Proceedings of the American Thoracic Society Email Content Delivery
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

The Proceedings of the American Thoracic Society 4:686-691 (2007)
© 2007 The American Thoracic Society
doi: 10.1513/pats.200706-081SD
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Camp, P. G.
Right arrow Articles by Goring, S. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Camp, P. G.
Right arrow Articles by Goring, S. M.

Gender and the Diagnosis, Management, and Surveillance of Chronic Obstructive Pulmonary Disease

Pat G. Camp1 and Sarah M. Goring2

1 James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, St. Paul's Hospital; and 2 Department of Health Care and Epidemiology, University of British Columbia, Vancouver, Canada

Correspondence and requests for reprints should be addressed to Pat G. Camp, M.Sc., PT, James Hogg iCAPTURE Centre for Cardiovascular and Pulmonary Research, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6. E-mail: pgcamp{at}interchange.ubc.ca

ABSTRACT

Following in the footsteps of cardiovascular researchers and clinicians, the pulmonary scientific community is beginning to explore how gender may impact the diagnosis, treatment, and surveillance of chronic obstructive pulmonary disease (COPD). Investigators and clinicians in this field are tackling the complex questions surrounding how differences in male/female biology may interact with gender differences in environmental, societal, cultural, and behavioral determinants of health to influence outcomes in COPD. In this article, issues such as gender differences in symptoms, gender diagnostic bias, differential impact of therapies, including smoking cessation and pharmacologic management, as well as the impact of these issues on COPD surveillance, are discussed. Current knowledge from the literature coupled with discussions from a 1-day symposium on gender and COPD diagnosis, management, and surveillance are detailed, including recommendations on where future research endeavors may be targeted.

Key Words: women • gender bias • chronic obstructive pulmonary disease • epidemiology

Chronic obstructive pulmonary disease (COPD) is a devastating illness that causes great suffering in afflicted individuals and imposes an enormous burden to society. Professional respiratory societies worldwide acknowledge that the disease is underdiagnosed and undertreated (1–3).

The prevailing notion that COPD primarily affects men may put women at particular risk of underdiagnosis. There may also be gender differences in need, access, and effect of treatment for COPD. This report will provide an overview of differences between men and women in terms of the diagnosis, management, and surveillance of COPD and identify areas for future investigation.

Although often used interchangeably, "sex" and "gender" are considered by some to be distinct concepts (4). Sex refers to the primary and secondary sex characteristics that distinguish males and females but is often used to encompass all anatomic and physiologic attributes that may differ between males and females. Gender is the result of the societal, environmental, cultural, and individual influences that may be termed "masculine" or "feminine" and which allow an individual to identify themselves as either male or female. It is not always clear whether a difference in the diagnosis, management, and surveillance of COPD is due to the sex or the gender of an individual. To remain consistent, we will usually refer to gender differences throughout this report, although it should be noted that many of the differences we will discuss may be rooted in the genetic and biological differences between men and women.

WHAT DO WE KNOW ABOUT GENDER DIFFERENCES IN DIAGNOSIS, MANAGEMENT, AND SURVEILLANCE OF COPD?

Diagnosis
Physicians should consider COPD in patients presenting with chronic cough, chronic sputum production, and progressive or persistent dyspnea, and who have a history of exposure to risk factors of COPD (1). To confirm the diagnosis and assess the severity of the disease, the physician should administer a lung function test. For many patients, the pathway to a COPD diagnosis begins with the reporting of respiratory symptoms to their physician; therefore, gender differences in symptoms are important to consider. Symptoms of COPD include respiratory-related symptoms, such as dyspnea, cough, sputum production, wheezing, and chest tightness, as well as associated conditions, such as anxiety, depression, and weight loss (1).

Several studies have examined gender differences in symptom reporting (Table 1). Women with COPD are more likely report dyspnea (5–7) but less likely to report phlegm production (6, 8). In addition, women with COPD are more likely to have depression, anxiety, and fatigue compared with men, even after adjusting for lung function (9, 10). Data on gender differences in health-related quality of life (HRQL) have been less consistent. Although several studies have reported worse HRQL in women (11, 12), others have reported a greater decline in HRQL over time in men (13) or no gender differences in HRQL (14).


