => "Chronic obstructive pulmonary disease" 1 => "Asthma" 2 => "Asthma–COPD overlap" 3 => "Consensus" 4 => "Delphi" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec863539" "palabras" => array:5 [ 0 => "Enfermedad pulmonar obstructiva crónica" 1 => "Asma" 2 => "Solapamiento asma y EPOC" 3 => "Consenso" 4 => "Delphi" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Following a proposal by the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR), sponsor of the Spanish COPD Guidelines (GesEPOC) and the Spanish Guidelines on the Management of Asthma (GEMA), authors of both papers have unified the criteria for the diagnosis of asthma–COPD overlap (ACO).</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This consensus defines ACO as the presence in a given patient of three elements: significant smoking exposure, chronic airflow limitation and asthma. Diagnosis is confirmed when a patient (35 years of age or older), smoker or ex-smoker of more than 10 pack-years, presents airflow limitation (post-bronchodilator FEV<span class="elsevierStyleInf">1</span>/FVC <0.7) that persists after treatment with bronchodilators and inhaled corticosteroids (even after systemic corticosteroids in selected cases), and an objective current diagnosis of asthma (according to GEMA criteria). In cases in which the diagnosis of asthma cannot be demonstrated, marked positive results on a bronchodilator test (FEV<span class="elsevierStyleInf">1</span> ≥15% and ≥400<span class="elsevierStyleHsp" style=""></span>ml) or elevated blood eosinophil count (≥300<span class="elsevierStyleHsp" style=""></span>eosinophils/μL) will also be diagnostic of ACO.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The opinion of another 33 experts who had not participated in the consensus was sought using a modified Delphi survey. Up to 80% of respondents gave a very positive opinion of the consensus, and declared that it was better than other previous proposals. The GesEPOC-GEMA consensus on ACO provides a unique perspective of the diagnostic problem, using a simple proposal and a pragmatic diagnostic algorithm that can be applied at any healthcare level.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A instancias de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), promotora de la Guía española de la EPOC (GesEPOC) y de la Guía Española para el Manejo del Asma (GEMA), autores de ambas guías han unificado criterios diagnósticos del solapamiento asma y EPOC (Asthma-COPD Overlap [ACO]).</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Este consenso define al ACO como la coexistencia en un mismo paciente de tres elementos: tabaquismo, limitación crónica al flujo aéreo y asma. La confirmación diagnóstica se establece cuando un paciente (≥35 años) fumador o exfumador (≥10 paquetes-año) presenta obstrucción o limitación crónica al flujo aéreo (FEV<span class="elsevierStyleInf">1</span>/FVC post-broncodilatador <70%), que persiste tras tratamiento broncodilatador y esteroideo inhalado (incluso oral en casos seleccionados) y diagnóstico objetivo de asma actual (según criterios GEMA). En los casos en los que este último no se pueda establecer, se aceptará una prueba broncodilatadora espirométrica muy positiva (FEV<span class="elsevierStyleInf">1</span> ≥15% y ≥400<span class="elsevierStyleHsp" style=""></span>ml) o una elevada eosinofilia en sangre (≥300<span class="elsevierStyleHsp" style=""></span>eosinófilos/μl).</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Se solicitó la opinión (mediante encuesta Delphi modificada) a otros 33 expertos que no habían participado en la elaboración del consenso. Un 80% de estos lo valoró positivamente, incluso superior a otras propuestas recientes. El consenso GesEPOC-GEMA sobre ACO proporciona una visión unitaria del problema, con una propuesta conceptual sencilla y un algoritmo diagnóstico pragmático, aplicable en cualquier nivel sanitario de nuestro ámbito.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plaza V, Álvarez F, Calle M, Casanova C, Cosío BG, López-Viña A, et al. Consenso sobre el solapamiento de asma y EPOC (ACO) entre la Guía española de la EPOC (GesEPOC) y la Guía Española para el Manejo del Asma (GEMA). Arch Bronconeumol. 2017;53:443–449.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0205" class="elsevierStylePara elsevierViewall">Agüero, Ramón (Neumología, H. U. Marqués de Valdecilla, Santander).</p> <p id="par0210" class="elsevierStylePara elsevierViewall">Alcázar, Bernardino (Neumología, H. de Alta Resolución EPHP, Loja, Granada).</p> <p id="par0215" class="elsevierStylePara elsevierViewall">Almagro, Pere (Medicina Interna, H. Mutua de Terrassa, Terrassa, Barcelona).</p> <p id="par0220" class="elsevierStylePara elsevierViewall">Almonacid, Carlos (Neumología, H. U. Ramón y Cajal, Madrid).</p> <p id="par0225" class="elsevierStylePara elsevierViewall">Ancochea, Julio (Neumología, H. U. de la Princesa, Madrid).</p> <p id="par0230" class="elsevierStylePara elsevierViewall">Boixeda, Ramón (Medicina Interna, Servicio de Medicina Interna Hospital de Mataro¿, Mataró, Barcelona).</p> <p id="par0235" class="elsevierStylePara elsevierViewall">Carretero, José Ángel (Neumología, H. Royo Villanova, Zaragoza).