Brazilian Journal of Pulmonology

ISSN (on-line): 1806-3756 | ISSN (printed): 1806-3713

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Year 2003 - Volume 29  - Number 1  (January/February)

Upgrading

1 - Publicações em Pneumologia - Novos ou velhos rumos?

Carlos Alberto de Castro Pereira

J Bras Pneumol.2003;29(1):1-

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Editorial

2 - Uma simples infecção por pneumococo...

Anna Sara S. Levin

J Bras Pneumol.2003;29(1):2-3

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Original Article

3 - Prevalence of Streptococcus pneumoniae resistance to penicillin in two hospital from Caxias do Sul

Prevalência de resistência à penicilina do Streptococcus pneumoniae em dois hospitais de Caxias do Sul

Wilson Paloschi Spiandorello, Fernanda Morsch, Franca Stedile Angeli Spiandorello

J Bras Pneumol.2003;29(1):15-20

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Streptococcus pneumoniae resistance to penicillin was studied in two hospitals in Caxias do Sul, Rio Grande do Sul, Brazil, between May 1998 and November 2001. From the 176 strains of invasive Streptococcus pneumoniae that were identified, 2.28% (CI 0.62-5.74) presented intermediate resistance, and 3.42% (CI 1.26-7.31) presented high-level resistance. Conclusion was that the use of penicillin in Caxias do Sul was still justified as treatment of pneumococcal pneumonia, differently from other centers where the penicillin was replaced by other antibiotics. These results confirm the statement of IDSA (Infectious Diseases Society of America) guideline for the management of community-acquired pneumonia in adults, that the choice of antimicrobial drug to treat pneumococcal pneumonia should be guided by local or regional prevalence of resistance to penicillin.

 


4 - Hospitalization due to tuberculosis at a university hospital

Hospitalização por tuberculose em hospital universitário

Sandra Aparecida Ribeiro, Thaís Nemoto Matsui

J Bras Pneumol.2003;29(1):9-14

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Patients with active tuberculosis (Tb) can be admitted to hospital due to other health problems, Tb not being the admission diagnosis. In this study, the authors analyzed 141 inpatients with Tb, notified to the São Paulo Hospital Central Control of Infectious Diseases, during the period of august, 1999 to April, 2001, trying to identify causes of admission, risk factors, and duration of hospitalization. Of the total number of patients, 63% were male and 37% female, mean age being 38 years-old. 28% were smokers, 23% were alcoholics, and 17% were drug addicts. 23% of them reported previous Tb. 42% were HIV positive. 54.6% of the patients presented pulmonary tuberculosis and 67.5% of them had positive sputum. 22% of the patients had side effects to Tb treatment during hospitalization, drug-induced hepatitis (65.7%) and gastric intolerance (25.7%) being the most frequent. 8.5% of the patients required intensive care, staying there for 11 days, and 54% of the patients stayed at an infirmary with respiratory isolation. 17.7% of the patients died in hospital and 52% due to Tb. The patients were hospitalized for 29 days and isolated for 18 days. Drug addicts and smokers patients had longer hospital stays. HIV positive patients who had positive sputum had the same hospitalization period as others.

 


6 - Psychological profile and nicotine dependence in smoking undergraduate students of UFMT

Características de personalidade e dependência nicotínica em universitários fumantes da UFMT

Regina de Cássia Rondina, Clovis Botelho, Ageo Mário Cândido da Silva, Ricardo Gorayeb