View this table:
[in this window]
[in a new window]

  		TABLE 1. GENDER DIFFERENCES IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE SYMPTOMS

 
Even if men and women report similar respiratory symptoms to their physician, little is known about how a physician may interpret those symptoms. Chapman and colleagues (15) conducted a study in the United States and Canada, which was repeated in Spain by Miravitlles and coworkers (16). In these studies, physicians were presented with hypothetical case scenarios. Half of the physicians were told the hypothetical patient was female; the other half were told the patient was male. Physicians were asked to give the most likely diagnosis based on the case summary (symptoms, past medical history, smoking history). They were then given hypothetical spirometry results (indicating COPD) and asked again for a most likely diagnosis. Finally, the physicians were told that a 1-week course of oral corticosteroids did not improve symptoms in the patient, and were again asked their most likely diagnosis. The results of both studies are summarized in Table 2.


View this table:
[in this window]
[in a new window]

  		TABLE 2. PERCENTAGE OF SAMPLE DIAGNOSED WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE AT EACH STAGE OF THE SURVEY

 
The results indicate that, in the absence of spirometry, physicians may be more likely to diagnose males with COPD than females, all other factors being equal. In the Spanish study, the proportion of female cases diagnosed with COPD was the same as male cases after spirometry results were given; however, in the United States/Canada study, the gender bias persisted, even after information on the failed course of steroids was given.

As suggested by these studies, an objective measure of lung function should be administered to reduce the possibility of gender bias. Spirometry utilization, however, is low. Anthonisen and colleagues (17) reported that, in patients coded with COPD, spirometry utilization ranged from 27% in patients with only one physician visit per year to 53% for patients with greater than 19 visits per year. In Chapman and colleagues' study, when given the option, only 22% of physicians requested a spirometry test. Compounding the gender bias, women in particular may be less likely to receive a spirometry test: Watson and coworkers (6) found that the odds ratio of being given a spirometry test is 0.84 for women compared with men (95% confidence interval, 0.72–0.98).

Without spirometry testing, symptomatic women with COPD may be diagnosed with asthma instead. Dales and colleagues (18) found the prevalence of physician-diagnosed asthma was twice as high among women as men; however, bronchodilator responsiveness did not differ between the two genders. Others have also reported a greater likelihood for women with COPD to be incorrectly diagnosed with asthma than men (6, 19).

Management
There are several options for treating COPD. They include smoking cessation, pharmacologic therapy, rehabilitation, oxygen therapy, and surgical options.

Smoking cessation.
This topic is reviewed in depth by Greaves and Richardson (see pp. 673–677), but it is important to understand how gender and sex differences in smoking behavior and cessation can affect the clinical management of COPD.

Smoking is the main causal agent of COPD, and cessation of smoking is the only method currently known to slow lung function decline (1). Female smokers tend to have higher levels of nicotine dependence and experience more depressive and withdrawal symptoms compared with male smokers (20). In addition, female smokers may be at greater risk for developing COPD, possibly due to sex differences in the metabolism of cigarette smoke (21). This area is explored in greater detail by Sin and colleagues (see pp. 669–672).

It is frequently cited in the COPD literature that men have a higher success rate of long-term smoking cessation than women (22, 23) and that women attempt to quit less frequently than men (24). This may be due in part that pharmacologic therapies are less effective in women; although bupropion sustained-release (SR) therapy is effective for smoking cessation compared with placebo in female smokers, male smokers who take bupropion SR are nevertheless more successful than women in quitting (22). Success in quitting may also be related to access to all resources available; in one study, women were equally likely to receive advice to quit smoking and to be referred to a smoking cessation program as men, but they were less likely to receive a prescription for nicotine patches (25). Few gender difference in patient safety have been reported for pharmacotherapies for smoking cessation; researchers from the Lung Health Study reported that there were no between-gender differences for adverse events in nicotine gum use (26).

Pharmacologic management of COPD.
Currently, there are no medications available to slow the decline in lung function. Rather than aim to do this, pharmacotherapy is used to prevent and control symptoms, reduce the frequency and severity of exacerbations, improve health status, and improve exercise tolerance.

Few studies have investigated gender bias in medication prescribing. Dales and coworkers (18) found that, for patients with mild and moderate COPD, the proportion of females on respiratory medications was twice that of males; however, there was no difference in medication use in men and women with severe COPD. Conversely, Sestini and investigators (27) found that men with COPD were more likely than women to be on the "new" dry powder inhalers versus metered dose inhalers. Studies on gender differences in vaccination history have had conflicting results. One Spanish study found males were more likely to be vaccinated against influenza (28) but less likely to be vaccinated against pneumococcus (29).

