Consensus for managing patients with chronic obstructive pulmonary disease according to the CODEX index

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The most widely used classic variables have been dyspnea and the forced expiratory volume during the first second after the bronchodilator test, expressed as a percentage of the theoretical (FEV1%).<a class="elsevierStyleCrossRef" href="#bib0265">2</a> More recently, the important role of exacerbations and comorbidities in reducing survival has been recognized.<a class="elsevierStyleCrossRefs" href="#bib0270">3,4</a> These variables have been combined in various multidimensional indices, which improve the indices’ predictive capacity. The most recognized index is BODE, composed of body mass index (BMI) (B), FEV1% (O), dyspnea (D) and exercise capacity (E), measured by the distance traveled in the 6-min walk test. BODEx replaces the walking test with the history of severe exacerbations in the past year (Ex). Other indices include ADO (age, dyspnea and airflow obstruction) and DOSE (dyspnea, obstruction, smoking and exacerbations).<a class="elsevierStyleCrossRef" href="#bib0280">5</a>In 2014, the development and validation of the CODEX index was published. Compared with BODEx, CODEX replaces BMI with comorbidity (C), measured with the age-adjusted Charlson index and preserves the same cutoff points for FEV1%, dyspnea and severe exacerbations in the past year.<a class="elsevierStyleCrossRef" href="#bib0285">6</a> CODEX was the first multicomponent scale designed and validated to predict the risk of readmissions and mortality for patients hospitalized for COPD. CODEX was developed in the COPD in Internal Medicine Departments (EPOC en servicios de medicina interna, ESMI) cohort study, while its validation was conducted in 3 other previously published cohorts.<a class="elsevierStyleCrossRefs" href="#bib0275">4,7–9</a> The index has subsequently been revalidated in outpatients with severe COPD to assess the risk of mortality and readmission at 3 months and has demonstrated its usefulness in predicting mortality in the longer term.<a class="elsevierStyleCrossRefs" href="#bib0305">10–13</a>Various recent studies have suggested that a better approach to treating COPD and its comorbidities could have a positive impact on these patients’ survival.<a class="elsevierStyleCrossRef" href="#bib0325">14</a> Treating comorbidities improves the survival of patients with COPD and, conversely, treating COPD can decrease the mortality by other causes, especially cardiovascular.<a class="elsevierStyleCrossRefs" href="#bib0330">15–17</a> Patients therefore need an overall assessment of their COPD treatment and associated diseases.<a class="elsevierStyleCrossRef" href="#bib0345">18</a>The aim of this study was to prepare recommendations specifically adapted for patients who would have had their CODEX index calculated based on the variables employed for its calculation, to thereby offer a personalized therapeutic management strategy.Materials and methodsLiterature reviewA group of experts composed of 6 internal medicine specialists (scientific committee) developed various clinical questions aimed at creating recommendations based on the items of the CODEX index and grouped as follows: basic concepts and recommendations associated with the comorbidities according to the Charlson index, with pulmonary function according to the FEV1%, with the degree of dyspnea, with exacerbations and with patient follow-up.We conducted a literature search in PubMed and the Cochrane Plus Library to identify publications that could answer these questions. The keywords were adapted to each question or group of questions and included Mesh terms and combined free searches. All searches included at least the study disease “chronic obstructive pulmonary disease” and other specific terms. We applied language (Spanish and English), temporal (studies published since on 2012) and study type filters (clinical practice guidelines, systematic reviews, meta-analyses and consensus documents). For a number of the questions, the criteria needed to be broadened when the literature was insufficient to answer the questions. A number of publications were added at the scientific committee's discretion.Once the articles of interest were identified, we removed the duplicates and conducted a first screening by reading the title and abstract. The resulting articles were read in their entirety to select the ones that passed the synthesis stage.Literature synthesis and preparation of recommendationsWe created a summary of the selected publications aimed at answering the clinical questions, extracting the contents related to each topic. This synthesis served as a basis for preparing the responses (recommendations and their respective scientific rationale). The group created 108 recommendations. To classify the evidence and grade the recommendations, we employed the evidence categorization system based on the Oxford Centre for Evidence-Based Medicine.<a class="elsevierStyleCrossRef" href="#bib0350">19</a> When recommendations from other guidelines and consensuses were adopted, the categorization of the original sources were maintained, and we established the degree of recommendation “expert opinion” for the recommendations prepared by the scientific committee, based on their experience in clinical practice.Validating the recommendationsThe generated recommendations were reviewed by an external expert panel. At the suggestion of the scientific committee, we invited specialists from internal medicine, pneumology and primary care throughout Spain. To ensure a sufficient level of experience to assess the recommendations, we established the following inclusion criteria: the specialists treated patients with COPD and comorbidities, COPD was one of the specialist's main areas of dedication/interest, the specialists had more than 3 years of experience in treating patients with COPD, and at least 20% of their healthcare consultations involved patients with COPD. The invitation was sent by e-mail, and the consultation was conducted online. All experts were supplied with a supporting document for the recommendations. For each proposed recommendation, 4 possible responses were offered, ranging from 1 (strongly disagree) to 4 (strongly agree). A space was provided for comments. The consultation took place between February and March 2018.To analyze the results, we grouped the 1+2 votes (disagreements) and the 3+4 votes (agreements). We calculated the percentage of agreements and determined the degree of consensus as follows: (a) unanimous agreement, when the entire expert panel was in agreement; (b) consensus, when ≥80% of the experts were in agreement; and (c) disagreement, when the degree of consensus was not reached. For space reasons, the recommendations agreed upon with ≥95% of the votes are shown in the “agreement” block, except for the follow-up recommendations. The recommendations with <95% agreement are available as <a class="elsevierStyleCrossRef" href="#sec0100">supplemental material (appendix)</a>.Implementing the recommendationsAfter closing the consultation with the external panel, the expert committee met to assess the results and agree on the criteria for inclusion of the agreed upon recommendations in the tool that helps calculate the CODEX (iCODEX), available online and as an application.ResultsArticle identification and selectionWe identified 273 publications from which we ultimately selected 33 articles for the literature synthesis (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Validation of the external expert panelOf the 99 invited experts, 91 responded (91.9%), 62 of whom (68.1%) met the inclusion criteria. Of the 62 participants, 49 (79.0%) were internal medicine specialists, 11 (17.7%) were pneumology specialists, and 2 (3.2%) were primary care specialists. Of the 108 items consulted, consensus was reached on 96 (88.9%), 16 with unanimous agreement and 80 with consensus. There were only 12 recommendations (11.1%) with disagreement.Recommendations associated with comorbiditiesWe developed recommendations regarding cardiovascular diseases, kidney disease, diabetes, osteoporosis and dementia but not for ulcerative disease, liver disease, hemiplegia, cancer or AIDS, which are also included in the Charlson index (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In general, we considered that cardiovascular diseases, diabetes, kidney disease and osteoporosis in patients with COPD should be treated as in patients without COPD, following the recommendations of the main clinical practice guidelines for COPD and for its associated comorbidities.<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> We considered that COPD should be considered a high cardiovascular risk (CVR) disease that requires treating the other CVR factors with the therapeutic objectives established in the guidelines for these circumstances.<a class="elsevierStyleCrossRefs" href="#bib0365">22,23</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>There were 8 recommendations that did not achieve consensus and were related to cardiovascular diseases chronic kidney disease and dementia (<a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S1, supplemental material</a>).Recommendations associated with pulmonary functionFor patients with FEV1<50% and an MMRC dyspnea degree of 0–1, the initial treatment should be a long-acting bronchodilator, adding a second bronchodilator if the symptoms and exacerbations cannot be controlled. For patients with FEV1<50% and an MMRC dyspnea degree of 2–4, the use of dual bronchodilation at the start may be assessed. There was no consensus on whether the initial treatment for this patient group should be a long-acting muscarinic antagonist (LAMA) or a long-acting beta agonist (LABA). If the patient has persistent exacerbations, triple therapy with LAMA, LABA and an inhaled corticosteroid (IC) should be started. Finally, for patients with FEV1 ≥50%, recommendations were only established for cases with a high risk of exacerbations, in which the recommendation is to identify the phenotype to adjust the treatment, administering a LAMA and LABA as the first choice. For cases with the mixed COPD-asthma phenotype, the recommended treatment is generally the combination LABA and IC (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>) and <a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S2, supplemental material</a>).<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Recommendations associated with dyspneaWe divided the recommendations into 2 categories: those associated with an MMRC dyspnea grade 0–1 and those associated with a dyspnea grade 2–4. In the 2 cases, the base drug treatment needs to be reassessed, giving preference to a LAMA or a LABA for an MMRC of 0–1 and to dual therapy (LAMA+LABA) in the case of previous monotherapy and an MMRC of 2–4 (expert opinion). In both cases, it is advisable to reassess the nondrug measures (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S3, supplemental material</a>). There were no disagreements in this section.<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Recommendations associated with exacerbationsExacerbations are considered severe if they require hospital care. A patient that has experienced an exacerbation is predisposed to new exacerbations; it is therefore important to optimize the patient's management to prevent these new exacerbations.<a class="elsevierStyleCrossRef" href="#bib0375">24</a> Good control of the comorbidities decreases mortality in patients who have experienced an exacerbation.<a class="elsevierStyleCrossRef" href="#bib0325">14</a> Similarly, the patient's CVR should be assessed, the various associated CVR factors should be carefully treated, and the drug and nondrug treatment should be optimized.<a class="elsevierStyleCrossRefs" href="#bib0355">20–22</a> For patients with frequent exacerbations despite treatment with dual bronchodilation, it is advisable to add an IC. In addition, other treatments should be assessed such as roflumilast, macrolides and mucolytics, individually according to the patient's profile, as well as the recommendation for other nondrug measures (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S4, supplemental material</a>).<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>General recommendations for management and follow-upWe established general recommendations for management and follow-up not associated with the patient's profile or condition (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S5, supplemental material</a>). COPD should be considered an independent high CVR factor, because the risk of cardiovascular events is higher than in the general population, especially after exacerbations.<a class="elsevierStyleCrossRef" href="#bib0380">25</a> We also included recommendations on smoking cessation, diet and physical activity. We identified how and for which patient profile lung cancer screening should be performed, as well as when to continue with home respiratory rehabilitation. Due to the greater risk of complications due to COPD-associated respiratory infections, we recommend the influenza vaccination for all patients, as well as the pneumococcal vaccination depending on age, pulmonary obstruction and comorbidities. Consensus was not reached on 2 recommendations related to lung cancer screening (<a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S5, supplemental material</a>).<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>In terms of follow-up, once the patient is discharged after hospitalization for an exacerbation, the outpatient follow-up should be optimized according to each patient's needs and the resources available.<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> In this consensus, we offer specific recommendations for the follow-up visit, including aspects on assessment and treatment. Additionally, proper coordination with the primary care team and the patient's regular physician should be ensured, performing annual spirometry and chest computed tomography for patients with suspected bronchiectasis.<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a>DiscussionAs far as we know, this is the first study to combine a multicomponent index for determining the prognosis of patients with COPD with recommendations adapted to the scores of the various components of this index.<a class="elsevierStyleCrossRef" href="#bib0385">26</a>The study strengths include the fact that the use of the recommendations can help adapt the COPD treatment to the patient characteristics and comorbidities, thereby personalizing the therapy. One of the strengths of the CODEX index is the inclusion of an assessment of these patients’ comorbidities. To this end, CODEX uses the Charlson index, one of the most recognized comorbidity scales that has shown an excellent predictive capacity in various populations, including patients with COPD.<a class="elsevierStyleCrossRef" href="#bib0390">27</a>Another study strength is that we employed and adapted recognized clinical guidelines (such as the Global Initiative for Chronic Obstructive Lung Disease [GOLD] and the Spanish Guidelines for Chronic Obstructive Pulmonary Disease [Guía española de la enfermedad pulmonar obstructiva crónica, GesEPOC], the integrated care plan for patients with exacerbated COPD and the Spanish Society of Internal Medicine protocol for managing comorbidities in COPD) along with other recent publications to develop the recommendations, which has resulted in a high-quality and practical document, avoiding the duplication of work already performed.The study's limitations include the fact that the assessment process for the external group was conducted in a single round. However, the high number of participants and the high percentage of consensus grants a relevant weight to the results. Finally, the methodology for obtaining consensus was solid and enabled us to ultimately obtain a high-quality document, given that it is based on a literature review, the preparation of recommendations by a group of recognized experts and on the individual assessment of a large group of experts on COPD independent from the scientific committee that prepared the recommendations.Given the high number of recommendations that could hinder their use and implementation, we opted for an implementation format that is visual, schematic and practical to facilitate its applicability, in an online and app format. After implementing these recommendations in iCODEX, its usefulness and applicability should be assessed, as well as the potential for improving the prognosis resulting from compliance with the suggested recommendations.ConclusionsThe CODEX index can be calculated using iCODEX, a support tool for specialists who treat patients with COPD, available online or as an application. The index predicts the mortality and risk of readmission and, after the preparation of the present consensus document, now covers 96 recommendations directed at physicians who treat patients with COPD. These recommendations aim to improve the treatment of patients through a personalized approach to each patient for whom the CODEX index is calculated.FundingThe present project was sponsored by Chiesi Laboratories (Spain), who did not intervene in the design, data analysis or preparation of the manuscript.Conflicts of interestRB, MGA and FLG declare that they have no conflicts of interest. JDM declares having received consulting fees from Bayer, Boehringer Ingelheim and Novartis. JR declares having received consulting fees from Ferrer and Chiesi Laboratories and financial assistance for scientific meetings from Novartis. PA declares having received consulting fees from GlaxoSmithKline, Laboratories Esteve, Rovi, Menarini and Novartis." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1271822" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1176789" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1271823" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1176790" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Background" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Materials and methods" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Literature review" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Literature synthesis and preparation of recommendations" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Validating the recommendations" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Implementing the recommendations" ] ] ] 6 => array:3 [ "identificador" => "sec0035" "titulo" => "Results" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0040" "titulo" => "Article identification and selection" ] 1 => array:2 [ "identificador" => "sec0045" "titulo" => "Validation of the external expert panel" ] 2 => array:2 [ "identificador" => "sec0050" "titulo" => "Recommendations associated with comorbidities" ] 3 => array:2 [ "identificador" => "sec0055" "titulo" => "Recommendations associated with pulmonary function" ] 4 => array:2 [ "identificador" => "sec0060" "titulo" => "Recommendations associated with dyspnea" ] 5 => array:2 [ "identificador" => "sec0065" "titulo" => "Recommendations associated with exacerbations" ] 6 => array:2 [ "identificador" => "sec0070" "titulo" => "General recommendations for management and follow-up" ] ] ] 7 => array:2 [ "identificador" => "sec0075" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0080" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0085" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0090" "titulo" => "Conflicts of interest" ] 11 => array:2 [ "identificador" => "xack436622" "titulo" => "Acknowledgements" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-01-31" "fechaAceptado" => "2019-03-18" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1176789" "palabras" => array:6 [ 0 => "Chronic obstructive pulmonary disease" 1 => "Disease severity index" 2 => "Prognosis" 3 => "Mortality" 4 => "Consensus" 5 => "CODEX" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1176790" "palabras" => array:6 [ 0 => "Enfermedad pulmonar obstructiva crónica" 1 => "Índice de gravedad de la enfermedad" 2 => "Pronóstico" 3 => "Mortalidad" 4 => "Consenso" 5 => "CODEX" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The comorbidity, obstruction, dyspnea, exacerbations (CODEX) index is the first multicomponent scale designed to predict the risk of readmissions and mortality at 1 year for patients hospitalised for chronic obstructive pulmonary disease (COPD). The index includes the comorbidities (C) (measured by the Charlson index), the degree of obstruction (O) (assessed by the forced expiratory volume in 1 second percentage), dyspnea (D) (stratified according to the modified Medical Research Council scale) and exacerbations (EX) in the previous year. Our objective was to prepare recommendations based on the index's various components for personalized therapeutic management.To this end, we performed a literature search based on guidelines, consensuses and systematic reviews, as a basis for preparing recommendations on basic concepts, comorbidities, dyspnea, pulmonary obstruction, exacerbations and follow-up. The recommendations were then subjected to an external assessment process by a multidisciplinary group of 62 experts.In total, 108 recommendations were created, 96 of which achieved consensus, including the recommendation that COPD be considered a high-risk cardiovascular disease, as well as several specific recommendations on managing the various comorbidities. A consensus was reached on the recommended treatments in the guidelines for the various levels of obstruction, dyspnea and exacerbations, adapted to the CODEX scores. Advice is also offered for patient follow-up after hospital discharge, which includes aspects on assessment, treatment and care coordination." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El índice CODEX es la primera escala multicomponente diseñada para predecir el riesgo de mortalidad y reingresos al año en los pacientes hospitalizados por EPOC. Su cálculo incluye las comorbilidades medidas por el índice de Charlson (C), el grado de obstrucción valorado por el FEV1% (O), la disnea estratificada según la escala modificada del Medical Research Council (D) y las exacerbaciones en el año previo (EX). Nuestro objetivo fue elaborar recomendaciones basadas en los diferentes componentes del índice para un manejo terapéutico personalizado.Para ello se realizó una búsqueda bibliográfica basada en guías, consensos y revisiones sistemáticas, como base para elaborar recomendaciones sobre: generalidades, comorbilidades, disnea, obstrucción pulmonar, exacerbaciones y seguimiento. Seguidamente, se sometieron a un proceso de valoración externo por un grupo multidisciplinar de 62 expertos.En total se realizaron 108 recomendaciones, de las cuales se alcanzó consenso en 96. Entre ellas se destaca que la EPOC debe considerarse como una enfermedad de riesgo cardiovascular alto y varias recomendaciones específicas sobre el manejo de las diferentes comorbilidades. Se consensuaron los tratamientos aconsejados para los diferentes niveles de obstrucción, disnea y exacerbaciones recomendados en las guías, adaptadas a las puntuaciones del CODEX. Se ofrecen también unos consejos para el seguimiento tras el alta hospitalaria del paciente, en los que se incluyen aspectos sobre la valoración, el tratamiento y la coordinación asistencial." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Boixeda R, Díez-Manglano J, Gómez-Antúnez M, López-García F, Recio J, Almagro P. Consenso para el manejo de pacientes con EPOC según el índice CODEX. Rev Clin Esp. 2019;219:494–504." ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "The following are the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0100" ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1912 "Ancho" => 2349 "Tamanyo" => 146175 ] ] "descripcion" => array:1 [ "en" => "Flow diagram for obtaining the articles." ] ] 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:2 [ "leyenda" => "Abbreviations: COPD, chronic obstructive pulmonary disease; DoR, grade of recommendation; LoE, level of evidence." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1+2, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3+4, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular diseases</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R26. For patients with COPD, ischemic heart disease should be treated according to clinical practice guidelines<a class="elsevierStyleCrossRefs" href="#bib0355">20,21,23</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Renal diseases</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R32. For patients with COPD and chronic renal failure, the drug dosage needs to be adjusted to the renal function (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R33. For patients with COPD and diabetes, the cardiovascular risk should be assessed (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R34. For patients with COPD and diabetes, the glycated hemoglobin levels should be periodically checked (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R35. For patients with COPD and diabetes, the glomerular filtration rate should be periodically calculated (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Osteoporosis</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R40. All patients with COPD should be advised to perform physical exercise and eat a diet rich in calcium and vitamin D to prevent osteoporosis<a class="elsevierStyleCrossRef" href="#bib0370">23</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R41. For patients with COPD, the osteoporosis should be treated in a similar manner as in patients without COPD<a class="elsevierStyleCrossRefs" href="#bib0355">20,21,23</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dementia or diagnosed cognitive impairment</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R43. For patients with COPD and cognitive impairment, the presence of hypoxemia should be ruled out<a class="elsevierStyleCrossRef" href="#bib0370">23</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R46. For patients with COPD and cognitive impairment, the use of inhalation devices should be supervised (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R47. For patients with COPD and cognitive impairment who cannot use an inhalation device, spacing chambers or nebulizers should be employed (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Consensus recommendations with ≥95% agreement associated with the patient's comorbidities." ] ] 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:3 [ "leyenda" => "Abbreviations: ACO, asthma-COPD overlap; COPD, chronic obstructive pulmonary disease; DoR, degree of recommendation; FEV1, forced expiratory volume in one second; IC, inhaled corticosteroids; LABA, long-acting beta agonists; LAMA, long-acting muscarinic antagonists; LoE, level of evidence; MMRC, modified dyspnea scale; TT, triple therapy." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1+2, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3+4, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary function FEV1<50% and dyspnea 0–1 on the MMRC</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R64. For patients with COPD, FEV1<50% and dyspnea of 0–1 on the MMRC, the initial treatment should be a long-acting bronchodilator (preferably a LAMA) if this has not been previously prescribed<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R65. For patients with COPD, FEV1<50% and dyspnea of 0–1 on the MMRC who remain symptomatic despite the use of a long-acting bronchodilator, a second bronchodilator should be added, and the response assessed. Given that many patients report no dyspnea due to reduced activity, this point should be questioned directly<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R66. For patients with COPD, FEV1<50% and dyspnea of 0–1 on the MMRC who have persistent exacerbations despite treatment with a long-acting bronchodilator, a second bronchodilator should be added<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary function FEV1<50% and dyspnea 2–4 on the MMRC</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R69. For patients with COPD, FEV1<50%, dyspnea ≥2 on the MMRC and persistent dyspnea despite monotherapy with a LAMA or LABA, the recommendation is to employ 2bronchodilators (LAMA+LABA)<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R70. For patients with COPD, FEV1<50% and dyspnea ≥2 on the MMRC, the start of treatment with LAMA+LABA may be assessed<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R71. For patients with COPD, FEV1<50%, dyspnea ≥2 on the MMRC and ACO, treatment should be started with LABA+IC<a class="elsevierStyleCrossRef" href="#bib0355">20</a> (LoE, 3; DoR, C). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R72. For patients with COPD, FEV1<50%, dyspnea ≥2 on the MMRC and persistent exacerbations despite treatment with dual therapy (LAMA+LABA or IC+LABA), treatment should be started with TT with LAMA+LABA+IC<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R73. For patients with COPD, FEV1<50%, dyspnea ≥2 on the MMRC and persistent exacerbations despite treatment with TT with LAMA+LABA+IC, treatment with roflumilast may be considered if the patient has chronic bronchitis and presented exacerbations in the past year<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary function FEV1≥50%</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R77. For patients with COPD, FEV1 ≥50%, high-risk criteria (MMRC ≥2 despite treatment and ≥2 exacerbations or 1 exacerbation resulting in hospitalization in the past year) and insufficient control, the phenotype should be identified, and new drugs added according to this phenotype.<a class="elsevierStyleCrossRef" href="#bib0355">20</a>,<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "Recommendation adapted from the source, graded with the GRADE system as weakly in favor." ] ] ] "descripcion" => array:1 [ "en" => "Consensus recommendations with ≥95% agreement associated with the patient's pulmonary function according to the forced expiratory volume in 1 second." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: COPD, chronic obstructive pulmonary disease; DoR, degree of recommendation; GOLD, Global Initiative for Chronic Obstructive Lung Disease; LABA, long-acting beta agonists; LAMA, long-acting muscarinic antagonists; LoE, level of evidence; MMRC, modified Medical Research Council dyspnea scale." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1+2, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3+4, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea of 0–1 on the MMRC</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R55. For patients with COPD and dyspnea 0–1 on the MMRC, the nondrug measures (such as smoking cessation and physical exercise) should be reassessed<a class="elsevierStyleCrossRef" href="#bib0355">20</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R56. For patients with COPD and dyspnea 0–1 on the MMRC, the influenza and pneumococcal vaccinations should be reassessed<a class="elsevierStyleCrossRef" href="#bib0355">20</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dyspnea of 2–4 on the MMRC</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R57. For patients with COPD and dyspnea of 2–4 on the MMRC, the base treatment should be reassessed (according to GOLD: class C–D)<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R58. For patients with COPD and dyspnea 2–4 on the MMRC, the bronchodilator treatment should be optimized (e.g., progress to dual bronchodilation [LAMA+LABA] for patients undergoing monotherapy) (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R59. For patients with COPD and dyspnea 2–4 on the MMRC, the nondrug measures (such as smoking cessation and physical exercise) should be reassessed (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R60. For patients with COPD and dyspnea 2–4 on the MMRC, the influenza and pneumococcal vaccinations should be reassessed (expert opinion). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Consensus recommendations with ≥95% agreement associated with the patient's degree of dyspnea according to the modified dyspnea scale." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Abbreviations: COPD, chronic obstructive pulmonary disease; CVR, cardiovascular risk; DoR, degree of recommendation; IC, inhaled corticosteroids; LABA, long-acting beta-2 agonists; LAMA, long-acting muscarinic antagonists; LoE, level of evidence; TT, triple therapy." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1+2, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3+4, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drug treatment of cardiovascular risk factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R78. For patients with COPD and severe exacerbations, their overall CVR should be assessed, according to the European CVR prevention standards<a class="elsevierStyleCrossRefs" href="#bib0355">20,22</a> (LoE, 5; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R90. For patients with exacerbated COPD, the classical CVR factors should be thoroughly treated<a class="elsevierStyleCrossRefs" href="#bib0380">25,28</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R92. For patients with COPD, there is no need to withdraw the cardioselective β-blockers indicated for other diseases given that the drugs are safe<a class="elsevierStyleCrossRef" href="#bib0400">29</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C6. For patients with COPD who have experienced an exacerbation, good control of the comorbidities reduces mortality<a class="elsevierStyleCrossRef" href="#bib0405">30</a> (LoE, 1). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Drug treatment to prevent new exacerbations</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C5. Long-acting bronchodilators (LAMA/LABA) reduce the number of exacerbations<a class="elsevierStyleCrossRefs" href="#bib0355">20,21,31–33</a> (LoE, 1). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R80. For patients with COPD and frequent exacerbations despite optimal bronchodilator treatment, adding an IC is indicated<a class="elsevierStyleCrossRefs" href="#bib0335">16,20,21,31,34</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R81. For patients with high-risk COPD who have had 2or more moderate-severe exacerbations in the past year despite treatment with 2drugs, the recommendation is TT (LAMA+LABA+IC)<a class="elsevierStyleCrossRefs" href="#bib0335">16,20,21,31,34</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nondrug treatment to prevent new exacerbations</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R86. For patients with COPD, the recommendation is to encourage physical activity and self-care to prevent exacerbations, always in conjunction with other types of measures<a class="elsevierStyleCrossRefs" href="#bib0430">35–39</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Consensus recommendations with ≥95% agreement associated with the patient's severe exacerbations." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Abbreviations: COPD, chronic obstructive pulmonary disease; CVD, cardiovascular disease; CVR, cardiovascular risk; DoR, grade of recommendation; LoE, level of evidence." "tablatextoimagen" => array:1 [ 0 => array:1 [ "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="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1+2, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3+4, n (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking cessation counseling</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R8. All patients with COPD who smoke should be given educational information that helps them understand their disease, facilitating the knowledge and tools necessary for maintaining and improving their health and wellbeing and ceasing their smoking habit<a class="elsevierStyleCrossRef" href="#bib0355">20</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">COPD as a CVR disease</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C1. COPD should be considered an independent factor of very high cardiovascular risk that manifests by increased systemic inflammation and markers of atherosclerosis, with a greater risk of developing ischemic heart disease, heart failure and arrhythmias, and that increases mortality<a class="elsevierStyleCrossRefs" href="#bib0455">40–43</a> (LoE, 2). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R1. Due to the high risk of CVD that patients with COPD present, the recommendation is to promptly identify the presence of CVD before it manifests clinically, because CVD can result in a poorer prognosis for the COPD<a class="elsevierStyleCrossRefs" href="#bib0275">4,41,43,44</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Smoking</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">C3. For patients with COPD who smoke, treating the tobacco use is based on combining behavioral cognitive therapy and drug treatment<a class="elsevierStyleCrossRefs" href="#bib0480">45–49</a> (LoE, 2). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R9. Health professionals should provide the necessary assistance to patients with COPD who smoke to increase their motivation and promote smoking cessation at any point of the healthcare process, including hospitalization<a class="elsevierStyleCrossRef" href="#bib0505">50</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diet and exercise</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R11. Patients with COPD should receive nutritional education designed to prevent malnutrition and obesity.<a class="elsevierStyleCrossRef" href="#bib0510">51</a>,<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R13. For all patients with COPD, regular physical activity should be recommended.<a class="elsevierStyleCrossRef" href="#bib0355">20</a>,<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R14. For all patients with COPD, moderate-intensity physical activity should be recommended through a schedule of walks, with the objective of walking between 20–30min/5 days a week.<a class="elsevierStyleCrossRef" href="#bib0510">51</a>,<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R15. For all patients with COPD, aerobic exercise using a cycle ergometer (15–30min/day) is recommended as an alternative to moderate physical activity through a schedule of walks.<a class="elsevierStyleCrossRef" href="#bib0510">51</a>,<a class="elsevierStyleCrossRef" href="#tblfn0010">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 (4.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">59 (95.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Respiratory rehabilitation</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R17. Patients with COPD who have undergone respiratory rehabilitation should continue performing respiratory rehabilitation exercises at home and regular physical activity indefinitely<a class="elsevierStyleCrossRef" href="#bib0510">51</a> (LoE, 5; DoR, D). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vaccination</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R18. Patients with COPD should be advised to take the annual influenza vaccination.<a class="elsevierStyleCrossRef" href="#bib0510">51</a>,<a class="elsevierStyleCrossRef" href="#tblfn0015">b</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R20. All patients with COPD older than 65 years who have not been previously vaccinated should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360">21</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R21. All patients with COPD younger than 65 years with FEV1<40% should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360">21</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R22. All patients with COPD younger than 65 years with comorbidities, especially cardiac, should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360">21</a> (LoE, 2; DoR, B). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"></td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " colspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Follow-up</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R93. For stable patients, the recommendation is to optimize the outpatient follow-up according to the patient's symptoms and needs and based on the available resources<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 2; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 (3.2) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 (96.8) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R94. For patients with stable COPD, the symptoms should be assessed in each follow-up visit, as well as the presence of exacerbations, tobacco use, comorbidities, treatment appropriateness to the clinical situation, therapeutic compliance and the inhalation technique<a class="elsevierStyleCrossRefs" href="#bib0355">20,21</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R98. For patients with COPD who just experienced an exacerbation that has ended, the treatment should be adjusted to optimize the control and prevent future exacerbations<a class="elsevierStyleCrossRef" href="#bib0510">51</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 (1.6) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">61 (98.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Consensus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">R100. For patients hospitalized for a COPD exacerbation, therapeutic reconciliation should be conducted prior to discharge, providing information in writing on the changes performed in the patients’ long-term therapy<a class="elsevierStyleCrossRef" href="#bib0510">51</a> (LoE, 1; DoR, A). \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 (0.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62 (100.0) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unanimous agreement \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "a" "nota" => "Recommendation adapted from the source, with agreement from the group." ] 1 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "b" "nota" => "Recommendation adapted from the source, graded with the GRADE system as strong." ] ] ] "descripcion" => array:1 [ "en" => "Consensus recommendations with ≥95% agreement regarding the basic concepts of management and follow-up of patients with chronic obstructive pulmonary disease." ] ] 6 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 151975 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:51 [ 0 => array:3 [ "identificador" => "bib0260" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990–2013: quantifying the epidemiological transition" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "BD 2013 DALYs and HALE Collaborators" "etal" => true "autores" => array:6 [ 0 => "C.J. Murray" 1 => "R.M. Barber" 2 => "K.J. Foreman" 3 => "A. Abbasoglu Ozgoren" 4 => "F. Abd-Allah" 5 => "S.F. Abera" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(15)61340-X" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2015" "volumen" => "386" "paginaInicial" => "2145" "paginaFinal" => "2191" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26321261" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0265" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Finding the best thresholds of FEV1 and dyspnea to predict 5-year survival in COPD patients: the COCOMICS study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "P. Martinez-Camblor" 2 => "J.B. Soriano" 3 => "J.M. Marin" 4 => "I. Alfageme" 5 => "C. Casanova" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0089866" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2014" "volumen" => "9" "paginaInicial" => "e89866" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24587085" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0270" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.J. Soler-Cataluna" 1 => "M.A. Martinez-Garcia" 2 => "P. Roman Sanchez" 3 => "E. Salcedo" 4 => "M. Navarro" 5 => "R. Ochando" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2005.040527" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2005" "volumen" => "60" "paginaInicial" => "925" "paginaFinal" => "931" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16055622" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0275" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD: the EPOC en Servicios de medicina interna (ESMI) study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "F.J. Cabrera" 2 => "J. Diez" 3 => "R. Boixeda" 4 => "M.B. Alonso Ortiz" 5 => "C. Murio" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.11-2413" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2012" "volumen" => "142" "paginaInicial" => "1126" "paginaFinal" => "1133" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23303399" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0280" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Multicomponent índices to predict survival in COPD: the COCOMICS study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Marin" 1 => "I. Alfageme" 2 => "P. Almagro" 3 => "C. Casanova" 4 => "C. Esteban" 5 => "J.J. Soler-Cataluna" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00121012" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2013" "volumen" => "42" "paginaInicial" => "323" "paginaFinal" => "332" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23222874" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0285" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Short- and medium-term prognosis in patients hospitalized for COPD exacerbation: the CODEX index" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "J.B. Soriano" 2 => "F.J. Cabrera" 3 => "R. Boixeda" 4 => "M.B. Alonso-Ortiz" 5 => "B. Barreiro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.13-1328" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2014" "volumen" => "145" "paginaInicial" => "972" "paginaFinal" => "980" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24077342" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0290" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pseudomonas aeruginosa in patients hospitalised for COPD exacerbation: a prospective study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Garcia-Vidal" 1 => "P. Almagro" 2 => "V. Romani" 3 => "M. Rodriguez-Carballeira" 4 => "E. Cuchi" 5 => "L. Canales" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00003309" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "1072" "paginaFinal" => "1078" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19386694" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0295" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mortality after hospitalization for COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "E. Calbo" 2 => "A. Ochoa de Echaguen" 3 => "B. Barreiro" 4 => "S. Quintana" 5 => "J.L. Heredia" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.121.5.1441" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2002" "volumen" => "121" "paginaInicial" => "1441" "paginaFinal" => "1448" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12006426" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0300" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Post-hospital mortality in patients re-admitted due to COPD. Utility of BODE index" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Sanjaume" 1 => "P. Almagro" 2 => "M. Rodriguez-Carballeira" 3 => "B. Barreiro" 4 => "J.L. Heredia" 5 => "J. Garau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0014-2565(09)72339-2" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2009" "volumen" => "209" "paginaInicial" => "364" "paginaFinal" => "370" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19775584" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0305" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prognostic assessment of mortality and hospitalizations of outpatients with advanced chronic obstructive pulmonary disease. Usefulness of the CODEX index" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Navarro" 1 => "R. Costa" 2 => "M. Rodriguez-Carballeira" 3 => "S. Yun" 4 => "A. Lapuente" 5 => "A. Barrera" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2015.06.004" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2015" "volumen" => "215" "paginaInicial" => "431" "paginaFinal" => "438" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26183602" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0310" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The PEARL score predicts 90-day readmission or death after hospitalisation for acute exacerbation of COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Echevarria" 1 => "J. Steer" 2 => "K. Heslop-Marshall" 3 => "S.C. Stenton" 4 => "P.M. Hickey" 5 => "R. Hughes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thoraxjnl-2016-209298" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2017" "volumen" => "72" "paginaInicial" => "686" "paginaFinal" => "693" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28235886" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0315" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Octogenarian patients with chronic obstructive pulmonary disease: characteristics and usefulness of prognostic indexes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Golpe" 1 => "M. Suarez-Valor" 2 => "A. Veres-Racamonde" 3 => "E. Cano-Jimenez" 4 => "I. Martin-Robles" 5 => "P. Sanjuan-Lopez" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Med Clin (Barc)" "fecha" => "2018" "volumen" => "151" "paginaInicial" => "53" "paginaFinal" => "58" ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0320" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "External validation and recalibration of the CODEX index in COPD patients. A 3 CIAplus cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "P. Martínez-Camblor" 2 => "M. Miravitlles" 3 => "M. Rodríguez" 4 => "A. Navarro" 5 => "B. Lamprecht" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/15412555.2018.1484440" "Revista" => array:6 [ "tituloSerie" => "COPD" "fecha" => "2019" "volumen" => "14" "paginaInicial" => "1" "paginaFinal" => "10" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27723367" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0325" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Recent improvement in long-term survival after a COPD hospitalisation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "M. Salvado" 2 => "C. Garcia-Vidal" 3 => "M. Rodriguez-Carballeira" 4 => "M. Delgado" 5 => "B. Barreiro" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.124818" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "298" "paginaFinal" => "302" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20388752" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0330" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Time for a longer and better life for patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "L. Vanfleteren" 1 => "A. Ullman" 2 => "L.M. Fabbri" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:3 [ "tituloSerie" => "Eur Respir J" "fecha" => "2018" "volumen" => "51" ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0335" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Once-daily single-inhaler triple versus dual therapy in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.A. Lipson" 1 => "F. Barnhart" 2 => "N. Brealey" 3 => "J. Brooks" 4 => "G.J. Criner" 5 => "N.C. Day" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa1713901" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2018" "volumen" => "378" "paginaInicial" => "1671" "paginaFinal" => "1680" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29668352" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0340" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Inhaled corticosteroid containing combinations and mortality in COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Vestbo" 1 => "L. Fabbri" 2 => "A. Papi" 3 => "S. Petruzzelli" 4 => "M. Scuri" 5 => "A. Guasconi" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01675-2018" "Revista" => array:4 [ "tituloSerie" => "Eur. Respir. J" "fecha" => "2018" "volumen" => "52" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30385603" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0345" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic obstructive pulmonary disease is just one component of the complex multimorbidities in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "E.M. Clini" 1 => "B. Beghe" 2 => "L.M. Fabbri" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201302-0230ed" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2013" "volumen" => "187" "paginaInicial" => "668" "paginaFinal" => "671" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23540872" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0350" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Levels of evidence document" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Oxford Centre for Evidence-Based Medicine" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:1 [ "fecha" => "2011" ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0355" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía de Práctica Clínica para el Diagnóstico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Crónica (EPOC) – Guía Española de la EPOC (GesEPOC). Versión 2017" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Grupo de Trabajo de GesEPOC" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Bronconeumol" "fecha" => "2017" "volumen" => "53" "numero" => "Extraordinario 1" "paginaInicial" => "2" "paginaFinal" => "64" ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0360" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.F. Vogelmeier" 1 => "G.J. Criner" 2 => "F.J. Martinez" 3 => "A. Anzueto" 4 => "P.J. Barnes" 5 => "J. Bourbeau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.201701-0218PP" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2017" "volumen" => "195" "paginaInicial" => "557" "paginaFinal" => "582" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28128970" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0365" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "2016 European Guidelines on cardiovascular disease prevention in clinical practice: the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts). Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR)" "etal" => true "autores" => array:6 [ 0 => "M.F. Piepoli" 1 => "A.W. Hoes" 2 => "S. Agewall" 3 => "C. Albus" 4 => "C. Brotons" 5 => "A.L. Catapano" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehw106" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2016" "volumen" => "37" "paginaInicial" => "2315" "paginaFinal" => "2381" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27222591" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0370" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Protocolos: manejo diagnóstico y terapéutico de las comorbilidades en la EPOC" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "J. Díez-Manglano" 1 => "F. López-García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:5 [ "fecha" => "2014" "paginaInicial" => "1" "paginaFinal" => "259" "editorial" => "Sociedad Española de Medicina Interna (SEMI) y Elsevier SL" "editorialLocalizacion" => "Barcelona" ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0375" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Susceptibility to exacerbation in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.R. Hurst" 1 => "J. Vestbo" 2 => "A. Anzueto" 3 => "N. Locantore" 4 => "H. Mullerova" 5 => "R. Tal-Singer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0909883" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2010" "volumen" => "363" "paginaInicial" => "1128" "paginaFinal" => "1138" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20843247" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0380" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.L. Chang" 1 => "S.C. Robinson" 2 => "G.D. Mills" 3 => "G.D. Sullivan" 4 => "N.C. Karalus" 5 => "J.D. McLachlan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2010.155333" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2011" "volumen" => "66" "paginaInicial" => "764" "paginaFinal" => "768" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21474497" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0385" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consenso de seguimiento y tratamiento para la EPOC según el Índice CODEX" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P. Almagro" 1 => "B.R. Diéz-Manglano" 2 => "J. Gómez-Antúnez" 3 => "M.F. López-García" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2018" "volumen" => "218" "paginaInicial" => "3" ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0390" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pseudomonas aeruginosa and mortality after hospital admission for chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "M. Salvado" 2 => "C. Garcia-Vidal" 3 => "M. Rodriguez-Carballeira" 4 => "E. Cuchi" 5 => "J. Torres" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1159/000331224" "Revista" => array:6 [ "tituloSerie" => "Respiration" "fecha" => "2012" "volumen" => "84" "paginaInicial" => "36" "paginaFinal" => "43" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21996555" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0395" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Invasive coronary angiography in patients with acute exacerbated COPD and elevated plasma troponin" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C. Pizarro" 1 => "N. Herweg-Steffens" 2 => "M. Buchenroth" 3 => "W. Schulte" 4 => "C. Schaefer" 5 => "C. Hammerstingl" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2147/COPD.S110746" "Revista" => array:6 [ "tituloSerie" => "Int J Chron Obstruct Pulmon Dis" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "2081" "paginaFinal" => "2089" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27695304" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0400" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Effect of beta blockers on mortality after myocardial infarction in adults with COPD: Population based cohort study of UK electronic healthcare records" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.K. Quint" 1 => "E. Herrett" 2 => "K. Bhaskaran" 3 => "A. Timmis" 4 => "H. Hemingway" 5 => "J.A. Wedzicha" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/bmj.f6650" "Revista" => array:5 [ "tituloSerie" => "BMJ" "fecha" => "2013" "volumen" => "347" "paginaInicial" => "f6650" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24270505" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0405" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Early and long-term outcomes of older adults after acute care encounters for chronic obstructive pulmonary disease exacerbation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L. Genao" 1 => "M.T. Durheim" 2 => "X. Mi" 3 => "J.L. Todd" 4 => "H.E. Whitson" 5 => "L.H. Curtis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1513/AnnalsATS.201504-250OC" "Revista" => array:6 [ "tituloSerie" => "Ann Am Thorac Soc" "fecha" => "2015" "volumen" => "12" "paginaInicial" => "1805" "paginaFinal" => "1812" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26394180" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0410" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevention of acute exacerbations of COPD: American College of Chest Physicians and Canadian Thoracic Society Guideline" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G.J. Criner" 1 => "J. Bourbeau" 2 => "R.L. Diekemper" 3 => "D.R. Ouellette" 4 => "D. Goodridge" 5 => "P. Hernandez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.14-1676" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2015" "volumen" => "147" "paginaInicial" => "894" "paginaFinal" => "942" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25321320" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0415" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improved outcomes in patients with chronic obstructive pulmonary disease treated with salmeterol compared with placebo/usual therapy: results of a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.A. Stockley" 1 => "P.J. Whitehead" 2 => "M.K. Williams" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/1465-9921-7-147" "Revista" => array:5 [ "tituloSerie" => "Respir Res" "fecha" => "2006" "volumen" => "7" "paginaInicial" => "147" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17196106" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0420" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A 4-year trial of tiotropium in chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.P. Tashkin" 1 => "B. Celli" 2 => "S. Senn" 3 => "D. Burkhart" 4 => "S. Kesten" 5 => "S. Menjoge" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa0805800" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2008" "volumen" => "359" "paginaInicial" => "1543" "paginaFinal" => "1554" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18836213" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0425" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease (TRIBUTE): a double-blind, parallel group, randomised controlled trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Papi" 1 => "J. Vestbo" 2 => "L. Fabbri" 3 => "M. Corradi" 4 => "H. Prunier" 5 => "G. Cohuet" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(18)30206-X" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2018" "volumen" => "391" "paginaInicial" => "1076" "paginaFinal" => "1084" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29429593" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0430" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Characteristics of effective self-management interventions in patients with COPD: individual patient data meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N.H. Jonkman" 1 => "H. Westland" 2 => "J.C. Trappenburg" 3 => "R.H. Groenwold" 4 => "E.W. Bischoff" 5 => "J. Bourbeau" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/13993003.01860-2015" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2016" "volumen" => "48" "paginaInicial" => "55" "paginaFinal" => "68" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27126694" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0435" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The minimal important difference in physical activity in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Demeyer" 1 => "C. Burtin" 2 => "M. Hornikx" 3 => "C.A. Camillo" 4 => "H. van Remoortel" 5 => "D. Langer" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0154587" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "e0154587" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27124297" "web" => "Medline" ] ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0440" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "S.G. Adams" 1 => "P.K. Smith" 2 => "P.F. Allan" 3 => "A. Anzueto" 4 => "J.A. Pugh" 5 => "J.E. Cornell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archinte.167.6.551" "Revista" => array:6 [ "tituloSerie" => "Arch Intern Med" "fecha" => "2007" "volumen" => "167" "paginaInicial" => "551" "paginaFinal" => "561" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17389286" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0445" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.E. Jordan" 1 => "S. Majothi" 2 => "N.R. Heneghan" 3 => "D.B. Blissett" 4 => "R.D. Riley" 5 => "A.J. Sitch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3310/hta191020" "Revista" => array:6 [ "tituloSerie" => "Health Technol Assess" "fecha" => "2015" "volumen" => "19" "paginaInicial" => "1" "paginaFinal" => "516" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26691209" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0450" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Lenferink" 1 => "M. Brusse-Keizer" 2 => "P.D. van der Valk" 3 => "P.A. Frith" 4 => "M. Zwerink" 5 => "E.M. Monninkhof" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Cochrane Database Syst Rev" "fecha" => "2017" "volumen" => "8" "paginaInicial" => "CD011682" ] ] ] ] ] ] 39 => array:3 [ "identificador" => "bib0455" "etiqueta" => "40" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardiovascular comorbidity in COPD: systematic literature review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "H. Mullerova" 1 => "A. Agusti" 2 => "S. Erqou" 3 => "D.W. Mapel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.12-2847" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2013" "volumen" => "144" "paginaInicial" => "1163" "paginaFinal" => "1178" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23722528" "web" => "Medline" ] ] ] ] ] ] ] ] 40 => array:3 [ "identificador" => "bib0460" "etiqueta" => "41" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Subclinical atherosclerosis risk markers in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "L.Y. Wang" 1 => "Y.N. Zhu" 2 => "J.J. Cui" 3 => "K.Q. Yin" 4 => "S.X. Liu" 5 => "Y.H. Gao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rmed.2016.12.004" "Revista" => array:6 [ "tituloSerie" => "Respir Med" "fecha" => "2017" "volumen" => "123" "paginaInicial" => "18" "paginaFinal" => "27" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28137492" "web" => "Medline" ] ] ] ] ] ] ] ] 41 => array:3 [ "identificador" => "bib0465" "etiqueta" => "42" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "W. Chen" 1 => "J. Thomas" 2 => "M. Sadatsafavi" 3 => "J.M. FitzGerald" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S2213-2600(15)00241-6" "Revista" => array:6 [ "tituloSerie" => "Lancet Respir Med" "fecha" => "2015" "volumen" => "3" "paginaInicial" => "631" "paginaFinal" => "639" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26208998" "web" => "Medline" ] ] ] ] ] ] ] ] 42 => array:3 [ "identificador" => "bib0470" "etiqueta" => "43" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chronic obstructive pulmonary disease and sudden cardiac death: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. Van den Berg" 1 => "B.H. Stricker" 2 => "G.G. Brusselle" 3 => "L. Lahousse" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.tcm.2016.04.001" "Revista" => array:6 [ "tituloSerie" => "Trends Cardiovasc Med" "fecha" => "2016" "volumen" => "26" "paginaInicial" => "606" "paginaFinal" => "613" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27234353" "web" => "Medline" ] ] ] ] ] ] ] ] 43 => array:3 [ "identificador" => "bib0475" "etiqueta" => "44" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Study of the comorbidities in hospitalized patients due to decompensated chronic obstructive pulmonary disease attended in the Internal Medicine Services ECCO Study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Almagro" 1 => "F. Lopez Garcia" 2 => "F.J. Cabrera" 3 => "L. Montero" 4 => "D. Morchon" 5 => "J. Diez" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rce.2009.12.002" "Revista" => array:6 [ "tituloSerie" => "Rev Clin Esp" "fecha" => "2010" "volumen" => "210" "paginaInicial" => "101" "paginaFinal" => "108" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20226938" "web" => "Medline" ] ] ] ] ] ] ] ] 44 => array:3 [ "identificador" => "bib0480" "etiqueta" => "45" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "C.A. Jimenez-Ruiz" 1 => "F. Masa" 2 => "M. Miravitlles" 3 => "R. Gabriel" 4 => "J.L. Viejo" 5 => "C. Villasante" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1378/chest.119.5.1365" "Revista" => array:6 [ "tituloSerie" => "Chest" "fecha" => "2001" "volumen" => "119" "paginaInicial" => "1365" "paginaFinal" => "1370" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11348940" "web" => "Medline" ] ] ] ] ] ] ] ] 45 => array:3 [ "identificador" => "bib0485" "etiqueta" => "46" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Hoogendoorn" 1 => "T.L. Feenstra" 2 => "R.T. Hoogenveen" 3 => "M.P. Rutten-van Molken" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.131631" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "711" "paginaFinal" => "718" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20685746" "web" => "Medline" ] ] ] ] ] ] ] ] 46 => array:3 [ "identificador" => "bib0490" "etiqueta" => "47" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Smoking cessation interventions in COPD: A network meta-analysis of randomised trials" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. Strassmann" 1 => "B. Bausch" 2 => "A. Spaar" 3 => "J. Kleijnen" 4 => "O. Braendli" 5 => "M.A. Puhan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1183/09031936.00167708" "Revista" => array:6 [ "tituloSerie" => "Eur Respir J" "fecha" => "2009" "volumen" => "34" "paginaInicial" => "634" "paginaFinal" => "640" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19357145" "web" => "Medline" ] ] ] ] ] ] ] ] 47 => array:3 [ "identificador" => "bib0495" "etiqueta" => "48" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "High rate of smoking abstinence in COPD patients: smoking cessation by hospitalization" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "B.M. Sundblad" 1 => "K. Larsson" 2 => "L. Nathell" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1080/14622200802023890" "Revista" => array:6 [ "tituloSerie" => "Nicotine Tob Res" "fecha" => "2008" "volumen" => "10" "paginaInicial" => "883" "paginaFinal" => "890" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18569763" "web" => "Medline" ] ] ] ] ] ] ] ] 48 => array:3 [ "identificador" => "bib0500" "etiqueta" => "49" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An official ATS statement: grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H.J. Schunemann" 1 => "R. Jaeschke" 2 => "D.J. Cook" 3 => "W.F. Bria" 4 => "A.A. el-Solh" 5 => "A. Ernst" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1164/rccm.200602-197ST" "Revista" => array:6 [ "tituloSerie" => "Am J Respir Crit Care Med" "fecha" => "2006" "volumen" => "174" "paginaInicial" => "605" "paginaFinal" => "614" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16931644" "web" => "Medline" ] ] ] ] ] ] ] ] 49 => array:3 [ "identificador" => "bib0505" "etiqueta" => "50" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prevalence, diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "L. Shahab" 1 => "M.J. Jarvis" 2 => "J. Britton" 3 => "R. West" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2006.064410" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2006" "volumen" => "61" "paginaInicial" => "1043" "paginaFinal" => "1047" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17040932" "web" => "Medline" ] ] ] ] ] ] ] ] 50 => array:3 [ "identificador" => "bib0510" "etiqueta" => "51" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Proceso asistencial integrado del paciente con EPOC exacerbado (PACEX-EPOC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.J. Soler-Cataluña" 1 => "A. Fernández-Villar" 2 => "M. Román" 3 => "J. Ancochea" 4 => "B. Alcázar" 5 => "P. Almagro" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2015" "editorial" => "Respira-Fundación Española del Pulmón-SEPAR" "editorialLocalizacion" => "Barcelona" ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack436622" "titulo" => "Acknowledgements" "texto" => "The authors would like to thank all of the experts of the validated external group (<a class="elsevierStyleCrossRef" href="#sec0100">appendix, Table S6, supplemental material</a>), as well as the Chiesi laboratories for helping implement this study. The authors would also like to thank Veronica Albert and Antoni Torres of GOC Networking for their technical support throughout the project." "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/22548874/0000021900000009/v3_201912041809/S2254887419301110/v3_201912041809/en/main.assets" "Apartado" => array:4 [ "identificador" => "3982" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Special Article" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/22548874/0000021900000009/v3_201912041809/S2254887419301110/v3_201912041809/en/main.pdf?idApp=WRCEE&text.app=https://revclinesp.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2254887419301110?idApp=WRCEE"]

