Expert consensus recommendations for the management of asthma in older adults

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del asma en personas mayores" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1964 "Ancho" => 2508 "Tamanyo" => 207471 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Choice of device type according to patient coordination and inspiratory flow. BAI: breath-actuated pMDI; DPI: dry-powder inhaler; pMDI: pressurised metered-dose inhaler; SMI: soft mist inhaler. Extracted from Bustamante et al.<a class="elsevierStyleCrossRef" href="#bib0420">84</a>." ] ] ] "textoCompleto" => "IntroductionAlthough it is well established that asthma is an identifiable public health problem in patients of any age, there is still a certain tendency to assume de facto and erroneously that such an entity is almost always found in children and young people who are otherwise healthy<a class="elsevierStyleCrossRef" href="#bib0005">1</a>. This error of assessment seems to dismiss the fact that it is with precisely a considerable number of older individuals (65 years or older) that asthma causes a substantial burden of disease and adopts specific peculiarities that make it difficult to identify and treat properly<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.Epidemiological studies show that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6–10%, with a higher prevalence among women aged 64–75 years and no differences according to sex after 75 years of age. These differences between the sexes disappear from the age of 75<a class="elsevierStyleCrossRef" href="#bib0015">3</a>. The onset of most cases of asthma dates back a long time (sometimes to childhood and especially to adulthood), but the onset of asthma de novo, after 65, is not uncommon<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>. Some authors estimate the incidence at 60–100 cases per 100,000<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>. Also, two-thirds of deaths due to asthma occur at this stage of life<a class="elsevierStyleCrossRefs" href="#bib0015">3,4</a>. This does not necessarily imply that all cases start off as severe, but in many cases the degree of airway obstruction is significant and with little reversibility, due to the presence of bronchiectasis, bronchial remodelling or its coinciding with chronic obstructive pulmonary disease (COPD)<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. Finally, asthma at these ages tends to result in a substantial number of hospital admissions, longer hospital stays, and, from the funder’s point of view, significant direct economic costs<a class="elsevierStyleCrossRefs" href="#bib0015">3,5</a>.Asthma in elderly people is an underestimated and undertreated reality today, and its magnitude will no doubt continue to grow in view of the future prospects of population pyramids<a class="elsevierStyleCrossRef" href="#bib0030">6</a>. According to the statistics of the Continuous Register of the National Statistics Institute, as of January 1, 2017, 8,764,204 people aged 65 and over were registered in Spain (18.8% of the total population). Projections from the National Statistics Institute predict that by 2066, the figure will exceed 14,000,000 (almost 35% of the population)<a class="elsevierStyleCrossRef" href="#bib0035">7</a>.The aim of this paper is to update the main guidelines that health professionals should consider for the treatment of these patients, after reviewing the key aspects that modulate asthma expression in older cohorts.MethodologyTo achieve this consensus, a Recommendations Working Group (RWG) was set up with seven experts (MP, AGB, AT, EMM, FJA, IU and MB), whose main function was to review and synthesize the available evidence and formulate conclusions (C) and recommendations (R). To validate the formulated Cs and Rs, a Recommendations Validation Group was set up, made up of 71 experts from different autonomous scientific societies (Appendix A).A literature review was conducted in the Pubmed and Cochrane and Scopus databases (Web of Science) that included original articles, reviews (systematic or narrative) and meta-analysis, which was limited to articles with an abstract section, in English or Spanish, and published from 2009 to the present. Search strategies were developed with the keywords “asthma AND elderly/geriatric/aging/older patients” in order to identify the most relevant evidence regarding the treatment of asthma in older patients with asthma. All the studies that focused on or included information relative to the disease in the population segment in the initial report, were selected manually and with double review, and the clinical guidelines and other documents known to RWG members that were not already included were added. The RWG reviewed and synthesized the literature to, based on the evidence and its experience in clinical practice and taking into account the needs of the patient profile who is the object of this consensus, developed various Cs and Rs. These Cs and Rs were analysed and evaluated in a face-to-face consensus conference of the Asthma Area of the Spanish Society of Pneumology and Thoracic Surgery (SEPAR) of 2019 in the context of the Congress of said Scientific Society. The Cs and Rs were shared on screen and the members of the RWG expressed their degree of agreement or disagreement, with a scale from 1 to 4 (1 strongly disagreed and 4 strongly agreed) using televoting devices. In the first round, all the Cs and Rs made by the RWG were evaluated, the results were totalled and the agreement percentages of the votes were calculated as 1 and 2 (disagreement) and 3 and 4 (agreement). The Rs/Cs that obtained more than 70% agreement were considered as consensual. All the Cs or Rs that obtained between 35% and 70% of agreement and those that had 35% or less of the votes were considered doubts or discrepancies, respectively, resulting in a room discussion regarding the supporting evidence, its content or its wording. All the C and R comments that did not reach a consensus were compiled for further elaboration, together with the discussion comments, to be considered in this paper. Additional recommendations were also drawn from the conclusions of the debate in the face-to-face meeting. The amended and added proposals were subjected to vote in a second round using an online televoting system.Finally, the RWG drafted the manuscript, which was subjected to successive revisions by this same group until final approval by all signatories.Periodic updates will be made as considered by the Autonomous Asthma Forum at its biannual meetings.Relevant aspects of asthma in the elderlyFrom a biological point of view, aging is the consequence of the accumulation, over time, of a wide variety of molecular and cellular damage, which results in a general decrease in physiological reserves, a gradual decline in physical and mental abilities, an increased risk of disease and, eventually, death<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. Such damage includes, but is not limited to, genomic instability, telomere wear, epigenetic changes, mitochondrial dysfunction, adult stem cell depletion, loss of proteostasis, and altered intercellular communications. All this is intrinsically linked by integrating what has come to be known as the “seven pillars of aging”<a class="elsevierStyleCrossRef" href="#bib0045">9</a>. The deterioration is not linear or uniform and its link with age in years is relative: some septuagenarians enjoy excellent health and manage perfectly, while others are fragile and need help to manage their basic needs<a class="elsevierStyleCrossRef" href="#bib0040">8</a>. These differences have a genetic justification modulated by the randomness of the mechanisms of aging, the influence of the environment (and the existence of inequalities in health) and the particular behaviour of each person<a class="elsevierStyleCrossRefs" href="#bib0040">8,9</a>.Four events predict the idiosyncrasy of asthma in advanced age: immunosenescence, loss of lung function over time, a tendency to hypoperception of the symptoms, and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0015">3,10,11</a>.ImmunosenescenceThe term immunosenescence describes the transformation and decline undergone by the innate and adaptive immune responses with age<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a>. With regard to asthma, the phenomenon of immunosenescence is largely responsible for the persistence of inflammation of the airways, and the remodelling and involvement of infectious agents in the exacerbations suffered by elderly patients<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a>. With regard to asthma, the phenomenon of immunosenescence is largely responsible for the persistence of inflammation of the airways, and the remodelling and involvement of infectious agents in the exacerbations suffered by elderly patients<a class="elsevierStyleCrossRefs" href="#bib0050">10–12</a>. At the same time, immunosenescence is accompanied by the development of a low-grade, systemic, sterile, asymptomatic, chronic inflammatory condition, dominated by the tumour necrosis factor α and interleukins 1β and 6, which is known as inflammaging<a class="elsevierStyleCrossRefs" href="#bib0060">12,13</a>. According to the antagonistic pleiotropy theory of aging, the immune response that allows survival during the early stages of life and is beneficial to the body, would be harmful in the final stages, as it favours the development of pathological situations capable of reducing longevity of the individual<a class="elsevierStyleCrossRefs" href="#bib0070">14,15</a>. Immunosenescence and inflammaging would be closely related to the continued accumulation of endogenous metabolic “garbage” that has not been suitably processed by normal homeostatic anti-inflammatory mechanisms. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the effects of the immunosenescence/inflammaging on the innate and adaptive response and its impact on asthma<a class="elsevierStyleCrossRefs" href="#bib0055">11,12</a>.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Lung functionWith age (and especially in advanced age), the chest wall tends to stiffen, the respiratory muscles lose strength, and the residual volume increases (hyperinflation) due to the reduction of the elastic retraction of the parenchyma itself<a class="elsevierStyleCrossRef" href="#bib0080">16</a>. <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a> summarises the main changes detected in the lung function of older people with asthma (some related to aging and others to the disease itself) which, combined, can lead to increased asthma severity and difficulties in treatment<a class="elsevierStyleCrossRef" href="#bib0055">11</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>HypoperceptionDyspnoea is one of the major clinical manifestations of asthma that, in many cases, reflects the severity of the process and its loss of control, regardless of the lung function deterioration<a class="elsevierStyleCrossRefs" href="#bib0080">16,17</a>. It has been shown that the sensation of basal dyspnoea tends to attenuate in line with the aging of the asthmatic individual<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>, and that older asthmatics are worse at identifying the increase in airway resistance than young adults with asthma<a class="elsevierStyleCrossRefs" href="#bib0095">19–21</a>. The cause is not yet well defined. Perhaps the most widely accepted hypothesis is that, with age, the number and/or activity of vagal lung receptors responsible for transmitting information to the central nervous system decreases<a class="elsevierStyleCrossRef" href="#bib0085">17</a>. Hypoperception of dyspnoea is also exacerbated in many older people due to the “well-being paradox,” a circumstance where a reasonably high satisfaction with life concurs with low expectations about one's own health, which often leads to a tendency to minimise symptoms<a class="elsevierStyleCrossRef" href="#bib0110">22</a>. Either way, hypoperception tends to promote therapeutic non-compliance and make self-treatment guidelines difficult to follow<a class="elsevierStyleCrossRefs" href="#bib0085">17,18</a>.MultimorbidityMultimorbidity is a predominant variable, as it is common in the elderly, it is linked to polypharmacy (sponsoring the risk of drug interactions)<a class="elsevierStyleCrossRef" href="#bib0115">23</a>, and is per se a cardinal element for understanding and dealing with the management of asthma refractory to treatment<a class="elsevierStyleCrossRefs" href="#bib0090">18,24–27</a>. Various epidemiological studies have analysed the significance of multimorbidity in asthma indicating that, for this age segment and with some differences between men and women, patients have an increased incidence risk of pneumonia, respiratory infections, rhinitis, sinusitis, heart disease, ischaemia, depression and/or anxiety, obesity, dyslipidaemia, pathological gastroesophageal reflux, sleep disorders, osteoporosis, cerebrovascular disease and COPD<a class="elsevierStyleCrossRefs" href="#bib0125">25,28–31</a>. It has been put forward that aging itself would be another comorbidity of asthma<a class="elsevierStyleCrossRef" href="#bib0160">32</a>, although aging and fragility are not completely interchangeable concepts<a class="elsevierStyleCrossRefs" href="#bib0025">5,26</a>. Fragility is defined as an increased vulnerability to stressors, linked to a decrease/deregulation of the physiological reserves of multiple systems, which causes difficulty in maintaining homeostasis<a class="elsevierStyleCrossRefs" href="#bib0135">27,33</a>. Fragility and multimorbidity predict disability (restriction or loss of ability to perform an activity) and, in turn, disability can exacerbate fragility and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0135">27,33</a>.The consensus-drawn conclusions regarding the general aspects of asthma in the elderly are:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">-From a biological point of view, aging is the consequence of the accumulation, over time, of a wide amount of molecular and cellular damage, which results in a general decrease in physiological reserves, a gradual decline in physical and mental abilities, an increased risk of disease and, eventually, death. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0010">-Such damage includes genomic instability, telomere wear, epigenetic changes, mitochondrial dysfunction, adult stem cell depletion, loss of proteostasis, and altered intercellular communications<a class="elsevierStyleCrossRef" href="#bib0045">9</a>.</li><li class="elsevierStyleListItem" id="lsti0015">-These changes are not linear or uniform, and their link to aging in years is relative<a class="elsevierStyleCrossRef" href="#bib0045">9</a>.</li><li class="elsevierStyleListItem" id="lsti0020">-Several events determine the peculiarities of asthma in the elderly: immunosenescence/inflammaging, the lung function corrections experienced over the years, the tendency to hypoperception of symptoms, the “well-being paradox” and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0015">3,4,13,15</a>,<a class="elsevierStyleCrossRefs" href="#bib0105">21,34</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0025">-It has been postulated that aging may be one more comorbidity of asthma. However, it should be remembered that aging and fragility are not, a priori, completely interchangeable terms<a class="elsevierStyleCrossRefs" href="#bib0025">5,26,32</a>.</li></ul>The consensus-drawn conclusions regarding the relevant aspects of asthma in the elderly are:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030">-In the elderly there are more diagnostic errors, either due to underdiagnosis or false diagnoses; only half of the patients have a correct diagnosis of asthma<a class="elsevierStyleCrossRef" href="#bib0175">35</a>.</li><li class="elsevierStyleListItem" id="lsti0035">-The underdiagnosis of asthma in the elderly is due, among other reasons, to the patient’s lack of perception of symptoms, the acceptance of dyspnoea as “normal” at an advanced age, and the reduction in physical activity<a class="elsevierStyleCrossRef" href="#bib0175">35</a>.</li><li class="elsevierStyleListItem" id="lsti0040">-False diagnoses are due to the tendency to associate asthma symptoms with other diseases (eg COPD, congestive heart failure, and gastroesophageal reflux). (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0045">-The potential risk factors and triggers for asthma in the elderly are similar to those of other age groups<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,11,12</a>,<a class="elsevierStyleCrossRefs" href="#bib0180">36,37</a>.</li><li class="elsevierStyleListItem" id="lsti0050">-In this age group, asthma can be triggered by infections due to immune disorders related to aging<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,11,12</a>,<a class="elsevierStyleCrossRefs" href="#bib0180">36,37</a>.</li><li class="elsevierStyleListItem" id="lsti0055">-The comorbidity associated with asthma, the severity of the disease, and the greater difficulty involved in its treatment worsen the quality of life of older patients<a class="elsevierStyleCrossRefs" href="#bib0005">1,34,38</a>.</li><li class="elsevierStyleListItem" id="lsti0060">-Among the main factors that explain the poor control of the disease in this age group are: the presence of associated comorbidities, polymedicine with risk of drug interactions, and poor therapeutic adherence<a class="elsevierStyleCrossRef" href="#bib0195">39</a>.</li></ul>DiagnosisClinical presentationMedical history is the key element leading to establishing the diagnosis of asthma. In the elderly the manifestations of the disease are similar to the rest of the stages of life<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,40</a>. However, compared to young asthmatics, older asthmatics have more morbidity and poorer quality of life, and are more likely to have poorer overall health, symptoms of depression, and limitations in their daily activities<a class="elsevierStyleCrossRef" href="#bib0205">41</a>. Also, in at least half of these patients, the diagnosis of asthma is recent. Factors that may influence the diagnosis include poor perception of signs and symptoms, the presence of extrapulmonary manifestations, the effects of aging on the respiratory system, and technical difficulties for making reliable measurements of lung function<a class="elsevierStyleCrossRef" href="#bib0175">35</a>. Sometimes these patients do not indicate their symptoms, or they attribute dyspnoea to normal aging or other comorbidities, such as cardiovascular disease or obesity. Not externalising the symptoms can be due to many causes, such as fear, depression, cognitive impairment, social isolation, or lack of education<a class="elsevierStyleCrossRef" href="#bib0205">41</a>. It is also common for the doctor to focus on other entities (cardiovascular disease and COPD) in this age group<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>. The differential diagnosis with COPD is not always easy and, in addition, both entities can coexist<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>.Although the prevalence of atopy may decrease with age and asthma in older adults has characteristically been reported as non-atopic, the atopic condition has generally increased in recent decades, and is known to contribute to the appearance of asthma in these populations. Thus, the results of some recent studies show that the prevalence of allergic sensitisation may be high, which supports that a mechanism mediated by immunoglobulin E may be involved in asthma at these ages<a class="elsevierStyleCrossRefs" href="#bib0210">42–46</a>.Older asthmatics can generally be divided into two groups: those with early-onset and long-term asthma, and those with late-onset symptoms<a class="elsevierStyleCrossRef" href="#bib0235">47</a>. It is seen that patients in the first group have more severe and frequent symptoms, an increase in the number of hospitalisations and emergency room visits, and worse lung function<a class="elsevierStyleCrossRefs" href="#bib0240">48,49</a>. In addition, these patients tend to have more severe and irreversible or partially reversible bronchial obstruction, than those with late-onset asthma<a class="elsevierStyleCrossRefs" href="#bib0030">6,50</a>. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the possible clinical and functional differences between early- and late-onset asthma.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Definitely, as the symptoms are nonspecific, confirmation of the diagnosis requires the use of respiratory function tests<a class="elsevierStyleCrossRefs" href="#bib0015">3,40</a>.Regarding the clinical presentation of asthma in the elderly, the working group concludes that:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0065">-The clinical symptoms of asthma in the elderly do not differ substantially from asthma in the young, although it has peculiarities such as lower perception of symptoms, worse quality of life, symptoms derived from other comorbidities, extrapulmonary diseases, and difficulty in externalising asthma symptoms<a class="elsevierStyleCrossRefs" href="#bib0010">2,3,40</a>.