Conferencia Dr. Josep Morera Prat

1. EPOC: 11 Guías y 11 Mitos
Memorial Dr. J.M. Cosío
Oviedo, 11 – 11 -11 , 11:11 h. Dr. Josep Morera

4. PROFECÍA
Murray JL, et al. Lancet 1997; 349: 1498–1504

5. PROFECÍA
Murray JL, et al. Lancet 1997; 349: 1498–1504

6. Índice
Índice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones

7. Las 11 Guías
Las 11 Guías
1. Terminology, Definitions, and Classification of Chronic Pulmonary Emphysema and
Related Conditions: A Report of the Conclusions of a Ciba Guest Symposium Thorax
1959;14:286-299)
2. Standards for the diagnosis and care of patients with chronic obstructive pulmonary
disease (COPD) and asthma. This official statement of the American Thoracic Society
was adopted by the ATS Board of Directors, November 1986. Am Rev Respir Dis. 1987
Jul;136(1):225-44.
3. Siafakas NM, Vermeire P, Pride NB, Paoletti P, Gibson J, Howard P, Yernault JC,
Decramer M, Higenbottam T, Postma DS, et al. Optimal assessment and management
of chronic obstructive pulmonary disease (COPD). The European Respiratory
Society Task Force. Eur Respir J. 1995 Aug;8(8):1398-420.
4. Montemayor T, Alfajeme I, Escudero C, Morera J, Sánchez Agudo L. [Guidelines on the
diagnosis and treatment of chronic obstructive lung disease. The SEPAR Working
Group. The Spanish Society of Pneumology and Thoracic Surgery]. Arch
Bronconeumol. 1996 Jun-Jul; 32 (6): 285-301.
5. BTS guidelines for the management of chronic obstructive pulmonary disease. The
COPD Guidelines Group of the Standards of Care Committee of the BTS. Thorax. 1997
Dec;52 Suppl 5:S1-28.

8. Las 11 Guías
Las 11 Guías
6. Pauwels RA, Buist AS, Calverley PM, Jenkins CR, Hurd SS; GOLD Scientific Committee.
Global strategy for the diagnosis, management, and prevention of chronic obstructive
pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease
(GOLD) Workshop summary. Am J Respir Crit Care Med. 2001 Apr;163(5):1256-76.
7. Barberà JA, Peces-Barba G, Agustí AG, Izquierdo JL, Monsó E, Montemayor T, Viejo JL;
Sociedad Española de Neumología y Cirugía Torácica (SEPAR). [Clinical guidelines for
the diagnosis and treatment of chronic obstructive pulmonary disease]. Arch
Bronconeumol. 2001 Jun;37(6):297-316.
8. Celli BR, MacNee W; ATS/ERS Task Force. Standards for the diagnosis and treatment of
patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J. 2004
Jun;23(6):932-46.
9. Halpin D. NICE guidance for COPD. Thorax. 2004 Mar;59(3):181-2.
10. Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C,
Rodriguez-Roisin R, van Weel C, Zielinski J; Global Initiative for Chronic Obstructive
Lung Disease. Global strategy for the diagnosis, management, and prevention of
chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit
Care Med. 2007 Sep 15;176(6):532-55.

9. Las 11 Guías
Las 11 Guías
11. Peces-Barba G, Barberà JA, Agustí A, Casanova C, Casas A, Izquierdo JL, Jardim J,
López Varela V, Monsó E, Montemayor T, Viejo JL. [Diagnosis and management of
chronic obstructive pulmonary disease: joint guidelines of the Spanish Society of
Pulmonology and Thoracic Surgery (SEPAR) and the Latin American Thoracic Society
(ALAT)]. Arch Bronconeumol. 2008 May;44(5):271-81.
Qaseem A, Wilt TJ, Weinberger SE, Hanania NA, Criner G, van der Molen T, Marciniuk DD,
Denberg T, Schünemann H, Wedzicha W, MacDonald R, Shekelle P; American College of
Physicians; American College of Chest Physicians; American Thoracic Society; European
Respiratory Society. Diagnosis and management of stable chronic obstructive pulmonary
disease: a clinical practice guideline update from the American College of Physicians,
American College of Chest Physicians, American Thoracic Society, and European
Respiratory Society. Ann Intern Med. 2011 Aug 2;155(3):179-91.
Grupo de Trabajo de GESEPOC. [Moving towards a new focus on COPD. The Spanish COPD
Guidelines (GESEPOC)]. Arch Bronconeumol. 2011 Aug;47(8):379-81.