In 1998, the Food and Drug Administration requested that all National Institutes of Health–funded safety and efficacy trials should include women (30), yet historically the proportion of men in the key COPD clinical trials has ranged from 65 to 100% (31–36). For this reason, it is difficult to state with certainty any differences between men and women in terms of medication efficacy or safety. There also has been little investigation on how sex differences in lung anatomy and physiology may affect dosage and effectiveness of inhaled medications.

The effects of salmeterol/fluticasone combination therapy or tiotropium on lung function, symptoms, and quality of life are similar in men and women (30, 36). Budesonide has been shown to lead to a reduction in phlegm prevalence among men but not women (37), yet drug safety has been a matter of concern. A case-control study (38) showed a slight association between inhaled corticosteroid use and hip fracture, but this sample was composed almost entirely of women (79%). Conversely, a 1999 trial investigating the effects of budesonide showed no effect on bone density and fracture; however, this sample was composed of mostly male participants (73%) (39).

Management of exacerbations and related outcomes.
In a multicenter study of 397 subjects presenting to an emergency department with an acute exacerbation of COPD, Cydulka and colleagues (8) found higher relapse rates among men compared with women. The authors did not find any gender differences in care provided in the hospital: doctors' compliance with treatment guidelines was equally poor in the treatment of both male and female patients. They hypothesized four possible reasons for the gender difference in relapse rates: (1) men are released from emergency care sicker, (2) men have more severe COPD or their exacerbations are much worse (and their survey did not capture that), (3) men fail to adhere to newly prescribed regimens after their emergency department visit, or (4) men may have a lower tolerance for symptoms and simply report more problems. However, they also found that women were less likely to self-medicate with anticholinergic agents, and were less likely to seek emergency care within the first 24 hours of exacerbation.

Although this study focused primarily on gender differences in treatment of exacerbations in the emergency department, other studies have addressed gender differences in treatment outcomes. Gudmundsson and investigators (40) found no difference between men and women in mortality after hospital admission for COPD among 416 patients in five Nordic countries, nor did Raine and coworkers (41) in a study of 46,587 hospital admissions to 91 units across England, Wales, and Northern Ireland. Conversely, Patil and colleagues (42) found an increased risk for in-hospital mortality in men in an administrative data analysis of over 70,000 patients admitted for an acute exacerbation of COPD. Sunyer and coworkers (43) also identified a higher all-cause mortality rate among men in a population-based cohort study of 15,517 patients with COPD residing in Barcelona; however, given the differences in expected survival between men and women, they compared the mortality rates with the general population, and found that the rate ratio was higher among women.

Similar to the results of Cydulka and colleagues (8), Cao and investigators (44) found, in a cross-sectional survey of 186 patients with COPD in Singapore, that men were at higher risk of multiple hospital admissions in a year for acute exacerbations than women.

Pulmonary rehabilitation.
The components of pulmonary rehabilitation programs vary widely; however, a comprehensive rehabilitation program includes exercise therapy, nutritional counseling, and education (45). Little is known about the effects of pulmonary rehabilitation on women, because most studies have been reported on men (46, 47). Haggerty and colleagues (48) assessed improvements in various outcome measures in 164 subjects (54% female) enrolled in pulmonary rehabilitation. They found that women experienced larger improvements in the mastery and emotion subscales of the Chronic Respiratory Disease Questionnaire (CRDQ), and the psychosocial subscale of the Pulmonary Function Status Scale (PFSS); however, all other outcomes (other subscales of the CRDQ and the PFSS, and six-minute-walk distance) were equal. It is unclear which aspect of rehabilitation contributed most to these improvements, as the programs were comprehensive. Foy and colleagues (47) found that both women and men improved their quality of life after a 3-month exercise program; however, men continued to improve in HRQL when continuing the program to 18 months, whereas women gained no additional benefit from the extended duration of the program.

Surveillance
Although COPD is considered an extremely prevalent disease, the measurement and monitoring of the true burden of illness remain problematic. COPD is considered to be widely underdiagnosed: over 63% of Americans with low lung function had never been previously diagnosed with COPD (49). Prevalence estimates have relied on self-report, administrative databases, or lung function testing in large, population-based samples. Each method may contribute to under- or overestimates of COPD in men and women. By self-report, women tend to have a higher prevalence of COPD compared with men (50). However, using billing data from administrative health service databases, men tend to have a higher prevalence of COPD than women (51).