</li></ul>Complementary examinationsTo diagnose asthma in this age group, it is essential to perform a spirometry with bronchodilator test, but it may also be important to perform a chest X-ray and an electrocardiogram for the differential diagnosis and study of other associated diseases<a class="elsevierStyleCrossRef" href="#bib0255">51</a>.Respiratory function testsAs with other age groups, the diagnosis of asthma requires proof of reversibility of the forced expiratory volume in the first second (FEV1) with the bronchodilator or high-dose inhaled or systemic steroid testing, as well as bronchial hyperreactivity testing<a class="elsevierStyleCrossRef" href="#bib0260">52</a>. Reversibility at an advanced age is sometimes reduced by the irreversible structural changes due to airway remodeling<a class="elsevierStyleCrossRef" href="#bib0265">53</a>. The FEV1/forced vital capacity (FVC) ratio decreases with age and is not valid in the elderly, so it is essential to have age-adjusted values. The FEV1/FVC rate has been reported to be 75–64% for 65-year-olds and 67–56% for 85-year-olds. Additionally, the use of the post-bronchodilator FEV1/FVC index is important to prevent false positivity. The use of FEV1/forced expiratory volume at 6 seconds (FEV6) has also been proposed as a significant independent factor of mortality due to cardiopulmonary cause and all causes in elderly patients<a class="elsevierStyleCrossRef" href="#bib0270">54</a>.Although elderly patients with cognitive impairment and apraxia may have difficulty performing the spirometric manoeuvre correctly<a class="elsevierStyleCrossRefs" href="#bib0275">55,56</a>, there is strong evidence that quality spirometry with reversibility testing can be obtained in most elderly patients<a class="elsevierStyleCrossRefs" href="#bib0285">57–61</a>. When the spirometry shows an obstruction, the reversibility test is mandatory. Additionally, the degree of reversibility can be assessed in response to regular treatment over a period of time.In the case of irreversible obstruction, this may be due to more severe remodelling of the disease, an overlap with COPD, or the presence of bronchiectasis with segmental pulmonary fibrosis<a class="elsevierStyleCrossRefs" href="#bib0310">62–66</a>. Therefore, a CT scan would be indicated in these patients.Maximum expiratory flow (MEF) variability may be less significant for the elderly, as it decreases with age due to increased chest wall stiffness, muscle weakness, and lack of coordination. In addition, the absence of MEF variability does not exclude the diagnosis of asthma<a class="elsevierStyleCrossRef" href="#bib0335">67</a>.The study of bronchial hyperreactivity using bronchial provocation tests has a very high negative predictive value for the diagnosis of asthma. However, it is rarely performed in the elderly<a class="elsevierStyleCrossRef" href="#bib0010">2</a>. These tests may be contraindicated in some patients with low basal function or comorbidities, such as cardiovascular disease<a class="elsevierStyleCrossRef" href="#bib0340">68</a>. With this in mind, it is important to consider that aging is associated with structural and physiological changes in the lung<a class="elsevierStyleCrossRef" href="#bib0345">69</a>, which may influence the response to spasmodic stimulation. It has not yet been shown whether the slope of the dose-response curve during the provocation test, rather than the magnitude of the bronchial response, can help differentiate the airway response to the spasmodic stimulation between asthma and COPD<a class="elsevierStyleCrossRef" href="#bib0350">70</a>.In cases of severe and not completely reversible obstruction, tests such as measurements of lung volume (residual volume) or carbon monoxide diffusion (DLCO) may be useful for the differential diagnosis between asthma and COPD<a class="elsevierStyleCrossRefs" href="#bib0340">68,70,71</a>. The DLCO study is useful, fast, relatively inexpensive, and well standardised<a class="elsevierStyleCrossRefs" href="#bib0200">40,72</a>. Emphysema decreases DLCO values with a high positive predictive value, while bronchiectasis and chronic bronchitis do not affect DLCO and they are normal or high in patients with asthma.Measurements of bronchial inflammation and allergic sensitisationBlood and sputum eosinophil measurements may be important for classification into eosinophilic phenotypes, although they may be affected by previous treatment with inhaled steroids<a class="elsevierStyleCrossRef" href="#bib0010">2</a>.As mentioned, atopy can be serious in the elderly. A study in the United States found that the prevalence of allergic sensitisation was 75.4% between the ages of 20 and 40 and 65.2% in individuals >55 years old<a class="elsevierStyleCrossRef" href="#bib0215">43</a>. In addition, there were no significant differences registered between patients who developed asthma before 40 years of age and those who developed asthma after the age of 40. Another important fact collected in this and other studies is that in these older patients, mites are the most prevalent allergens, with a greater sensitisation exclusively to indoor air allergens<a class="elsevierStyleCrossRef" href="#bib0215">43</a>.Finally, the measurement of nitric oxide as a marker for the diagnosis of asthma and as a control of the disease is controversial, with some studies showing benefits and some studies not supporting its usefulness<a class="elsevierStyleCrossRef" href="#bib0365">73</a>. In addition, it is important to note that there is an increase in the levels of exhaled nitric oxide associated with age<a class="elsevierStyleCrossRef" href="#bib0370">74</a>.The recommendations of the working group on complementary examinations are:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070">-The bronchodilator test spirometry is the fundamental test for the diagnosis of asthma in the elderly<a class="elsevierStyleCrossRef" href="#bib0260">52</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0075">-The FEV1/FVC ratio decreases with age so it is essential to have values adjusted to this variable<a class="elsevierStyleCrossRef" href="#bib0265">53</a>.</li><li class="elsevierStyleListItem" id="lsti0080">-Despite the difficulties of performing spirometry in the elderly, especially in patients with cognitive impairment and apraxia, it is possible to obtain quality spirometry in most patients. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0085">-For the differential diagnosis between asthma and COPD in cases of severe and not completely reversible obstruction, performing a DLCO may be helpful<a class="elsevierStyleCrossRefs" href="#bib0340">68,70,71</a>.</li><li class="elsevierStyleListItem" id="lsti0090">-For differential diagnosis with other diseases (COPD, bronchiectasis) or associated comorbidities, a CT scan may be indicated<a class="elsevierStyleCrossRefs" href="#bib0310">62–66</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0095">-Although less common than at an early age, atopy may be present in asthma of an elderly patient, so an allergy study is important at this age too<a class="elsevierStyleCrossRefs" href="#bib0210">42–46</a>.</li></ul>Multidimensional evaluationWhen treating an elderly patient, it is important to assess the different dimensions that can influence the diagnosis, and the subsequent treatment provided<a class="elsevierStyleCrossRef" href="#bib0350">70</a>.Cognitive function evaluationIt is important to assess the cognitive function objectively using questionnaires (eg Mini-Mental State Examination), which will help to establish the severity of the asthma and the patient's ability to identify their symptoms properly. This, in turn, will help treatment adherence, as there is a relationship between cognitive function as measured by questionnaires and the ability to perform inhalation manoeuvers<a class="elsevierStyleCrossRef" href="#bib0375">75</a>. It is also important to evaluate the verbal memory or praxis or executive function<a class="elsevierStyleCrossRef" href="#bib0350">70</a>, using other questionnaires that evaluate these dimensions such as the Rey 15-item memory test, or the Clock test<a class="elsevierStyleCrossRef" href="#bib0350">70</a>.Mood evaluationAnxiety-depression is associated with asthma, which in turn is associated with poor perception of symptoms, leading to an incorrect classification of its severity<a class="elsevierStyleCrossRef" href="#bib0350">70</a> and is closely related to worse disease control<a class="elsevierStyleCrossRef" href="#bib0380">76</a>. There are different scales that can be used to evaluate anxiety and depression in the elderly such as the Geriatric Depression Scale and the Hospital Anxiety and Depression Scale<a class="elsevierStyleCrossRef" href="#bib0350">70</a>.Evaluation of the patient’s physical functionPhysical function is considered an indicator of health in the elderly. Thus, the speed of walking is related to quality of life, disability and mortality<a class="elsevierStyleCrossRef" href="#bib0350">70</a>. There are different measurement methods that can be used in regular practice, although the most commonly used Submaximal Stress Test in respiratory patients is the Six Minute Walk Test<a class="elsevierStyleCrossRef" href="#bib0350">70</a>, which evaluates poor exercise tolerance due to functional respiratory impairment.The recommendations of the Working Group on the multidimensional evaluation of asthma in the elderly are:<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100">-In the treatment of asthma in the elderly patient it is advisable to include the evaluation of cognitive function through objective questionnaires. These allow the abilities for the perception of symptoms and the realisation/adherence to treatment to be evaluated<a class="elsevierStyleCrossRefs" href="#bib0350">70,75</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0105">-Anxiety-depression is associated with an unrealistic perception of symptoms, which causes poor asthma control. Therefore, an evaluation of the anxiety-depression suffered by the elderly person is helpful in avoiding poor control<a class="elsevierStyleCrossRef" href="#bib0350">70</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0110">-Physical function is considered an indicator of health in the elderly<a class="elsevierStyleCrossRef" href="#bib0350">70</a>.</li></ul>Differential diagnosisIn the elderly, the clinical presentation of asthma is heterogeneous, and a differential diagnosis should be made with different diseases, including COPD. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the main differential diagnoses of asthma in adulthood.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>With regard to COPD, the main confounding factors are<a class="elsevierStyleCrossRef" href="#bib0010">2</a>:<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115">•Age per se. Asthma is associated with childhood/adolescence and with COPD in adulthood.</li><li class="elsevierStyleListItem" id="lsti0120">•Heterogeneity and clinical presentation. Sometimes the guiding symptoms of asthma do not predominate at night.</li><li class="elsevierStyleListItem" id="lsti0125">•Low perception of the symptoms or inadequate description of the symptoms.</li></ul>The recommendations of the working group on the differential diagnosis of elderly patients with asthma are:<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130">-In older patients do not rule out the diagnosis of late-onset asthma, even though other differential diagnoses should be considered, mainly respiratory or cardiac conditions<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0135">-In patients with a history of smoking, evaluate whether or not there is an overlap with COPD and/or heart disease<a class="elsevierStyleCrossRefs" href="#bib0010">2,3</a>. (Expert consensus).</li></ul>Asthma treatment in the elderlyAs at any age, the goal of treating asthma in the elderly is to achieve and maintain control of the disease as soon as possible, in addition to preventing exacerbations and chronic airflow obstruction, and minimising its mortality<a class="elsevierStyleCrossRef" href="#bib0385">77</a>.To achieve this, a global and individualised strategy should be followed, based on a staggered pharmacological treatment, as well as environmental control measures, asthma education, and attention to comorbidities.Pharmacological treatmentPharmacological treatment of asthma in the elderly does not differ from that recommended in clinical practice guidelines for other stages of life<a class="elsevierStyleCrossRefs" href="#bib0030">6,77</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Therapeutic optionsFor the treatment of severe asthma it is important to mention biological drugs, although data regarding their effects in older patients are scarce. Omalizumab and mepolizumab<a class="elsevierStyleCrossRefs" href="#bib0390">78–80</a> are the only two biologics that have efficacy and safety data available in persons over 75 years of age, with no evidence that a different dose is required for them compared to younger patients. Regarding benralizumab and reslizumab<a class="elsevierStyleCrossRefs" href="#bib0405">81–83</a>, the available studies only include populations between 12 and 75 years of age, with no differences in pharmacokinetic analysis in these patients.In any case, according to the Summaries of Product Characteristics of all the monoclonal antibodies approved for the treatment of asthma, no dose adjustment is required in elderly patients.Influence of age on treatmentOlder patients may experience psychological and neurological changes that affect their chances of treatment. Depressive disorders and other illnesses such as dementia require special vigilance, so further reinforcement in the education of these patients is of great importance.Age is a key factor to consider when choosing an inhaler, as older people may be unable to perform a proper inspiratory manoeuvre, or may even have difficulty learning how the devices work. For this reason, in the elderly patient it is often preferred to use pMDI devices coupled to an inhalation chamber or an SMI or BAI device<a class="elsevierStyleCrossRef" href="#bib0420">84</a> (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Possible adverse effects associated with ageAging is associated with changes in pharmacology that affect the distribution, metabolism and elimination of drugs, so that free drug concentrations increase, as does the distribution volume of fat-soluble drugs<a class="elsevierStyleCrossRef" href="#bib0425">85</a>. Beta-adrenergic agonists are known to be more likely to cause adverse effects such as tremors, tachycardia, or arrhythmias<a class="elsevierStyleCrossRef" href="#bib0430">86</a>.There are several meta-analyses on the side effects of inhaled corticosteroids (ICS) in the elderly, and these include an increased risk of non-vertebral bone fractures<a class="elsevierStyleCrossRef" href="#bib0435">87</a> and cataracts<a class="elsevierStyleCrossRef" href="#bib0440">88</a>, with fluticasone dipropionate being the steroid with the least number of adverse effects when administered at doses equipotent with other ICS<a class="elsevierStyleCrossRef" href="#bib0445">89</a>.Anticholinergics<a class="elsevierStyleCrossRef" href="#bib0450">90</a> and antileukotrienes are safe drugs in this population. Moreover, there are older studies that have shown beneficial effects in patients with associated cardiovascular disease, as they decrease the risk of stroke and heart attacks<a class="elsevierStyleCrossRef" href="#bib0455">91</a>. As for systemic glucocorticoids, if they are necessary, it is recommended that bone densitometry be performed before starting therapy and, if it is pathological, that appropriate preventive or therapeutic measures be taken.Adherence to treatmentIn general, elderly patients tend to have good rates of therapeutic adherence, with unconscious non-compliance being more frequent, mainly due to the difficulty of treatment with the inhalation devices<a class="elsevierStyleCrossRef" href="#bib0460">92</a>.The recommendations of the working group on the pharmacological treatment of asthma in the elderly are:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140">-Pharmacological treatment of asthma in the elderly does not differ from that recommended in clinical practice guidelines at other stages of life<a class="elsevierStyleCrossRefs" href="#bib0030">6,77</a>.</li><li class="elsevierStyleListItem" id="lsti0145">-Special attention should be paid to the choice of inhaler device based on the inspiratory flow and coordination capacity of each patient<a class="elsevierStyleCrossRef" href="#bib0420">84</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0150">-Not much data exists on the safety and efficacy of the use of biological drugs in poorly-controlled severe asthma in the elderly patient, although their use is not contraindicated. (Expert consensus).</li></ul>Environmental controlOne of the key aspects of controlling a person’s asthma is to avoid the triggers that can cause symptoms and exacerbations. Although aeroallergens are less important when it comes to triggering symptoms in the elderly compared to young patients, the implementation of a programme of measures to prevent or minimise exposure to aeroallergens is recommended. However, such programmes can be difficult to carry out due to the difficulty of life-style changes at this age<a class="elsevierStyleCrossRef" href="#bib0030">6</a>.Studies show that older asthmatic patients are more likely to present asthma symptoms when exposed to particulates from road traffic (PM10, PM2.5)<a class="elsevierStyleCrossRef" href="#bib0465">93</a>, and this exposure is related to a risk of hospitalisation<a class="elsevierStyleCrossRef" href="#bib0470">94</a> and longer hospital stays<a class="elsevierStyleCrossRef" href="#bib0475">95</a>. Since people of this age stay at home most of the day, it is important to consider that indoor pollution (PM10 and PM2.5 respirable particles, nitrogen dioxide, and tobacco smoke) increases the risk of respiratory symptoms<a class="elsevierStyleCrossRef" href="#bib0480">96</a>.As part of the education process aimed at older people living in urban centres with high levels of traffic pollution, advice should be provided as to how to avoid exposure during the hours of maximum pollution. Advice should also be given about the suitability of ventilating the rooms in which they spend most of the day.Finally, influenza vaccination is recommended, although it is less effective in preventing exacerbations than in young people. On the other hand, the recommended pneumococcal vaccination in patients with COPD has less evidence in asthmatic patients<a class="elsevierStyleCrossRef" href="#bib0155">31</a>.Regarding environmental control in asthma in the elderly, the working group recommends:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0155">-Measures to prevent or minimise exposure to airborne allergens and environmental pollution should be considered in education programmes<a class="elsevierStyleCrossRef" href="#bib0480">96</a>. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0160">-Ventilation for rooms where patients spend a greater number of hours is recommended. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0165">-An influenza vaccination and a pneumococcal vaccination is recommended. (Expert consensus).</li></ul>Patient educationHealth education is a process of teaching the concepts and skills needed to help the patient to cooperate in the treatment and control of their disease. To achieve this control, a process plan shared between the health team (doctor and nurse) and the patient should be elaborated. The usefulness of this action plan will depend on its being adapted to the patient’s individual characteristics and needs, and to disease progression. It is necessary to know the patient's attitudes towards the disease and listen to their opinions and fears about the medications they are receiving. This will help both the doctor regarding the treatment regime, and the patient’s self-treatment plans<a class="elsevierStyleCrossRef" href="#bib0020">4</a>.The education programme should include the determination of the level of adherence, classification, as far as possible, of the type of non-compliance of the patient (erratic, deliberate or involuntary), and promote the corresponding corrective measures in case of low adherence, which should be adapted to the type of non-compliant patient. The use of the Patient Asthma Concerns Tool<a class="elsevierStyleCrossRef" href="#bib0485">97</a> questionnaire is recommended in asthmatics of this age. However, some patients are unable to learn the use of a Metered Dose Inhaler (MDI) or Turbuhaler (TH) despite having a normal mental test, so it would be advisable to perform a training test to see if the patient will be able to learn the technique<a class="elsevierStyleCrossRef" href="#bib0275">55</a>.The recommendations of the working group on patient education are:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0170">-Self-treatment plans should be considered in the education programmes. These should explain how to recognise the symptoms of asthma and other illnesses with similar symptoms that also allow rescue therapy to be applied. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0175">-Educational measures are more difficult to implement in older patients because they find it more difficult to make lifestyle changes. (Expert consensus).</li><li class="elsevierStyleListItem" id="lsti0180">-It would be interesting to work on the validation of questionnaires that identify the needs of older patients, and that allow the implementation of specific education programmes for this age group. (Expert consensus).</li></ul>Comorbidity controlComorbidities can influence the diagnosis and evaluation of severity of asthma, as well as its control, the patient’s quality of life, and even contribute to morbidity and mortality<a class="elsevierStyleCrossRefs" href="#bib0005">1,34,38</a>. The most common comorbidities in the elderly with asthma are cardiopulmonary involvement, including pneumonia, other respiratory infections, acute myocardial infarction, sleep disorders, and COPD, although gastroesophageal reflux, diabetes mellitus and obesity are also common<a class="elsevierStyleCrossRef" href="#bib0150">30</a>.Polypharmacy is one of the main problems in these patients, and it can lead to an increased risk of adverse effects and drug interactions, as well as poor adherence<a class="elsevierStyleCrossRef" href="#bib0180">36</a>. Also, it should be borne in mind that there is a higher prevalence of renal failure in the elderly population<a class="elsevierStyleCrossRef" href="#bib0490">98</a> so the selection of drugs must be done carefully.Moreover, systemic or ocular beta-blockers are used frequently in this population, which can potentially worsen bronchospasm, so the use of cardioselective therapy is recommended<a class="elsevierStyleCrossRef" href="#bib0430">86</a>. Also, the use of beta-2 agonists increases the output of serum potassium to the intracellular space, favouring hypokalaemia, which is further increased in patients who use insulin and/or diuretics together<a class="elsevierStyleCrossRef" href="#bib0495">99</a>.The recommendations of the working group on comorbidity control are:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0185">-Although the goals of asthma therapy are the same for patients of all ages, in older adults with asthma it is necessary to take into account the presence of comorbidities and the need to minimise the number of therapies required (polypharmacy)<a class="elsevierStyleCrossRefs" href="#bib0150">30,36,98</a>. (Expert consensus).</li></ul>ConclusionsThe conclusions and recommendations contained in this consensus document, together with the degree of agreement reached by the committee of experts, are summarised in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>. This work is a first approach to offer practical recommendations for the challenges of treating asthma in the elderly patient, which should address issues not clearly addressed to date in the clinical practice guidelines for this disease. It should be noted, however, that the consensus methodology offers recommendations which, while serving as a practical guide for clinicians and endorsed by the agreement of disease experts, do not have the level of recommendations offered by a clinical practice guideline developed according to the latest regulations.<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>FundingThe authors of this manuscript have not received any financial contribution. The technical and methodological support has been financed by SEPAR through the funds of the Autonomous Asthma Forum.Conflict of interestThis consensus has been made through the initiative of the FORASMA group of SEPAR with own funds from this Scientific Society. The Recommendation Validation Group is listed below. The potential conflicts of interest of the Scientific Committee are declared as:Dr. A. Gómez-Bastero states that she has collaborated with ALK, AstraZeneca, Bial, Chiesi, GSK, Novartis and TEVA in talks, as well as to have attended conferences and scientific meetings.Dr. E. Martínez-Moragón states that she has received fees as a speaker for AstraZeneca, Chiesi, Teva and Novartis, and that she has been a consultant for ALK, AstraZeneca and Boehringer Ingelheim.Dr. FJ Alvarez states that in the last three years he has received fees for consulting work, giving lectures or grants to attend conferences and scientific meetings by ALK, AstraZeneca, Bial, Boheringer-Ingelheim, Chiesi, GSK, Menarini, Mundi -pharma, Novartis, Orion and TEVA.Dr. I. Urrutia states that he has received grants for research projects from Novartis, Menarini and Mundipharma, and has also received remuneration for scientific events from AstraZeneca, Bial Aristegui, GSK, Chiesi, Mundipharma, Menarini and TEVA.Dr. M. Blanco states that she has received fees for participating in courses, conferences and training activities sponsored by ALK, GSK, AstraZeneca, Chiesi, TEVA and Zambón.Dr. M. Perpiñá and Dr. A. Trisán declare that they have no conflicts of interests.ThanksThe authors thank the technical and methodological support provided by Medical Statistics Consulting (MSC) in the process of developing the recommendations and consensus, as well as the collaboration of Drs. Almudena Fuster-Matanzo and Blanca Piedrafita (MSC) in the coordination and editing of the manuscript." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres1838782" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1602431" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1838781" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1602430" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Relevant aspects of asthma in the elderly" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Immunosenescence" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Lung function" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Hypoperception" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Multimorbidity" ] ] ] 7 => array:3 [ "identificador" => "sec0040" "titulo" => "Diagnosis" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Clinical presentation" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Complementary examinations" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Respiratory function tests" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Measurements of bronchial inflammation and allergic sensitisation" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Multidimensional evaluation" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Cognitive function evaluation" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Mood evaluation" ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Evaluation of the patient’s physical function" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Differential diagnosis" ] ] ] 8 => array:3 [ "identificador" => "sec0090" "titulo" => "Asthma treatment in the elderly" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0095" "titulo" => "Pharmacological treatment" ] 1 => array:2 [ "identificador" => "sec0100" "titulo" => "Therapeutic options" ] 2 => array:2 [ "identificador" => "sec0105" "titulo" => "Influence of age on treatment" ] 3 => array:2 [ "identificador" => "sec0110" "titulo" => "Possible adverse effects associated with age" ] 4 => array:2 [ "identificador" => "sec0115" "titulo" => "Adherence to treatment" ] 5 => array:2 [ "identificador" => "sec0120" "titulo" => "Environmental control" ] 6 => array:2 [ "identificador" => "sec0125" "titulo" => "Patient education" ] 7 => array:2 [ "identificador" => "sec0130" "titulo" => "Comorbidity control" ] ] ] 9 => array:2 [ "identificador" => "sec0135" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0140" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0145" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "sec0150" "titulo" => "Thanks" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-06-29" "fechaAceptado" => "2021-04-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1602431" "palabras" => array:6 [ 0 => "Asthma" 1 => "Older adults" 2 => "Differential diagnosis" 3 => "Immunosenescence" 4 => "Treatment" 5 => "Comorbidities" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1602430" "palabras" => array:6 [ 0 => "Asma" 1 => "Personas mayores" 2 => "Diagnóstico diferencial" 3 => "Inmunosenescencia" 4 => "Tratamiento" 5 => "Comorbilidades" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Asthma is a public health problem in patients of any age, although there is still a tendency to erroneously assume that it is almost always confined to children and young people. Epidemiological studies indicate that, from the sixth decade of life, the prevalence of this disease in countries such as Spain reaches 6%–10%, with a higher prevalence among women aged 64–75 years. In addition, two-thirds of asthma deaths occur at this stage of life, resulting in a substantial number of hospital admissions, longer hospital stays and, from a finance point of view, significant direct economic costs. Asthma in older adults (65 years or older) is now a matter of great concern, the reality of which is underestimated and undertreated. It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population. This consensus, which brings together the latest evidence available, was conceived with this objective. The proposed recommendations/conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "El asma constituye un problema de salud pública presente en pacientes de cualquier edad, aunque continúa existiendo cierta tendencia a asumir de forma errónea que dicha entidad resulta casi siempre exclusiva de la infancia y de gente joven. Los estudios epidemiológicos señalan que, a partir de la sexta década de la vida, la prevalencia de esta patología en países como España alcanza el 6%–10%, con mayor predominio entre las mujeres de 64 a 75 años. Asimismo, dos tercios de las muertes debidas al asma acontecen en esta etapa de la vida, llegando a ocasionar un número de ingresos sustancial, estancias hospitalarias más prolongadas y, desde el punto de vista del financiador, unos costes económicos directos notables. En la actualidad el asma en las personas mayores (65 años o más) constituye un tema de enorme preocupación, cuya realidad se encuentra infravalorada e infratratada, por lo que resulta del todo necesario establecer unas recomendaciones adecuadas para el diagnóstico y tratamiento de la patología en esta población de edad. Con este objetivo nació este consenso que recoge la evidencia disponible más actualizada. Las recomendaciones/conclusiones que se proponen son el resultado de un consenso de tipo nominal desarrollado a lo largo del año 2019 y que han sido validadas por los panelistas en sucesivas rondas de votación." ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Perpiñá M, Gómez-Bastero A, Trisán A, Martínez-Moragón E, Álvarez-Gutiérrez FJ, Urrutia I, et al. Documento de consenso de expertos para el control del asma en personas mayores. Med Clin (Barc). 2022;159:53." ] 1 => array:3 [ "etiqueta" => "1" "nota" => "The affiliation of Miguel Perpiñá until 2016. He is currently retired." "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<elsevierMultimedia ident="tbl0025"></elsevierMultimedia>" "etiqueta" => "Appendix A" "titulo" => "Participants of the Recommendation Validation Group, appointed by the autonomous societies and the SEPAR Asthma Area (in alphabetical order)" "identificador" => "sec0155" ] ] ] ] "multimedia" => array:8 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2046 "Ancho" => 2925 "Tamanyo" => 473670 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Most notable consequences of immunosenescence and inflammaging on the innate and adaptive response, with repercussions on asthma. IFN-γ: interferon-γ; IgE: immunoglobulin E; IL: interleukin; MMP-9: Matrix metalloproteinase; NETs: neutrophil extracellular traps; ROS: reactive oxygen species; TLR: Toll-like receptor; TNF-α: tumor necrosis factor-α. Based on Skloot et al.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> and Baptist et al.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1087 "Ancho" => 2508 "Tamanyo" => 192258 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Significant changes in lung function present in asthma of the elderly." ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1964 "Ancho" => 2508 "Tamanyo" => 207471 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Fig. " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Choice of device type according to patient coordination and inspiratory flow. BAI: breath-actuated pMDI; DPI: dry-powder inhaler; pMDI: pressurised metered-dose inhaler; SMI: soft mist inhaler. Extracted from Bustamante et al.<a class="elsevierStyleCrossRef" href="#bib0420">84</a>." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "FEV1: forced expiratory volume in the first second." "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"> \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">Early-onset asthma \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">Late-onset asthma \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">Atopy \t\t\t\t\t\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">+++ \t\t\t\t\t\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">+ \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">Symptoms \t\t\t\t\t\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">+++ \t\t\t\t\t\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">+ \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">Impaired lung function \t\t\t\t\t\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">+++ \t\t\t\t\t\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">+ \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">Annual fall in FEV1 \t\t\t\t\t\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">+ \t\t\t\t\t\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">+++ \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">Obstruction reversibility \t\t\t\t\t\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">++ \t\t\t\t\t\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">+++ \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">Bronchial hyperreactivity \t\t\t\t\t\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">++ \t\t\t\t\t\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">++ \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Main clinical and functional differences between early- and late-onset asthma. The number of crosses indicate the probability of the event." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "NSAID: non-steroidal anti-inflammatory drugs; BNP: B-type natriuretic peptide; DLCO: diffusing capacity of the lung for carbon monoxide; COPD: chronic obstructive pulmonary disease; ACEI: angiotensin-converting enzyme inhibitors; NA: not applicable; GERD: gastroesophageal reflux disease; URT: upper respiratory tract.Adapted from Yawn BP and Han MK Practical considerations for the diagnosis and management of asthma in older adults. Mayo Clin Proc, 2017. 92 (11): p. 1697–1705. DOI: https://doi.org/10.1016/j.mayocp.2017.08.005." "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">Diagnosis \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">Trigger \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">Symptoms \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">History \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">Family history \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">Tests \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">Asthma \t\t\t\t\t\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">Allergens, NSAIDs, ACEIs, exercise or irritants such as tobacco \t\t\t\t\t\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">Cough, wheezing or dyspnoea predominantly at night \t\t\t\t\t\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">Atopy, allergic rhinitis \t\t\t\t\t\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">Asthma and/or atopy \t\t\t\t\t\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">Reversible obstruction, variability, bronchial hyperresponsiveness \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">Vocal cord dysfunction \t\t\t\t\t\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">Stress, obesity, GERD, exercise \t\t\t\t\t\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">Similar to wheezing \t\t\t\t\t\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">Often starts in adolescence. Rarely atopy or allergy in childhood \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Plateau in the inspiratory curve in spirometry. \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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">Objective is the abduction of the vocal cords \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">Rhinosinusitis \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Nasal blockage, rhinorrhea, facial pain. \t\t\t\t\t\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">May start at any age \t\t\t\t\t\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">Often associated with allergic rhinitis \t\t\t\t\t\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">Clinical tests, previous rhinoscopy, allergic evaluation \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">Gastrointestinal reflux \t\t\t\t\t\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">After meals, when laying down, or certain foods \t\t\t\t\t\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">Dyspepsia, pain, heartburn, regurgitation \t\t\t\t\t\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">More common in adults \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Response to antacids, oesophageal pH-metrics and manometry \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">Eosinophilic bronchitis \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Cough, may be similar to asthma \t\t\t\t\t\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">More common in adults \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Elevated sputum eosinophils in the absence of respiratory impairment \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">Post-infectious cough syndrome \t\t\t\t\t\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">URT infections \t\t\t\t\t\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">Cough \t\t\t\t\t\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">Recent URT infection \t\t\t\t\t\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">NA \t\t\t\t\t\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">Laboratory \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">Cough induced by ACE inhibitors \t\t\t\t\t\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">After the introduction of ACEI \t\t\t\t\t\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">Non-productive cough \t\t\t\t\t\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">After introducing the medication \t\t\t\t\t\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">Unknown \t\t\t\t\t\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">Discontinue medication and improvement of symptoms \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">Obstruction of the airways due to neoplasm \t\t\t\t\t\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">Onset or worsening in days or weeks \t\t\t\t\t\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">Dyspnoea, weight loss \t\t\t\t\t\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">Smoking or chronic exposure to other irritants \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Imaging techniques \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">Primary tracheobronchomalacia \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Wheezing with or without dyspnoea \t\t\t\t\t\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">Early-onset \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Imaging techniques or bronchoscopy \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">Secondary tracheobronchomalacia \t\t\t\t\t\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">After trauma (surgery, accident or intubation) or chronic infection \t\t\t\t\t\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">Dyspnoea, cough, hemoptysis. Not specific \t\t\t\t\t\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">Onset in adulthood \t\t\t\t\t\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">No \t\t\t\t\t\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">Imaging techniques or bronchoscopy \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">COPD \t\t\t\t\t\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">Irritants or infections \t\t\t\t\t\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">Cough, sputum and dyspnoea predominate in the morning \t\t\t\t\t\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">Exposure to tobacco smoke or other harmful particles \t\t\t\t\t\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">Family history of COPD \t\t\t\t\t\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">DLCO disorder, more often hypoxemia \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">Chronic non-obstructive bronchitis \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Productive cough \t\t\t\t\t\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">Any age. Most common in smokers \t\t\t\t\t\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">NA \t\t\t\t\t\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">No respiratory impairment \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">Chronic heart failure \t\t\t\t\t\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">Heart disease decompensation \t\t\t\t\t\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">Dyspnoea at rest and exercise, orthopnea, oedema in lower limbs, cough \t\t\t\t\t\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">Basal heart disease, episodes of previous heart failure \t\t\t\t\t\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">Variable \t\t\t\t\t\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">Echocardiogram alterations, pro-BNP elevation, and radiological alterations \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Main differential diagnoses of asthma in the elderly." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "Education, environmental control, and comorbidity control. Consider immunotherapy with allergens in steps 2–4.LTRA: leukotriene receptor antagonists; ICS: inhaled corticosteroids; OCS: oral corticosteroids; IM: intramuscular; LABA: long-acting ß2 agonists; SABA: short-acting ß2 adrenergic agonists.Modified from GEMA 5.0<a class="elsevierStyleCrossRef" href="#bib0385">77</a>." "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"> \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">Step 1 \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">Step 2 \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">Step 3 \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">Step 4 \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">Step 5 \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">Step 6 \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">Of choice \t\t\t\t\t\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"> \t\t\t\t\t\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">ICS low doses \t\t\t\t\t\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">ICS low dose + LABA \t\t\t\t\t\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">ICS medium dose + LABA \t\t\t\t\t\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">ICS high dose + LABA \t\t\t\t\t\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">Treatment of the previous step + biologics according to phenotypes: omalizumab, mepolizumab, reslizumab, benralizumab, dupilumab \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">Other options \t\t\t\t\t\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"> \t\t\t\t\t\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">LTRA \t\t\t\t\t\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">ICS medium dose \t\t\t\t\t\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">ICS medium dose + LTRA \t\t\t\t\t\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">If poor control, add one or more: Tiotropium and/or \t\t\t\t\t\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">If previous options fail: \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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">ICS low dose + LTRA \t\t\t\t\t\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"> \t\t\t\t\t\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">LTRA and/or \t\t\t\t\t\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">Endobronchial thermoplasty \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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">Theophylline and/or \t\t\t\t\t\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">If poor control persists, consider: \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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">Azithromycin \t\t\t\t\t\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">- Corticosteroids OCS \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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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">- Triamcinolone IM \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">On demand \t\t\t\t\t\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">SABA \t\t\t\t\t\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">SABA \t\t\t\t\t\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">SABA or \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \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"> \t\t\t\t\t\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">or \t\t\t\t\t\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">or \t\t\t\t\t\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">ICS + formoterol \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \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"> \t\t\t\t\t\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">ICS + formoterol \t\t\t\t\t\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">ICS + formoterol<a class="elsevierStyleCrossRef" href="#tblfn0005">*</a> or \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \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"> \t\t\t\t\t\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">or \t\t\t\t\t\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">ICS + salbutamol<a class="elsevierStyleCrossRef" href="#tblfn0005">*</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="left" 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="left" 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="left" 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="left" 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"> \t\t\t\t\t\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">ICS + salbutamol \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\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"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "No maintenance treatment." ] ] ] "descripcion" => array:1 [ "en" => "Therapeutic steps for adult asthma maintenance treatment." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "DLCO: diffusing capacity of the lung for carbon monoxide; COPD: chronic obstructive pulmonary disease; FVC: forced vital capacity; FEV1: forced expiratory volume in one second; CT: computed tomography scan." "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">General aspects \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">Percentage of agreement (71 experts) \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">- From a biological point of view, aging is the consequence of the accumulation of a wide variety of molecular and cellular damage over time, leading to a general decrease in physiological reserves, a gradual decline in physical and mental capacity, an increased risk of illness, and ultimately death. \t\t\t\t\t\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">95.3% \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">- Such damage includes genomic instability, telomere wear, epigenetic changes, mitochondrial dysfunction, adult stem cell depletion, loss of proteostasis, and alterations in intercellular communications. \t\t\t\t\t\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">100.0% \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">- These changes are not linear or uniform and their link with age in years is relative. \t\t\t\t\t\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">95.1% \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">- Several events determine the peculiarities of asthma in the elderly: immunosenescence/inflammaging, the lung function corrections experienced over the years, the tendency to hypoperception of symptoms, the “well-being paradox” and multimorbidity. \t\t\t\t\t\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">98.0% \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">- It has been postulated that aging may be one more commorbidity of asthma. However, it should be remembered that aging and fragility are not, a priori, completely interchangeable terms. \t\t\t\t\t\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">87.0% \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Relevant aspects</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">- In the elderly there are more diagnostic errors, either due to underdiagnosis or false diagnoses; only half the patients have a correct diagnosis of asthma. \t\t\t\t\t\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">97.9% \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">- The underdiagnosis of asthma in the elderly population is due, among other reasons, to the patient’s lack of perception of the symptoms, accepting dyspnoea as something “normal” at an advanced age, and to the reduction of physical activity. \t\t\t\t\t\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">96.0% \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">- False diagnoses are due to the tendency to associate asthma symptoms with other diseases (eg COPD, congestive heart failure, and gastroesophageal reflux). \t\t\t\t\t\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">91.5% \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">- The potential risk factors and triggers for asthma in the elderly are similar to those in other age groups. \t\t\t\t\t\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">74.0% \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">- In this age group, asthma can be triggered by infections due to immune disorders related to aging. \t\t\t\t\t\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">84.1% \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">- Asthma-associated commorbidity, disease severity, and the increased difficulty involved in its treatment, worsen the quality of life of older patients. \t\t\t\t\t\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">88.2% \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">- Among the main factors that explain the poor control of the disease in this age group are: the presence of associated commorbidities, polymedicine with risk of drug interactions, and poor therapeutic adherence. \t\t\t\t\t\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">92.0% \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diagnosis</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">Clinical presentation \t\t\t\t\t\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"> \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">The clinical symptoms of asthma in the elderly do not differ substantially from asthma in the young, although it has peculiarities such as a lack of perception of symptoms, worse quality of life, symptoms derived from other commorbidities, extrapulmonary diseases, and difficulty in externalising asthma symptoms. \t\t\t\t\t\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">96.0% \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">Complementary explorations \t\t\t\t\t\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"> \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">- Bronchodilator test spirometry is the fundamental test for the diagnosis of asthma in the elderly. \t\t\t\t\t\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">82.0% \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">- The FEV1/FVC ratio decreases with age so it is essential to have values adjusted to this variable. \t\t\t\t\t\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">98.1% \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">- Despite the difficulties of performing spirometry in the elderly, especially in patients with cognitive impairment and apraxia, it is possible to obtain quality spirometry in most patients. \t\t\t\t\t\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">83.0% \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">- For the differential diagnosis between asthma and COPD in cases of severe and not completely reversible obstruction, performing DLCO may be helpful. \t\t\t\t\t\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">98.1% \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">- For the differential diagnosis with other diseases (COPD, bronchiectasis) or associated commorbidities, a CT scan may be indicated. \t\t\t\t\t\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">79.2% \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">- Although less common than at an early age, atopy may be present in the asthma of the elderly patient, so an allergy study is also very important at this age as well. \t\t\t\t\t\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">90.7% \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">Multidimensional evaluation \t\t\t\t\t\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"> \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">- In the management of asthma in the elderly patient it is advisable to include the evaluation of cognitive function by means of objective questionnaires. These assess the capabilities for the perception of symptoms and the implementation/adherence to treatments. \t\t\t\t\t\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">86.0% \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">- Anxiety-depression is related to an unrealistic perception of the symptoms, which causes poor control of asthma. Therefore, an anxiety-depression assessment in the elderly is helpful in avoiding poor control. \t\t\t\t\t\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">90.6% \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">- Physical function is considered an indicator of health in the elderly. \t\t\t\t\t\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">97.9% \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">Differential diagnosis \t\t\t\t\t\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"> \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">- In older patients, the diagnosis of late-onset asthma is not ruled out, although other differential diagnoses must be considered, mainly respiratory or cardiac. \t\t\t\t\t\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">98.0% \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">- In patients with a history of smoking, assess whether or not there is an overlap with COPD and/or heart disease. \t\t\t\t\t\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">100.0% \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 " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment</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">Pharmacological treatment \t\t\t\t\t\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"> \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">- The pharmacological treatment of asthma in the elderly does not differ from that advised in the clinical practice guidelines at other stages of life. \t\t\t\t\t\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">90.6% \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">- Special attention should be paid to the choice of the inhaler device based on the inspiratory flow and coordination capacity of each patient. \t\t\t\t\t\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">98.1% \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">- Not much data exists on the safety and efficacy of the use of biological drugs in poorly-controlled severe asthma in the elderly patient, although their use is not contraindicated. \t\t\t\t\t\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">92,3% \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">Environmental control \t\t\t\t\t\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"> \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">- Measures to prevent or minimise exposure to aero-allergens and environmental pollution should be considered in education programmes. \t\t\t\t\t\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">99.0% \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">- Ventilation for rooms where patients spend a greater number of hours is recommended. \t\t\t\t\t\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">79.2% \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">- An influenza vaccination and a pneumococcal vaccination is recommended. \t\t\t\t\t\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">96.1% \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">Patient education \t\t\t\t\t\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"> \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">- Self-management plans should be considered in the education programmes. These should explain how to recognise the symptoms of asthma and other illnesses with similar symptoms, that also allow rescue therapy to be applied. \t\t\t\t\t\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">94.2% \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">- Educational measures are more difficult to implement in older patients because they have more difficulty making changes in their lifestyle. \t\t\t\t\t\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">73.1% \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">- It would be interesting to work on the validation of questionnaires that identify the needs of older patients, and that allow the implementation of specific education programmes for this age group. \t\t\t\t\t\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">92.2% \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">Commorbidity control \t\t\t\t\t\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"> \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">- Although the objectives of asthma therapy are the same for patients of all ages, in the older adult with asthma it is necessary to take into account the presence of commorbidities and the need to minimise the number of therapies required (polypharmacy) \t\t\t\t\t\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">92.0% \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] "descripcion" => array:1 [ "en" => "Summary of recommendations for the management and treatment of asthma in the elderly." ] ] 7 => array:5 [ "identificador" => "tbl0025" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => false "mostrarDisplay" => true "tabla" => array:1 [ "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=""><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">Carlos Almonacid Sánchez \t\t\t\t\t\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">SEPAR \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">Rubén Andújar Espinosa \t\t\t\t\t\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">SOMUPAR \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">Ebymar Arismendi \t\t\t\t\t\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">SOCAP \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">Aurelio Arnedillo Muñoz \t\t\t\t\t\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">NEUMOSUR \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">Enric Barbeta \t\t\t\t\t\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">SOCAP \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">Irina Bobolea \t\t\t\t\t\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">SEPAR \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">Ana Boldova Loscertales \t\t\t\t\t\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">SADAR-PNEUMARAGON \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">Carlos Bujalance Cabrera \t\t\t\t\t\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">SOCAMPAR \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">Francisco Javier Callejas González \t\t\t\t\t\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">SOCAMPAR \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">Concepción Cañete Ramos \t\t\t\t\t\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">SEPAR \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">José Ángel Carretero Gracia \t\t\t\t\t\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">SEPAR \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">Francisco Casas Maldonado \t\t\t\t\t\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">NEUMOSUR \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">Manuel Castilla Martínez \t\t\t\t\t\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">SOMUPAR \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">José Antonio Castillo Vizuete \t\t\t\t\t\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">SEPAR \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">Pilar Cebollero Rivas \t\t\t\t\t\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">SVNPAR \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">Carolina Cisneros Serrano \t\t\t\t\t\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">SEPAR \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">Astrid Crespo Lessmann \t\t\t\t\t\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">SEPAR \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">Alfredo de Diego Damiá \t\t\t\t\t\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">SEPAR \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">David Díaz Pérez \t\t\t\t\t\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">SEPAR \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">Christian Domingo Ribas \t\t\t\t\t\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">SEPAR \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">Ana Isabel Enríquez Rodríguez \t\t\t\t\t\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">ASTURPAR \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">Luis Manuel Entrenas Costa \t\t\t\t\t\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">NEUMOSUR \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">Marta María García Clemente \t\t\t\t\t\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">ASTURPAR \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">Borja García Cosío \t\t\t\t\t\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">AIRE \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">Rocío García \t\t\t\t\t\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">SEPAR \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">Juan Luis García Rivero \t\t\t\t\t\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">SEPAR \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">Jordi Giner Donaire \t\t\t\t\t\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">SEPAR \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">Raúl Godoy \t\t\t\t\t\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">SOCAMPAR \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">M. del Carmen Gómez Neira \t\t\t\t\t\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">SEPAR \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">M. Teresa Gómez Vizcaíno \t\t\t\t\t\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">SEAR \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">Francisco Javier González Barcala \t\t\t\t\t\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">SOGAPAR \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">Luis Hernández Blasco \t\t\t\t\t\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">SVNEUMO \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">Javier Hueto Pérez de Heredia \t\t\t\t\t\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">SVNPAR \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">Hemily K. Izaguirre Flores \t\t\t\t\t\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">NEUMOCAN \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">Carlos Jiménez-Ruiz \t\t\t\t\t\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">SEPAR \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">Alberto Levy Naón \t\t\t\t\t\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">NEUMOSUR \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">Antolín López Viña \t\t\t\t\t\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">SEPAR \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">Vicente Macián Gisbert \t\t\t\t\t\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">SEPAR \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">Pedro J. Marcos \t\t\t\t\t\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">SOGAPAR \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">Carlos Martínez Rivera \t\t\t\t\t\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">SEPAR \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">Juan F. Medina Gallardo \t\t\t\t\t\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">SEPAR \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">Carlos Melero Moreno \t\t\t\t\t\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">SEPAR \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">Francisco Javier Michel de La Rosa \t\t\t\t\t\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">SVNPAR \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">Xavier Muñoz \t\t\t\t\t\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">SOCAP \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">Alicia Padilla Galo \t\t\t\t\t\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">SEPAR \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">Abel Pallarés Sanmartín \t\t\t\t\t\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">SOGAPAR \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">Luisa Pareja Hernández \t\t\t\t\t\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">SEPAR \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">Gerardo Pérez Chica \t\t\t\t\t\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">SEPAR \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">Luis Pérez de Llano \t\t\t\t\t\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">SEPAR \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">Vicente Plaza \t\t\t\t\t\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">SEPAR \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">César Picado \t\t\t\t\t\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">SEPAR \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">Ana Pueyo Bastida \t\t\t\t\t\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">SOCALPAR \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">Jacinto Ramos González \t\t\t\t\t\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">SOCALPAR \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">Berta Román Bernal \t\t\t\t\t\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">NEUMOCAN \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">Auxiliadora Romero Falcón \t\t\t\t\t\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">SEPAR \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">Pedro J. Romero Palacios \t\t\t\t\t\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">SEPAR \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">Silvia Sánchez Cuéllar \t\t\t\t\t\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">NEUMOMADRID \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">Fernando Sánchez-Toril López \t\t\t\t\t\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">SEPAR \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">Joan Serra Batlles \t\t\t\t\t\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">SOCAP \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">José Serrano Pariente \t\t\t\t\t\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">AIRE \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">Ana Sogo Sagardía \t\t\t\t\t\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">SEPAR \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">Manuel Agustín Sojo González \t\t\t\t\t\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">SEAR \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">José J. Soto Campos \t\t\t\t\t\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">SEPAR \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">Elisabet Vera Solsona \t\t\t\t\t\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">SADAR-PNEUMOARAGON \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">Nerea Zabala Urionaguena \t\t\t\t\t\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">SEPAR \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:99 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Burden of comorbidity in individuals with asthma" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1136/thx.2009.131078" "Revista" => array:6 [ "tituloSerie" => "Thorax" "fecha" => "2010" "volumen" => "65" "paginaInicial" => "612" "paginaFinal" => "618" "link" => array:1 [ …1] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma in the elderly: diagnosis and management" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaci.2010.05.035" "Revista" => array:6 [ "tituloSerie" => "J Allergy Clin Immunol" "fecha" => "2010" "volumen" => "126" "paginaInicial" => "681" "paginaFinal" => "687" "link" => array:1 [ …1] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma in older adults" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/s0140-6736(10)61087-2" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2010" "volumen" => "376" "paginaInicial" => "803" "paginaFinal" => "813" "link" => array:1 [ …1] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma and ageing: an end user’s perspective—the perception and problems with the management of asthma in the elderly" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2222.2011.03718.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Allergy" "fecha" => "2011" "volumen" => "41" "paginaInicial" => "471" "paginaFinal" => "481" "link" => array:1 [ …1] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Age-related differences in clinical outcomes for acute asthma in the United States, 2006-2008" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaci.2012.01.061" "Revista" => array:6 [ "tituloSerie" => "J Allergy Clin Immunol" "fecha" => "2012" "volumen" => "129" "paginaInicial" => "1252" "paginaFinal" => "1258.e1" "link" => array:1 [ …1] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asthma in the elderly: current understanding and future research needs—a report of a National Institute on Aging (NIA) workshop" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.jaci.2011.06.048" "Revista" => array:6 [ "tituloSerie" => "J Allergy Clin Immunol" "fecha" => "2011" "volumen" => "128" "paginaInicial" => "S4" "paginaFinal" => "24" "link" => array:1 [ …1] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0035" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Abellán García A, Pérez Díaz AGA, Pujol Rodríguez JR. 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Consensus statement

