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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Over the past few decades&#44; frequent changes in recommendations for the diagnosis and treatment of chronic obstructive pulmonary disease &#40;COPD&#41; and the growing number of available treatments have led to clinical scenarios of varying complexity that cannot always be resolved by the current guidelines&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> This situation is particularly acute in the area of primary care &#40;PC&#41;&#44; where numerous diseases from different specialist areas are evaluated with limited time and resources&#46; As a result&#44; the PC physician often encounters clinical scenarios not addressed by the current recommendations&#44; complicating the management of COPD patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3&#44;4</span></a> In response to this situation&#44; the Spanish Society of Pulmonology and Thoracic Surgery &#40;SEPAR&#41; has launched an initiative entitled &#8220;Enabling a Community Approach to Respiratory Diseases&#58; the HACER COPD project&#8221;&#44; as a way to facilitate the management of COPD in this care setting&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of HACER COPD was to design 2 pocket cards that physicians could use for quick reference&#44; containing a simplified therapeutic scheme for stable COPD and the management of exacerbations&#44; with clinical criteria for referral to the respiratory medicine department if necessary&#46; To develop these cards&#44; SEPAR contacted the major PA scientific societies and invited them to a face-to-face meeting&#46; The working group consisted of a representative from each PA society&#44; including the Spanish Society of Family and Community Medicine &#40;semFYC&#41;&#44; the Spanish Society of Primary Care Physicians &#40;SEMERGEN&#41;&#44; and the Spanish Society of General and Family Physicians &#40;SEMG&#41;&#44; the SEPAR COPD area coordinator&#44; and a member of the SEPAR executive committee&#44; who acted as group coordinator&#46; The SEPAR secretary&#39;s office took care of technical and administrative needs&#46; The representatives of each society were asked to develop 2 simple algorithms for stable COPD and exacerbations that would be discussed during the meeting&#44; held in Madrid on October 30&#44; 2019 at SEPAR headquarters&#44; with the aim of agreeing on a final version&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The HACER COPD algorithm for the management of stable disease is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>a&#46; The top of the card addresses diagnosis and the need to meet 3 criteria &#40;exposure&#44; symptoms&#44; and bronchial obstruction&#41;&#46; The treatment section of the card contains a reminder of the need for adequate non-pharmacological treatment&#44; including smoking cessation&#44; exercise&#44; and influenza and pneumococcal vaccinations&#46; Pharmacological interventions are represented in the card by a 3-step scale&#44; based on dyspnea and exacerbations as the main therapeutic objectives in the community&#46; The card reminds users that therapeutic adherence&#44; inhalation technique&#44; and the influence of comorbidities on clinical presentation should be taken into account during treatment escalation&#46; The card includes the option of starting with 1 or 2 bronchodilators&#44; depending on the degree of dyspnea&#46; Referral to respiratory medicine is advised if the patient does not achieve stability with the maximum inhaled treatment&#44; due to either exacerbations or dyspnea&#46; Finally&#44; the card includes the modified Medical Research Council scale currently recommended for the assessment of dyspnea<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1&#44;2</span></a> as a reminder&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The HACER COPD algorithm for the management of exacerbations is shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>b&#46; The clinical approach described for the diagnosis of exacerbation underlines the need to rule out other diseases that may cause increased respiratory symptoms&#46; The algorithm then seeks to determine the potential severity of the exacerbation according to saturation measured using pulse oximetry&#46; The card recommends that patients with exacerbations of acute or chronic respiratory failure should be referred to a hospital&#46; For patients with normal oxygenation&#44; a therapeutic algorithm is established in which underlying inhaled treatment is maintained and intensified with short-acting bronchodilators&#44; administering oral corticosteroids and adding antibiotics if sputum is purulent&#44; with an assessment after 48&#8211;72<span class="elsevierStyleHsp" style=""></span>h&#46; Finally&#44; the card includes a reminder of dosing guidelines for oral corticosteroids and the main antibiotics available in PA&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Schemes for COPD management need to maintain a delicate balance between being exhaustive but complex&#44; or simpler but incomplete&#46; Both approaches have their advantages and disadvantages&#46; HACER COPD is intended to be a simple strategy that strikes a balance between correct treatment in PA and referral of patients to respiratory medicine&#46; This algorithm uses dyspnea as the initial classifier and determinant of bronchodilator therapy in stable disease&#46; Dyspnea is the main reason for COPD patients seeking help&#59; this is the most limiting symptom of the disease and carries implications for prognosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5&#44;6</span></a> Nevertheless&#44; HACER COPD contains some controversial areas&#59; for example&#44; certain markers such as blood eosinophils and bronchial reversibility have not been included&#46; As a result&#44; the therapeutic escalation schedule is simpler than those currently proposed&#46; Another aspect of the algorithm that might raise questions is the idea of mild exacerbation&#44; which&#44; instead of being defined in detail&#44; has been left to medical judgment&#46; The committee understands that mild exacerbations would be those that respond well to inhalers&#44; without the need for oral steroids or antibiotics&#44; in line with current guidelines&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The aim of this simplified algorithm is to provide practical solutions to the early management of COPD in the PA setting&#46; The variables it uses are easily measurable and listed in an order that is logical and easy to remember&#46; Although COPD is a complex&#44; heterogeneous disease&#44; we believe that this simplified approach complies with current recommendations and&#44; because of its simplicity&#44; will help more COPD patients gain access to the right treatment&#46; Sometimes&#44; less is more&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">This project received an unrestricted grant from GlaxoSmithKline&#44; S&#46;A&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of Interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">CCL has received honoraria in the past 3 years for lectures&#44; scientific consultancy&#44; and clinical trial participation from &#40;in alphabetical order&#41;&#58; AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; Esteve&#44; Ferrer&#44; Gebro&#44; GlaxoSmithKline&#44; Menarini&#44; and Novartis&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">JTGS has received honoraria in the last 3 years from GSK&#44; BIAL&#44; Pfizer&#44; AstraZeneca&#44; Chiesi&#44; TEVA&#44; and Mylan&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">JLLC has received honoraria in the past 3 years for lectures&#44; scientific consultancy&#44; clinical trial participation&#44; and writing of papers from &#40;in alphabetical order&#41;&#58; AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; CSL Behring&#44; Esteve&#44; Ferrer&#44; Gebro&#44; GlaxoSmithKline&#44; Grifols&#44; Menarini&#44; Novartis&#44; Rovi and Teva&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">JMP has received honoraria in the past 3 years for lectures&#44; scientific advice and clinical study participation from AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; GlaxoSmithKline&#44; Menarini&#44; Novartis&#44; Pfizer&#44; semFYC&#44; and SERMAS&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">JATC has received honoraria in the past 3 years for teaching activities&#44; scientific consultancy&#44; clinical trial participation&#44; and writing of papers for&#58; AstraZeneca&#44; Boehringer Ingelheim&#44; Chiesi&#44; Esteve&#44; Ferrer&#44; GlaxoSmithKline&#44; Menarini&#44; Novartis&#44; Rovi&#44; and Teva&#46;</p></span></span>"
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