</p> <p id="par0240" class="elsevierStylePara elsevierViewall">Cisneros, Carolina (Neumología, H. U. de la Princesa, Madrid).</p> <p id="par0245" class="elsevierStylePara elsevierViewall">Delgado, Julio (Alergología, H. Virgen Macarena, Sevilla).</p> <p id="par0250" class="elsevierStylePara elsevierViewall">Entrenas, Luis Manuel (Neumología, H. U. Reina de Sofía, Córdoba).</p> <p id="par0255" class="elsevierStylePara elsevierViewall">Esteban, Cristóbal (Neumología, H. de Galdakao, Usansolo, Vizcaya).</p> <p id="par0260" class="elsevierStylePara elsevierViewall">Fernández Villar, José Alberto (H. Álvaro Qunqueiro, Vigo, Pontevedra).</p> <p id="par0265" class="elsevierStylePara elsevierViewall">Gómez, María (Medicina Interna, H. G. U. Gregorio Marañón, Madrid).</p> <p id="par0270" class="elsevierStylePara elsevierViewall">Ignacio García, José María (Neumología, H. Quirón, Marbella, Málaga).</p> <p id="par0275" class="elsevierStylePara elsevierViewall">Izquierdo-Alonso, José Luis (Neumología, H. U. Guadalajara).</p> <p id="par0280" class="elsevierStylePara elsevierViewall">López-Campos, José Luis (Neumología, H. U. Virgen del Rocío, Sevilla).</p> <p id="par0285" class="elsevierStylePara elsevierViewall">López-García, Francisco (Medicina Interna, H. G. U. de Elche, Elche, Alicante).</p> <p id="par0290" class="elsevierStylePara elsevierViewall">Marín, José María (Neumología, H. U. Miguel Servet, Zaragoza).</p> <p id="par0295" class="elsevierStylePara elsevierViewall">Martínez-Moragón, Eva (Neumología, H. U. Dr. Peset, Valencia).</p> <p id="par0300" class="elsevierStylePara elsevierViewall">Molina, Jesús (Atención Primaria, Francia <span class="elsevierStyleSmallCaps">I</span>, Fuenlabrada, Madrid).</p> <p id="par0305" class="elsevierStylePara elsevierViewall">Muñoz, Xavier (Neumología, H. G. U. Vall d’Hebron, Barcelona).</p> <p id="par0310" class="elsevierStylePara elsevierViewall">Olaguíbel, José María (Alergología, C. H. de Navarra, Pamplona).</p> <p id="par0315" class="elsevierStylePara elsevierViewall">Quintano, José Antonio (Atención Primaria, Centro de Salud Lucena <span class="elsevierStyleSmallCaps">I</span>, Lucena, Córdoba).</p> <p id="par0320" class="elsevierStylePara elsevierViewall">Recio, Jesús Pedro (Medicina Interna, H. G. U. Vall d’Hebron, Barcelona).</p> <p id="par0325" class="elsevierStylePara elsevierViewall">Riesco, Juan Antonio (Neumología, H. San Pedro de Alcántara, Cáceres).</p> <p id="par0330" class="elsevierStylePara elsevierViewall">Sabadell, Carles (Neumología, H. de Figueres, Girona).</p> <p id="par0335" class="elsevierStylePara elsevierViewall">Sastre, Joaquín (Alergología, Fundación Jiménez Díaz, Madrid).</p> <p id="par0340" class="elsevierStylePara elsevierViewall">Serrano, José (Neumología, H. Comarcal d’Inca, Inca, Mallorca).</p> <p id="par0345" class="elsevierStylePara elsevierViewall">Simonet, Pere (Atención Primaria. EAP Viladecans-2, Viladecans, Barcelona).</p> <p id="par0350" class="elsevierStylePara elsevierViewall">Torrego, Alfons (Neumología, H. de la Santa Creu i Sant Pau, Barcelona).</p> <p id="par0355" class="elsevierStylePara elsevierViewall">Trigueros, Juan Antonio (Atención Primaria, Centro de Salud de Menasalbas, Menasalbas, Toledo).</p> <p id="par0360" class="elsevierStylePara elsevierViewall">Urrutia, Isabel (Neumología, H. de Galdakao, Vizcaya).</p> <p id="par0365" class="elsevierStylePara elsevierViewall">Valero, Antonio (Alergología, H. Clínic, Barcelona).</p>" "etiqueta" => "Annex" "titulo" => "Participants in the Consensus Survey (in Alphabetical Order)" "identificador" => "sec0050" ] ] ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2092 "Ancho" => 1583 "Tamanyo" => 136989 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Diagnostic confirmation of asthma–COPD overlap.</p> <p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">*Persistent after treatment with ICS/LABA (6 months). In some cases also after a cycle of oral corticosteroids (15 days).</p> <p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">ACO: asthma–COPD overlap; c: cells; ICS: inhaled corticosteroids; LABA: long-acting β<span class="elsevierStyleInf">2</span>-agonist; PBD: post-bronchodilator; p-y: pack-years.</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Reproduced with permission of the European Respiratory Society ©: Eur Respir J 2017;49:1700068, <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1183/13993003.00068-2017">doi:10.1183/13993003.00068-2017</span>.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Prevalence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Diagnostic Criterion \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="4" align="left" valign="top"><span class="elsevierStyleItalic">Population studies</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>De Marco et al.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">16</span></a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Italy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.6% (20–44 years), 2.1% (45–64 years), 4.5% (65–84 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of COPD and asthma \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>Van Boven et al.