Expert consensus recommendations for the management of asthma in older adults

Documento de consenso de expertos para el control del asma en personas mayores

Miguel Perpiñáa,1, Ana Gómez-Basterob, Andrea Trisánc, Eva Martínez-Moragónd, Francisco Javier Álvarez-Gutiérreze,

Corresponding author

fjavieralvarez2008@gmail.com

Corresponding author.

, Isabel Urrutiaf, Marina Blanco-Apariciog

a Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Valencia, Spain

b Servicio de Neumología, Hospital Virgen Macarena, Sevilla, Spain

c Servicio de Neumología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain

d Servicio de Neumología, Hospital Universitario Doctor Peset, Valencia, Spain

e Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Hospital Virgen del Rocío, Sevilla, Spain

f Unidad de Asma y Enfermedades Ocupacionales-Medioambientales, Servicio de Neumología, Hospital Galdakao-Usansolo, Bizkaia, Spain

g Servicio de Neumología, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Although it is well established that asthma is an identifiable public health problem in patients of any age&#44; there is still a certain tendency to assume de facto and erroneously that such an entity is almost always found in children and young people who are otherwise healthy<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a>&#46; This error of assessment seems to dismiss the fact that it is with precisely a considerable number of older individuals &#40;65 years or older&#41; that asthma causes a substantial burden of disease and adopts specific peculiarities that make it difficult to identify and treat properly<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Epidemiological studies show that&#44; from the sixth decade of life&#44; the prevalence of this disease in countries such as Spain reaches 6&#8211;10&#37;&#44; with a higher prevalence among women aged 64&#8211;75 years and no differences according to sex after 75 years of age&#46; These differences between the sexes disappear from the age of 75<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>&#46; The onset of most cases of asthma dates back a long time &#40;sometimes to childhood and especially to adulthood&#41;&#44; but the onset of asthma de novo&#44; after 65&#44; is not uncommon<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; Some authors estimate the incidence at 60&#8211;100 cases per 100&#44;000<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; Also&#44; two-thirds of deaths due to asthma occur at this stage of life<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a>&#46; This does not necessarily imply that all cases start off as severe&#44; but in many cases the degree of airway obstruction is significant and with little reversibility&#44; due to the presence of bronchiectasis&#44; bronchial remodelling or its coinciding with chronic obstructive pulmonary disease &#40;COPD&#41;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; Finally&#44; asthma at these ages tends to result in a substantial number of hospital admissions&#44; longer hospital stays&#44; and&#44; from the funder&#8217;s point of view&#44; significant direct economic costs<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;5</span></a>&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Asthma in elderly people is an underestimated and undertreated reality today&#44; and its magnitude will no doubt continue to grow in view of the future prospects of population pyramids<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46; According to the statistics of the Continuous Register of the National Statistics Institute&#44; as of January 1&#44; 2017&#44; 8&#44;764&#44;204 people aged 65 and over were registered in Spain &#40;18&#46;8&#37; of the total population&#41;&#46; Projections from the National Statistics Institute predict that by 2066&#44; the figure will exceed 14&#44;000&#44;000 &#40;almost 35&#37; of the population&#41;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The aim of this paper is to update the main guidelines that health professionals should consider for the treatment of these patients&#44; after reviewing the key aspects that modulate asthma expression in older cohorts&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0025" class="elsevierStylePara elsevierViewall">To achieve this consensus&#44; a Recommendations Working Group &#40;RWG&#41; was set up with seven experts &#40;MP&#44; AGB&#44; AT&#44; EMM&#44; FJA&#44; IU and MB&#41;&#44; whose main function was to review and synthesize the available evidence and formulate conclusions &#40;C&#41; and recommendations &#40;R&#41;&#46; To validate the formulated Cs and Rs&#44; a Recommendations Validation Group was set up&#44; made up of 71 experts from different autonomous scientific societies &#40;Appendix A&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">A literature review was conducted in the Pubmed and Cochrane and Scopus databases &#40;Web of Science&#41; that included original articles&#44; reviews &#40;systematic or narrative&#41; and meta-analysis&#44; which was limited to articles with an abstract section&#44; in English or Spanish&#44; and published from 2009 to the present&#46; Search strategies were developed with the keywords &#8220;asthma AND elderly&#47;geriatric&#47;aging&#47;older patients&#8221; in order to identify the most relevant evidence regarding the treatment of asthma in older patients with asthma&#46; All the studies that focused on or included information relative to the disease in the population segment in the initial report&#44; were selected manually and with double review&#44; and the clinical guidelines and other documents known to RWG members that were not already included were added&#46; The RWG reviewed and synthesized the literature to&#44; based on the evidence and its experience in clinical practice and taking into account the needs of the patient profile who is the object of this consensus&#44; developed various Cs and Rs&#46; These Cs and Rs were analysed and evaluated in a face-to-face consensus conference of the Asthma Area of the Spanish Society of Pneumology and Thoracic Surgery &#40;SEPAR&#41; of 2019 in the context of the Congress of said Scientific Society&#46; The Cs and Rs were shared on screen and the members of the RWG expressed their degree of agreement or disagreement&#44; with a scale from 1 to 4 &#40;1 strongly disagreed and 4 strongly agreed&#41; using televoting devices&#46; In the first round&#44; all the Cs and Rs made by the RWG were evaluated&#44; the results were totalled and the agreement percentages of the votes were calculated as 1 and 2 &#40;disagreement&#41; and 3 and 4 &#40;agreement&#41;&#46; The Rs&#47;Cs that obtained more than 70&#37; agreement were considered as consensual&#46; All the Cs or Rs that obtained between 35&#37; and 70&#37; of agreement and those that had 35&#37; or less of the votes were considered doubts or discrepancies&#44; respectively&#44; resulting in a room discussion regarding the supporting evidence&#44; its content or its wording&#46; All the C and R comments that did not reach a consensus were compiled for further elaboration&#44; together with the discussion comments&#44; to be considered in this paper&#46; Additional recommendations were also drawn from the conclusions of the debate in the face-to-face meeting&#46; The amended and added proposals were subjected to vote in a second round using an online televoting system&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally&#44; the RWG drafted the manuscript&#44; which was subjected to successive revisions by this same group until final approval by all signatories&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Periodic updates will be made as considered by the Autonomous Asthma Forum at its biannual meetings&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Relevant aspects of asthma in the elderly</span><p id="par0045" class="elsevierStylePara elsevierViewall">From a biological point of view&#44; aging is the consequence of the accumulation&#44; over time&#44; of a wide variety of molecular and cellular damage&#44; which results in a general decrease in physiological reserves&#44; a gradual decline in physical and mental abilities&#44; an increased risk of disease and&#44; eventually&#44; death<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; Such damage includes&#44; but is not limited to&#44; genomic instability&#44; telomere wear&#44; epigenetic changes&#44; mitochondrial dysfunction&#44; adult stem cell depletion&#44; loss of proteostasis&#44; and altered intercellular communications&#46; All this is intrinsically linked by integrating what has come to be known as the &#8220;seven pillars of aging&#8221;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46; The deterioration is not linear or uniform and its link with age in years is relative&#58; some septuagenarians enjoy excellent health and manage perfectly&#44; while others are fragile and need help to manage their basic needs<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>&#46; These differences have a genetic justification modulated by the randomness of the mechanisms of aging&#44; the influence of the environment &#40;and the existence of inequalities in health&#41; and the particular behaviour of each person<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a>&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Four events predict the idiosyncrasy of asthma in advanced age&#58; immunosenescence&#44; loss of lung function over time&#44; a tendency to hypoperception of the symptoms&#44; and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;10&#44;11</span></a>&#46;</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Immunosenescence</span><p id="par0055" class="elsevierStylePara elsevierViewall">The term immunosenescence describes the transformation and decline undergone by the innate and adaptive immune responses with age<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a>&#46; With regard to asthma&#44; the phenomenon of immunosenescence is largely responsible for the persistence of inflammation of the airways&#44; and the remodelling and involvement of infectious agents in the exacerbations suffered by elderly patients<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a>&#46; With regard to asthma&#44; the phenomenon of immunosenescence is largely responsible for the persistence of inflammation of the airways&#44; and the remodelling and involvement of infectious agents in the exacerbations suffered by elderly patients<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#8211;12</span></a>&#46; At the same time&#44; immunosenescence is accompanied by the development of a low-grade&#44; systemic&#44; sterile&#44; asymptomatic&#44; chronic inflammatory condition&#44; dominated by the tumour necrosis factor &#945; and interleukins 1&#946; and 6&#44; which is known as <span class="elsevierStyleItalic">inflammaging</span><a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a>&#46; According to the antagonistic pleiotropy theory of aging&#44; the immune response that allows survival during the early stages of life and is beneficial to the body&#44; would be harmful in the final stages&#44; as it favours the development of pathological situations capable of reducing longevity of the individual<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">14&#44;15</span></a>&#46; Immunosenescence and inflammaging would be closely related to the continued accumulation of endogenous metabolic &#8220;garbage&#8221; that has not been suitably processed by normal homeostatic anti-inflammatory mechanisms&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the effects of the immunosenescence&#47;inflammaging on the innate and adaptive response and its impact on asthma<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11&#44;12</span></a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Lung function</span><p id="par0060" class="elsevierStylePara elsevierViewall">With age &#40;and especially in advanced age&#41;&#44; the chest wall tends to stiffen&#44; the respiratory muscles lose strength&#44; and the residual volume increases &#40;hyperinflation&#41; due to the reduction of the elastic retraction of the parenchyma itself<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>&#46; <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a> summarises the main changes detected in the lung function of older people with asthma &#40;some related to aging and others to the disease itself&#41; which&#44; combined&#44; can lead to increased asthma severity and difficulties in treatment<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Hypoperception</span><p id="par0065" class="elsevierStylePara elsevierViewall">Dyspnoea is one of the major clinical manifestations of asthma that&#44; in many cases&#44; reflects the severity of the process and its loss of control&#44; regardless of the lung function deterioration<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#44;17</span></a>&#46; It has been shown that the sensation of basal dyspnoea tends to attenuate in line with the aging of the asthmatic individual<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#44; and that older asthmatics are worse at identifying the increase in airway resistance than young adults with asthma<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#8211;21</span></a>&#46; The cause is not yet well defined&#46; Perhaps the most widely accepted hypothesis is that&#44; with age&#44; the number and&#47;or activity of vagal lung receptors responsible for transmitting information to the central nervous system decreases<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>&#46; Hypoperception of dyspnoea is also exacerbated in many older people due to the &#8220;well-being paradox&#44;&#8221; a circumstance where a reasonably high satisfaction with life concurs with low expectations about one&#39;s own health&#44; which often leads to a tendency to minimise symptoms<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>&#46; Either way&#44; hypoperception tends to promote therapeutic non-compliance and make self-treatment guidelines difficult to follow<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a>&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Multimorbidity</span><p id="par0070" class="elsevierStylePara elsevierViewall">Multimorbidity is a predominant variable&#44; as it is common in the elderly&#44; it is linked to polypharmacy &#40;sponsoring the risk of drug interactions&#41;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>&#44; and is per se a cardinal element for understanding and dealing with the management of asthma refractory to treatment<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">18&#44;24&#8211;27</span></a>&#46; Various epidemiological studies have analysed the significance of multimorbidity in asthma indicating that&#44; for this age segment and with some differences between men and women&#44; patients have an increased incidence risk of pneumonia&#44; respiratory infections&#44; rhinitis&#44; sinusitis&#44; heart disease&#44; ischaemia&#44; depression and&#47;or anxiety&#44; obesity&#44; dyslipidaemia&#44; pathological gastroesophageal reflux&#44; sleep disorders&#44; osteoporosis&#44; cerebrovascular disease and COPD<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#44;28&#8211;31</span></a>&#46; It has been put forward that aging itself would be another comorbidity of asthma<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a>&#44; although aging and fragility are not completely interchangeable concepts<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26</span></a>&#46; Fragility is defined as an increased vulnerability to stressors&#44; linked to a decrease&#47;deregulation of the physiological reserves of multiple systems&#44; which causes difficulty in maintaining homeostasis<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;33</span></a>&#46; Fragility and multimorbidity predict disability &#40;restriction or loss of ability to perform an activity&#41; and&#44; in turn&#44; disability can exacerbate fragility and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27&#44;33</span></a>&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The consensus-drawn conclusions regarding the general aspects of asthma in the elderly are&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">From a biological point of view&#44; aging is the consequence of the accumulation&#44; over time&#44; of a wide amount of molecular and cellular damage&#44; which results in a general decrease in physiological reserves&#44; a gradual decline in physical and mental abilities&#44; an increased risk of disease and&#44; eventually&#44; death&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0085" class="elsevierStylePara elsevierViewall">Such damage includes genomic instability&#44; telomere wear&#44; epigenetic changes&#44; mitochondrial dysfunction&#44; adult stem cell depletion&#44; loss of proteostasis&#44; and altered intercellular communications<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0090" class="elsevierStylePara elsevierViewall">These changes are not linear or uniform&#44; and their link to aging in years is relative<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0095" class="elsevierStylePara elsevierViewall">Several events determine the peculiarities of asthma in the elderly&#58; immunosenescence&#47;inflammaging&#44; the lung function corrections experienced over the years&#44; the tendency to hypoperception of symptoms&#44; the &#8220;well-being paradox&#8221; and multimorbidity<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4&#44;13&#44;15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;34</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0100" class="elsevierStylePara elsevierViewall">It has been postulated that aging may be one more comorbidity of asthma&#46; However&#44; it should be remembered that aging and fragility are not&#44; a priori&#44; completely interchangeable terms<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;26&#44;32</span></a>&#46;</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">The consensus-drawn conclusions regarding the relevant aspects of asthma in the elderly are&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">In the elderly there are more diagnostic errors&#44; either due to underdiagnosis or false diagnoses&#59; only half of the patients have a correct diagnosis of asthma<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">The underdiagnosis of asthma in the elderly is due&#44; among other reasons&#44; to the patient&#8217;s lack of perception of symptoms&#44; the acceptance of dyspnoea as &#8220;normal&#8221; at an advanced age&#44; and the reduction in physical activity<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">False diagnoses are due to the tendency to associate asthma symptoms with other diseases &#40;eg COPD&#44; congestive heart failure&#44; and gastroesophageal reflux&#41;&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">The potential risk factors and triggers for asthma in the elderly are similar to those of other age groups<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;11&#44;12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">In this age group&#44; asthma can be triggered by infections due to immune disorders related to aging<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;11&#44;12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">The comorbidity associated with asthma&#44; the severity of the disease&#44; and the greater difficulty involved in its treatment worsen the quality of life of older patients<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;34&#44;38</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Among the main factors that explain the poor control of the disease in this age group are&#58; the presence of associated comorbidities&#44; polymedicine with risk of drug interactions&#44; and poor therapeutic adherence<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>&#46;</p></li></ul></p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Diagnosis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Clinical presentation</span><p id="par0145" class="elsevierStylePara elsevierViewall">Medical history is the key element leading to establishing the diagnosis of asthma&#46; In the elderly the manifestations of the disease are similar to the rest of the stages of life<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;40</span></a>&#46; However&#44; compared to young asthmatics&#44; older asthmatics have more morbidity and poorer quality of life&#44; and are more likely to have poorer overall health&#44; symptoms of depression&#44; and limitations in their daily activities<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46; Also&#44; in at least half of these patients&#44; the diagnosis of asthma is recent&#46; Factors that may influence the diagnosis include poor perception of signs and symptoms&#44; the presence of extrapulmonary manifestations&#44; the effects of aging on the respiratory system&#44; and technical difficulties for making reliable measurements of lung function<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a>&#46; Sometimes these patients do not indicate their symptoms&#44; or they attribute dyspnoea to normal aging or other comorbidities&#44; such as cardiovascular disease or obesity&#46; Not externalising the symptoms can be due to many causes&#44; such as fear&#44; depression&#44; cognitive impairment&#44; social isolation&#44; or lack of education<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>&#46; It is also common for the doctor to focus on other entities &#40;cardiovascular disease and COPD&#41; in this age group<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; The differential diagnosis with COPD is not always easy and&#44; in addition&#44; both entities can coexist<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">Although the prevalence of atopy may decrease with age and asthma in older adults has characteristically been reported as non-atopic&#44; the atopic condition has generally increased in recent decades&#44; and is known to contribute to the appearance of asthma in these populations&#46; Thus&#44; the results of some recent studies show that the prevalence of allergic sensitisation may be high&#44; which supports that a mechanism mediated by immunoglobulin E may be involved in asthma at these ages<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;46</span></a>&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Older asthmatics can generally be divided into two groups&#58; those with early-onset and long-term asthma&#44; and those with late-onset symptoms<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>&#46; It is seen that patients in the first group have more severe and frequent symptoms&#44; an increase in the number of hospitalisations and emergency room visits&#44; and worse lung function<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48&#44;49</span></a>&#46; In addition&#44; these patients tend to have more severe and irreversible or partially reversible bronchial obstruction&#44; than those with late-onset asthma<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;50</span></a>&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the possible clinical and functional differences between early- and late-onset asthma&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Definitely&#44; as the symptoms are nonspecific&#44; confirmation of the diagnosis requires the use of respiratory function tests<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;40</span></a>&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Regarding the clinical presentation of asthma in the elderly&#44; the working group concludes that&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">The clinical symptoms of asthma in the elderly do not differ substantially from asthma in the young&#44; although it has peculiarities such as lower perception of symptoms&#44; worse quality of life&#44; symptoms derived from other comorbidities&#44; extrapulmonary diseases&#44; and difficulty in externalising asthma symptoms<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3&#44;40</span></a>&#46;</p></li></ul></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Complementary examinations</span><p id="par0175" class="elsevierStylePara elsevierViewall">To diagnose asthma in this age group&#44; it is essential to perform a spirometry with bronchodilator test&#44; but it may also be important to perform a chest X-ray and an electrocardiogram for the differential diagnosis and study of other associated diseases<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Respiratory function tests</span><p id="par0180" class="elsevierStylePara elsevierViewall">As with other age groups&#44; the diagnosis of asthma requires proof of reversibility of the forced expiratory volume in the first second &#40;FEV1&#41; with the bronchodilator or high-dose inhaled or systemic steroid testing&#44; as well as bronchial hyperreactivity testing<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#46; Reversibility at an advanced age is sometimes reduced by the irreversible structural changes due to airway remodeling<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>&#46; The FEV1&#47;forced vital capacity &#40;FVC&#41; ratio decreases with age and is not valid in the elderly&#44; so it is essential to have age-adjusted values&#46; The FEV1&#47;FVC rate has been reported to be 75&#8211;64&#37; for 65-year-olds and 67&#8211;56&#37; for 85-year-olds&#46; Additionally&#44; the use of the post-bronchodilator FEV1&#47;FVC index is important to prevent false positivity&#46; The use of FEV1&#47;forced expiratory volume at 6 seconds &#40;FEV6&#41; has also been proposed as a significant independent factor of mortality due to cardiopulmonary cause and all causes in elderly patients<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a>&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Although elderly patients with cognitive impairment and apraxia may have difficulty performing the spirometric manoeuvre correctly<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55&#44;56</span></a>&#44; there