10. Las 11 Guías
Las 11 Guías
Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or
pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range
from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to
respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may
contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a
patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a
postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated
decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an
alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the
airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to
COPD when common comorbid conditions, such as heart failure, are associated with the same
symptoms…
Ann Intern Med. 2011;155:179-191.

11. Las 11 Guías
Las 11 Guías
br ar
n om
de
Chronic obstructive pulmonary disease (COPD) is a slowly progressive disease involving the airways or
es
pulmonary parenchyma (or both) that results in airflow obstruction. Manifestations of COPD range
nt
from dyspnea, poor exercise tolerance, chronic cough with or without sputum production, and wheezing to
s a co
respiratory failure or cor pulmonale. Exacerbations of symptoms and concomitant chronic diseases may
r a ba
a b ta
contribute to the severity of COPD in individual patients. A diagnosis of COPD is confirmed when a
al
patient who has symptoms of COPD is found to have airflow obstruction (generally defined as a
p
postbronchodilator FEV1–FVC ratio less than 0.70, but taking into account that age-associated
4 49
decreases in FEV1–FVC ratio may lead to overdiagnosis in elderly persons) in the absence of an
alternative explanation for the symptoms (for example, left ventricular failure or deconditioning) or the
airflow obstruction (for example, asthma). Clinicians should be careful to avoid attributing symptoms to
COPD when common comorbid conditions, such as heart failure, are associated with the same
symptoms…
Ann Intern Med. 2011;155:179-191.

12. Las 11 Guías
Las 11 Guías
GOLD’2001
 No menciona tabaquismo en definición.
 No menciona que el efecto del tabaco es dosis/efecto.
 No se menciona la palabra “Smoke” hasta después de
688 palabras y 2 tablas, y 688 palabras más hasta
repetirla.
 No definen si en ensayos clínicos deben excluirse los
no fumadores / ex.
 Clasificación de severidad confusa / discutible

13. Las 11 Guías
Las 11 Guías
RISK FACTORS
• Host Factors
– Genes
– Airway Hyperresponsiveness
– Lung Growth
• Exposures
– Tobacco Smoke
– Occupational Dust and Chemicals
– Outdoor and Indoor Air Pollution
– Infections
– Socioeconomic Status

14. Índice
Índice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones

15. Los 11 Mitos
EXCESIVA INFLUENCIA DE LA FILOSOFIA DE LA CIENCIA
Filosofía de la Ciencia: Método
inductivo Vs método Refutacionista
Epidemiology: an introduction. Kenneth J. Rothman.
KJ Rothman - Oxford University Press
What is Causation?. Cap. 2

16. Los 11 Mitos
VS POSITIVISTAS / NOMINALISTES
La navaja de Occam (navaja de Ockham o principio de economía o de parsimonia) hace referencia a un tipo de
razonamiento basado en una premisa muy simple: en igualdad de condiciones la solución más sencilla es
probablemente la correcta. El postulado es entia non sunt multiplicanda praeter necessitatem, o «no ha de presumirse la
existencia de más cosas que las absolutamente necesarias».

17. Los 11 Mitos
PRINCIPIS DE HILL
1. Human experiments
2. Strength of association
3. Consistency of association
4. Temporal relationship
5. Dose-response gradient
6. Biological plausibility
7. Epidemiological plausibility
8. Specificity
9. Analogy
Coultas D.B & Samet J.M. Cigarrette Smoking. Ch 7 de Clinical epidemiology of COPD. M. Decker,
N.Y. 1989, pp 109-138.