J Bras Pneumol.2003;29(1):21-27

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Introduction: Data on the relationship between personality profile and nicotine addiction may help health professionals in the design and improvement of programs for the treatment and prevention of addiction. Objective: To investigate the relationship between the personality profile and nicotine addiction in a group of smoking undergraduate students. Methods: A total of 1,245 undergraduate students were randomly selected among 10,500 students enrolled at the UFMT - Cuiabá campus in 2001. A standard questionnaire was applied for social characterization and to determine the pattern of cigarette consumption, with 80 students being considered smokers. These students were then submitted to the Fagerström Test (1978) of nicotine addiction and to the reduced version of the Comrey Personality Scale (CPS) which determines personality dimensions. Results: Analysis of the mean scores (Student t-test) revealed a marginal or inversely proportional borderline association between addiction and the Order x Lack of Compulsion scale (p = 0.06), and a negative or inversely proportional association between the CPS Extroversion x Introversion (p = 0.002) and Control of Validity scales (p = 0.04). Linear regression of the Fagerström Test points confirmed the inversely proportional borderline association between addiction and the Order x Lack of Compulsion (p = 0.06) and CPS Extroversion x Introversion scales (p = 0.02). However, controlling for interference of daily cigarette consumption, only the Extroversion x Introversion scale remained associated with addiction (p = 0.001). Conclusions: Smoker and nicotine dependent students are less extrovert than non-dependent smokers.

 


7 - Validation of the Airways questionnaire 20 - AQ20 in patients with chronic obstructive pulmonary disease (COPD) in Brazil

Validação do questionário de vias aéreas 20 ("Airways questionnaire 20" - AQ20) em pacientes portadores de doença pulmonar obstrutiva crônica (DPOC) no Brasil

Aquiles Camelier, Fernanda Rosa, Paul Jones, José Roberto Jardim

J Bras Pneumol.2003;29(1):28-35

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Introduction: A great emphasis has been placed on health-related quality of life of COPD patients and specific questionnaires have been developed in order to measure it. Interventions directed to improve symptoms and decrease morbi-mortality may be evaluated by such questionnaires. Objective: This study describes the language and cultural adaptation of a new (and short) disease-specific health status questionnaire developed for chronic obstructive pulmonary diseases: the Airways Questionnaire 20 (AQ20). This questionnaire has only 20 simple items, and is one of the shortest ones ever described in the literature. Methods: In order to validate this questionnaire in Brazil, an initial translation from English to Portuguese has been made. The cultural adaptation was taken into consideration and then a back translation to English was undertaken, in order to obtain a final Portuguese version. Correlations were made with FEV1, SpO2, BMI and another disease specific health status questionnaire, the Saint George Respiratory Questionnaire (SGRQ), previously validated in Brazil. To test the reproducibility of AQ20, the interclass correlation ratio was done. Results: The interclass correlation ratio for the total score was a = 0.90 (intraobserver variability) and a = 0.93 (interobserver variability). The correlation with total SGRQ score was 0.76, with p < 0.001. Conclusion: It can be concluded that the Brazilian Portuguese version of AQ20 is reproducible, with good correlation with SGRQ total score, which makes it a valid questionnaire to measure health status in obstructive patients in Brazil.

 


Review Article

8 - Linear growth in asthmatic children

O crescimento de crianças com asma

Maria Ângela Reis de Góes Monteiro Antonio, José Dirceu Ribeiro, Adyléia Aparecida Dalbo Contrera Toro, Aquiles Eugenico Piedrabuena, André Moreno Morcillo

J Bras Pneumol.2003;29(1):36-42

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The growth of children with asthma has attracted great interest because it is a chronic respiratory illness whose prevalence in childhood has increased during the last decades. The relationship between asthma and growth has been studied for a long time, but the great variability of diagnosis, therapy, and different methods of investigation make it difficult to disentangle the factors that are responsible for the growth retardation detected by some authors. As a result of different observations, there remain many doubts about the impact of asthma on child and adolescent growth. The aim of this paper is to provide a general view on the issue.

 


Case Report

9 - Sternal chondrosarcoma

Condrossarcoma de esterno

Nelson Perelman Rosenberg, Ivo Leuck Jr., Celso Schuler, Fernando Delgiovo, Eduardo Spadari de Araújo, Paula Vasconcelos Martini

J Bras Pneumol.2003;29(1):43-44

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Sternal neoplasms are very uncommon. The lack of consistent reports in the literature renders it difficult to make prospective evaluations. The authors report the case of a seventy-year old woman who presented with a chondrosarcoma of the sternum, treated at their service.