Surveillance data on hospitalizations or mortality for COPD tend to rely on identifying patients based on the International Classification of Diseases (ICD) coding system. Including or excluding specific codes can have a powerful impact on surveillance. Lacasse and colleagues (52) found that including the code ICD-9 490 (bronchitis, not specified as acute or chronic) doubled the prevalence of COPD in the Canadian province of Quebec. If women are more prevalent than men in this diagnostic code class, this would have a strong impact on our estimates of disease prevalence and any other subsequent surveillance measures.

DEVELOPING THE RESEARCH AGENDA: WHAT DO WE NEED TO KNOW ABOUT GENDER DIFFERENCES IN THE DIAGNOSIS, MANAGEMENT, AND SURVEILLANCE OF COPD?

Diagnosis
The prevalence of COPD symptoms is different for women versus men. Women and men may experience the same symptoms but perceive and/or report them differently; or they may experience different symptoms due to differences in their physiology and biology. To date, it has been difficult to determine the relative impacts of social and cultural versus physiologic influences on symptom reporting. Becklake and Kauffmann (53) speculate that a societal ideal of athleticism may influence men to be less likely to describe themselves as breathless than women. In addition, sociocultural factors may also influence women to be less likely to answer "yes" to questions about sputum or phlegm production. Physiologic research on dyspnea has provided some information on how sex differences in lung and airway size can influence the experience of dyspnea during exercise (54), yet we still know little about male/female differences in other symptoms, including differences in cough sensation, the biological properties of sputum, or differences in the mechanics of pulmonary hygiene. An interdisciplinary research approach could address the interaction of physiologic determinants of symptoms with the important sociologic influences that affect how men and women perceive and report their symptoms.

Gender bias in the diagnosis of COPD is to be expected when the epidemiology of a disease makes a dramatic shift in terms of male–female prevalence. Physicians are at risk for assuming COPD in men and asthma in women, but the use of spirometry to confirm a COPD diagnosis or methacholine challenge tests to confirm asthma should help alleviate this potential bias. Physicians must recognize that, although a woman may not report sputum or phlegm production and a man may not report breathlessness, a diagnosis of COPD should still be considered. A spirometric test provides an objective assessment of airway obstruction, and should be used whenever COPD is a possible diagnosis. However, the low use of spirometry in general is a cause for concern. A qualitative study on physician decision-making behavior with respect to spirometry referral could elucidate the barriers to referral. In addition, a policy analysis on lung function testing, including access, billing, and accreditation is also necessary to understand the clinical climate surrounding COPD and spirometry utilization.

Much of the data we have are from population-based studies, with large proportions of white subjects. We know little about the prevalence, symptoms, and diagnostic bias in men and women in vulnerable populations, including First Nations, Native Americans, Inuit, Métis, and new immigrants. A recent study found that 25% of aboriginal children living on reserves had evidence of airflow limitation diagnostic of asthma, and that smoking rates in aboriginal homes were 73% (55). However, there is little information on the epidemiology and diagnostic issues in these groups. Without this information, it will be very difficult to direct resources to ensure accurate, culturally relevant, and timely diagnosis for both men and women.

Management
The finding that pharmacologic therapies are only somewhat effective in maintaining a smoke-free status in women compared with men requires further research into two key areas. First, a better knowledge on the physiology of addiction in women versus men may advance the development of sex-specific pharmacologic therapies. Second, research on how to incorporate counseling and other aids to address the unique behavioral, psychological, and sociological stressors and barriers to women's success in quitting is needed.

Smoking behavior is closely related to cultural tradition for many aboriginal and immigrant communities and within these cultures there will be gender differences in how, why, and what individuals smoke. The denormalization of smoking with subsequent smoking cessation programs for these groups will require extensive research on both gender- and culturally relevant messaging in order to developr effective programs.

There are very few data on gender differences in the efficacy and safety of COPD medications. Vestbo and colleagues' (30) analysis of the Trial of Inhaled Steroids and Long-acting Beta2-agonists (TRISTAN) data is a step in the right direction. It would be beneficial to conduct a similar secondary analysis on data from other clinical trials, or to pool data for analysis if the individual studies are not adequately powered to test for gender differences. In addition, future clinical trials on pharmacologic efficacy and safety must ensure adequate recruitment of both men and women.