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Consensus for managing patients with chronic obstructive pulmonary disease according to the CODEX index

Consenso para el manejo de pacientes con EPOC según el índice CODEX

R. Boixedaa, J. Díez-Manglanob, M. Gómez-Antúnezc, F. López-Garcíad, J. Recioe, P. Almagrof,

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19908pam@comb.cat

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a Servicio de Medicina Interna, Hospital de Mataró, Mataró, Barcelona, Spain

b Servicio de Medicina Interna, Hospital Universitario Miguel Servet, Zaragoza, Spain

c Servicio de Medicina Interna, Hospital General Universitario Gregorio Marañón, Madrid, Spain

d Servicio de Medicina Interna, Hospital General de Elche, Elche, Alicante, Spain

e Servicio de Medicina Interna, Hospital Vall d’Hebron, Barcelona, Spain

f Unidad de paciente crónico complejo, Servicio de Medicina Interna, Hospital Universitari Mútua de Terrassa, Terrassa, Barcelona, Spain

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which improve the indices&#8217; predictive capacity&#46; The most recognized index is BODE&#44; composed of body mass index &#40;BMI&#41; &#40;B&#41;&#44; FEV<span class="elsevierStyleInf">1</span>&#37; &#40;O&#41;&#44; dyspnea &#40;D&#41; and exercise capacity &#40;E&#41;&#44; measured by the distance traveled in the 6-min walk test&#46; BODEx replaces the walking test with the history of severe exacerbations in the past year &#40;Ex&#41;&#46; Other indices include ADO &#40;age&#44; dyspnea and airflow obstruction&#41; and DOSE &#40;dyspnea&#44; obstruction&#44; smoking and exacerbations&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2014&#44; the development and validation of the CODEX index was published&#46; Compared with BODEx&#44; CODEX replaces BMI with comorbidity &#40;C&#41;&#44; measured with the age-adjusted Charlson index and preserves the same cutoff points for FEV<span class="elsevierStyleInf">1</span>&#37;&#44; dyspnea and severe exacerbations in the past year&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">6</span></a> CODEX was the first multicomponent scale designed and validated to predict the risk of readmissions and mortality for patients hospitalized for COPD&#46; CODEX was developed in the COPD in Internal Medicine Departments &#40;<span class="elsevierStyleItalic">EPOC en servicios de medicina interna</span>&#44; ESMI&#41; cohort study&#44; while its validation was conducted in 3 other previously published cohorts&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">4&#44;7&#8211;9</span></a> The index has subsequently been revalidated in outpatients with severe COPD to assess the risk of mortality and readmission at 3 months and has demonstrated its usefulness in predicting mortality in the longer term&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">10&#8211;13</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Various recent studies have suggested that a better approach to treating COPD and its comorbidities could have a positive impact on these patients&#8217; survival&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">14</span></a> Treating comorbidities improves the survival of patients with COPD and&#44; conversely&#44; treating COPD can decrease the mortality by other causes&#44; especially cardiovascular&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">15&#8211;17</span></a> Patients therefore need an overall assessment of their COPD treatment and associated diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">18</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this study was to prepare recommendations specifically adapted for patients who would have had their CODEX index calculated based on the variables employed for its calculation&#44; to thereby offer a personalized therapeutic management strategy&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Materials and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Literature review</span><p id="par0025" class="elsevierStylePara elsevierViewall">A group of experts composed of 6 internal medicine specialists &#40;scientific committee&#41; developed various clinical questions aimed at creating recommendations based on the items of the CODEX index and grouped as follows&#58; basic concepts and recommendations associated with the comorbidities according to the Charlson index&#44; with pulmonary function according to the FEV<span class="elsevierStyleInf">1</span>&#37;&#44; with the degree of dyspnea&#44; with exacerbations and with patient follow-up&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a literature search in PubMed and the Cochrane Plus Library to identify publications that could answer these questions&#46; The keywords were adapted to each question or group of questions and included Mesh terms and combined free searches&#46; All searches included at least the study disease &#8220;chronic obstructive pulmonary disease&#8221; and other specific terms&#46; We applied language &#40;Spanish and English&#41;&#44; temporal &#40;studies published since on 2012&#41; and study type filters &#40;clinical practice guidelines&#44; 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This synthesis served as a basis for preparing the responses &#40;recommendations and their respective scientific rationale&#41;&#46; The group created 108 recommendations&#46; To classify the evidence and grade the recommendations&#44; we employed the evidence categorization system based on the Oxford Centre for Evidence-Based Medicine&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">19</span></a> When recommendations from other guidelines and consensuses were adopted&#44; the categorization of the original sources were maintained&#44; and we established the degree of recommendation &#8220;expert opinion&#8221; for the recommendations prepared by the scientific committee&#44; based on their experience in clinical practice&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Validating the recommendations</span><p id="par0045" class="elsevierStylePara elsevierViewall">The generated recommendations were reviewed by an external expert panel&#46; At the suggestion of the scientific committee&#44; we invited specialists from internal medicine&#44; pneumology and primary care throughout Spain&#46; To ensure a sufficient level of experience to assess the recommendations&#44; we established the following inclusion criteria&#58; the specialists treated patients with COPD and comorbidities&#44; COPD was one of the specialist&#39;s main areas of dedication&#47;interest&#44; the specialists had more than 3 years of experience in treating patients with COPD&#44; and at least 20&#37; of their healthcare consultations involved patients with COPD&#46; The invitation was sent by e-mail&#44; and the consultation was conducted online&#46; All experts were supplied with a supporting document for the recommendations&#46; For each proposed recommendation&#44; 4 possible responses were offered&#44; ranging from 1 &#40;strongly disagree&#41; to 4 &#40;strongly agree&#41;&#46; A space was provided for comments&#46; The consultation took place between February and March 2018&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">To analyze the results&#44; we grouped the 1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2 votes &#40;disagreements&#41; and the 3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4 votes &#40;agreements&#41;&#46; We calculated the percentage of agreements and determined the degree of consensus as follows&#58; &#40;a&#41; unanimous agreement&#44; when the entire expert panel was in agreement&#59; &#40;b&#41; consensus&#44; when &#8805;80&#37; of the experts were in agreement&#59; and &#40;c&#41; disagreement&#44; when the degree of consensus was not reached&#46; For space reasons&#44; the recommendations agreed upon with &#8805;95&#37; of the votes are shown in the &#8220;agreement&#8221; block&#44; except for the follow-up recommendations&#46; The recommendations with &#60;95&#37; agreement are available as <a class="elsevierStyleCrossRef" href="#sec0100">supplemental material &#40;appendix&#41;</a>&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Implementing the recommendations</span><p id="par0055" class="elsevierStylePara elsevierViewall">After closing the consultation with the external panel&#44; the expert committee met to assess the results and agree on the criteria for inclusion of the agreed upon recommendations in the tool that helps calculate the CODEX &#40;iCODEX&#41;&#44; available online and as an application&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Article identification and selection</span><p id="par0060" class="elsevierStylePara elsevierViewall">We identified 273 publications from which we ultimately selected 33 articles for the literature synthesis &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Validation of the external expert panel</span><p id="par0065" class="elsevierStylePara elsevierViewall">Of the 99 invited experts&#44; 91 responded &#40;91&#46;9&#37;&#41;&#44; 62 of whom &#40;68&#46;1&#37;&#41; met the inclusion criteria&#46; Of the 62 participants&#44; 49 &#40;79&#46;0&#37;&#41; were internal medicine specialists&#44; 11 &#40;17&#46;7&#37;&#41; were pneumology specialists&#44; and 2 &#40;3&#46;2&#37;&#41; were primary care specialists&#46; Of the 108 items consulted&#44; consensus was reached on 96 &#40;88&#46;9&#37;&#41;&#44; 16 with unanimous agreement and 80 with consensus&#46; There were only 12 recommendations &#40;11&#46;1&#37;&#41; with disagreement&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Recommendations associated with comorbidities</span><p id="par0070" class="elsevierStylePara elsevierViewall">We developed recommendations regarding cardiovascular diseases&#44; kidney disease&#44; diabetes&#44; osteoporosis and dementia but not for ulcerative disease&#44; liver disease&#44; hemiplegia&#44; cancer or AIDS&#44; which are also included in the Charlson index &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In general&#44; we considered that cardiovascular diseases&#44; diabetes&#44; kidney disease and osteoporosis in patients with COPD should be treated as in patients without COPD&#44; following the recommendations of the main clinical practice guidelines for COPD and for its associated comorbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> We considered that COPD should be considered a high cardiovascular risk &#40;CVR&#41; disease that requires treating the other CVR factors with the therapeutic objectives established in the guidelines for these circumstances&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">22&#44;23</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">There were 8 recommendations that did not achieve consensus and were related to cardiovascular diseases chronic kidney disease and dementia &#40;<a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S1&#44; supplemental material</a>&#41;&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Recommendations associated with pulmonary function</span><p id="par0080" class="elsevierStylePara elsevierViewall">For patients with FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and an MMRC dyspnea degree of 0&#8211;1&#44; the initial treatment should be a long-acting bronchodilator&#44; adding a second bronchodilator if the symptoms and exacerbations cannot be controlled&#46; For patients with FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and an MMRC dyspnea degree of 2&#8211;4&#44; the use of dual bronchodilation at the start may be assessed&#46; There was no consensus on whether the initial treatment for this patient group should be a long-acting muscarinic antagonist &#40;LAMA&#41; or a long-acting beta agonist &#40;LABA&#41;&#46; If the patient has persistent exacerbations&#44; triple therapy with LAMA&#44; LABA and an inhaled corticosteroid &#40;IC&#41; should be started&#46; Finally&#44; for patients with FEV<span class="elsevierStyleInf">1</span> &#8805;50&#37;&#44; recommendations were only established for cases with a high risk of exacerbations&#44; in which the recommendation is to identify the phenotype to adjust the treatment&#44; administering a LAMA and LABA as the first choice&#46; For cases with the mixed COPD-asthma phenotype&#44; the recommended treatment is generally the combination LABA and IC &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41; and <a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S2&#44; supplemental material</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Recommendations associated with dyspnea</span><p id="par0085" class="elsevierStylePara elsevierViewall">We divided the recommendations into 2 categories&#58; those associated with an MMRC dyspnea grade 0&#8211;1 and those associated with a dyspnea grade 2&#8211;4&#46; In the 2 cases&#44; the base drug treatment needs to be reassessed&#44; giving preference to a LAMA or a LABA for an MMRC of 0&#8211;1 and to dual therapy &#40;LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA&#41; in the case of previous monotherapy and an MMRC of 2&#8211;4 &#40;expert opinion&#41;&#46; In both cases&#44; it is advisable to reassess the nondrug measures &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S3&#44; supplemental material</a>&#41;&#46; There were no disagreements in this section&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Recommendations associated with exacerbations</span><p id="par0090" class="elsevierStylePara elsevierViewall">Exacerbations are considered severe if they require hospital care&#46; A patient that has experienced an exacerbation is predisposed to new exacerbations&#59; it is therefore important to optimize the patient&#39;s management to prevent these new exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">24</span></a> Good control of the comorbidities decreases mortality in patients who have experienced an exacerbation&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">14</span></a> Similarly&#44; the patient&#39;s CVR should be assessed&#44; the various associated CVR factors should be carefully treated&#44; and the drug and nondrug treatment should be optimized&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#8211;22</span></a> For patients with frequent exacerbations despite treatment with dual bronchodilation&#44; it is advisable to add an IC&#46; In addition&#44; other treatments should be assessed such as roflumilast&#44; macrolides and mucolytics&#44; individually according to the patient&#39;s profile&#44; as well as the recommendation for other nondrug measures &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S4&#44; supplemental material</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">General recommendations for management and follow-up</span><p id="par0095" class="elsevierStylePara elsevierViewall">We established general recommendations for management and follow-up not associated with the patient&#39;s profile or condition &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> and <a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S5&#44; supplemental material</a>&#41;&#46; COPD should be considered an independent high CVR factor&#44; because the risk of cardiovascular events is higher than in the general population&#44; especially after exacerbations&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">25</span></a> We also included recommendations on smoking cessation&#44; diet and physical activity&#46; We identified how and for which patient profile lung cancer screening should be performed&#44; as well as when to continue with home respiratory rehabilitation&#46; Due to the greater risk of complications due to COPD-associated respiratory infections&#44; we recommend the influenza vaccination for all patients&#44; as well as the pneumococcal vaccination depending on age&#44; pulmonary obstruction and comorbidities&#46; Consensus was not reached on 2 recommendations related to lung cancer screening &#40;<a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S5&#44; supplemental material</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In terms of follow-up&#44; once the patient is discharged after hospitalization for an exacerbation&#44; the outpatient follow-up should be optimized according to each patient&#39;s needs and the resources available&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> In this consensus&#44; we offer specific recommendations for the follow-up visit&#44; including aspects on assessment and treatment&#46; Additionally&#44; proper coordination with the primary care team and the patient&#39;s regular physician should be ensured&#44; performing annual spirometry and chest computed tomography for patients with suspected bronchiectasis&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a></p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0105" class="elsevierStylePara elsevierViewall">As far as we know&#44; this is the first study to combine a multicomponent index for determining the prognosis of patients with COPD with recommendations adapted to the scores of the various components of this index&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">26</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">The study strengths include the fact that the use of the recommendations can help adapt the COPD treatment to the patient characteristics and comorbidities&#44; thereby personalizing the therapy&#46; One of the strengths of the CODEX index is the inclusion of an assessment of these patients&#8217; comorbidities&#46; To this end&#44; CODEX uses the Charlson index&#44; one of the most recognized comorbidity scales that has shown an excellent predictive capacity in various populations&#44; including patients with COPD&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">27</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">Another study strength is that we employed and adapted recognized clinical guidelines &#40;such as the Global Initiative for Chronic Obstructive Lung Disease &#91;GOLD&#93; and the Spanish Guidelines for Chronic Obstructive Pulmonary Disease &#91;<span class="elsevierStyleItalic">Gu&#237;a espa&#241;ola de la enfermedad pulmonar obstructiva cr&#243;nica</span>&#44; GesEPOC&#93;&#44; the integrated care plan for patients with exacerbated COPD and the Spanish Society of Internal Medicine protocol for managing comorbidities in COPD&#41; along with other recent publications to develop the recommendations&#44; which has resulted in a high-quality and practical document&#44; avoiding the duplication of work already performed&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">The study&#39;s limitations include the fact that the assessment process for the external group was conducted in a single round&#46; However&#44; the high number of participants and the high percentage of consensus grants a relevant weight to the results&#46; Finally&#44; the methodology for obtaining consensus was solid and enabled us to ultimately obtain a high-quality document&#44; given that it is based on a literature review&#44; the preparation of recommendations by a group of recognized experts and on the individual assessment of a large group of experts on COPD independent from the scientific committee that prepared the recommendations&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Given the high number of recommendations that could hinder their use and implementation&#44; we opted for an implementation format that is visual&#44; schematic and practical to facilitate its applicability&#44; in an online and app format&#46; After implementing these recommendations in iCODEX&#44; its usefulness and applicability should be assessed&#44; as well as the potential for improving the prognosis resulting from compliance with the suggested recommendations&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conclusions</span><p id="par0130" class="elsevierStylePara elsevierViewall">The CODEX index can be calculated using iCODEX&#44; a support tool for specialists who treat patients with COPD&#44; available online or as an application&#46; The index predicts the mortality and risk of readmission and&#44; after the preparation of the present consensus document&#44; now covers 96 recommendations directed at physicians who treat patients with COPD&#46; These recommendations aim to improve the treatment of patients through a personalized approach to each patient for whom the CODEX index is calculated&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">The present project was sponsored by <span class="elsevierStyleGrantSponsor" id="gs1">Chiesi Laboratories &#40;Spain&#41;</span>&#44; who did not intervene in the design&#44; data analysis or preparation of the manuscript&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflicts of interest</span><p id="par0140" class="elsevierStylePara elsevierViewall">RB&#44; MGA and FLG declare that they have no conflicts of interest&#46; JDM declares having received consulting fees from Bayer&#44; Boehringer Ingelheim and Novartis&#46; JR declares having received consulting fees from Ferrer and Chiesi Laboratories and financial assistance for scientific meetings from Novartis&#46; PA declares having received consulting fees from GlaxoSmithKline&#44; Laboratories Esteve&#44; Rovi&#44; Menarini and Novartis&#46;</p></span></span>"
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          "titulo" => "Background"
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          "titulo" => "Materials and methods"
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              "titulo" => "Recommendations associated with dyspnea"