is strong evidence that quality spirometry with reversibility testing can be obtained in most elderly patients<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57&#8211;61</span></a>&#46; When the spirometry shows an obstruction&#44; the reversibility test is mandatory&#46; Additionally&#44; the degree of reversibility can be assessed in response to regular treatment over a period of time&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In the case of irreversible obstruction&#44; this may be due to more severe remodelling of the disease&#44; an overlap with COPD&#44; or the presence of bronchiectasis with segmental pulmonary fibrosis<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#8211;66</span></a>&#46; Therefore&#44; a CT scan would be indicated in these patients&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">Maximum expiratory flow &#40;MEF&#41; variability may be less significant for the elderly&#44; as it decreases with age due to increased chest wall stiffness&#44; muscle weakness&#44; and lack of coordination&#46; In addition&#44; the absence of MEF variability does not exclude the diagnosis of asthma<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">67</span></a>&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The study of bronchial hyperreactivity using bronchial provocation tests has a very high negative predictive value for the diagnosis of asthma&#46; However&#44; it is rarely performed in the elderly<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46; These tests may be contraindicated in some patients with low basal function or comorbidities&#44; such as cardiovascular disease<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">68</span></a>&#46; With this in mind&#44; it is important to consider that aging is associated with structural and physiological changes in the lung<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a>&#44; which may influence the response to spasmodic stimulation&#46; It has not yet been shown whether the slope of the dose-response curve during the provocation test&#44; rather than the magnitude of the bronchial response&#44; can help differentiate the airway response to the spasmodic stimulation between asthma and COPD<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">In cases of severe and not completely reversible obstruction&#44; tests such as measurements of lung volume &#40;residual volume&#41; or carbon monoxide diffusion &#40;DLCO&#41; may be useful for the differential diagnosis between asthma and COPD<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;70&#44;71</span></a>&#46; The DLCO study is useful&#44; fast&#44; relatively inexpensive&#44; and well standardised<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;72</span></a>&#46; Emphysema decreases DLCO values with a high positive predictive value&#44; while bronchiectasis and chronic bronchitis do not affect DLCO and they are normal or high in patients with asthma&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Measurements of bronchial inflammation and allergic sensitisation</span><p id="par0210" class="elsevierStylePara elsevierViewall">Blood and sputum eosinophil measurements may be important for classification into eosinophilic phenotypes&#44; although they may be affected by previous treatment with inhaled steroids<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">As mentioned&#44; atopy can be serious in the elderly&#46; A study in the United States found that the prevalence of allergic sensitisation was 75&#46;4&#37; between the ages of 20 and 40 and 65&#46;2&#37; in individuals <span class="elsevierStyleUnderline">&#62;</span>55 years old<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46; In addition&#44; there were no significant differences registered between patients who developed asthma before 40 years of age and those who developed asthma after the age of 40&#46; Another important fact collected in this and other studies is that in these older patients&#44; mites are the most prevalent allergens&#44; with a greater sensitisation exclusively to indoor air allergens<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">43</span></a>&#46;</p><p id="par0220" class="elsevierStylePara elsevierViewall">Finally&#44; the measurement of nitric oxide as a marker for the diagnosis of asthma and as a control of the disease is controversial&#44; with some studies showing benefits and some studies not supporting its usefulness<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a>&#46; In addition&#44; it is important to note that there is an increase in the levels of exhaled nitric oxide associated with age<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a>&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">The recommendations of the working group on complementary examinations are&#58;<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">The bronchodilator test spirometry is the fundamental test for the diagnosis of asthma in the elderly<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0235" class="elsevierStylePara elsevierViewall">The FEV1&#47;FVC ratio decreases with age so it is essential to have values adjusted to this variable<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Despite the difficulties of performing spirometry in the elderly&#44; especially in patients with cognitive impairment and apraxia&#44; it is possible to obtain quality spirometry in most patients&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">For the differential diagnosis between asthma and COPD in cases of severe and not completely reversible obstruction&#44; performing a DLCO may be helpful<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">68&#44;70&#44;71</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0250" class="elsevierStylePara elsevierViewall">For differential diagnosis with other diseases &#40;COPD&#44; bronchiectasis&#41; or associated comorbidities&#44; a CT scan may be indicated<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">62&#8211;66</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0255" class="elsevierStylePara elsevierViewall">Although less common than at an early age&#44; atopy may be present in asthma of an elderly patient&#44; so an allergy study is important at this age too<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42&#8211;46</span></a>&#46;</p></li></ul></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Multidimensional evaluation</span><p id="par0260" class="elsevierStylePara elsevierViewall">When treating an elderly patient&#44; it is important to assess the different dimensions that can influence the diagnosis&#44; and the subsequent treatment provided<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Cognitive function evaluation</span><p id="par0265" class="elsevierStylePara elsevierViewall">It is important to assess the cognitive function objectively using questionnaires &#40;eg Mini-Mental State Examination&#41;&#44; which will help to establish the severity of the asthma and the patient&#39;s ability to identify their symptoms properly&#46; This&#44; in turn&#44; will help treatment adherence&#44; as there is a relationship between cognitive function as measured by questionnaires and the ability to perform inhalation manoeuvers<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a>&#46; It is also important to evaluate the verbal memory or praxis or executive function<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#44; using other questionnaires that evaluate these dimensions such as the Rey 15-item memory test&#44; or the Clock test<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Mood evaluation</span><p id="par0270" class="elsevierStylePara elsevierViewall">Anxiety-depression is associated with asthma&#44; which in turn is associated with poor perception of symptoms&#44; leading to an incorrect classification of its severity<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a> and is closely related to worse disease control<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a>&#46; There are different scales that can be used to evaluate anxiety and depression in the elderly such as the Geriatric Depression Scale and the Hospital Anxiety and Depression Scale<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Evaluation of the patient&#8217;s physical function</span><p id="par0275" class="elsevierStylePara elsevierViewall">Physical function is considered an indicator of health in the elderly&#46; Thus&#44; the speed of walking is related to quality of life&#44; disability and mortality<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46; There are different measurement methods that can be used in regular practice&#44; although the most commonly used Submaximal Stress Test in respiratory patients is the Six Minute Walk Test<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#44; which evaluates poor exercise tolerance due to functional respiratory impairment&#46;</p><p id="par0280" class="elsevierStylePara elsevierViewall">The recommendations of the Working Group on the multidimensional evaluation of asthma in the elderly are&#58;<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0285" class="elsevierStylePara elsevierViewall">In the treatment of asthma in the elderly patient it is advisable to include the evaluation of cognitive function through objective questionnaires&#46; These allow the abilities for the perception of symptoms and the realisation&#47;adherence to treatment to be evaluated<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">70&#44;75</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0290" class="elsevierStylePara elsevierViewall">Anxiety-depression is associated with an unrealistic perception of symptoms&#44; which causes poor asthma control&#46; Therefore&#44; an evaluation of the anxiety-depression suffered by the elderly person is helpful in avoiding poor control<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0295" class="elsevierStylePara elsevierViewall">Physical function is considered an indicator of health in the elderly<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>&#46;</p></li></ul></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Differential diagnosis</span><p id="par0300" class="elsevierStylePara elsevierViewall">In the elderly&#44; the clinical presentation of asthma is heterogeneous&#44; and a differential diagnosis should be made with different diseases&#44; including COPD&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the main differential diagnoses of asthma in adulthood&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0305" class="elsevierStylePara elsevierViewall">With regard to COPD&#44; the main confounding factors are<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a>&#58;<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">&#8226;</span><p id="par0310" class="elsevierStylePara elsevierViewall">Age per se&#46; Asthma is associated with childhood&#47;adolescence and with COPD in adulthood&#46;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">&#8226;</span><p id="par0315" class="elsevierStylePara elsevierViewall">Heterogeneity and clinical presentation&#46; Sometimes the guiding symptoms of asthma do not predominate at night&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">&#8226;</span><p id="par0320" class="elsevierStylePara elsevierViewall">Low perception of the symptoms or inadequate description of the symptoms&#46;</p></li></ul></p><p id="par0325" class="elsevierStylePara elsevierViewall">The recommendations of the working group on the differential diagnosis of elderly patients with asthma are&#58;<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0330" class="elsevierStylePara elsevierViewall">In older patients do not rule out the diagnosis of late-onset asthma&#44; even though other differential diagnoses should be considered&#44; mainly respiratory or cardiac conditions<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0335" class="elsevierStylePara elsevierViewall">In patients with a history of smoking&#44; evaluate whether or not there is an overlap with COPD and&#47;or heart disease<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li></ul></p></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Asthma treatment in the elderly</span><p id="par0340" class="elsevierStylePara elsevierViewall">As at any age&#44; the goal of treating asthma in the elderly is to achieve and maintain control of the disease as soon as possible&#44; in addition to preventing exacerbations and chronic airflow obstruction&#44; and minimising its mortality<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a>&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">To achieve this&#44; a global and individualised strategy should be followed&#44; based on a staggered pharmacological treatment&#44; as well as environmental control measures&#44; asthma education&#44; and attention to comorbidities&#46;</p><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Pharmacological treatment</span><p id="par0350" class="elsevierStylePara elsevierViewall">Pharmacological treatment of asthma in the elderly does not differ from that recommended in clinical practice guidelines for other stages of life<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;77</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Therapeutic options</span><p id="par0355" class="elsevierStylePara elsevierViewall">For the treatment of severe asthma it is important to mention biological drugs&#44; although data regarding their effects in older patients are scarce&#46; Omalizumab and mepolizumab<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">78&#8211;80</span></a> are the only two biologics that have efficacy and safety data available in persons over 75 years of age&#44; with no evidence that a different dose is required for them compared to younger patients&#46; Regarding benralizumab and reslizumab<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">81&#8211;83</span></a>&#44; the available studies only include populations between 12 and 75 years of age&#44; with no differences in pharmacokinetic analysis in these patients&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">In any case&#44; according to the Summaries of Product Characteristics of all the monoclonal antibodies approved for the treatment of asthma&#44; no dose adjustment is required in elderly patients&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Influence of age on treatment</span><p id="par0365" class="elsevierStylePara elsevierViewall">Older patients may experience psychological and neurological changes that affect their chances of treatment&#46; Depressive disorders and other illnesses such as dementia require special vigilance&#44; so further reinforcement in the education of these patients is of great importance&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Age is a key factor to consider when choosing an inhaler&#44; as older people may be unable to perform a proper inspiratory manoeuvre&#44; or may even have difficulty learning how the devices work&#46; For this reason&#44; in the elderly patient it is often preferred to use pMDI devices coupled to an inhalation chamber or an SMI or BAI device<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Possible adverse effects associated with age</span><p id="par0375" class="elsevierStylePara elsevierViewall">Aging is associated with changes in pharmacology that affect the distribution&#44; metabolism and elimination of drugs&#44; so that free drug concentrations increase&#44; as does the distribution volume of fat-soluble drugs<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">85</span></a>&#46; Beta-adrenergic agonists are known to be more likely to cause adverse effects such as tremors&#44; tachycardia&#44; or arrhythmias<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a>&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">There are several meta-analyses on the side effects of inhaled corticosteroids &#40;ICS&#41; in the elderly&#44; and these include an increased risk of non-vertebral bone fractures<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a> and cataracts<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a>&#44; with fluticasone dipropionate being the steroid with the least number of adverse effects when administered at doses equipotent with other ICS<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a>&#46;</p><p id="par0385" class="elsevierStylePara elsevierViewall">Anticholinergics<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">90</span></a> and antileukotrienes are safe drugs in this population&#46; Moreover&#44; there are older studies that have shown beneficial effects in patients with associated cardiovascular disease&#44; as they decrease the risk of stroke and heart attacks<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">91</span></a>&#46; As for systemic glucocorticoids&#44; if they are necessary&#44; it is recommended that bone densitometry be performed before starting therapy and&#44; if it is pathological&#44; that appropriate preventive or therapeutic measures be taken&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Adherence to treatment</span><p id="par0390" class="elsevierStylePara elsevierViewall">In general&#44; elderly patients tend to have good rates of therapeutic adherence&#44; with unconscious non-compliance being more frequent&#44; mainly due to the difficulty of treatment with the inhalation devices<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a>&#46;</p><p id="par0395" class="elsevierStylePara elsevierViewall">The recommendations of the working group on the pharmacological treatment of asthma in the elderly are&#58;<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0400" class="elsevierStylePara elsevierViewall">Pharmacological treatment of asthma in the elderly does not differ from that recommended in clinical practice guidelines at other stages of life<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;77</span></a>&#46;</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">-</span><p id="par0405" class="elsevierStylePara elsevierViewall">Special attention should be paid to the choice of inhaler device based on the inspiratory flow and coordination capacity of each patient<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">-</span><p id="par0410" class="elsevierStylePara elsevierViewall">Not much data exists on the safety and efficacy of the use of biological drugs in poorly-controlled severe asthma in the elderly patient&#44; although their use is not contraindicated&#46; &#40;Expert consensus&#41;&#46;</p></li></ul></p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Environmental control</span><p id="par0415" class="elsevierStylePara elsevierViewall">One of the key aspects of controlling a person&#8217;s asthma is to avoid the triggers that can cause symptoms and exacerbations&#46; Although aeroallergens are less important when it comes to triggering symptoms in the elderly compared to young patients&#44; the implementation of a programme of measures to prevent or minimise exposure to aeroallergens is recommended&#46; However&#44; such programmes can be difficult to carry out due to the difficulty of life-style changes at this age<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>&#46;</p><p id="par0420" class="elsevierStylePara elsevierViewall">Studies show that older asthmatic patients are more likely to present asthma symptoms when exposed to particulates from road traffic &#40;PM10&#44; PM2&#46;5&#41;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a>&#44; and this exposure is related to a risk of hospitalisation<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a> and longer hospital stays<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a>&#46; Since people of this age stay at home most of the day&#44; it is important to consider that indoor pollution &#40;PM10 and PM2&#46;5 respirable particles&#44; nitrogen dioxide&#44; and tobacco smoke&#41; increases the risk of respiratory symptoms<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a>&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">As part of the education process aimed at older people living in urban centres with high levels of traffic pollution&#44; advice should be provided as to how to avoid exposure during the hours of maximum pollution&#46; Advice should also be given about the suitability of ventilating the rooms in which they spend most of the day&#46;</p><p id="par0430" class="elsevierStylePara elsevierViewall">Finally&#44; influenza vaccination is recommended&#44; although it is less effective in preventing exacerbations than in young people&#46; On the other hand&#44; the recommended pneumococcal vaccination in patients with COPD has less evidence in asthmatic patients<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a>&#46;</p><p id="par0435" class="elsevierStylePara elsevierViewall">Regarding environmental control in asthma in the elderly&#44; the working group recommends&#58;<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">-</span><p id="par0440" class="elsevierStylePara elsevierViewall">Measures to prevent or minimise exposure to airborne allergens and environmental pollution should be considered in education programmes<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">-</span><p id="par0445" class="elsevierStylePara elsevierViewall">Ventilation for rooms where patients spend a greater number of hours is recommended&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">-</span><p id="par0450" class="elsevierStylePara elsevierViewall">An influenza vaccination and a pneumococcal vaccination is recommended&#46; &#40;Expert consensus&#41;&#46;</p></li></ul></p></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Patient education</span><p id="par0455" class="elsevierStylePara elsevierViewall">Health education is a process of teaching the concepts and skills needed to help the patient to cooperate in the treatment and control of their disease&#46; To achieve this control&#44; a process plan shared between the health team &#40;doctor and nurse&#41; and the patient should be elaborated&#46; The usefulness of this action plan will depend on its being adapted to the patient&#8217;s individual characteristics and needs&#44; and to disease progression&#46; It is necessary to know the patient&#39;s attitudes towards the disease and listen to their opinions and fears about the medications they are receiving&#46; This will help both the doctor regarding the treatment regime&#44; and the patient&#8217;s self-treatment plans<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>&#46;</p><p id="par0460" class="elsevierStylePara elsevierViewall">The education programme should include the determination of the level of adherence&#44; classification&#44; as far as possible&#44; of the type of non-compliance of the patient &#40;erratic&#44; deliberate or involuntary&#41;&#44; and promote the corresponding corrective measures in case of low adherence&#44; which should be adapted to the type of non-compliant patient&#46; The use of the Patient Asthma Concerns Tool<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a> questionnaire is recommended in asthmatics of this age&#46; However&#44; some patients are unable to learn the use of a Metered Dose Inhaler &#40;MDI&#41; or Turbuhaler &#40;TH&#41; despite having a normal mental test&#44; so it would be advisable to perform a training test to see if the patient will be able to learn the technique<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a>&#46;</p><p id="par0465" class="elsevierStylePara elsevierViewall">The recommendations of the working group on patient education are&#58;<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">-</span><p id="par0470" class="elsevierStylePara elsevierViewall">Self-treatment plans should be considered in the education programmes&#46; These should explain how to recognise the symptoms of asthma and other illnesses with similar symptoms that also allow rescue therapy to be applied&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">-</span><p id="par0475" class="elsevierStylePara elsevierViewall">Educational measures are more difficult to implement in older patients because they find it more difficult to make lifestyle changes&#46; &#40;Expert consensus&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">-</span><p id="par0480" class="elsevierStylePara elsevierViewall">It would be interesting to work on the validation of questionnaires that identify the needs of older patients&#44; and that allow the implementation of specific education programmes for this age group&#46; &#40;Expert consensus&#41;&#46;</p></li></ul></p></span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Comorbidity control</span><p id="par0485" class="elsevierStylePara elsevierViewall">Comorbidities can influence the diagnosis and evaluation of severity of asthma&#44; as well as its control&#44; the patient&#8217;s quality of life&#44; and even contribute to morbidity and mortality<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;34&#44;38</span></a>&#46; The most common comorbidities in the elderly with asthma are cardiopulmonary involvement&#44; including pneumonia&#44; other respiratory infections&#44; acute myocardial infarction&#44; sleep disorders&#44; and COPD&#44; although gastroesophageal reflux&#44; diabetes mellitus and obesity are also common<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>&#46;</p><p id="par0490" class="elsevierStylePara elsevierViewall">Polypharmacy is one of the main problems in these patients&#44; and it can lead to an increased risk of adverse effects and drug interactions&#44; as well as poor adherence<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a>&#46; Also&#44; it should be borne in mind that there is a higher prevalence of renal failure in the elderly population<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">98</span></a> so the selection of drugs must be done carefully&#46;</p><p id="par0495" class="elsevierStylePara elsevierViewall">Moreover&#44; systemic or ocular beta-blockers are used frequently in this population&#44; which can potentially worsen bronchospasm&#44; so the use of cardioselective therapy is recommended<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a>&#46; Also&#44; the