Without prospective data on corticosteroid side effects with similar numbers of men and women enrolled, we won't know whether inhaled corticosteroids pose a serious risk of osteoporosis and fracture, whether this risk is particularly heightened in women, whether the risk is consistent across all age groups or at different points in a woman's reproductive timeline, or whether there is an accelerated risk in men or women with preexisting bone density problems.

Further research on exacerbations must address gender-based factors, such as how differences in access to health care, health-seeking behavior, and perception of symptoms interact with sex-based factors, such as pulmonary hygiene during an exacerbation and bronchial hyperresponsiveness, to produce differences in outcomes between men and women with acute exacerbations of COPD.

Although more information is emerging regarding gender differences in how dyspnea is perceived during exercise, we have little information on many other aspects of pulmonary rehabilitation. Further studies, including those using qualitative methodology, would help to better understand issues of access to programs, gender differences to barriers in participating and continuing with exercise programs, whether programs are gender-sensitive and meet the educational and psychosocial needs of both men and women, and whether exercise programs need to consider differences between men and women in terms of physiology.

Surveillance
Why different surveillance methods would yield gender differences in prevalence estimates is unknown. Administrative health services data have been validated against hospital and physician medical records, but few of these validations have been reported by gender (56–58). The potential misdiagnosis of COPD as asthma, particularly among women, may also bias statistics derived using ICD coding.

Further to the issue of coding, the selection of diagnostic coding for use in COPD surveillance has not been thoroughly examined to determine how different ICD-9/10 codes yield different prevalence and mortality estimates over time for women versus men. Specifically, better characterization over time of patients coded with ICD-9 490 would help to determine if indeed these patients represent individuals with COPD and should be included in estimates of disease prevalence.

CONCLUSIONS

Research on gender differences in the diagnosis, management, and surveillance of COPD is in its infancy, but these beginning steps herald an exciting time for both researchers and clinicians. None of these issues can be studied solely in the biomedical laboratory or in the field; they all require an appreciation of the complex interplay between physiology, psychology, sociology, culture, public policy, and many other factors. In this article, we have articulated a few of the key research findings in the areas of gender differences in COPD diagnosis, management, and surveillance and have identified several gaps in the current knowledge. Addressing these important research areas will ultimately result in better care of men and women with COPD as well as improve the ability for accurate surveillance of this disease.

ACKNOWLEDGMENTS

This article was based on a round table discussion at the "Towards a Research Agenda on Gender and Chronic Obstructive Pulmonary Disease" conference, which was sponsored by the Canadian Institutes of Health Research (Institute of Gender and Health), the Canadian Tobacco Control Research Initiative, and by ICEBERGS (http://www.icebergs.ubc.ca). The authors thank the participants of the conference for their insightful discussions.

FOOTNOTES

Supported by the Canadian Institutes of Health Research (CIHR) Fellowship and ICEBERGS, a CIHR-funded interdisciplinary team focused on gender and COPD research (P.G.C.); and the University of British Columbia Graduate Fellowship and the Shaughnessy Hospital Volunteer Society Fellowship in Health Care (S.M.G.).

Conflict of Interest Statement: Neither author has a financial relationship with a commercial entity that has an interest in the subject of this manuscript.

(Received in original form June 28, 2007; accepted in final form August 13, 2007)