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            1 => "&#205;ndice de gravedad de la enfermedad"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The comorbidity&#44; obstruction&#44; dyspnea&#44; exacerbations &#40;CODEX&#41; index is the first multicomponent scale designed to predict the risk of readmissions and mortality at 1 year for patients hospitalised for chronic obstructive pulmonary disease &#40;COPD&#41;&#46; The index includes the comorbidities &#40;C&#41; &#40;measured by the Charlson index&#41;&#44; the degree of obstruction &#40;O&#41; &#40;assessed by the forced expiratory volume in 1 second percentage&#41;&#44; dyspnea &#40;D&#41; &#40;stratified according to the modified Medical Research Council scale&#41; and exacerbations &#40;EX&#41; in the previous year&#46; Our objective was to prepare recommendations based on the index&#39;s various components for personalized therapeutic management&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">To this end&#44; we performed a literature search based on guidelines&#44; consensuses and systematic reviews&#44; as a basis for preparing recommendations on basic concepts&#44; comorbidities&#44; dyspnea&#44; pulmonary obstruction&#44; exacerbations and follow-up&#46; The recommendations were then subjected to an external assessment process by a multidisciplinary group of 62 experts&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In total&#44; 108 recommendations were created&#44; 96 of which achieved consensus&#44; including the recommendation that COPD be considered a high-risk cardiovascular disease&#44; as well as several specific recommendations on managing the various comorbidities&#46; A consensus was reached on the recommended treatments in the guidelines for the various levels of obstruction&#44; dyspnea and exacerbations&#44; adapted to the CODEX scores&#46; Advice is also offered for patient follow-up after hospital discharge&#44; which includes aspects on assessment&#44; treatment and care coordination&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El &#237;ndice CODEX es la primera escala multicomponente dise&#241;ada para predecir el riesgo de mortalidad y reingresos al a&#241;o en los pacientes hospitalizados por EPOC&#46; Su c&#225;lculo incluye las comorbilidades medidas por el &#237;ndice de Charlson &#40;C&#41;&#44; el grado de obstrucci&#243;n valorado por el FEV1&#37; &#40;O&#41;&#44; la disnea estratificada seg&#250;n la escala modificada del Medical Research Council &#40;D&#41; y las exacerbaciones en el a&#241;o previo &#40;EX&#41;&#46; Nuestro objetivo fue elaborar recomendaciones basadas en los diferentes componentes del &#237;ndice para un manejo terap&#233;utico personalizado&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Para ello se realiz&#243; una b&#250;squeda bibliogr&#225;fica basada en gu&#237;as&#44; consensos y revisiones sistem&#225;ticas&#44; como base para elaborar recomendaciones sobre&#58; generalidades&#44; comorbilidades&#44; disnea&#44; obstrucci&#243;n pulmonar&#44; exacerbaciones y seguimiento&#46; Seguidamente&#44; se sometieron a un proceso de valoraci&#243;n externo por un grupo multidisciplinar de 62 expertos&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">En total se realizaron 108 recomendaciones&#44; de las cuales se alcanz&#243; consenso en 96&#46; Entre ellas se destaca que la EPOC debe considerarse como una enfermedad de riesgo cardiovascular alto y varias recomendaciones espec&#237;ficas sobre el manejo de las diferentes comorbilidades&#46; Se consensuaron los tratamientos aconsejados para los diferentes niveles de obstrucci&#243;n&#44; disnea y exacerbaciones recomendados en las gu&#237;as&#44; adaptadas a las puntuaciones del CODEX&#46; Se ofrecen tambi&#233;n unos consejos para el seguimiento tras el alta hospitalaria del paciente&#44; en los que se incluyen aspectos sobre la valoraci&#243;n&#44; el tratamiento y la coordinaci&#243;n asistencial&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Please cite this article as&#58; Boixeda R&#44; D&#237;ez-Manglano J&#44; G&#243;mez-Ant&#250;nez M&#44; L&#243;pez-Garc&#237;a F&#44; Recio J&#44; Almagro P&#46; Consenso para el manejo de pacientes con EPOC seg&#250;n el &#237;ndice CODEX&#46; Rev Clin Esp&#46; 2019&#59;219&#58;494&#8211;504&#46;</p>"
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            "apendice" => "<p id="par0155" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0100"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Flow diagram for obtaining the articles&#46;</p>"
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#59; DoR&#44; grade of recommendation&#59; LoE&#44; level of evidence&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Cardiovascular diseases</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R26&#46; For patients with COPD&#44; ischemic heart disease should be treated according to clinical practice guidelines<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21&#44;23</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Renal diseases</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R32&#46; For patients with COPD and chronic renal failure&#44; the drug dosage needs to be adjusted to the renal function &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diabetes</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R33&#46; For patients with COPD and diabetes&#44; the cardiovascular risk should be assessed &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R34&#46; For patients with COPD and diabetes&#44; the glycated hemoglobin levels should be periodically checked &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R35&#46; For patients with COPD and diabetes&#44; the glomerular filtration rate should be periodically calculated &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Osteoporosis</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R40&#46; All patients with COPD should be advised to perform physical exercise and eat a diet rich in calcium and vitamin D to prevent osteoporosis<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">23</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R41&#46; For patients with COPD&#44; the osteoporosis should be treated in a similar manner as in patients without COPD<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21&#44;23</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dementia or diagnosed cognitive impairment</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R43&#46; For patients with COPD and cognitive impairment&#44; the presence of hypoxemia should be ruled out<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">23</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R46&#46; For patients with COPD and cognitive impairment&#44; the use of inhalation devices should be supervised &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R47&#46; For patients with COPD and cognitive impairment who cannot use an inhalation device&#44; spacing chambers or nebulizers should be employed &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations with &#8805;95&#37; agreement associated with the patient&#39;s comorbidities&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; ACO&#44; asthma-COPD overlap&#59; COPD&#44; chronic obstructive pulmonary disease&#59; DoR&#44; degree of recommendation&#59; FEV<span class="elsevierStyleInf">1</span>&#44; forced expiratory volume in one second&#59; IC&#44; inhaled corticosteroids&#59; LABA&#44; long-acting beta agonists&#59; LAMA&#44; long-acting muscarinic antagonists&#59; LoE&#44; level of evidence&#59; MMRC&#44; modified dyspnea scale&#59; TT&#44; triple therapy&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pulmonary function FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">50&#37; and dyspnea 0&#8211;1 on the MMRC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R64&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and dyspnea of 0&#8211;1 on the MMRC&#44; the initial treatment should be a long-acting bronchodilator &#40;preferably a LAMA&#41; if this has not been previously prescribed<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R65&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and dyspnea of 0&#8211;1 on the MMRC who remain symptomatic despite the use of a long-acting bronchodilator&#44; a second bronchodilator should be added&#44; and the response assessed&#46; Given that many patients report no dyspnea due to reduced activity&#44; this point should be questioned directly<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R66&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and dyspnea of 0&#8211;1 on the MMRC who have persistent exacerbations despite treatment with a long-acting bronchodilator&#44; a second bronchodilator should be added<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pulmonary function FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">50&#37; and dyspnea 2&#8211;4 on the MMRC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R69&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; dyspnea &#8805;2 on the MMRC and persistent dyspnea despite monotherapy with a LAMA or LABA&#44; the recommendation is to employ 2<span class="elsevierStyleHsp" style=""></span>bronchodilators &#40;LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA&#41;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R70&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37; and dyspnea &#8805;2 on the MMRC&#44; the start of treatment with LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA may be assessed<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R71&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; dyspnea &#8805;2 on the MMRC and ACO&#44; treatment should be started with LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IC<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a> &#40;LoE&#44; 3&#59; DoR&#44; C&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R72&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; dyspnea &#8805;2 on the MMRC and persistent exacerbations despite treatment with dual therapy &#40;LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA or IC<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA&#41;&#44; treatment should be started with TT with LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IC<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R73&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>50&#37;&#44; dyspnea &#8805;2 on the MMRC and persistent exacerbations despite treatment with TT with LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IC&#44; treatment with roflumilast may be considered if the patient has chronic bronchitis and presented exacerbations in the past year<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Pulmonary function FEV</span><span class="elsevierStyleInf"><span class="elsevierStyleItalic">1</span></span><span class="elsevierStyleItalic">&#8805;50&#37;</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R77&#46; For patients with COPD&#44; FEV<span class="elsevierStyleInf">1</span> &#8805;50&#37;&#44; high-risk criteria &#40;MMRC &#8805;2 despite treatment and &#8805;2 exacerbations or 1 exacerbation resulting in hospitalization in the past year&#41; and insufficient control&#44; the phenotype should be identified&#44; and new drugs added according to this phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
          "notaPie" => array:1 [
            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Recommendation adapted from the source&#44; graded with the GRADE system as weakly in favor&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations with &#8805;95&#37; agreement associated with the patient&#39;s pulmonary function according to the forced expiratory volume in 1 second&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#59; DoR&#44; degree of recommendation&#59; GOLD&#44; Global Initiative for Chronic Obstructive Lung Disease&#59; LABA&#44; long-acting beta agonists&#59; LAMA&#44; long-acting muscarinic antagonists&#59; LoE&#44; level of evidence&#59; MMRC&#44; modified Medical Research Council dyspnea scale&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dyspnea of 0&#8211;1 on the MMRC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R55&#46; For patients with COPD and dyspnea 0&#8211;1 on the MMRC&#44; the nondrug measures &#40;such as smoking cessation and physical exercise&#41; should be reassessed<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R56&#46; For patients with COPD and dyspnea 0&#8211;1 on the MMRC&#44; the influenza and pneumococcal vaccinations should be reassessed<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Dyspnea of 2&#8211;4 on the MMRC</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R57&#46; For patients with COPD and dyspnea of 2&#8211;4 on the MMRC&#44; the base treatment should be reassessed &#40;according to GOLD&#58; class C&#8211;D&#41;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R58&#46; For patients with COPD and dyspnea 2&#8211;4 on the MMRC&#44; the bronchodilator treatment should be optimized &#40;e&#46;g&#46;&#44; progress to dual bronchodilation &#91;LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA&#93; for patients undergoing monotherapy&#41; &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R59&#46; For patients with COPD and dyspnea 2&#8211;4 on the MMRC&#44; the nondrug measures &#40;such as smoking cessation and physical exercise&#41; should be reassessed &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R60&#46; For patients with COPD and dyspnea 2&#8211;4 on the MMRC&#44; the influenza and pneumococcal vaccinations should be reassessed &#40;expert opinion&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations with &#8805;95&#37; agreement associated with the patient&#39;s degree of dyspnea according to the modified dyspnea scale&#46;</p>"
        ]
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        "etiqueta" => "Table 4"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#59; CVR&#44; cardiovascular risk&#59; DoR&#44; degree of recommendation&#59; IC&#44; inhaled corticosteroids&#59; LABA&#44; long-acting beta-2 agonists&#59; LAMA&#44; long-acting muscarinic antagonists&#59; LoE&#44; level of evidence&#59; TT&#44; triple therapy&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drug treatment of cardiovascular risk factors</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R78&#46; For patients with COPD and severe exacerbations&#44; their overall CVR should be assessed&#44; according to the European CVR prevention standards<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;22</span></a> &#40;LoE&#44; 5&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R90&#46; For patients with exacerbated COPD&#44; the classical CVR factors should be thoroughly treated<a class="elsevierStyleCrossRefs" href="#bib0380"><span class="elsevierStyleSup">25&#44;28</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R92&#46; For patients with COPD&#44; there is no need to withdraw the cardioselective &#946;-blockers indicated for other diseases given that the drugs are safe<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">29</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C6&#46; For patients with COPD who have experienced an exacerbation&#44; good control of the comorbidities reduces mortality<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">30</span></a> &#40;LoE&#44; 1&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Drug treatment to prevent new exacerbations</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C5&#46; Long-acting bronchodilators &#40;LAMA&#47;LABA&#41; reduce the number of exacerbations<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21&#44;31&#8211;33</span></a> &#40;LoE&#44; 1&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R80&#46; For patients with COPD and frequent exacerbations despite optimal bronchodilator treatment&#44; adding an IC is indicated<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">16&#44;20&#44;21&#44;31&#44;34</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R81&#46; For patients with high-risk COPD who have had 2<span class="elsevierStyleHsp" style=""></span>or more moderate-severe exacerbations in the past year despite treatment with 2<span class="elsevierStyleHsp" style=""></span>drugs&#44; the recommendation is TT &#40;LAMA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>LABA<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>IC&#41;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">16&#44;20&#44;21&#44;31&#44;34</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Nondrug treatment to prevent new exacerbations</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R86&#46; For patients with COPD&#44; the recommendation is to encourage physical activity and self-care to prevent exacerbations&#44; always in conjunction with other types of measures<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">35&#8211;39</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations with &#8805;95&#37; agreement associated with the patient&#39;s severe exacerbations&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "detalles" => array:1 [
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            "identificador" => "at5"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; COPD&#44; chronic obstructive pulmonary disease&#59; CVD&#44; cardiovascular disease&#59; CVR&#44; cardiovascular risk&#59; DoR&#44; grade of recommendation&#59; LoE&#44; level of evidence&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:1 [
              "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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">1<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>2&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">3<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>4&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Degree of agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Smoking cessation counseling</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R8&#46; All patients with COPD who smoke should be given educational information that helps them understand their disease&#44; facilitating the knowledge and tools necessary for maintaining and improving their health and wellbeing and ceasing their smoking habit<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">COPD as a CVR disease</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C1&#46; COPD should be considered an independent factor of very high cardiovascular risk that manifests by increased systemic inflammation and markers of atherosclerosis&#44; with a greater risk of developing ischemic heart disease&#44; heart failure and arrhythmias&#44; and that increases mortality<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">40&#8211;43</span></a> &#40;LoE&#44; 2&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R1&#46; Due to the high risk of CVD that patients with COPD present&#44; the recommendation is to promptly identify the presence of CVD before it manifests clinically&#44; because CVD can result in a poorer prognosis for the COPD<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">4&#44;41&#44;43&#44;44</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Smoking</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>C3&#46; For patients with COPD who smoke&#44; treating the tobacco use is based on combining behavioral cognitive therapy and drug treatment<a class="elsevierStyleCrossRefs" href="#bib0480"><span class="elsevierStyleSup">45&#8211;49</span></a> &#40;LoE&#44; 2&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R9&#46; Health professionals should provide the necessary assistance to patients with COPD who smoke to increase their motivation and promote smoking cessation at any point of the healthcare process&#44; including hospitalization<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">50</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diet and exercise</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R11&#46; Patients with COPD should receive nutritional education designed to prevent malnutrition and obesity&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R13&#46; For all patients with COPD&#44; regular physical activity should be recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">20</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R14&#46; For all patients with COPD&#44; moderate-intensity physical activity should be recommended through a schedule of walks&#44; with the objective of walking between 20&#8211;30<span class="elsevierStyleHsp" style=""></span>min&#47;5 days a week&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R15&#46; For all patients with COPD&#44; aerobic exercise using a cycle ergometer &#40;15&#8211;30<span class="elsevierStyleHsp" style=""></span>min&#47;day&#41; is recommended as an alternative to moderate physical activity through a schedule of walks&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3 &#40;4&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">59 &#40;95&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Respiratory rehabilitation</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R17&#46; Patients with COPD who have undergone respiratory rehabilitation should continue performing respiratory rehabilitation exercises at home and regular physical activity indefinitely<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a> &#40;LoE&#44; 5&#59; DoR&#44; D&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Vaccination</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R18&#46; Patients with COPD should be advised to take the annual influenza vaccination&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">b</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R20&#46; All patients with COPD older than 65 years who have not been previously vaccinated should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R21&#46; All patients with COPD younger than 65 years with FEV<span class="elsevierStyleInf">1</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>40&#37; should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R22&#46; All patients with COPD younger than 65 years with comorbidities&#44; especially cardiac&#44; should be routinely administered the polysaccharide pneumococcal vaccination<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; B&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Follow-up</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R93&#46; For stable patients&#44; the recommendation is to optimize the outpatient follow-up according to the patient&#39;s symptoms and needs and based on the available resources<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 2&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2 &#40;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">60 &#40;96&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R94&#46; For patients with stable COPD&#44; the symptoms should be assessed in each follow-up visit&#44; as well as the presence of exacerbations&#44; tobacco use&#44; comorbidities&#44; treatment appropriateness to the clinical situation&#44; therapeutic compliance and the inhalation technique<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">20&#44;21</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R98&#46; For patients with COPD who just experienced an exacerbation that has ended&#44; the treatment should be adjusted to optimize the control and prevent future exacerbations<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1 &#40;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">61 &#40;98&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Consensus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>R100&#46; For patients hospitalized for a COPD exacerbation&#44; therapeutic reconciliation should be conducted prior to discharge&#44; providing information in writing on the changes performed in the patients&#8217; long-term therapy<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">51</span></a> &#40;LoE&#44; 1&#59; DoR&#44; A&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0 &#40;0&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62 &#40;100&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unanimous agreement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Consensus recommendations with &#8805;95&#37; agreement regarding the basic concepts of management and follow-up of patients with chronic obstructive pulmonary disease&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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          "identificador" => "bibs0015"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Global&#44; regional&#44; and national disability-adjusted life years &#40;DALYs&#41; for 306 diseases and injuries and healthy life expectancy &#40;HALE&#41; for 188 countries&#44; 1990&#8211;2013&#58; quantifying the epidemiological transition"
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                        0 => array:3 [
                          "colaboracion" => "BD 2013 DALYs and HALE Collaborators"
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                          "autores" => array:6 [
                            0 => "C&#46;J&#46; Murray"
                            1 => "R&#46;M&#46; Barber"
                            2 => "K&#46;J&#46; Foreman"
                            3 => "A&#46; Abbasoglu Ozgoren"
                            4 => "F&#46; Abd-Allah"
                            5 => "S&#46;F&#46; Abera"
                          ]
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                      "titulo" => "Finding the best thresholds of FEV1 and dyspnea to predict 5-year survival in COPD patients&#58; the COCOMICS study"
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                          "etal" => true
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                        "volumen" => "9"
                        "paginaInicial" => "e89866"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24587085"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease"
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                            0 => "J&#46;J&#46; Soler-Cataluna"
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                            2 => "P&#46; Roman Sanchez"
                            3 => "E&#46; Salcedo"
                            4 => "M&#46; Navarro"
                            5 => "R&#46; Ochando"
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Thorax"
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                        "volumen" => "60"
                        "paginaInicial" => "925"
                        "paginaFinal" => "931"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16055622"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                      "titulo" => "Comorbidities and short-term prognosis in patients hospitalized for acute exacerbation of COPD&#58; the EPOC en Servicios de medicina interna &#40;ESMI&#41; study"
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                            2 => "J&#46; Diez"
                            3 => "R&#46; Boixeda"
                            4 => "M&#46;B&#46; Alonso Ortiz"
                            5 => "C&#46; Murio"
                          ]
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                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Chest"
                        "fecha" => "2012"
                        "volumen" => "142"
                        "paginaInicial" => "1126"
                        "paginaFinal" => "1133"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23303399"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0280"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multicomponent &#237;ndices to predict survival in COPD&#58; the COCOMICS study"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            2 => "P&#46; Almagro"
                            3 => "C&#46; Casanova"
                            4 => "C&#46; Esteban"
                            5 => "J&#46;J&#46; Soler-Cataluna"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00121012"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2013"
                        "volumen" => "42"
                        "paginaInicial" => "323"
                        "paginaFinal" => "332"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23222874"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Short- and medium-term prognosis in patients hospitalized for COPD exacerbation&#58; the CODEX index"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            2 => "F&#46;J&#46; Cabrera"
                            3 => "R&#46; Boixeda"
                            4 => "M&#46;B&#46; Alonso-Ortiz"
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Chest"
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                        "paginaInicial" => "972"
                        "paginaFinal" => "980"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24077342"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0290"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pseudomonas aeruginosa in patients hospitalised for COPD exacerbation&#58; a prospective study"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Garcia-Vidal"
                            1 => "P&#46; Almagro"
                            2 => "V&#46; Romani"
                            3 => "M&#46; Rodriguez-Carballeira"
                            4 => "E&#46; Cuchi"
                            5 => "L&#46; Canales"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00003309"
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                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2009"
                        "volumen" => "34"
                        "paginaInicial" => "1072"
                        "paginaFinal" => "1078"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19386694"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Mortality after hospitalization for COPD"
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                            2 => "A&#46; Ochoa de Echaguen"
                            3 => "B&#46; Barreiro"
                            4 => "S&#46; Quintana"
                            5 => "J&#46;L&#46; Heredia"
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                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.121.5.1441"
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                        "tituloSerie" => "Chest"
                        "fecha" => "2002"
                        "volumen" => "121"
                        "paginaInicial" => "1441"
                        "paginaFinal" => "1448"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12006426"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Post-hospital mortality in patients re-admitted due to COPD&#46; Utility of BODE index"
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                        0 => array:2 [
                          "etal" => false
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                            2 => "M&#46; Rodriguez-Carballeira"
                            3 => "B&#46; Barreiro"
                            4 => "J&#46;L&#46; Heredia"
                            5 => "J&#46; Garau"
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1016/s0014-2565(09)72339-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2009"
                        "volumen" => "209"
                        "paginaInicial" => "364"
                        "paginaFinal" => "370"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19775584"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Prognostic assessment of mortality and hospitalizations of outpatients with advanced chronic obstructive pulmonary disease&#46; Usefulness of the CODEX index"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Navarro"
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                            2 => "M&#46; Rodriguez-Carballeira"
                            3 => "S&#46; Yun"
                            4 => "A&#46; Lapuente"
                            5 => "A&#46; Barrera"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2015"
                        "volumen" => "215"
                        "paginaInicial" => "431"
                        "paginaFinal" => "438"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26183602"
                            "web" => "Medline"
                          ]
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                ]
              ]
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              "identificador" => "bib0310"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The PEARL score predicts 90-day readmission or death after hospitalisation for acute exacerbation of COPD"
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                            3 => "S&#46;C&#46; Stenton"
                            4 => "P&#46;M&#46; Hickey"
                            5 => "R&#46; Hughes"
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                        ]
                      ]
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                    0 => array:2 [
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                        "tituloSerie" => "Thorax"
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                        "paginaInicial" => "686"
                        "paginaFinal" => "693"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28235886"
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                          ]
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                ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Octogenarian patients with chronic obstructive pulmonary disease&#58; characteristics and usefulness of prognostic indexes"
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                            2 => "A&#46; Veres-Racamonde"
                            3 => "E&#46; Cano-Jimenez"
                            4 => "I&#46; Martin-Robles"
                            5 => "P&#46; Sanjuan-Lopez"
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                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:1 [
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                        "tituloSerie" => "Med Clin &#40;Barc&#41;"
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                        "paginaFinal" => "58"
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                    ]
                  ]
                ]
              ]
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            12 => array:3 [
              "identificador" => "bib0320"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "External validation and recalibration of the CODEX index in COPD patients&#46; A 3 CIAplus cohort study"
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                    0 => array:2 [
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                        "tituloSerie" => "COPD"
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                        "volumen" => "14"
                        "paginaInicial" => "1"
                        "paginaFinal" => "10"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27723367"
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                ]
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              "identificador" => "bib0325"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Recent improvement in long-term survival after a COPD hospitalisation"
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                            5 => "B&#46; Barreiro"
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                          0 => array:2 [
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                ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Time for a longer and better life for patients with COPD"
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                    ]
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                    0 => array:1 [
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                    ]
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                ]
              ]
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              "identificador" => "bib0335"
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                    0 => array:2 [
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                        "tituloSerie" => "N Engl J Med"
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                        "paginaInicial" => "1671"
                        "paginaFinal" => "1680"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29668352"
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                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30385603"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Chronic obstructive pulmonary disease is just one component of the complex multimorbidities in patients with COPD"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
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                        "paginaInicial" => "668"
                        "paginaFinal" => "671"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23540872"
                            "web" => "Medline"
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                  ]
                ]
              ]
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              "identificador" => "bib0350"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Levels of evidence document"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Oxford Centre for Evidence-Based Medicine"
                          ]
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                    0 => array:1 [
                      "Libro" => array:1 [
                        "fecha" => "2011"
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                      "titulo" => "Gu&#237;a de Pr&#225;ctica Cl&#237;nica para el Diagn&#243;stico y Tratamiento de Pacientes con Enfermedad Pulmonar Obstructiva Cr&#243;nica &#40;EPOC&#41; &#8211; Gu&#237;a Espa&#241;ola de la EPOC &#40;GesEPOC&#41;&#46; Versi&#243;n 2017"
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                            0 => "Grupo de Trabajo de GesEPOC"
                          ]
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                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Bronconeumol"
                        "fecha" => "2017"
                        "volumen" => "53"
                        "numero" => "Extraordinario 1"
                        "paginaInicial" => "2"
                        "paginaFinal" => "64"
                      ]
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                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Global strategy for the diagnosis&#44; management&#44; and prevention of chronic obstructive lung disease 2017 report&#46; GOLD executive summary"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;F&#46; Vogelmeier"
                            1 => "G&#46;J&#46; Criner"
                            2 => "F&#46;J&#46; Martinez"
                            3 => "A&#46; Anzueto"
                            4 => "P&#46;J&#46; Barnes"
                            5 => "J&#46; Bourbeau"
                          ]
                        ]
                      ]
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                    0 => array:2 [
                      "doi" => "10.1164/rccm.201701-0218PP"
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                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2017"
                        "volumen" => "195"
                        "paginaInicial" => "557"
                        "paginaFinal" => "582"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28128970"
                            "web" => "Medline"
                          ]
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                      ]
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                  ]
                ]
              ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:1 [
                      "autores" => array:1 [
                        0 => array:3 [
                          "colaboracion" => "2016 European Guidelines on cardiovascular disease prevention in clinical practice&#58; the Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice &#40;constituted by representatives of 10 societies and by invited experts&#41;&#46; Developed with the special contribution of the European Association for Cardiovascular Prevention &#38; Rehabilitation &#40;EACPR&#41;"
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                          "autores" => array:6 [
                            0 => "M&#46;F&#46; Piepoli"
                            1 => "A&#46;W&#46; Hoes"
                            2 => "S&#46; Agewall"
                            3 => "C&#46; Albus"
                            4 => "C&#46; Brotons"
                            5 => "A&#46;L&#46; Catapano"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1093/eurheartj/ehw106"
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                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "37"
                        "paginaInicial" => "2315"
                        "paginaFinal" => "2381"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27222591"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                    0 => array:2 [
                      "titulo" => "Protocolos&#58; manejo diagn&#243;stico y terap&#233;utico de las comorbilidades en la EPOC"
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                        0 => array:2 [
                          "etal" => false
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                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:5 [
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                        "editorialLocalizacion" => "Barcelona"
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                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0375"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Susceptibility to exacerbation in chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;R&#46; Hurst"
                            1 => "J&#46; Vestbo"
                            2 => "A&#46; Anzueto"
                            3 => "N&#46; Locantore"
                            4 => "H&#46; Mullerova"
                            5 => "R&#46; Tal-Singer"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0909883"
                      "Revista" => array:6 [
                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2010"
                        "volumen" => "363"
                        "paginaInicial" => "1128"
                        "paginaFinal" => "1138"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20843247"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0380"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Biochemical markers of cardiac dysfunction predict mortality in acute exacerbations of COPD"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;L&#46; Chang"
                            1 => "S&#46;C&#46; Robinson"
                            2 => "G&#46;D&#46; Mills"
                            3 => "G&#46;D&#46; Sullivan"
                            4 => "N&#46;C&#46; Karalus"
                            5 => "J&#46;D&#46; McLachlan"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
                      "doi" => "10.1136/thx.2010.155333"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2011"
                        "volumen" => "66"
                        "paginaInicial" => "764"
                        "paginaFinal" => "768"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21474497"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0385"
              "etiqueta" => "26"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consenso de seguimiento y tratamiento para la EPOC seg&#250;n el &#205;ndice CODEX"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "P&#46; Almagro"
                            1 => "B&#46;R&#46; Di&#233;z-Manglano"
                            2 => "J&#46; G&#243;mez-Ant&#250;nez"
                            3 => "M&#46;F&#46; L&#243;pez-Garc&#237;a"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2018"
                        "volumen" => "218"
                        "paginaInicial" => "3"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            26 => array:3 [
              "identificador" => "bib0390"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pseudomonas aeruginosa and mortality after hospital admission for chronic obstructive pulmonary disease"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Almagro"
                            1 => "M&#46; Salvado"
                            2 => "C&#46; Garcia-Vidal"
                            3 => "M&#46; Rodriguez-Carballeira"
                            4 => "E&#46; Cuchi"
                            5 => "J&#46; Torres"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000331224"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respiration"
                        "fecha" => "2012"
                        "volumen" => "84"
                        "paginaInicial" => "36"
                        "paginaFinal" => "43"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21996555"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Invasive coronary angiography in patients with acute exacerbated COPD and elevated plasma troponin"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46; Pizarro"
                            1 => "N&#46; Herweg-Steffens"
                            2 => "M&#46; Buchenroth"
                            3 => "W&#46; Schulte"
                            4 => "C&#46; Schaefer"
                            5 => "C&#46; Hammerstingl"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2147/COPD.S110746"
                      "Revista" => array:6 [