18. Los 11 Mitos
Martin J. Tobin. Chest. 2008 May;
133(5):1071-4; discussion 1074-7.

19. Los 11 Mitos
DEFINICIÓN Y CATEGORIZACIÓN CLÍNICA
ENFERMEDAD
4 Causa - Etiología
S Desorden Funcional
Í 3 Característico
N
D Lesión Anatómica
R 2 Característica
O
M
E 1 Descripción Clínica
Basado en J. G. Scadding.
Principles of definition in medicione. Lancet, 1959; 1: 323-325 .
Meaning of diagnostic terms in bronchopulmonary disease. BMJ, 1963; 2: 1425-1430.
The semantics of medical diagnosis. Niomed. Comput, 1972; 3: 83-90.
Helath and disease: what can medicine do for philosophy?. J. Med. Ethics, 1988; 14: 118-124.
Definition on asthma. In: Bronchial asthma, mechanisms and therapeutics, 3erd ed. Boston: Litle Brown; 1993. p.1-13.

20. Los 11 Mitos
EPOC: NOSOLOGÍA
1. Miravitlles M, Morera J. It's time for an aetiology-based
definition of chronic obstructive pulmonary disease.
Respirology. 2007 May;12(3):317-9.
2. Morera J, Miravitlles M. [Chronic obstructive pulmonary disease:
disease or Zugzwang's syndrome?] Med Clin (Barc). 2008 May
10;130(17):655-6.
3. Snider GL. Nosology for our day: its application to chronic
obstructive pulmonary disease. Am J Respir Crit Care Med.
2003 Mar 1;167(5):678-83.

21. Los 11 Mitos
R. Pellegrino, V. Brusasco, G. Viegi, R.O. Crapo, F. Burgos, R. Casaburie, A.
Coates, C.P.M. van der Grinten, P. Gustafsson, J. Hankinson, R. Jensen, D.C.
Johnson, N. MacIntyreee, R. McKay***, M.R. Miller, D. Navajas, O.F. Pedersen
and J. Wanger.

22. Los 11 Mitos
NECESIDAD ÚNICO CRITERIO

23. Los 11 Mitos
¿Y LOS SÍNTOMAS?
Can Global Initiative for Chronic Obstructive Lung Disease Stage 0
Provide Prognostic Information on Long-term Mortality in Men?
Stavem K, et al. Chest, 2006; 130: 318-25

24. Los 11 Mitos
http://www.goldcopd.com.
BODE: Celli BR, Cote CG, et al. The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic
obstructive pulmonary disease. N Engl J Med. 2004 Mar 4;350(10):1005-12.
ADO: Puhan MA, Garcia-Aymerich J, et al. Expansion of the prognostic assessment of patients with chronic obstructive
pulmonary disease: the updated BODE index and the ADO index. Lancet. 2009 Aug 29;374(9691):704-11.
DOSE: Jones RC, Donaldson GC, et al.. Derivation and Validation of a Composite Index of Severity in Chronic Obstructive
Pulmonary Disease - The DOSE Index. Am J Respir Crit Care Med. 2009 Sep 24.

25. Los 11 Mitos
¿Y LOS SÍNTOMAS?
GOLD – DIAGNÓSTICO DIFERENCIAL
 Asma
 Insuficiencia cardíaca
 Bronquiectasias
 Tuberculosis
 Bronquiolitis obliterante
 Panbronquiolitis difusa
Global Strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.
Update 2003 (GOLD). http://www.goldcopd.com.

26. Los 11 Mitos
CAUSAS EPOC-SÍNDROME
200-500 Causas ?!

27. Los 11 Mitos
Am J Respir Crit Care Med. 2009 Aug 1;180(3):257-64.

28. Los 11 Mitos
Am J Respir Crit Care Med. 2009 Aug 1;180(3):257-64.

29. Los 11 Mitos
Chest. 2004 Aug;126(2):622-9.

30. Los 11 Mitos
Chest. 2004 Aug;126(2):622-9.

32. Los 11 Mitos

33. Los 11 Mitos
Respiration 2005;72:221

34. Los 11 Mitos
Clinical Bronchiolitis Obliterans in Workers at a Microwave-Popcorn Plant
Kreiss K, et al. NEJM, 2002; 347: 330-338
100 Volatile Organic Compounds
Diacetyl (2,3-butanedione)

35. Los 11 Mitos
Does Distinction
Between Asthma
and COPD Matter?
Kraft M. AJRCCM, 2006; 174: 238-
244.

36. Los 11 Mitos
CONFUSIÓN
… Potentially, the common mechanism by which major risk
… Potentially, the common mechanism by which major risk
factors such as smoking, hyperlipidaemia, obesity, and
factors such as smoking, hyperlipidaemia, obesity, and
hypertension lead to chronic disease is systemic
hypertension lead to chronic disease is systemic
inflammation…
inflammation…
Lancet. 2007 Sep 1;370(9589):797-9.

37. Prozac
Rinitis // Sinusitis
Rinitis Sinusitis
Hernia inguinal
Hernia inguinal
Neuropatia S.
Neuropatia S.
vegetativo
vegetativo

38. Los 11 Mitos
N Engl J Med. 2010 Jan 21;362(3):217-27.

39. Los 11 Mitos
N Engl J Med. 2010 Jan 21;362(3):217-27.

40. Los 11 Mitos
Biochem. Soc. Trans. (2009) 37, 814–818;
Am J Respir Crit Care Med Vol 176. pp 1281–1288, 2007

41. Los 11 Mitos
Am J Respir Crit Care Med. 2011 Aug 11.

42. Los 11 Mitos
N Engl J Med. 2011 Sep 29;365(13):1184-92.

43. Los 11 Mitos
N Engl J Med. 2011 Sep 29;365(13):1184-92.

44. Los 11 Mitos
COPD: the dangerous underestimate of 15%.
Rennard SI, Vestbo J.
Decline in FEV1 and airfl ow limitation related to
occupational exposures in men of an urban community.
Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.
Lancet. 2006 Apr 15;367(9518):1216-9.

45. Los 11 Mitos
COPD: the dangerous underestimate of 15%.
Rennard SI, Vestbo J.
Lancet. 2006 Apr 15;367(9518):1216-9.

46. Los 11 Mitos
COPD: the dangerous underestimate of 15%.
Rennard SI, Vestbo J.
Decline in FEV1 and airfl ow limitation related to
occupational exposures in men of an urban community.
Humerfelt S, Gulsvik A, Skjaerven R, et al. Eur Respir J 1993; 6: 1095–103.
Lancet. 2006 Apr 15;367(9518):1216-9.

47. Los 11 Mitos
Proc Am Thorac Soc. 2006;3(1):58-65.
A homeopathic remedy for early COPD
Enright P. Respir Med. 2011 Nov;105(11):1573-5.
Enright P. Prim Care Respir J. 2011 Mar;20(1):6-8.

48. Los 11 Mitos
Chest. 2009 Jan;135(1):173-80.

49. Los 11 Mitos
Chest. 2009 Jan;135(1):173-80.

50. Los 11 Mitos
FENOTIPOS
Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.

51. Los 11 Mitos
FENOTIPOS
Homes Dones
Cortesía Dr. de Torres

52. Los 11 Mitos
FENOTIPOS
El fenotipo está determinado fundamentalmente por el genotipo, o por la identidad de
los alelos, los cuales, individualmente, cargan una o más posiciones en los cromosomas.
Algunos fenotipos están determinados por los múltiples genes, y además influidos por
factores del medio. De esta manera, la identidad de uno, o de unos pocos alelos
conocidos, no siempre permite una predicción del fenotipo. En este sentido, la
interacción entre el genotipo y el fenotipo ha sido descrita usando la simple ecuación
que se expone a continuación:
Ambiente + Genotipo + Ambiente* Genotipo = Fenotipo
En conclusión, el fenotipo es cualquier característica detectable de un organismo
(estructural, bioquímico, fisiológico o conductual) determinado por una interacción
entre su genotipo y su medio.
El conjunto de la variabilidad fenotípica recibe el nombre de polifasia o polifenismo.
http://es.wikipedia.org/wiki/Fenotipo

53. Los 11 Mitos
Phenotype classically refers to any observable characteristic of
an organism, and up until now, multiple disease characteristics
have been termed COPD phenotypes. We, however, propose the
following variation on this definition: ‘‘a single or combination of
disease attributes that describe differences between individuals
with COPD as they relate to clinically meaningful outcomes
(symptoms, exacerbations, response to therapy, rate of disease
progression, or death).’’
Am J Respir Crit Care Med 2010; 182: 589–604.

54. Los 11 Mitos
Thorax. 2008 September ; 63(9): 761–767.

55. Los 11 Mitos
Respirology (2011) 16, 264–268

56. Los 11 Mitos
Thorax. 2009; 64(8): 728-35.

57. Los 11 Mitos
Thorax. 2009; 64(8): 728-35.
Marin, et al. Am J Respir Crit Care Med Vol 182. pp 325–331, 2010

58. Los 11 Mitos
Am J Respir Crit Care Med, 2004; 170: 400–407
Martínez-García MÁ , et al. Chest. 2011 Nov;140(5):1130-7.

59. Los 11 Mitos
¿Paciente sano? o ¿Paciente no sano?

60. Los 11 Mitos

63. Los 11 Mitos
DIAGNÓSTICO Y PRONÓSTICO

64. Los 11 Mitos
DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO
 Muy fumadores (hasta ahora predominio varón)
 ≈ 50 paquetes/año acumulados
 Disnea de esfuerzo
 “Velcro” basales
 Acropaquia >50%
 > 65 años
 DLCO ↓↓↓
 Espirometría / volúmenes = desconcertantes
 Tx tórax = tórax sucio
 TAC = >enfisema paraseptal !!
 HAP
 Carcinoma
 Enfermedad coronaria +++

65. Los 11 Mitos
DIAGNÓSTICO Y PRONÓSTICO

66. Los 11 Mitos
DIAGNÓSTICO Y PRONÓSTICO: CUADRO CLÍNICO (DIFICULTADES)
 Previamente catalogados de EPOC (leves / moderados)
 Enfisema precede ≈5 años a fibrosis
 Espirometría poco reveladora
 Efecto “joven/vieja”
 TAC (no siempre fácil de interpretar)
 (No hacemos ni TAC ni difusión = guías)
 No sabíamos que el humo del cigarrillo producía fibrosis pulmonar !!!???

67. Los 11 Mitos
DIAGNÓSTICO Y PRONÓSTICO
Combined pulmonary fibrosis and emphysema: a distinct underrecognised
entity.
Cottin V, Nunes H, Brillet PY, Delaval P, Devouassoux G, Tillie-Leblond I, Israel-Biet D,
Court-Fortune I, Valeyre D, Cordier JF; Groupe d'Etude et de Recherche sur les
Maladies Orphelines Pulmonaires (GERM O P).
Eur Respir J. 2005 Oct;26(4):586-93.

68. Los 11 Mitos
LECCIONES PASADAS DE LA HISTORIA
¿Coincidente o relación causal?
¿Cita o encuentro?
Humo de cigarrillo
The spectrum of smoking-related interstitial lung disorders: the
never-ending story of smoke and disease.
Selman M. Chest. 2003 Oct;124(4):1185-7.
Smoking: an injury with many lung manifestations.
Flaherty KR, Hunninghake GG. Am J Respir Crit Care Med. 2005 Nov 1;172(9):1070-1.

69. Los 11 Mitos
LECCIONES PASADAS DE LA HISTORIA: AVISOS
Relation of smoking and age to findings in lung parenchyma: a microscopic study.
Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.
Smoking Habits And Age In Relation To Pulmonary Changes. Rupture Of Alveolar
Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.
Auerbach O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov
14;269:1045-54.
J Occup Med. 1988 Jan;30(1):33-9).

70. Los 11 Mitos
LECCIONES PASADAS DE LA HISTORIA: AVISOS
93,3
<60 60-69 70+ 90,7 90,6
100 82,5
Age
Severe Pulmonary Fibrosis %
80
Relation of smoking and age to findings in lung parenchyma: a microscopic study.
62,7
Auerbach O, Garfinkel L, Hammond EC. Chest. 1974 Jan;65(1):29-35.
50
60
39,1
32,7
40
Smoking Habits 20 Age In Relation To Pulmonary Changes. Rupture Of Alveolar
And 1,9
6,9
Septums, Fibrosis And Thickening Of Walls Of Small Arteries And Arterioles.
Auerbach0O, Stout Ap, Hammond Ec, Garfinkel L. N Engl J Med. 1963 Nov
No. In group 36 52 32 87 87 38 205 200 43 83 96 15
0 <1 1_2 2+
14;269:1045-54.
Cigarettes – Packs/Day
J Occup Med. 1988 Jan;30(1):33-9).

71. Los 11 Mitos
ÚLTIMAS NOTICIAS
Diagnosis of usual interstitial pneumonia and distinction from other
fibrosing interstitial lung diseases.
Katzenstein AL, Mukhopadhyay S, Myers JL.
 23 piezas lobectomía por tumor pulmonar
 20 fumadores
 Examen histológico: fibrosis >25% slides. En 12/20
(60%) fumadores 0 en no fumadores
 Describe SRIF (Smoking-Related Fibrosis Disease)
Hum Pathol. 2008 Sep;39(9):1275-94.

72. Los 11 Mitos
ÚLTIMAS NOTICIAS
Idiopathic pulmonary fibrosis and emphysema: decreased survival associated
with severe pulmonary arterial hypertension.
Mejía M, Carrillo G, Rojas-Serrano J, Estrada A, Suárez T, Alonso D, Barrientos E,
Gaxiola M, Navarro C, Selman M.
30% !!! Chest. 2009 Jul;136(1):10-5.

73. Los 11 Mitos
ÚLTIMAS NOTICIAS
The rising incidence of idiopathic pulmonary fibrosis in the U.K.
Navaratnam V, Fleming KM, West J, Smith CJ, Jenkins RG, Fogarty A, Hubbard RB.
 ↑ 5% por año
 5.000 nuevos casos por año (UK) =
 [≈ 4.000 en España ?!]
 5.000 +/a
 >+ que por cáncer ovárico, linfoma,
leucemia, hipernefroma o mesotelioma.
YA NO ES HUÉRFANA…
Thorax. 2011 Jun;66(6):462-7.

74. Los 11 Mitos
N Engl J Med 2011;364:897-906.

75. Los 11 Mitos
N Engl J Med 2011;364:897-906.

76. Los 11 Mitos
ESPECULACIONES
“Blue Bloater / Blow-up”
Inspirados en: Dornhorst AC. Lancet. 1955 Jun 11;268(6876):1185-7.

77. Los 11 Mitos
Thorax. 2011 Aug;66(8):643-5.

78. Los 11 Mitos
N Engl J Med. 2011 May 12;364(19):1795-806.

79. Los 11 Mitos
Petersen & Niklason

80. Los 11 Mitos
 Even more effective tobacco legislation, including prevention of passive smoking
exposure for children in cars and at home. Legislation works17dor, if it does not,
let us prorogue parliament at once!
 Recognition that airborne pollution is a human rights issuedif you live in a
Western city you cannot avoid air pollution.
 The roots of much disease are in povertydand yet it is not only low and middle
income countries that are affected. All major Western countries still have
substantial poverty affecting children.
 Finally, invest in research to understand early lung development, and devise
interventions to operate before the lungs are shot to pieces.
Thorax. 2011 Aug;66(8):645-6.

81. Índice
Índice
1) Las 11 Guías
2) Los 11 Mitos
3) Conclusiones

82. Conclusiones
Conclusiones
MITOS
1) Factor de Riesgo o Causa
2) Cociente Fijo
3) Es Fácil de Diagnosticar
4) El Gran Síndrome Inflamatorio
5) La Irreversibilidad
6) La Comorbilidad

83. Conclusiones
Conclusiones
MITOS
7) La Suscetibilidad
8) La Importancia de los Genes
9) Envejecimiento
10) Los Fenotipos
11) El Cigarrillo no Produce Fibrosis

84. Muchas Gracias