REFERENCES

  1. Pauwels RA, Buist AS, Ma P, Jenkins CR, Hurd SS. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): executive summary. Respir Care 2001;46:798–825.[Medline]
  2. Celli BR, MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23:932–946.[Free Full Text]
  3. O'Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk D, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, et al. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease-2003. Can Respir J 2003;10(Suppl A):11A–65A.[Medline]
  4. A Report of the Task Force on the NIH's Women's Health Research Agenda for the Twenty-first Century. Bethesda, MD: National Institutes of Health; 1999. NIH Publication No. 99-4385.
  5. Kauffmann F, Becklake M. Maladies obstructives pulmonaires: un paradigme de la complexite des differences de sante entre hommes et femmes. In: Saurel-Cubizolles MJ, Blondell B, editors. La Sante des Femmes. Paris: Flammarion, Medecine et Sciences; 1996.
  6. Watson L, Vestbo J, Postma DS, Decramer M, Rennard S, Kiri VA, Vermeire PA, Soriano JB. Gender differences in the management and experience of chronic obstructive pulmonary disease. Respir Med 2004;98:1207–1213.[CrossRef][Medline]
  7. de Torres JP, Casanova C, Hernandez C, Abreu J, Aguirre-Jaime A, Celli BR. Gender and COPD in patients attending a pulmonary clinic. Chest 2005;128:2012–2016.[CrossRef][Medline]
  8. Cydulka RK, Rowe BH, Clark S, Emerman CL, Rimm AR, Camargo CA. Gender differences in emergency department patients with chronic obstructive pulmonary disease exacerbations. Acad Emerg Med 2005;12:1173–1179.[CrossRef][Medline]
  9. Di Marco F, Verga M, Reggente M, Maria Casanova F, Santus P, Blasi F. Allegra L, Centanni S. Anxiety and depression in COPD patients: the roles of gender and disease severity. Respir Med 2006;100:1767–1774.[CrossRef][Medline]
  10. Gift AG, Shepard CE. Fatigue and other symptoms in patients with chronic obstructive pulmonary disease: do women and men differ? J Obstet Gynecol Neonatal Nurs 1999;28:201–208.[CrossRef][Medline]
  11. Katzura H, Yamada K, Wakagayashi R, Kida K. Gender-associated differences in dyspnea and health-related quality of life in patients with chronic obstructive pulmonary disease. Respirology 2007;12:427–432.[CrossRef][Medline]
  12. Low G, Gutman G. Examining the role of gender in health-related quality of life: perceptions of older adults with chronic obstructive pulmonary disease. J Gerontol Nurs 2006;21:42–49.[CrossRef]
  13. Hesselink AE, van der Windt PA, Penninx BW, Wijnhoven HA, Twisk JW, Bouter LM, van Eijk JT. What predicts change in pulmonary function and quality of life in asthma or COPD? J Asthma 2006;43:513–519.[CrossRef][Medline]
  14. Stahl E, Lindberg A, Jansson SA, Ronmark E, Svensson K, Andersson F, Lofdahl CG, Lundback B. Health-related quality of life is related to COPD severity. Health Qual Life Outcomes 2005;9:56.
  15. Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest 2001;119:1691–1695.[CrossRef][Medline]
  16. Miravitlles M, de la Roza C, Naberan K, Lamban M, Gobartt E, Martin A, Chapman KR. Attitudes toward the diagnosis of chronic obstructive pulmonary disease in primary care [Spanish]. Arch Bronconeumol 2006;42:3–8.[CrossRef][Medline]
  17. Anthonisen NR, Wooldrage K, Manfreda J. Use of spirometry and respiratory drugs in Manitobans over 35 years of age with obstructive lung diseases. Can Respir J 2005;12:69–74.[Medline]
  18. Dales RE, Mehdizadeh A, Aaron SD, Vandemheen KL, Clinch J. Sex differences in the clinical presentation and management of airflow obstruction. Eur Respir J 2006;28:319–322.[Abstract/Free Full Text]
  19. Chapman KR. Chronic obstructive pulmonary disease: are women more susceptible than men? Clin Chest Med 2004;25:331–341.[CrossRef][Medline]
  20. Panday S, Reddy SP, Ruiter RAC, Bergstrom E, de Vries H. Nicotine dependence and withdrawal symptoms among occasional smokers. J Adolesc Health 2007;40:144–150.[CrossRef][Medline]
  21. Ben-Laken Cohen S, Paré PD, Man SFP, Sin DD. The growing burden of chronic obstructive pulmonary disease and lung cancer in women: examining sex differences in cigarette smoke metabolism. Am J Respir Crit Care Med 2007;176:113–120.[Abstract/Free Full Text]