 


10 - Coccidioidomycosis: an unusual cause of acute respiratory distress syndrome

Coccidioidomicose: causa rara de síndrome do desconforto respiratório agudo

Kelson Nobre Veras, Bruno C. de Souza Figueirêdo, Liline Maria Soares Martins, Jayro T. Paiva Vasconcelos, Bodo Wanke

J Bras Pneumol.2003;29(1):45-48

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A male farmer, 20 years old, from the countryside of the State of Piauí, developed acute respiratory infection. Despite adequate antimicrobial therapy, there was worsening respiratory manifestations demanding mechanical ventilation. Radiographs showed diffuse pulmonary infiltrates. PaO2/FiO2 was 58. Direct microscopy and culture from tracheal aspirates disclosed Coccidioides immitis. Autochthonous cases of coccidioidomycosis have only recently been described in Brazil, most of them from the State of Piauí. C. immitis has been isolated from humans, dogs and armadillos (Dasypus novemcinctus), and also from soil samples of armadillo's burrows. Therapeutic failure to antimicrobials and patient's origin from recognized endemic areas should alert for the possibility of acute pulmonary coccidioidomycosis.

 


Letters to the Editor

11 - Tratamento compulsório da tuberculose: avanço ou retrocesso?

Sandra Aparecida Ribeiro

J Bras Pneumol.2003;29(1):50-52

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Year 2003 - Volume 29  - Number 2  (March/April)

Editorial

1 - Pleurodese: qual agente deve ser utilizado?

Richard W. Light

J Bras Pneumol.2003;29(2):53-54

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2 - Fatores de risco para tuberculose multirresistente adquirida

Afrânio Lineu Kritski

J Bras Pneumol.2003;29(2):55-56

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Original Article

3 - Pleurodesis induced by intrapleural injection of silver nitrate or talc in rabbits. Can it be used in humans?

Pleurodese induzida pela injeção intrapleural de nitrato de prata ou talco em coelhos: há perspectivas para o uso em humanos?

Francisco S. Vargas, Leila Antonangelo, Marcelo A.C. Vaz, Evaldo Marchi, Vera Luiza Capelozzi, Eduardo H. Genofre, Lisete R. Teixeira

J Bras Pneumol.2003;29(2):57-63

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Objective: To evaluate the pleurodesis and the lung damage caused by intrapleural silver nitrate or talc in an experimental model in rabbits to consider the use in human beings. Design: 112 rabbits were randomized to receive intrapleural 0.5% silver nitrate or 400 mg/kg talc slurry in 2 ml saline. Eight rabbits in each group were sacrificed 1, 2, 4, 6, 8, 10, or 12 months post injection. The degree of pleurodesis (gross pleural fibrosis and inflammation), lung damage (collapse and edema), and cellular infiltrates were graded on a 0 to 4 scale. Results: The intrapleural injection of silver nitrate produced a better pleurodesis than did the intrapleural injection of talc slurry. The lung damage was moderate 1 month after silver nitrate and greater than after talc. They were similar as from the second month. Conclusions: The better pleurodesis induced by silver nitrate persists for at least one year. The more evident lung damage after silver nitrate was mild with reversible changes which show a clear tendency to normalize with time. For these reasons, the efficacy of silver nitrate as a sclerosing agent in humans should be evaluated.

 


Keywords: Pleurodesis. Talc. Silver nitrate. Pleural effusion.

 

4 - Sleep pattern in patients with COPD and correlation among the gasometric, spirometric, and polysomnographic variants

Padrão do sono em pacientes portadores de doença pulmonar obstrutiva crônica e correlação entre variáveis gasométricas, espirométricas e polissonográficas