<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">25</span></a> (2016) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.5 per 1000 inhabitants (≥18 years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of COPD and asthma \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>Rhee et al.<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">38</span></a> (2014) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Korea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.54% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of COPD and asthma \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>Marsh et al.<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">39</span></a> (2008) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Combination of chronic bronchitis, emphysema and asthma, with and without incomplete airflow reversibility \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>Miravitlles et al.<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">12</span></a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">17.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with COPD and previous diagnosis of asthma before the age of 40 years \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>Soriano et al.<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">40</span></a> (2003) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA and United Kingdom \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Diagnosis of COPD and asthma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" 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="4" align="left" valign="top"><span class="elsevierStyleItalic">Studies of selected patient cohorts</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>Cosio et al.<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">22</span></a> (2016) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients diagnosed with COPD with at least 1 of the major criteria (previous history of asthma or bronchodilator response to salbutamol >15% and 400<span class="elsevierStyleHsp" style=""></span>ml) or 2 minor criteria (IGE >100<span class="elsevierStyleHsp" style=""></span>IU, or history of atopy, or bronchodilator response >12% and 200<span class="elsevierStyleHsp" style=""></span>ml on 2 occasions, or eosinophilia in blood >5%) \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>Miravitlles et al.<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">41</span></a> (2014) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients diagnosed with COPD with at least 1 of the major criteria (previous history of asthma, or bronchodilator response to salbutamol >15% and 400<span class="elsevierStyleHsp" style=""></span>ml, or eosinophilia in sputum) or 2 minor criteria (IGE >100<span class="elsevierStyleHsp" style=""></span>IU, or history of atopy, or bronchodilator response >12% and 200<span class="elsevierStyleHsp" style=""></span>ml on 2 occasions, or eosinophilia in blood >5%) \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>Golpe et al.<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">42</span></a> (2014) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21.3% (COPD with biomass exposure)<br>5% (COPD with tobacco smoke exposure) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients diagnosed with COPD with at least 1 of the major criteria (previous history of asthma, or bronchodilator response to salbutamol >15% and 400<span class="elsevierStyleHsp" style=""></span>ml, or FE<span class="elsevierStyleInf">NO</span> >40<span class="elsevierStyleHsp" style=""></span>ppb) or 2 minor criteria (IGE >100<span class="elsevierStyleHsp" style=""></span>IU, or history of atopy, or bronchodilator response >12% and 200<span class="elsevierStyleHsp" style=""></span>ml on 2 occasions) \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>Kiljander et al.<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">43</span></a> (2015) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Finland \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">27.4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults with a diagnosis of asthma and smoking (≥10 pack-years) with post-bronchodilator FEV<span class="elsevierStyleInf">1</span>/FVC ≤0.70 \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>Izquierdo-Alonso et al.<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">21</span></a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults with a diagnosis of COPD with KCO >80%, no emphysema on imaging tests, and history of asthma before the age of 40 years \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>Miravitlles et al.<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">23</span></a> (2015) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Adults with COPD and a previous diagnosis of asthma \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>Menezes et al.<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">11</span></a> (2014) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Latin America \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11.6% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Post-bronchodilator FEV<span class="elsevierStyleInf">1</span>/FVC <0.7 and asthma (wheezing in the last 12 months plus bronchodilator response of FEV<span class="elsevierStyleInf">1</span>/FVC 200<span class="elsevierStyleHsp" style=""></span>ml and 12% or medical diagnosis of asthma) \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>Louie et al.