                        "tituloSerie" => "Int J Chron Obstruct Pulmon Dis"
                        "fecha" => "2016"
                        "volumen" => "11"
                        "paginaInicial" => "2081"
                        "paginaFinal" => "2089"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27695304"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0400"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Effect of beta blockers on mortality after myocardial infarction in adults with COPD&#58; Population based cohort study of UK electronic healthcare records"
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "E&#46; Herrett"
                            2 => "K&#46; Bhaskaran"
                            3 => "A&#46; Timmis"
                            4 => "H&#46; Hemingway"
                            5 => "J&#46;A&#46; Wedzicha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/bmj.f6650"
                      "Revista" => array:5 [
                        "tituloSerie" => "BMJ"
                        "fecha" => "2013"
                        "volumen" => "347"
                        "paginaInicial" => "f6650"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24270505"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Early and long-term outcomes of older adults after acute care encounters for chronic obstructive pulmonary disease exacerbation"
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                          "etal" => false
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                            3 => "J&#46;L&#46; Todd"
                            4 => "H&#46;E&#46; Whitson"
                            5 => "L&#46;H&#46; Curtis"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1513/AnnalsATS.201504-250OC"
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                        "tituloSerie" => "Ann Am Thorac Soc"
                        "fecha" => "2015"
                        "volumen" => "12"
                        "paginaInicial" => "1805"
                        "paginaFinal" => "1812"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26394180"
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                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0410"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevention of acute exacerbations of COPD&#58; American College of Chest Physicians and Canadian Thoracic Society Guideline"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            2 => "R&#46;L&#46; Diekemper"
                            3 => "D&#46;R&#46; Ouellette"
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                            5 => "P&#46; Hernandez"
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                        ]
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1378/chest.14-1676"
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                        "tituloSerie" => "Chest"
                        "fecha" => "2015"
                        "volumen" => "147"
                        "paginaInicial" => "894"
                        "paginaFinal" => "942"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25321320"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Improved outcomes in patients with chronic obstructive pulmonary disease treated with salmeterol compared with placebo&#47;usual therapy&#58; results of a meta-analysis"
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                        0 => array:2 [
                          "etal" => false
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1186/1465-9921-7-147"
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                        "tituloSerie" => "Respir Res"
                        "fecha" => "2006"
                        "volumen" => "7"
                        "paginaInicial" => "147"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17196106"
                            "web" => "Medline"
                          ]
                        ]
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                    ]
                  ]
                ]
              ]
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              "identificador" => "bib0420"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A 4-year trial of tiotropium in chronic obstructive pulmonary disease"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            4 => "S&#46; Kesten"
                            5 => "S&#46; Menjoge"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1056/NEJMoa0805800"
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                        "tituloSerie" => "N Engl J Med"
                        "fecha" => "2008"
                        "volumen" => "359"
                        "paginaInicial" => "1543"
                        "paginaFinal" => "1554"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18836213"
                            "web" => "Medline"
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                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Extrafine inhaled triple therapy versus dual bronchodilator therapy in chronic obstructive pulmonary disease &#40;TRIBUTE&#41;&#58; a double-blind&#44; parallel group&#44; randomised controlled trial"
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                        0 => array:2 [
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                            2 => "L&#46; Fabbri"
                            3 => "M&#46; Corradi"
                            4 => "H&#46; Prunier"
                            5 => "G&#46; Cohuet"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Lancet"
                        "fecha" => "2018"
                        "volumen" => "391"
                        "paginaInicial" => "1076"
                        "paginaFinal" => "1084"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29429593"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Characteristics of effective self-management interventions in patients with COPD&#58; individual patient data meta-analysis"
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                            3 => "R&#46;H&#46; Groenwold"
                            4 => "E&#46;W&#46; Bischoff"
                            5 => "J&#46; Bourbeau"
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                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2016"
                        "volumen" => "48"
                        "paginaInicial" => "55"
                        "paginaFinal" => "68"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27126694"
                            "web" => "Medline"
                          ]
                        ]
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                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "The minimal important difference in physical activity in patients with COPD"
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                            4 => "H&#46; van Remoortel"
                            5 => "D&#46; Langer"
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                    0 => array:2 [
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                        "tituloSerie" => "PLoS One"
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                        "volumen" => "11"
                        "paginaInicial" => "e0154587"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27124297"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            36 => array:3 [
              "identificador" => "bib0440"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Systematic review of the chronic care model in chronic obstructive pulmonary disease prevention and management"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46;G&#46; Adams"
                            1 => "P&#46;K&#46; Smith"
                            2 => "P&#46;F&#46; Allan"
                            3 => "A&#46; Anzueto"
                            4 => "J&#46;A&#46; Pugh"
                            5 => "J&#46;E&#46; Cornell"
                          ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archinte.167.6.551"
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                        "tituloSerie" => "Arch Intern Med"
                        "fecha" => "2007"
                        "volumen" => "167"
                        "paginaInicial" => "551"
                        "paginaFinal" => "561"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17389286"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            37 => array:3 [
              "identificador" => "bib0445"
              "etiqueta" => "38"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease &#40;COPD&#41;&#58; an evidence synthesis and economic analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46;E&#46; Jordan"
                            1 => "S&#46; Majothi"
                            2 => "N&#46;R&#46; Heneghan"
                            3 => "D&#46;B&#46; Blissett"
                            4 => "R&#46;D&#46; Riley"
                            5 => "A&#46;J&#46; Sitch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3310/hta191020"
                      "Revista" => array:6 [
                        "tituloSerie" => "Health Technol Assess"
                        "fecha" => "2015"
                        "volumen" => "19"
                        "paginaInicial" => "1"
                        "paginaFinal" => "516"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26691209"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            38 => array:3 [
              "identificador" => "bib0450"
              "etiqueta" => "39"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Self-management interventions including action plans for exacerbations versus usual care in patients with chronic obstructive pulmonary disease"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46; Lenferink"
                            1 => "M&#46; Brusse-Keizer"
                            2 => "P&#46;D&#46; van der Valk"
                            3 => "P&#46;A&#46; Frith"
                            4 => "M&#46; Zwerink"
                            5 => "E&#46;M&#46; Monninkhof"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:4 [
                        "tituloSerie" => "Cochrane Database Syst Rev"
                        "fecha" => "2017"
                        "volumen" => "8"
                        "paginaInicial" => "CD011682"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            39 => array:3 [
              "identificador" => "bib0455"
              "etiqueta" => "40"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Cardiovascular comorbidity in COPD&#58; systematic literature review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "H&#46; Mullerova"
                            1 => "A&#46; Agusti"
                            2 => "S&#46; Erqou"
                            3 => "D&#46;W&#46; Mapel"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.12-2847"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2013"
                        "volumen" => "144"
                        "paginaInicial" => "1163"
                        "paginaFinal" => "1178"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23722528"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            40 => array:3 [
              "identificador" => "bib0460"
              "etiqueta" => "41"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Subclinical atherosclerosis risk markers in patients with chronic obstructive pulmonary disease&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "L&#46;Y&#46; Wang"
                            1 => "Y&#46;N&#46; Zhu"
                            2 => "J&#46;J&#46; Cui"
                            3 => "K&#46;Q&#46; Yin"
                            4 => "S&#46;X&#46; Liu"
                            5 => "Y&#46;H&#46; Gao"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rmed.2016.12.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Respir Med"
                        "fecha" => "2017"
                        "volumen" => "123"
                        "paginaInicial" => "18"
                        "paginaFinal" => "27"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28137492"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            41 => array:3 [
              "identificador" => "bib0465"
              "etiqueta" => "42"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease&#58; a systematic review and meta-analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "W&#46; Chen"
                            1 => "J&#46; Thomas"
                            2 => "M&#46; Sadatsafavi"
                            3 => "J&#46;M&#46; FitzGerald"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S2213-2600(15)00241-6"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Respir Med"
                        "fecha" => "2015"
                        "volumen" => "3"
                        "paginaInicial" => "631"
                        "paginaFinal" => "639"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26208998"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            42 => array:3 [
              "identificador" => "bib0470"
              "etiqueta" => "43"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Chronic obstructive pulmonary disease and sudden cardiac death&#58; a systematic review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;E&#46; Van den Berg"
                            1 => "B&#46;H&#46; Stricker"
                            2 => "G&#46;G&#46; Brusselle"
                            3 => "L&#46; Lahousse"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.tcm.2016.04.001"
                      "Revista" => array:6 [
                        "tituloSerie" => "Trends Cardiovasc Med"
                        "fecha" => "2016"
                        "volumen" => "26"
                        "paginaInicial" => "606"
                        "paginaFinal" => "613"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27234353"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            43 => array:3 [
              "identificador" => "bib0475"
              "etiqueta" => "44"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Study of the comorbidities in hospitalized patients due to decompensated chronic obstructive pulmonary disease attended in the Internal Medicine Services ECCO Study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Almagro"
                            1 => "F&#46; Lopez Garcia"
                            2 => "F&#46;J&#46; Cabrera"
                            3 => "L&#46; Montero"
                            4 => "D&#46; Morchon"
                            5 => "J&#46; Diez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2009.12.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2010"
                        "volumen" => "210"
                        "paginaInicial" => "101"
                        "paginaFinal" => "108"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20226938"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            44 => array:3 [
              "identificador" => "bib0480"
              "etiqueta" => "45"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Smoking characteristics&#58; differences in attitudes and dependence between healthy smokers and smokers with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "C&#46;A&#46; Jimenez-Ruiz"
                            1 => "F&#46; Masa"
                            2 => "M&#46; Miravitlles"
                            3 => "R&#46; Gabriel"
                            4 => "J&#46;L&#46; Viejo"
                            5 => "C&#46; Villasante"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1378/chest.119.5.1365"
                      "Revista" => array:6 [
                        "tituloSerie" => "Chest"
                        "fecha" => "2001"
                        "volumen" => "119"
                        "paginaInicial" => "1365"
                        "paginaFinal" => "1370"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11348940"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            45 => array:3 [
              "identificador" => "bib0485"
              "etiqueta" => "46"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Long-term effectiveness and cost-effectiveness of smoking cessation interventions in patients with COPD"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46; Hoogendoorn"
                            1 => "T&#46;L&#46; Feenstra"
                            2 => "R&#46;T&#46; Hoogenveen"
                            3 => "M&#46;P&#46; Rutten-van Molken"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2009.131631"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2010"
                        "volumen" => "65"
                        "paginaInicial" => "711"
                        "paginaFinal" => "718"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20685746"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            46 => array:3 [
              "identificador" => "bib0490"
              "etiqueta" => "47"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Smoking cessation interventions in COPD&#58; A network meta-analysis of randomised trials"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "R&#46; Strassmann"
                            1 => "B&#46; Bausch"
                            2 => "A&#46; Spaar"
                            3 => "J&#46; Kleijnen"
                            4 => "O&#46; Braendli"
                            5 => "M&#46;A&#46; Puhan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1183/09031936.00167708"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur Respir J"
                        "fecha" => "2009"
                        "volumen" => "34"
                        "paginaInicial" => "634"
                        "paginaFinal" => "640"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19357145"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            47 => array:3 [
              "identificador" => "bib0495"
              "etiqueta" => "48"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "High rate of smoking abstinence in COPD patients&#58; smoking cessation by hospitalization"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "B&#46;M&#46; Sundblad"
                            1 => "K&#46; Larsson"
                            2 => "L&#46; Nathell"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1080/14622200802023890"
                      "Revista" => array:6 [
                        "tituloSerie" => "Nicotine Tob Res"
                        "fecha" => "2008"
                        "volumen" => "10"
                        "paginaInicial" => "883"
                        "paginaFinal" => "890"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18569763"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            48 => array:3 [
              "identificador" => "bib0500"
              "etiqueta" => "49"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "An official ATS statement&#58; grading the quality of evidence and strength of recommendations in ATS guidelines and recommendations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "H&#46;J&#46; Schunemann"
                            1 => "R&#46; Jaeschke"
                            2 => "D&#46;J&#46; Cook"
                            3 => "W&#46;F&#46; Bria"
                            4 => "A&#46;A&#46; el-Solh"
                            5 => "A&#46; Ernst"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1164/rccm.200602-197ST"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Respir Crit Care Med"
                        "fecha" => "2006"
                        "volumen" => "174"
                        "paginaInicial" => "605"
                        "paginaFinal" => "614"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16931644"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            49 => array:3 [
              "identificador" => "bib0505"
              "etiqueta" => "50"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence&#44; diagnosis and relation to tobacco dependence of chronic obstructive pulmonary disease in a nationally representative population sample"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Shahab"
                            1 => "M&#46;J&#46; Jarvis"
                            2 => "J&#46; Britton"
                            3 => "R&#46; West"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/thx.2006.064410"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2006"
                        "volumen" => "61"
                        "paginaInicial" => "1043"
                        "paginaFinal" => "1047"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17040932"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            50 => array:3 [
              "identificador" => "bib0510"
              "etiqueta" => "51"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Proceso asistencial integrado del paciente con EPOC exacerbado &#40;PACEX-EPOC&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46;J&#46; Soler-Catalu&#241;a"
                            1 => "A&#46; Fern&#225;ndez-Villar"
                            2 => "M&#46; Rom&#225;n"
                            3 => "J&#46; Ancochea"
                            4 => "B&#46; Alc&#225;zar"
                            5 => "P&#46; Almagro"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Libro" => array:3 [
                        "fecha" => "2015"
                        "editorial" => "Respira-Fundaci&#243;n Espa&#241;ola del Pulm&#243;n-SEPAR"
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                    ]
                  ]
                ]
              ]
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        "texto" => "<p id="par0145" class="elsevierStylePara elsevierViewall">The authors would like to thank all of the experts of the validated external group &#40;<a class="elsevierStyleCrossRef" href="#sec0100">appendix&#44; Table S6&#44; supplemental material</a>&#41;&#44; as well as the Chiesi laboratories for helping implement this study&#46; The authors would also like to thank Veronica Albert and Antoni Torres of GOC Networking for their technical support throughout the project&#46;</p>"
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Article information

ISSN: 22548874
Original language: English

DOI:10.1016/j.rceng.2019.03.022

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