Carlos Eduardo Ventura Gaio dos Santos, Carlos Alberto de Assis Viegas

J Bras Pneumol.2003;29(2):69-74

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Objective: There are few studies on chronic obstructive pulmonary disease (COPD) establishing differences between the functional parameters of the disease and variants of sleep. The aim of the authors is to describe the sleep patterns of these patients and to investigate possible correlations among spirometric, gasometric, and polysomnographic variants. Methods: Transversal study using patients with COPD, submitted to spirometry, arterial gasometry, and polysomnography. Results: 21 male patients were studied with average age = 67 ± 9, 7 ± 4 average points in the Epworth sleep scale, average FEV1/FVC% = 54 ± 13.0, average PaO2 = 68 ± 11 mmHg, average PaCO2 = 37 ± 6 mmHg. Sleep efficiency decreased (65 ± 16%) with the decrease in slow wave sleep (8 ± 9%) and in rapid eye movement (REM) sleep (15 ± 8%). Average T90 = 43 ± 41%. Average apnea-hypopnea index (AHI) = 3 ± 5/h, two patients (9.5%) presented overlap syndrome. In the correlation analysis a correlation was observed between PaO2 and T90 (p < 0.01), PaCO2 and T90 (p < 0.05), and AHI and the cardiac rate in REM (p < 0.01). There was no correlation between spirometric and polysomnographic variants. Conclusion: The low sleep efficiency, the high number of awakenings, and shift in stages show the low quality of sleep. There were no linear correlations between the spirometric and polysomnographic variants.

 


4 - Profile of a Brazilian population with chronic obstructive pulmonary disease

Perfil de uma população brasileira com doença pulmonar obstrutiva crônica grave

Mateo Sainz Yaksic, Mauro Tojo, Alberto Cukier, Rafael Stelmach

J Bras Pneumol.2003;29(2):64-68

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Chronic obstructive pulmonary disease (COPD) is a public health problem. Tobacco smoking is the major cause, but not the only one. Air pollution, exposure to chemical compounds, environmental smoke exposure, and environmental tobacco smoke are among other contributing causes; viral and bacterial infection are risk factors too. Gender and weight loss are associated to the severity of the disease. Co-morbidity is frequent. Objective: To characterize a population of COPD outpatients followed at a tertiary medical service. Methods: Questionnaires were applied to patients with COPD. The data included gender, age, weight, body mass index (BMI), oxygen delivery users, and FEV1, exposure to tobacco smoke, exposure to wood smoke, tuberculosis antecedent and co-morbid diseases. Results: Of the 70 patients enrolled in the study, 70% (49) were male with an average age of 64 ± 10 years, an average weight of 63 ± 16 kg and an average BMI of 22 ± 5 kg/m2. 45,7% were oxygen dependent and the FEV1 average was 35 ± 14%. Nine (12.8%) patients never smoked, while 78.8% had quit tobacco smoking, (38 ± 11 pack/years was the average). Nine (12.8%) smoked straw cigarettes. Eighteen (25.7%) had environmental exposure to wood smoke. Eleven (15.7%) patients had tuberculosis, 5.7% complained of asthma symptoms, 2.8% had bronchiectasis, 11.4% diabetes mellitus, 51.4% hypertension, and 20% Cor pulmonale. Conclusion: Other possible COPD etiologies must be investigated. Determinants for the pulmonary injury could be environmental smoke exposure associated to former infections. Men with low BMI are typically representative of this severe patient population. Hypertension and Cor Pulmonale are frequent co-morbidity factors.

 


6 - Inhaled medication on asthma management: evaluation of how asthma patients, medical students, and doctors use the different devices

Inalantes no tratamento da asma: avaliação do domínio das técnicas de uso por pacientes, alunos de medicina e médicos residentes

Janaína Barbosa Muniz, Carlos Roberto Padovani, Irma Godoy

J Bras Pneumol.2003;29(2):75-81

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Asthma is characterized by variable airflow obstruction, hyperresponsiveness of airways to endogenous or exogenous stimuli and inflammation. Inadequacy of the techniques to use different inhalation devices is a cause of no response to treatment. The main purpose of this study was to evaluate how 20 medical students, 36 resident physicians on Internal Medicine/Pediatrics, and 40 asthma patients used three devices for inhalation therapy containing placebo. All patients were followed at the Pulmonary Outpatient Service of Botucatu Medical School and had been using inhaled medication during the last six months. The following devices were evaluated: metered dose inhalers (MDI), dry powder inhalers (DPI), and MDI attached to a spacer device. A single observer applied a protocol containing the main steps necessary to obtain a good inhaler technique to follow and grade the use of different devices. Health care professionals tested all three devices and patients tested only the device being used on their management. MDI was the device best known by doctors and patients. MDI use was associated with errors related to the coordination between inspiration and device activation. Failure do exhale completely before inhalation of the powder was the more frequent error observed with DPI use. In summary, patients have not been receiving repeated instruction on how to use inhaled medication and health care professionals are not well prepared to adequately teach their patients.