  22. Scharf D, Shiffman S. Are there gender differences in smoking cessation, with and without bupropion? Pooled- and meta-analysis of clinical trials of bupropion SR. Addiction 2004;99:1462–1469.[CrossRef][Medline]
  23. Gritz ER, Nielsen IR, Brooks LA. Smoking cessation and gender: the influence of physiological, psychological, and behavioral factors. J Am Med Womens Assoc 1996;51:35–42.[Medline]
  24. Bjornson W, Rand C, Connett JE, Lindgren P, Nides M, Pope F, Buist AS, Hoppe-Ryan C, O'Hara P. Gender differences in smoking cessation after 3 years in the Lung Health Study. Am J Public Health 1995;85:223–230.[Abstract/Free Full Text]
  25. Sherman SE, Fu SS, Joseph AM, Lanto AB, Yano EM. Gender differences in smoking cessation services received among veterans. Womens Health Issues 2005;15:126–133.[CrossRef][Medline]
  26. Wagena EJ, Zeegers MP, van Schayck CP, Wouters EF. Benefits and risks of pharmacological smoking cessation therapies in chronic obstructive pulmonary disease. Drug Saf 2003;26:381–403.[CrossRef][Medline]
  27. Sestini P, Cappiello V, Aliani M, Martucci P, Sena A, Vaghi A, Canessa PA, Neri M, Melani AS. Prescription bias and factors associated with improper use of inhalers. J Aerosol Med 2006;19:127–136.[CrossRef][Medline]
  28. Jimenez-Garcia R, Arinez-Fernandez MC, Garcia-Carballo M, Hernandez-Barrera V, de Miguel AG, Carrasco-Garrido P. Influenza vaccination coverage and related factors among Spanish patients with chronic obstructive pulmonary disease. Vaccine 2005;23:3679–3686.[CrossRef][Medline]
  29. Arinez-Fernandez MC, Carrasco-Garrido P, Garcia-Carballo M, Hernandez-Barrera V, de Miguel AG, Jiménez-Garcia R. Determinants of pneumococcal vaccination among patients with chronic obstructive pulmonary disease in Spain. Hum Vaccin 2006;2:99–104.[Medline]
  30. Vestbo J, Soriano JB, Anderson JA, Calverley P, Pauwels R, Jones P. Gender does not influence the response to the combination of salmeterol and fluticasone proprionate in COPD. Respir Med 2004;98:1045–1050.[CrossRef][Medline]
  31. Vincken W, van Noord JA, Greefhorst AP, Bantje TA, Kesten S, Korducki L, Cornelissen PJ. Improved health outcomes in patients with COPD during 1 year's treatment with tiotropium. Eur Respir J 2002;19:209–216.[Abstract/Free Full Text]
  32. Ikeda A, Nishimura K, Koyama H, Izumi T. Bronchodilating effects of combined therapy with clinical dosages of ipratropium bromide and salbutamol for stable COPD: comparison with ipratropium bromide alone. Chest 1995;107:401–405.[Medline]
  33. Mahler DA, Donohue JF, Barbee RA, Goldman MD, Gross NJ, Wisniewski ME, Yancey SW, Zakes BA, Rickard KA, Anderson WH. Efficacy of salmeterol xinafoate in the treatment of COPD. Chest 1999;115:957–965.[CrossRef][Medline]
  34. Dahl R, Greefhorst LA, Nowak D, Nonikov V, Byrne AM, Thomson MH, Till D, Della Cioppa G. Inhaled formoterol dry powder versus ipratropium bromide in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001;164:778–784.[Abstract/Free Full Text]
  35. Man WD, Mustfa N, Nikoletou D, Kaul S, Hart N, Rafferty GF, Donaldson N, Polkey MI, Moxham J. Effect of salmeterol on respiratory muscle activity during exercise in poorly reversible COPD. Thorax 2004;59:471–476.[Abstract/Free Full Text]
  36. O'Donnell DE, Fluge T, Gerken F, Hamilton A, Webb K, Aguilaniu B, Make B, Magnussen H. Effects of tiotropium on lung hyperinflation, dyspnoea and exercise tolerance in COPD. Eur Respir J 2004;23:832–840.[Abstract/Free Full Text]
  37. Watson L, Schouten JP, Lofdahl CG, Pride NB, Laitinen LA, Postma DS. Predictors of COPD symptoms: does the sex of the patient matter? Eur Respir J 2006;28:311–318.[Abstract/Free Full Text]
  38. Hubbard RB, Smith CJ, Smeeth L, Harrison TW, Tattersfield AE. Inhaled corticosteroids and hip fracture: a population-based case-control study. Am J Respir Crit Care Med 2002;166:1563–1566.[Abstract/Free Full Text]
  39. Pauwels RA, Lofdahl CG, Laitinen LA, Schouten JP, Postma DS, Pride NB, Ohlsson SV. Long-term treatment with inhaled budesonide in persons with mild chronic obstructive pulmonary disease who continue smoking. European Respiratory Society Study on Chronic Obstructive Pulmonary Disease. N Engl J Med 1999;340:1948–1953.[Abstract/Free Full Text]