<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">44</span></a> (2013) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">15.8% in respiratory medicine clinic; 24.3% in asthma clinic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Asthma with partial reversibility of airflow obstruction, with or without emphysema or DLCO <80%; or COPD with emphysema and reversible or partially reversible airflow obstruction, with or without exposure to allergens or reduced DLCO \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>Hardin et al.<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">24</span></a> (2011) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">USA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">13% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with COPD and previous diagnosis of asthma before the age of 40 years \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>Koblizek et al.<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">45</span></a> (2017) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Central and Eastern Europe \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.9% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Patients with COPD and asthma diagnosed before the age of 40 years, or with a positive bronchodilator response plus atopy \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477510.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">ACO Prevalence According to Diagnostic Criteria.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Median \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Mean \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">SD \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% Agreement \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1. How far do you agree with the term ACO, instead of ACOS? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">65.9 \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">2. The concept of ACO includes patients with different characteristics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.99 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.6 \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">3. A diagnosis of COPD is necessary for a diagnosis of ACO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.43 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.6 \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">4. A diagnosis of asthma is necessary for a diagnosis of ACO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.8 \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">5. Patients with a diagnosis of COPD and a diagnosis of asthma should be considered ACO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.39 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.14 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">88.6 \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">6. Patients with a diagnosis of COPD and >300 eosinophils in blood should be considered ACO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.58 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.6 \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">7. Eosinophilia in blood must be demonstrated on more than 1 occasion for it to have diagnostic value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">75.0 \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">8. Patients with a diagnosis of COPD and a very positive bronchodilator response (>400<span class="elsevierStyleHsp" style=""></span>ml and >15%) should be considered ACO \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.09 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.68 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.3 \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">9. A very positive bronchodilator response must be demonstrated on more than 1 occasion for it to have diagnostic value \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.3 \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">10. One way of establishing a diagnosis of ACO is the presence of COPD and >300 eosinophils in blood, in addition to a very positive bronchodilator test (>400<span class="elsevierStyleHsp" style=""></span>ml and >15%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.84 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.26 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">70.5 \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">11. The diagnosis of ACO proposed by GesEPOC in 2012 (major and minor criteria; Arch Bronconeumol 2012;48:331–337) was more appropriate than the GesEPOC-GEMA ACO Consensus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.55 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.45 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.3 \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">12. The diagnosis of ACO proposed by GEMA4.0 in 2015 (sequential algorithm of complementary examinations; Arch Bronconeumol 2015;51[S1]:1–68) was more appropriate than the GesEPOC-GEMA ACO Consensus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.59 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45.5 \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">13. The diagnostic criteria for ACO in patients initially classified as COPD or asthma may differ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4.36 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.62 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13.6 \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">14. How far do you agree with the strategy of administering a short course of oral corticosteroids to rule out asthma in selected cases? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.93 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">61.3 \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">15. How far do you agree with the criteria proposed in the GesEPOC-GEMA ACO Consensus for confirmation of the diagnosis of ACO? \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.05 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.7 \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">16. ACO patients must receive at least 1 bronchodilator and an inhaled corticosteroid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.75 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.4 \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">17. ACO patients must receive at least 1 bronchodilator, with the addition of an inhaled corticosteroid only in the case of exacerbations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.6 \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">18. With the current level of evidence, patients with severe ACO are candidates for receiving treatment with biological drugs \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.27 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.73 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40.9 \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">19. Evaluate your level of overall agreement with the GesEPOC-GEMA ACO Consensus proposed here \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.77 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.24 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">79.6 \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">20. The conceptual and diagnostic proposals of the GesEPOC-GEMA ACO Consensus are better than those of the recent GOLD 2016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.28 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72.8 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1477511.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Questions and Results of the Opinion Survey on the GesEPOC-GEMA ACO Consensus. 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Year/Month | Html | Total | |
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2024 October | 84 | 41 | 125 |
2024 September | 122 | 28 | 150 |
2024 August | 127 | 65 | 192 |
2024 July | 103 | 37 | 140 |
2024 June | 100 | 46 | 146 |
2024 May | 152 | 53 | 205 |
2024 April | 93 | 58 | 151 |
2024 March | 101 | 37 | 138 |
2024 February | 61 | 44 | 105 |
2024 January | 1 | 0 | 1 |
2023 June | 1 | 0 | 1 |
2023 March | 28 | 6 | 34 |
2023 February | 102 | 41 | 143 |
2023 January | 82 | 55 | 137 |
2022 December | 154 | 44 | 198 |
2022 November | 156 | 57 | 213 |
2022 October | 173 | 93 | 266 |
2022 September | 141 | 54 | 195 |
2022 August | 118 | 93 | 211 |
2022 July | 101 | 94 | 195 |
2022 June | 136 | 62 | 198 |
2022 May | 150 | 59 | 209 |
2022 April | 227 | 80 | 307 |
2022 March | 232 | 86 | 318 |
2022 February | 229 | 69 | 298 |
2022 January | 203 | 84 | 287 |
2021 December | 162 | 76 | 238 |
2021 November | 148 | 66 | 214 |
2021 October | 155 | 88 | 243 |
2021 September | 96 | 70 | 166 |
2021 August | 86 | 65 | 151 |
2021 July | 106 | 46 | 152 |
2021 June | 127 | 81 | 208 |
2021 May | 130 | 79 | 209 |
2021 April | 355 | 202 | 557 |
2021 March | 220 | 73 | 293 |
2021 February | 165 | 56 | 221 |
2021 January | 143 | 51 | 194 |
2020 December | 150 | 56 | 206 |
2020 November | 162 | 50 | 212 |
2020 October | 120 | 61 | 181 |
2020 September | 123 | 48 | 171 |
2020 August | 115 | 59 | 174 |
2020 July | 158 | 52 | 210 |
2020 June | 99 | 29 | 128 |
2020 May | 155 | 43 | 198 |
2020 April | 178 | 47 | 225 |
2020 March | 155 | 26 | 181 |
2020 February | 203 | 38 | 241 |
2020 January | 138 | 37 | 175 |
2019 December | 166 | 64 | 230 |
2019 November | 215 | 143 | 358 |
2019 October | 136 | 136 | 272 |
2019 September | 162 | 141 | 303 |
2019 August | 89 | 128 | 217 |
2019 July | 98 | 161 | 259 |
2019 June | 90 | 128 | 218 |
2019 May | 137 | 174 | 311 |
2019 April | 145 | 204 | 349 |
2019 March | 163 | 94 | 257 |
2019 February | 108 | 59 | 167 |
2019 January | 111 | 46 | 157 |
2018 December | 115 | 62 | 177 |
2018 November | 213 | 83 | 296 |
2018 October | 238 | 61 | 299 |
2018 September | 106 | 53 | 159 |
2018 May | 32 | 5 | 37 |
2018 April | 53 | 24 | 77 |
2018 March | 44 | 24 | 68 |
2018 February | 48 | 20 | 68 |
2018 January | 35 | 20 | 55 |
2017 December | 43 | 32 | 75 |
2017 November | 36 | 35 | 71 |
2017 September | 1 | 1 | 2 |
2017 August | 2 | 2 | 4 |
2017 July | 0 | 1 | 1 |
2017 June | 0 | 3 | 3 |