use of beta-2 agonists increases the output of serum potassium to the intracellular space&#44; favouring hypokalaemia&#44; which is further increased in patients who use insulin and&#47;or diuretics together<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">99</span></a>&#46;</p><p id="par0500" class="elsevierStylePara elsevierViewall">The recommendations of the working group on comorbidity control are&#58;<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">-</span><p id="par0505" class="elsevierStylePara elsevierViewall">Although the goals of asthma therapy are the same for patients of all ages&#44; in older adults with asthma it is necessary to take into account the presence of comorbidities and the need to minimise the number of therapies required &#40;polypharmacy&#41;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">30&#44;36&#44;98</span></a>&#46; &#40;Expert consensus&#41;&#46;</p></li></ul></p></span></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Conclusions</span><p id="par0510" class="elsevierStylePara elsevierViewall">The conclusions and recommendations contained in this consensus document&#44; together with the degree of agreement reached by the committee of experts&#44; are summarised in <a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#46; This work is a first approach to offer practical recommendations for the challenges of treating asthma in the elderly patient&#44; which should address issues not clearly addressed to date in the clinical practice guidelines for this disease&#46; It should be noted&#44; however&#44; that the consensus methodology offers recommendations which&#44; while serving as a practical guide for clinicians and endorsed by the agreement of disease experts&#44; do not have the level of recommendations offered by a clinical practice guideline developed according to the latest regulations&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Funding</span><p id="par0515" class="elsevierStylePara elsevierViewall">The authors of this manuscript have not received any financial contribution&#46; The technical and methodological support has been financed by SEPAR through the funds of the <span class="elsevierStyleGrantSponsor" id="gs0005">Autonomous Asthma Forum</span>&#46;</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conflict of interest</span><p id="par0520" class="elsevierStylePara elsevierViewall">This consensus has been made through the initiative of the FORASMA group of SEPAR with own funds from this Scientific Society&#46; The Recommendation Validation Group is listed below&#46; The potential conflicts of interest of the Scientific Committee are declared as&#58;</p><p id="par0525" class="elsevierStylePara elsevierViewall">Dr&#46; A&#46; G&#243;mez-Bastero states that she has collaborated with ALK&#44; AstraZeneca&#44; Bial&#44; Chiesi&#44; GSK&#44; Novartis and TEVA in talks&#44; as well as to have attended conferences and scientific meetings&#46;</p><p id="par0530" class="elsevierStylePara elsevierViewall">Dr&#46; E&#46; Mart&#237;nez-Morag&#243;n states that she has received fees as a speaker for AstraZeneca&#44; Chiesi&#44; Teva and Novartis&#44; and that she has been a consultant for ALK&#44; AstraZeneca and Boehringer Ingelheim&#46;</p><p id="par0535" class="elsevierStylePara elsevierViewall">Dr&#46; FJ Alvarez states that in the last three years he has received fees for consulting work&#44; giving lectures or grants to attend conferences and scientific meetings by ALK&#44; AstraZeneca&#44; Bial&#44; Boheringer-Ingelheim&#44; Chiesi&#44; GSK&#44; Menarini&#44; Mundi -pharma&#44; Novartis&#44; Orion and TEVA&#46;</p><p id="par0540" class="elsevierStylePara elsevierViewall">Dr&#46; I&#46; Urrutia states that he has received grants for research projects from Novartis&#44; Menarini and Mundipharma&#44; and has also received remuneration for scientific events from AstraZeneca&#44; Bial Aristegui&#44; GSK&#44; Chiesi&#44; Mundipharma&#44; Menarini and TEVA&#46;</p><p id="par0545" class="elsevierStylePara elsevierViewall">Dr&#46; M&#46; Blanco states that she has received fees for participating in courses&#44; conferences and training activities sponsored by ALK&#44; GSK&#44; AstraZeneca&#44; Chiesi&#44; TEVA and Zamb&#243;n&#46;</p><p id="par0550" class="elsevierStylePara elsevierViewall">Dr&#46; M&#46; Perpi&#241;&#225; and Dr&#46; A&#46; Tris&#225;n declare that they have no conflicts of interests&#46;</p></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Thanks</span><p id="par0555" class="elsevierStylePara elsevierViewall">The authors thank the technical and methodological support provided by Medical Statistics Consulting &#40;MSC&#41; in the process of developing the recommendations and consensus&#44; as well as the collaboration of Drs&#46; Almudena Fuster-Matanzo and Blanca Piedrafita &#40;MSC&#41; in the coordination and editing of the manuscript&#46;</p></span></span>"
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            2 => "Diagn&#243;stico diferencial"
            3 => "Inmunosenescencia"
            4 => "Tratamiento"
            5 => "Comorbilidades"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Asthma is a public health problem in patients of any age&#44; although there is still a tendency to erroneously assume that it is almost always confined to children and young people&#46; Epidemiological studies indicate that&#44; from the sixth decade of life&#44; the prevalence of this disease in countries such as Spain reaches 6&#37;&#8211;10&#37;&#44; with a higher prevalence among women aged 64&#8211;75 years&#46; In addition&#44; two-thirds of asthma deaths occur at this stage of life&#44; resulting in a substantial number of hospital admissions&#44; longer hospital stays and&#44; from a finance point of view&#44; significant direct economic costs&#46; Asthma in older adults &#40;65 years or older&#41; is now a matter of great concern&#44; the reality of which is underestimated and undertreated&#46; It is therefore essential to establish appropriate recommendations for the diagnosis and treatment of asthma in the aging population&#46; This consensus&#44; which brings together the latest evidence available&#44; was conceived with this objective&#46; The proposed recommendations&#47;conclusions are the result of a nominal consensus developed throughout 2019 and validated by panellists in successive rounds of voting&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">El asma constituye un problema de salud p&#250;blica presente en pacientes de cualquier edad&#44; aunque contin&#250;a existiendo cierta tendencia a asumir de forma err&#243;nea que dicha entidad resulta casi siempre exclusiva de la infancia y de gente joven&#46; Los estudios epidemiol&#243;gicos se&#241;alan que&#44; a partir de la sexta d&#233;cada de la vida&#44; la prevalencia de esta patolog&#237;a en pa&#237;ses como Espa&#241;a alcanza el 6&#37;&#8211;10&#37;&#44; con mayor predominio entre las mujeres de 64 a 75 a&#241;os&#46; Asimismo&#44; dos tercios de las muertes debidas al asma acontecen en esta etapa de la vida&#44; llegando a ocasionar un n&#250;mero de ingresos sustancial&#44; estancias hospitalarias m&#225;s prolongadas y&#44; desde el punto de vista del financiador&#44; unos costes econ&#243;micos directos notables&#46; En la actualidad el asma en las personas mayores &#40;65 a&#241;os o m&#225;s&#41; constituye un tema de enorme preocupaci&#243;n&#44; cuya realidad se encuentra infravalorada e infratratada&#44; por lo que resulta del todo necesario establecer unas recomendaciones adecuadas para el diagn&#243;stico y tratamiento de la patolog&#237;a en esta poblaci&#243;n de edad&#46; Con este objetivo naci&#243; este consenso que recoge la evidencia disponible m&#225;s actualizada&#46; Las recomendaciones&#47;conclusiones que se proponen son el resultado de un consenso de tipo nominal desarrollado a lo largo del a&#241;o 2019 y que han sido validadas por los panelistas en sucesivas rondas de votaci&#243;n&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:2 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Perpi&#241;&#225; M&#44; G&#243;mez-Bastero A&#44; Tris&#225;n A&#44; Mart&#237;nez-Morag&#243;n E&#44; &#193;lvarez-Guti&#233;rrez FJ&#44; Urrutia I&#44; et al&#46; Documento de consenso de expertos para el control del asma en personas mayores&#46; Med Clin &#40;Barc&#41;&#46; 2022&#59;159&#58;53&#46;</p>"
      ]
      1 => array:3 [
        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0015">The affiliation of Miguel Perpi&#241;&#225; until 2016&#46; He is currently retired&#46;</p>"
        "identificador" => "fn0005"
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="par0560" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tbl0025"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Participants of the Recommendation Validation Group&#44; appointed by the autonomous societies and the SEPAR Asthma Area &#40;in alphabetical order&#41;"
            "identificador" => "sec0155"
          ]
        ]
      ]
    ]
    "multimedia" => array:8 [
      0 => array:8 [
        "identificador" => "fig0005"
        "etiqueta" => "Fig&#46; 1"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 2046
            "Ancho" => 2925
            "Tamanyo" => 473670
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
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            "rol" => "short"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Most notable consequences of immunosenescence and inflammaging on the innate and adaptive response&#44; with repercussions on asthma&#46; IFN-&#947;&#58; interferon-&#947;&#59; IgE&#58; immunoglobulin E&#59; IL&#58; interleukin&#59; MMP-9&#58; Matrix metalloproteinase&#59; NETs&#58; neutrophil extracellular traps&#59; ROS&#58; reactive oxygen species&#59; TLR&#58; Toll-like receptor&#59; TNF-&#945;&#58; tumor necrosis factor-&#945;&#46; Based on Skloot et al&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and Baptist et al&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "fig0010"
        "etiqueta" => "Fig&#46; 2"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr2.jpeg"
            "Alto" => 1087
            "Ancho" => 2508
            "Tamanyo" => 192258
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0010"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Significant changes in lung function present in asthma of the elderly&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "fig0015"
        "etiqueta" => "Fig&#46; 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr3.jpeg"
            "Alto" => 1964
            "Ancho" => 2508
            "Tamanyo" => 207471
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        ]
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0015"
            "detalle" => "Fig&#46; "
            "rol" => "short"
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Choice of device type according to patient coordination and inspiratory flow&#46; BAI&#58; breath-actuated pMDI&#59; DPI&#58; dry-powder inhaler&#59; pMDI&#58; pressurised metered-dose inhaler&#59; SMI&#58; soft mist inhaler&#46; Extracted from Bustamante et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">84</span></a>&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0020"
            "detalle" => "Table "
            "rol" => "short"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">FEV1&#58; forced expiratory volume in the first second&#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">&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">Early-onset asthma&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">Late-onset asthma&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">Atopy&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">&#43;&#43;&#43;&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">&#43;&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">Symptoms&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">&#43;&#43;&#43;&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">&#43;&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">Impaired lung function&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">&#43;&#43;&#43;&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">&#43;&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">Annual fall in FEV1&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">&#43;&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">&#43;&#43;&#43;&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">Obstruction reversibility&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">&#43;&#43;&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">&#43;&#43;&#43;&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">Bronchial hyperreactivity&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">&#43;&#43;&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
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                  \t\t\t\t">&#43;&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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            ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Main clinical and functional differences between early- and late-onset asthma&#46; The number of crosses indicate the probability of the event&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
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            "identificador" => "at0025"
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">NSAID&#58; non-steroidal anti-inflammatory drugs&#59; BNP&#58; B-type natriuretic peptide&#59; DLCO&#58; diffusing capacity of the lung for carbon monoxide&#59; COPD&#58; chronic obstructive pulmonary disease&#59; ACEI&#58; angiotensin-converting enzyme inhibitors&#59; NA&#58; not applicable&#59; GERD&#58; gastroesophageal reflux disease&#59; URT&#58; upper respiratory tract&#46;</p><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Adapted from Yawn BP and Han MK Practical considerations for the diagnosis and management of asthma in older adults&#46; Mayo Clin Proc&#44; 2017&#46; 92 &#40;11&#41;&#58; p&#46; 1697&#8211;1705&#46; DOI&#58; <span class="elsevierStyleInterRef" id="intr0005" href="https://doi.org/10.1016/j.mayocp.2017.08.005">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;mayocp&#46;2017&#46;08&#46;005</span>&#46;</p>"
          "tablatextoimagen" => array:1 [
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              "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">Diagnosis&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">Trigger&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">Symptoms&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">History&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">Family history&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">Tests&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">Asthma&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">Allergens&#44; NSAIDs&#44; ACEIs&#44; exercise or irritants such as tobacco&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">Cough&#44; wheezing or dyspnoea predominantly at night&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">Atopy&#44; allergic rhinitis&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">Asthma and&#47;or atopy&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">Reversible obstruction&#44; variability&#44; bronchial hyperresponsiveness&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">Vocal cord dysfunction&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">Stress&#44; obesity&#44; GERD&#44; exercise&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">Similar to wheezing&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">Often starts in adolescence&#46; Rarely atopy or allergy in childhood&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">Variable&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">Plateau in the inspiratory curve in spirometry&#46;&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">&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">&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">&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">&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">&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">Objective is the abduction of the vocal cords&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">Rhinosinusitis&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">Variable&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">Nasal blockage&#44; rhinorrhea&#44; facial pain&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May start at any age&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">Often associated with allergic rhinitis&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">Clinical tests&#44; previous rhinoscopy&#44; allergic evaluation&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">Gastrointestinal reflux&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">After meals&#44; when laying down&#44; or certain foods&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">Dyspepsia&#44; pain&#44; heartburn&#44; regurgitation&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">More common in adults&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">Variable&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">Response to antacids&#44; oesophageal pH-metrics and manometry&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">Eosinophilic bronchitis&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">Variable&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">Cough&#44; may be similar to asthma&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">More common in adults&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">Variable&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">Elevated sputum eosinophils in the absence of respiratory impairment&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">Post-infectious cough syndrome&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">URT infections&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">Cough&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">Recent URT infection&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">NA&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">Laboratory&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">Cough induced by ACE inhibitors&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">After the introduction of ACEI&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">Non-productive cough&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">After introducing the medication&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">Unknown&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">Discontinue medication and improvement of symptoms&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">Obstruction of the airways due to neoplasm&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">Onset or worsening in days or weeks&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">Dyspnoea&#44; weight loss&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">Smoking or chronic exposure to other irritants&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">Variable&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">Imaging techniques&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">Primary tracheobronchomalacia&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">Variable&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">Wheezing with or without dyspnoea&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">Early-onset&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">Variable&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">Imaging techniques or bronchoscopy&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">Secondary tracheobronchomalacia&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">After trauma &#40;surgery&#44; accident or intubation&#41; or chronic infection&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">Dyspnoea&#44; cough&#44; hemoptysis&#46; Not specific&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">Onset in adulthood&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">No&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">Imaging techniques or bronchoscopy&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">COPD&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">Irritants or infections&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">Cough&#44; sputum and dyspnoea predominate in the morning&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">Exposure to tobacco smoke or other harmful particles&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">Family history of COPD&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">DLCO disorder&#44; more often hypoxemia&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">Chronic non-obstructive bronchitis&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">Variable&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">Productive cough&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">Any age&#46; Most common in smokers&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">NA&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">No respiratory impairment&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">Chronic heart failure&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">Heart disease decompensation&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">Dyspnoea at rest and exercise&#44; orthopnea&#44; oedema in lower limbs&#44; cough&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">Basal heart disease&#44; episodes of previous heart failure&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">Variable&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">Echocardiogram alterations&#44; pro-BNP elevation&#44; and radiological alterations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Main differential diagnoses of asthma in the elderly&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Education&#44; environmental control&#44; and comorbidity control&#46; Consider immunotherapy with allergens in steps 2&#8211;4&#46;</p><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">LTRA&#58; leukotriene receptor antagonists&#59; ICS&#58; inhaled corticosteroids&#59; OCS&#58; oral corticosteroids&#59; IM&#58; intramuscular&#59; LABA&#58; long-acting &#223;2 agonists&#59; SABA&#58; short-acting &#223;2 adrenergic agonists&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Modified from GEMA 5&#46;0<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a>&#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">&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">Step 1&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">Step 2&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">Step 3&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">Step 4&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">Step 5&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">Step 6&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">Of choice&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">&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">ICS low doses&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">ICS low dose&#8239;&#43;&#8239;LABA&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">ICS medium dose&#8239;&#43;&#8239;LABA&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">ICS high dose&#8239;&#43;&#8239;LABA&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">Treatment of the previous step&#8239;&#43;&#8239;biologics according to phenotypes&#58; <span class="elsevierStyleItalic">omalizumab&#44; mepolizumab&#44; reslizumab&#44; benralizumab&#44; dupilumab</span>&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">Other options&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">&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">LTRA&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">ICS medium dose&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">ICS medium dose&#8239;&#43;&#8239;LTRA&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">If poor control&#44; add one or more&#58; Tiotropium and&#47;or&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">If previous options fail&#58;&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">&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">&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">&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">ICS low dose&#8239;&#43;&#8239;LTRA&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">&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">LTRA and&#47;or&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">Endobronchial thermoplasty&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">&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">&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">&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">&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">&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">Theophylline and&#47;or&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">If poor control persists&#44; consider&#58;&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">&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">&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">&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">&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">&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">Azithromycin&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">- Corticosteroids OCS&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">&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">&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">&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">&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">&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">&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">- Triamcinolone IM&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">On demand&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">SABA&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">SABA&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">SABA or&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">&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">&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">&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">&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">or&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">or&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">ICS&#8239;&#43;&#8239;formoterol&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">&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">&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">&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">&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">ICS&#8239;&#43;&#8239;formoterol&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">ICS&#8239;&#43;&#8239;formoterol<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a> or&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">&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  " align="left" valign="\n