  40. Gudmundsson G, Gislason T, Lindberg E, Hallin R, Ulrik CS, Brondum E, Nieminen MM, Aine T, Bakke P, Janson C. Mortality in COPD patients discharged from hospital: the role of treatment and co-morbidity. Respir Res 2006;7:109.[CrossRef][Medline]
  41. Raine R, Goldfrad C, Rowan K, Black N. Influence of patient gender on admission to intensive care. J Epidemiol Community Health 2002;56:418–423.[Abstract/Free Full Text]
  42. Patil SP, Krishnan JA, Lechtzin MD, Diette GB. In-hospital mortality following acute exacerbations of chronic obstructive pulmonary disease. Arch Intern Med 2003;163:1180–1186.[Abstract/Free Full Text]
  43. Sunyer J, Anto JM, McFarlane D, Domingo A, Tobias A, Barcelo MA, Munoz A. Sex differences in mortality of people who visited emergency rooms for asthma and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1998;158:851–856.[Abstract/Free Full Text]
  44. Cao Z, Ong KC, Eng P, Tan WC, Ng TP. Frequent hospital readmissions for acute exacerbation of COPD and their associated factors. Respirology 2006;11:188–195.[CrossRef][Medline]
  45. Fabbri L, Pauwels RA, Hurd SS. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease: GOLD Executive Summary; updated 2003. COPD 2004;1:105–141.[Medline]
  46. Varkey AB. Chronic obstructive pulmonary disease in women: exploring gender differences. Curr Opin Pulm Med 2004;10:98–103.[CrossRef][Medline]
  47. Foy CG, Rejeski WJ, Berry MJ, Zaccaro D, Woodard CM. Gender moderates the effects of exercise therapy on health-related quality of life among COPD patients. Chest 2001;119:70–76.[CrossRef][Medline]
  48. Haggerty MC, Stockdale-Woolley R, Zuwallack R. Functional status in pulmonary rehabilitation participants. J Cardiopulm Rehabil 1999;19:35–42.[CrossRef][Medline]
  49. Mannino D, Homa D, Akinbami L, Ford E, Redd S. Chronic obstructive pulmonary disease surveillance: United States 1971–2000. MMWR CDC Surveill Summ 2002;51:1–16.
  50. Canadian Institute for Health Information; Canadian Lung Association; Health Canada; Statistics Canada. Respiratory disease in Canada. Ottawa, Canada: Health Canada; 2001.
  51. Chaudhry M, Camp PG, Abbott W, Levy RD, Sin DD, Road JD, Tregillus V, Platt H. A snapshot of COPD care in British Columbia. Vancouver, Canada: Ministry of Health, Government of British Columbia; 2005.
  52. Lacasse Y, Montori VM, Lanthier C, Maltais F. The validity of diagnosing chronic obstructive pulmonary disease from a large administrative database. Can Respir J 2005;12:251–256.[Medline]
  53. Becklake MR, Kauffmann F. Gender differences in airway behavior over the human life span. Thorax 1999;54:1119–1138.[Free Full Text]
  54. Ofir D, McBride I, Webb KA, Dudgeon DJ, O'Donnell DE. Gender differences in exertional dyspnea with advancing age [abstract]. Proc Am Thorac Soc 2006;3:A224.
  55. Sin DD, Sharpe HM, Cowie RL, Man SF. Spirometric findings among school-aged First Nations children on a reserve: a pilot study. Can Respir J 2004;11:45–48.[Medline]
  56. Soriano JB, Maier WC, Visick G, Pride N. Validation of general practitioner-diagnosed COPD in the UK General Practice Research Database. Eur J Epidemiol 2001;17:1075–1080.[CrossRef][Medline]
  57. Rawson NSB, D'Arcy C. Assessing the validity of diagnostic information in administrative health utilization data: experience in Saskatchewan. Pharmacoepidemiol Drug Saf 1998;7:389–398.[CrossRef][Medline]
  58. McKnight J, Scott A, Menzies D, Bourbeau J, Blais L, Lemiere C. A cohort study showed that health insurance databases were accurate to distinguish chronic obstructive pulmonary disease from asthma and classify disease severity. J Clin Epidemiol 2005;58:206–208.[CrossRef][Medline]
  59. Watson L, Vonk JM, Lofdahl CG, Pride NB, Pauwels RA, Laitinen LA, Schouten JP, Postma DS. Predictors of lung function and its decline in mild to moderate COPD in association with gender: results from the EUROSCOP study. Respir Med 2006;100:746–753.[CrossRef][Medline]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Camp, P. G.
Right arrow Articles by Goring, S. M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Camp, P. G.
Right arrow Articles by Goring, S. M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS