[COPD: bronchial and systemic inflammation]. / EPOC: inflamación bronquial y sistémica.

Chronic obstructive pulmonary disease (COPD) is considered to be an inflammatory disease of the airways, in which there can be low-grade systemic inflammation. The etiology of this disease is multifactorial but is mainly due to an anomalous and amplified inflammatory response to tobacco smoke. This inflammatory response involves innate and acquired immunity. The latter is characterized by a Th1-type (CD8) response and its presence seems to be associated with progression to advanced stages of the disease. Currently, it is unknown whether bronchial and systemic inflammation are related or whether they act as independent compartments. Most of the available data on COPD are drawn from cross-sectional studies and consequently a causal relation between the possible inflammatory mediators and the genetic factors involved in pulmonary and extrapulmonary involvement in this disease cannot be established. Further studies are required that would allow the inflammatory response to be correlated with the distinct COPD phenotypes.

[Chronic obstructive pulmonary disease in women]. / EPOC en la mujer.

The prevalence of chronic obstructive pulmonary disease (COPD) is increasing worldwide, mainly due to the increase in women. In developed countries, COPD in women is mainly a result of exposure to tobacco smoke and in developing countries to inhalation of biomass combustion products. Underdiagnosis of COPD is more common in women since this disease has classically been associated with men. Moreover, COPD in women shows certain differential features, such as a greater expression of aspects related to perception (dyspnea and health-related quality of life), a high prevalence of malnutrition, anxiety and depression, and a distinct distribution of emphysema from that in men. Better phenotypical characterization of COPD in women would allow its impact on the health system to be more accurately evaluated and more individualized therapeutic strategies to be designed.

[COPD disease and malnutrition]. / EPOC y malnutrición.

Weight loss and malnutrition related mainly to lean mass loss can develop in advanced stages of chronic obstructive pulmonary disease (COPD) and are a clear indication of phenotypic heterogeneity. The presence of weight loss and malnutrition is associated with a worse prognosis, independently of forced expiratory volume in 1 second (FEV(1)). The most widely accepted thresholds for risk are 21 for the body mass index (BMI) and 17 and 14 for men and women, respectively, for the fat-free mass index (FFMI). The coexistence of both defines a situation of greater nutritional risk (cachexia). Nevertheless, a reduction in FFMI is an independent risk factor, although not superior to a low BMI. Therefore, although obtaining FFMI by bioelectric impedanciometry is reliable and relatively easy, we recommend the use of this procedure only in patients with COPD and low weight (BMI < 21), together with more specific nutritional evaluation. Currently, longitudinal studies providing data on the behavior of BMI within the natural course of the disease are lacking. Moreover, there is no solid scientific evidence that confirms the main mechanisms of malnutrition in COPD. This lack of evidence explains the difficulty of the therapeutic management of these patients, which has not advanced in the last few decades. Nevertheless, current evidence suggests that initiating individually-tailored nutritional treatment combined with pulmonary rehabilitation programs (exercise) is reasonable in patients with cachexia. Further studies are required to provide greater insight into the physiopathology and the role of other therapeutic options (hormones, antiinflammatory drugs) in malnutrition in patients with COPD.

[COPD: what is there beyond BODE index?]. / Enfermedad pulmonar obstructiva crónica: ¿qué hay más allá del índice BODE?

Chronic obstructive pulmonary disease (COPD) is a multidimensional disease with wide phenotypic heterogeneity that is not adequately reflected by forced expiratory volume in 1 second (FEV(1)). Assessment of patients with COPD requires analysis of multiple variables that encompass respiratory and extrapulmonary involvement. These variables should be viable in clinical practice, should not provide duplicate information, and should have an effect on the course of the disease. The BODE index (FEV(1), dyspnea, body mass index and the 6-minute walk test) is the most obvious example of this conceptual approach and its acceptance among the scientific community has grown in the last few years. Nevertheless, other aspects of the disease not included in the BODE index, such as pulmonary hyperinsufflation, exacerbations and comorbidities, have been shown to be important in COPD. Moreover, the development of new technologies could allow imaging techniques and biomarkers to be incorporated, which would in turn improve characterization of the disease and allow more specific and individually-tailored patient management. Nevertheless, the role of all these factors in the evaluation of a highly prevalent disease such as COPD remains to be defined.