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                  \t\t\t\t">or&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">ICS&#8239;&#43;&#8239;salbutamol<a class="elsevierStyleCrossRef" href="#tblfn0005">&#42;</a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">ICS&#8239;&#43;&#8239;salbutamol&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">DLCO&#58; diffusing capacity of the lung for carbon monoxide&#59; COPD&#58; chronic obstructive pulmonary disease&#59; FVC&#58; forced vital capacity&#59; FEV1&#58; forced expiratory volume in one second&#59; CT&#58; computed tomography scan&#46;</p>"
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                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">General aspects&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">Percentage of agreement &#40;71 experts&#41;&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">- From a biological point of view&#44; aging is the consequence of the accumulation of a wide variety of molecular and cellular damage over time&#44; leading to a general decrease in physiological reserves&#44; a gradual decline in physical and mental capacity&#44; an increased risk of illness&#44; and ultimately death&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;3&#37;&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">- Such damage includes genomic instability&#44; telomere wear&#44; epigenetic changes&#44; mitochondrial dysfunction&#44; adult stem cell depletion&#44; loss of proteostasis&#44; and alterations in intercellular communications&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;0&#37;&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">- These changes are not linear or uniform and their link with age in years is relative&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">95&#46;1&#37;&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">- Several events determine the peculiarities of asthma in the elderly&#58; immunosenescence&#47;inflammaging&#44; the lung function corrections experienced over the years&#44; the tendency to hypoperception of symptoms&#44; the &#8220;well-being paradox&#8221; and multimorbidity&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;0&#37;&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">- It has been postulated that aging may be one more commorbidity of asthma&#46; However&#44; it should be remembered that aging and fragility are not&#44; a priori&#44; completely interchangeable terms&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">87&#46;0&#37;&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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Relevant aspects</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">- In the elderly there are more diagnostic errors&#44; either due to underdiagnosis or false diagnoses&#59; only half the patients have a correct diagnosis of asthma&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;9&#37;&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">- The underdiagnosis of asthma in the elderly population is due&#44; among other reasons&#44; to the patient&#8217;s lack of perception of the symptoms&#44; accepting dyspnoea as something &#8220;normal&#8221; at an advanced age&#44; and to the reduction of physical activity&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;0&#37;&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">- False diagnoses are due to the tendency to associate asthma symptoms with other diseases &#40;eg COPD&#44; congestive heart failure&#44; and gastroesophageal reflux&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">91&#46;5&#37;&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">- The potential risk factors and triggers for asthma in the elderly are similar to those in other age groups&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">74&#46;0&#37;&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">- In this age group&#44; asthma can be triggered by infections due to immune disorders related to aging&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">84&#46;1&#37;&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">- Asthma-associated commorbidity&#44; disease severity&#44; and the increased difficulty involved in its treatment&#44; worsen the quality of life of older patients&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">88&#46;2&#37;&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">- Among the main factors that explain the poor control of the disease in this age group are&#58; the presence of associated commorbidities&#44; polymedicine with risk of drug interactions&#44; and poor therapeutic adherence&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;0&#37;&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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Diagnosis</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="elsevierStyleBold">Clinical presentation</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="left" 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">The clinical symptoms of asthma in the elderly do not differ substantially from asthma in the young&#44; although it has peculiarities such as a lack of perception of symptoms&#44; worse quality of life&#44; symptoms derived from other commorbidities&#44; extrapulmonary diseases&#44; and difficulty in externalising asthma symptoms&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;0&#37;&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="elsevierStyleBold">Complementary explorations</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="left" 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">- Bronchodilator test spirometry is the fundamental test for the diagnosis of asthma in the elderly&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">82&#46;0&#37;&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">- The FEV1&#47;FVC ratio decreases with age so it is essential to have values adjusted to this variable&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;1&#37;&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">- Despite the difficulties of performing spirometry in the elderly&#44; especially in patients with cognitive impairment and apraxia&#44; it is possible to obtain quality spirometry in most patients&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">83&#46;0&#37;&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">- For the differential diagnosis between asthma and COPD in cases of severe and not completely reversible obstruction&#44; performing DLCO may be helpful&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;1&#37;&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">- For the differential diagnosis with other diseases &#40;COPD&#44; bronchiectasis&#41; or associated commorbidities&#44; a CT scan may be indicated&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;2&#37;&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">- Although less common than at an early age&#44; atopy may be present in the asthma of the elderly patient&#44; so an allergy study is also very important at this age as well&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;7&#37;&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="elsevierStyleBold">Multidimensional evaluation</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="left" 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">- In the management of asthma in the elderly patient it is advisable to include the evaluation of cognitive function by means of objective questionnaires&#46; These assess the capabilities for the perception of symptoms and the implementation&#47;adherence to treatments&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&#46;0&#37;&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">- Anxiety-depression is related to an unrealistic perception of the symptoms&#44; which causes poor control of asthma&#46; Therefore&#44; an anxiety-depression assessment in the elderly is helpful in avoiding poor control&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;6&#37;&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">- Physical function is considered an indicator of health in the elderly&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">97&#46;9&#37;&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="elsevierStyleBold">Differential diagnosis</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="left" 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">- In older patients&#44; the diagnosis of late-onset asthma is not ruled out&#44; although other differential diagnoses must be considered&#44; mainly respiratory or cardiac&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;0&#37;&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">- In patients with a history of smoking&#44; assess whether or not there is an overlap with COPD and&#47;or heart disease&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">100&#46;0&#37;&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 " colspan="2" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment</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="elsevierStyleBold">Pharmacological treatment</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="left" 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">- The pharmacological treatment of asthma in the elderly does not differ from that advised in the clinical practice guidelines at other stages of life&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">90&#46;6&#37;&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">- Special attention should be paid to the choice of the inhaler device based on the inspiratory flow and coordination capacity of each patient&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">98&#46;1&#37;&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">- Not much data exists on the safety and efficacy of the use of biological drugs in poorly-controlled severe asthma in the elderly patient&#44; although their use is not contraindicated&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#44;3&#37;&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="elsevierStyleBold">Environmental control</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="left" 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">- Measures to prevent or minimise exposure to aero-allergens and environmental pollution should be considered in education programmes&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">99&#46;0&#37;&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">- Ventilation for rooms where patients spend a greater number of hours is recommended&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">79&#46;2&#37;&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">- An influenza vaccination and a pneumococcal vaccination is recommended&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">96&#46;1&#37;&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="elsevierStyleBold">Patient education</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="left" 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">- Self-management plans should be considered in the education programmes&#46; These should explain how to recognise the symptoms of asthma and other illnesses with similar symptoms&#44; that also allow rescue therapy to be applied&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">94&#46;2&#37;&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">- Educational measures are more difficult to implement in older patients because they have more difficulty making changes in their lifestyle&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">73&#46;1&#37;&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">- It would be interesting to work on the validation of questionnaires that identify the needs of older patients&#44; and that allow the implementation of specific education programmes for this age group&#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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">92&#46;2&#37;&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="elsevierStyleBold">Commorbidity control</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="left" 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">- Although the objectives of asthma therapy are the same for patients of all ages&#44; in the older adult with asthma it is necessary to take into account the presence of commorbidities and the need to minimise the number of therapies required &#40;polypharmacy&#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">92&#46;0&#37;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Summary of recommendations for the management and treatment of asthma in the elderly&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><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">Carlos Almonacid S&#225;nchez&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">SEPAR&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">Rub&#233;n And&#250;jar Espinosa&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">SOMUPAR&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">Ebymar Arismendi&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">SOCAP&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">Aurelio Arnedillo Mu&#241;oz&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">NEUMOSUR&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">Enric Barbeta&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">SOCAP&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">Irina Bobolea&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">SEPAR&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">Ana Boldova Loscertales&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">SADAR-PNEUMARAGON&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">Carlos Bujalance Cabrera&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">SOCAMPAR&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">Francisco Javier Callejas Gonz&#225;lez&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">SOCAMPAR&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">Concepci&#243;n Ca&#241;ete Ramos&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">SEPAR&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">Jos&#233; &#193;ngel Carretero Gracia&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">SEPAR&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">Francisco Casas Maldonado&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">NEUMOSUR&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">Manuel Castilla Mart&#237;nez&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">SOMUPAR&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">Jos&#233; Antonio Castillo Vizuete&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">SEPAR&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">Pilar Cebollero Rivas&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">SVNPAR&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">Carolina Cisneros Serrano&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">SEPAR&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">Astrid Crespo Lessmann&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">SEPAR&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">Alfredo de Diego Dami&#225;&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">SEPAR&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">David D&#237;az P&#233;rez&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">SEPAR&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">Christian Domingo Ribas&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">SEPAR&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">Ana Isabel Enr&#237;quez Rodr&#237;guez&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">ASTURPAR&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">Luis Manuel Entrenas Costa&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">NEUMOSUR&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">Marta Mar&#237;a Garc&#237;a Clemente&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">ASTURPAR&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">Borja Garc&#237;a Cos&#237;o&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">AIRE&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">Roc&#237;o Garc&#237;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SEPAR&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">Juan Luis Garc&#237;a Rivero&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">SEPAR&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">Jordi Giner Donaire&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">SEPAR&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">Ra&#250;l Godoy&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">SOCAMPAR&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">M&#46; del Carmen G&#243;mez Neira&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">SEPAR&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">M&#46; Teresa G&#243;mez Vizca&#237;no&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">SEAR&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">Francisco Javier Gonz&#225;lez Barcala&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">SOGAPAR&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">Luis Hern&#225;ndez Blasco&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">SVNEUMO&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">Javier Hueto P&#233;rez de Heredia&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">SVNPAR&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">Hemily K&#46; Izaguirre Flores&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">NEUMOCAN&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">Carlos Jim&#233;nez-Ruiz&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">SEPAR&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">Alberto Levy Na&#243;n&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">NEUMOSUR&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">Antol&#237;n L&#243;pez Vi&#241;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SEPAR&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">Vicente Maci&#225;n Gisbert&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">SEPAR&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">Pedro J&#46; Marcos&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">SOGAPAR&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">Carlos Mart&#237;nez Rivera&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">SEPAR&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">Juan F&#46; Medina Gallardo&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">SEPAR&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">Carlos Melero Moreno&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">SEPAR&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">Francisco Javier Michel de La Rosa&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">SVNPAR&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">Xavier Mu&#241;oz&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">SOCAP&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">Alicia Padilla Galo&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">SEPAR&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">Abel Pallar&#233;s Sanmart&#237;n&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">SOGAPAR&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">Luisa Pareja Hern&#225;ndez&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">SEPAR&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">Gerardo P&#233;rez Chica&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">SEPAR&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">Luis P&#233;rez de Llano&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">SEPAR&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">Vicente Plaza&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">SEPAR&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">C&#233;sar Picado&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">SEPAR&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">Ana Pueyo Bastida&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">SOCALPAR&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">Jacinto Ramos Gonz&#225;lez&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">SOCALPAR&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">Berta Rom&#225;n Bernal&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">NEUMOCAN&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">Auxiliadora Romero Falc&#243;n&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">SEPAR&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">Pedro J&#46; Romero Palacios&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">SEPAR&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">Silvia S&#225;nchez Cu&#233;llar&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">NEUMOMADRID&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">Fernando S&#225;nchez-Toril L&#243;pez&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">SEPAR&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">Joan Serra Batlles&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">SOCAP&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">Jos&#233; Serrano Pariente&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">AIRE&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">Ana Sogo Sagard&#237;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="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">SEPAR&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">Manuel Agust&#237;n Sojo Gonz&#225;lez&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">SEAR&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">Jos&#233; J&#46; Soto Campos&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">SEPAR&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">Elisabet Vera Solsona&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">SADAR-PNEUMOARAGON&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">Nerea Zabala Urionaguena&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">SEPAR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
            ]
          ]
        ]
      ]
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                    0 => array:2 [
                      "titulo" => "Burden of comorbidity in individuals with asthma"
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                    0 => array:2 [
                      "doi" => "10.1136/thx.2009.131078"
                      "Revista" => array:6 [
                        "tituloSerie" => "Thorax"
                        "fecha" => "2010"
                        "volumen" => "65"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asthma in the elderly&#58; diagnosis and management"
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                        0 => array:2 [ …2]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaci.2010.05.035"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Allergy Clin Immunol"
                        "fecha" => "2010"
                        "volumen" => "126"
                        "paginaInicial" => "681"
                        "paginaFinal" => "687"
                        "link" => array:1 [ …1]
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              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asthma in older adults"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/s0140-6736(10)61087-2"
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                        "tituloSerie" => "Lancet"
                        "fecha" => "2010"
                        "volumen" => "376"
                        "paginaInicial" => "803"
                        "paginaFinal" => "813"
                        "link" => array:1 [ …1]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asthma and ageing&#58; an end user&#8217;s perspective&#8212;the perception and problems with the management of asthma in the elderly"
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                        0 => array:2 [ …2]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2222.2011.03718.x"
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                        "tituloSerie" => "Clin Exp Allergy"
                        "fecha" => "2011"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Age-related differences in clinical outcomes for acute asthma in the United States&#44; 2006-2008"
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                        0 => array:2 [ …2]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jaci.2012.01.061"
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                        "tituloSerie" => "J Allergy Clin Immunol"
                        "fecha" => "2012"
                        "volumen" => "129"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Asthma in the elderly&#58; current understanding and future research needs&#8212;a report of a National Institute on Aging &#40;NIA&#41; workshop"
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                        "tituloSerie" => "J Allergy Clin Immunol"
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