 


7 - Mortality due to pneumoconioses in macro regions of Brazil in the 1979-1998 period

Mortalidade por pneumoconioses nas macrorregiões do Brasil no período de 1979-1998

Hermano Albuquerque de Castro, Genésio Vicentin, Kellen Cristina Xavier Pereira

J Bras Pneumol.2003;29(2):82-88

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Pneumoconioses make up a group of lung diseases related to exposure to mineral dusts in work environments. This is a public health problem as such diseases could have already been eradicated in Brazil with the use of control measures in such environments. The aim in this paper was to map the distribution of deaths due to pneumoconioses in the different Brazilian geographical areas and states through an ecological survey carried out among the working population older than 15 years. The preliminary results of this investigation in the Brazilian macro regions in the period from 1979 to 1998 are presented. This study used mortality data from the Mortality Information System of Datasus - Data Processing Department of the Unified Health System, including codes from International Classification of Diseases (ICD) 9 and ICD 10. The results showed an increase of the coefficient of deaths due to pneumoconioses per 1 million inhabitants per year throughout this period. The shift from ICD 9 to ICD 10 showed an increase in the frequency of deaths, which was twice as high. As a conclusion, the coefficients of deaths due to pneumoconiosis does not describe this problem adequately, thus obscuring the transcendence and magnitude of the disease. To obtain more representative indicators it is necessary to know the population really exposed and the territorial distribution of the disease.

 


8 - Risk factors associated to acquired multidrug resistant tuberculosis

Fatores de risco para tuberculose multirresistente adquirida

Elizabeth Clara Barroso, Rosa Maria Salani Mota, Raimunda Oliveira Santos, Ana Lúcia Oliveira Sousa, Joana Brasileiro Barroso, Jorge Luís Nobre Rodrigues

J Bras Pneumol.2003;29(2):89-97

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Multidrug resistant tuberculosis (MDR-TB) is a serious, feared, and difficult to control problem, and is showing a growing tendency worldwide. Objective: To make a risk factors analysis for acquired MDR-TB. Methods: A population-based case-control study was conducted in a retrospective way. Multidrug resistance was defined as resistance to at least Rifampin (RFM) + Isoniazid (INH), and susceptible TB was defined as the case that had had the first treatment in a period similar to the first treatment of the MDR-TB cases, but that was cured at the moment of the interview. The selection of cases was made based on the list of Susceptibility Tests (ST) carried out at the Central Laboratory of Public Health of the State of Ceará, in the period 1990 to 1999. The Proportion Method was used to make a survey of resistance to the six antituberculosis drugs (isoniazid, rifampin, pyrazinamide, ethambutol, ethionamide, streptomycin) that represent the standard treatment in Brazil. Controls were selected from the book of registry of TB cases. Univariate and multivariate analysis was performed and statistical significance was considered with a p value < 0.05. Results: Of the 1,500 ST performed in the period, 266 strains were multidrug resistant. Only 153 patients were identified. Of these, 19 were excluded. The Group of Cases comprised 134 patients and the Controls, 185. The following risk factors were found after the multivariate analysis: lack of sewer in the domicile, alcoholism + tobacco smoking, number of previous treatments, irregular treatments and lung cavities. Conclusion: Based on the evidence, conclusion is that these five factors play a role in the development of acquired MDR-TB, and that neutralizing such factors can contribute to the control of tuberculosis.

 


Case Report

9 - Tuberculosis pericarditis in patients with AIDS

Pericardite tuberculosa em portadores da síndrome de imunodeficiência adquirida

Ruggero Bernardo Guidugli, Paul Albert Hamrick, Nancy Figueiroa de Rezende

J Bras Pneumol.2003;29(2):98-100

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Two quite dyspneic HIV positive patients were admitted to the Emergency Room; they presented with aspects and images suggesting pericardial effusion. The analysis of an initial liquid puncture did not show any specificity and the patients did not register any clinical improvement. Both patients were submitted to a subxiphoid pericardial window, all the effusion liquid was drained, and a biopsy of the pericardium tissue was completed revealing a granulomatous process. Good evolution was the result of specific treatment. Such findings draw attention to a high possibility of pericardial suffusion in AIDS patients being tuberculosis, in particular if one considers the high prevalence of this disease in Brazil. The results also showed that the opening of a subxiphoid pericardial window and the specific triple scheme is a procedure that leads to good therapeutic evolution in this kind of patients.

 


Review Article

10 - Reexpansion pulmonary edema

Edema pulmonar de reexpansão

Eduardo Henrique Genofre, Francisco S. Vargas, Lisete R. Teixeira, Marcelo Alexandre Costa Vaz, Evaldo Marchi

J Bras Pneumol.2003;29(2):101-106

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Reexpansion pulmonary edema (RPE) is a rare, but frequently lethal, clinical entity. The precise pathophysiologic abnormalities associated with this disorder are still unknown: decreased surfactant levels and a pro-inflammatory status are putative mechanisms. Early diagnosis is crucial, since prognosis depends on early recognition and prompt treatment. Considering the high mortality rates related to RPE, preventive measures are still the best available strategy for patient handling. This review provides a brief overview of the pathophysiology, diagnosis, treatment, and prevention of RPE, with practical recommendations for adequate intervention.

 


11 - Chronic obstructive pulmonary disease and malnutrition: why aren't we winning this battle?

Doença pulmonar obstrutiva crônica e desnutrição: por que não estamos vencendo a batalha?

Ivone Martins Ferreira

J Bras Pneumol.2003;29(2):107-115

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Objectives: To perform a review of the mechanisms involved in the origin of malnutrition in patients with chronic obstructive pulmonary disease (COPD) and a systematic review of randomized controlled studies to clarify the contribution of nutritional supplementation in patients with stable COPD. Methods: Systematic review of article published in this subject, in all languages from several sources, including Medline, Embase, Cinahl and Cochrane Registry in COPD, as well as studies presented in American and European. Results: Studies with nutritional supplementation longer than two weeks showed that the effect was not big and did not reach statistical significance. A study with linear regression showed that old age, relative anorexia, and high inflammatory response are associated with non-response to nutritional therapy. Conclusion: Currently, there is no evidence of the efficacy of nutritional supplementation in patients with COPD. Factors related to lack of response suggest a relationship with the degree of inflammation, including high levels of TNF alpha. Measuring inflammation markers may be useful to determine prognostic and adequate therapy. Treatment with anti-inflammatory cytokines or cytokine inhibitors are promising for the future.

 


Year 2003 - Volume 29  - Number 3  (May/June)

Editorial

1 - Mortalidade por fibrose pulmonar idiopática

José Antônio Baddini Martinez

J Bras Pneumol.2003;29(3):1-2

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Original Article

2 - Mortality due to idiopathic pulmonary fibrosis in the State of Rio Grande do Sul (Brazil)

Mortalidade por fibrose pulmonar idiopática no Rio Grande do Sul

Fabrício Picolli Fortuna, Christiano Perin, Letícia Cunha, Adalberto Sperb Rubin

J Bras Pneumol.2003;29(3):121-124

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Epidemiologic data on idiopathic pulmonary fibrosis are relatively scarce, and its real incidence and prevalence are unknown. Recent studies suggest that idiopathic pulmonary fibrosis mortality is rising in developed countries. Objectives: To describe idiopathic pulmonary fibrosis mortality in the State of Rio Grande do Sul (RS), Brazil, from 1970 to 2000, analyzing its trend and comparing it with that from other countries. Methods: Prevalence study, using data from the Brazilian Institute of Geography and Statistics (IBGE), analyzing death certificates in which idiopathic pulmonary fibrosis was stated as ultimate cause of death. Results: Annual mortality adjusted to population was 0.22/100,000 persons in the 1970's, 0.3/100,000 persons in the 1980's, and 0.48/100,000 persons in the 1990's. Total mortality rised 36% from 1970 to 1980, and 70% from 1980 to 1990. Mortality adjusted to population rised 36% and 60% during the same periods. The rise in both total and adjusted mortality from IPF was statistically significant (p < 0.05). The mean mortality rate per 100,000 persons during 1996 to 1998, however, was 0.683, corresponding to a rise of 70% when compared to the previous three-year period, which was 0.4 (p = 0.0002), probably reflecting encoding practices. Conclusion: There was a significant increase in IPF mortality in RS from 1970 to 2000, in part due to changes in coding practices. This increase is in conformity with observations in other countries, althought mortality rates in RS are considerably lower.

 


Keywords: Pulmonary fibrosis. Mortality.

 

3 - Epidemiological profile of lung tuberculosis infection and disease among cocaine users being treated in hospitals of São Paulo, Brazil

Perfil epidemiológico da tuberculose infecção e doença entre usuários de cocaína internados em serviços hospitalares da Grande São Paulo

Olavo Franco Ferreira Filho, Marilia Dalva Turchi, Ronaldo Laranjeiras, Adauto Castelo

J Bras Pneumol.2003;29(3):125-132

Resumo

Objetivo: Avaliar a prevalência e os fatores de risco para tuberculose (TB) infecção e doença entre usuários de drogas hospitalizados. Métodos: Estudo transversal em amostra de adictos maiores de 18 anos, internados em hospitais da região metropolitana da Grande São Paulo, com condições clínicas de responder a questionário padronizado e que concordaram em participar do estudo. A prevalência de TB infecção foi avaliada pela positividade ao teste tuberculínico (PPD) e de TB doença pelo achado de M. tuberculosis no escarro dos sintomáticos respiratórios. Resultados: Os sintomas respiratórios estavam presentes em 21,2% dos pacientes, sendo o emagrecimento e a tosse os mais freqüentes, os quais desapareciam com a interrupção do uso de cocaína. A prevalência geral de TB infecção foi de 28%. A prevalência de TB doença foi de 0,6%. Os fatores associados com PPD positivo foram: idade, cor/raça, tempo passado na prisão e antecedentes de uso de drogas na prisão. Conclusões: Não se encontrou prevalência aumentada de TB infecção e doença nesses pacientes. Adictos com maior idade tinham maior probabilidade de ter TB infecção, bem como aqueles com história de encarceramento.

 


Year 2003 - Volume 29  - Number 4  (July/August)

Editorial

1 - Baixa estatura mas alta espirometria

Noé Zamel

J Bras Pneumol.2003;29(4):175-

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2 - Monitoração da inflamação das vias aéreas na asma

Mark D. Inman

J Bras Pneumol.2003;29(4):176-

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Original Article

3 - Questionnaire of quality of life in patients with primary hyperhidrosis

Questionário de qualidade de vida em pacientes com hiperidrose primária

José Ribas Milanez de Campos, Paulo Kauffman, Eduardo de Campos Werebe, Laert Oliveira Andrade Filho, Sergio Kuzniek, Nelson Wolosker, Fábio Biscegli Jatene, Mariane Amir

J Bras Pneumol.2003;29(4):178-181

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Background: Hyperhidrosis or excessive sudoresis is a chronic disease associated with important subjective distress. Objective: To propose a specific questionnaire to evaluate the quality of life of patients with hyperhidrosis. Methods: From October 1995 to March 2002, 378 patients (234 females), with a mean age of 26.8 years, were evaluated before and after video-assisted thoracic sympathectomy. Results: Therapeutic success was obtained in 90% of the procedures. The recurrence rate was 10% for palmar and 11% for axillary hyperhidrosis; 27% of the patients who had recurrence were re-operated successfully. No serious complications were reported. Of the total number of patients, 91% answered to the quality of life questionnaire, and 86% of them reported improvement after the procedure. Conclusions: Thoracic sympathectomy is a therapeutic method capable of changing the quality of life of patients with hyperhidrosis. The questionnaire applied has shown these changes.

 


Keywords: Thoracic sympathectomy. Quality of life.

 

4 - Spirometric values in children and adolescents with short stature

Valores espirométricos de crianças e adolescentes com baixa estatura

Naiza Alessandra Dorneles, Nelson Augusto Rosário Filho, Carlos Antônio Riedi, Margareth Cristina Boguszewski, João Adriano de Barros

J Bras Pneumol.2003;29(4):182-187

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Background: Several factors influence the pulmonary function values considered normal. In children of short stature, there are difficulties in interpreting the pulmonary function. Objective: To assess spirometric values in children and adolescents with short stature and to identify a correction factor to adequately predict the expected values for this population. Method: A prospective selection of 77 patients was made, all with short stature and no respiratory disease. These patients were submitted to spirometry, transcutaneous hemoglobin oxygen saturation, chest perimeter measurement, and immediate hypersensitivity testing. Bone age was assessed by wrist X-rays. The data obtained by spirometry (FVC, FEV1, and FEF25-75%) were compared with those of Polgar and Promadhat (1971), predicted in three ways: a) by actual height; b) by height estimated at the 50th percentile for chronological age (CA); c) by height estimated at the 50th percentile for bone age (BA). Results: The mean height was 133.3 ± 13.2 cm, and the deficit in relation to the third percentile was 5.4 ± 6.0 cm. The values obtained for FVC, FEV1, FEF25-75%, were significantly higher than those predicted by actual height. The mean FEV1 obtained was 2.42 ± 0.71 L, and the predicted (actual height) was 2.10 ± 0.64 L; according to the height estimated by BA and CA, the values were 2.27 and 2.86 L, respectively. The mean FVC1 was 2.20 ± 0.6 L, and the predicted was 1.90 ± 0.55 L. With the height estimated for bone age and chronologic age, the predicted values were 2.10 and 2.60 L, respectively. Conclusion: Children and adolescents with short stature have higher spirometric values than predicted for their actual height. These findings suggest that the height estimated at the 50th percentile for bone age can be used to evaluate pulmonary function.

 


Keywords: Lung function. Short stature.

 

5 - Airway inflammation in steroid-naïve asthmatics: characteristics of induced sputum

Inflamação das vias aéreas em asmáticos virgens de tratamento com esteróides: características do escarro induzido

Simone Van de Sande Lee, Marcia Margaret Menezes Pizzichini, Leila John Marques, Samira Cardoso Ferreira, Emilio Pizzichini

J Bras Pneumol.2003;29(4):188-195

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Background: Airway inflammation, acknowledged as an important feature of asthma, can be assessed by the examination of induced sputum. Objective: To determine the pattern of inflammatory cells in induced sputum from stable steroid-naïve asthmatics, in Florianópolis, Santa Catarina. Method: The induced sputum from 34 asthmatics using exclusively inhaled bronchodilators on demand was examined. The patients' clinical characteristics were obtained at visit 1, and sputum was induced at visit 2. Differential cell count was performed on Giemsa-stained cytospins. Sputum was considered to be eosinophilic if there were ³ 3% eosinophils, and neutrophilic if there were ³ 65% neutrophils. Results: Results are expressed by median and interquartile range. The total cell count was 3.4 (3.7) x 106 cells/ml, and cell viability was 80.0 (16.4) %. The proportion of neutrophils was 14.4 (22.1) %, of eosinophils 6.4 (17.2) %, of macrophages 60.3 (37.5) %, and of lymphocytes 1.1 (1.2) %. Eosinophilic sputum was observed in 24 subjects (70.6%); none of them had neutrophilic sputum. There were no significant differences between the eosinophilic and non-eosinophilic groups concerning the measured clinical outcomes, total cell count and proportions of cells in the sputum, except for the proportion of eosinophils (14.4 [19.3] vs 0.4 [1.1], p < 0.001). Conclusions: In our environment, steroid-naïve asthmatics present a higher proportion of sputum eosinophils, as compared to the established reference values. The clinical and physiological parameters analyzed were unable to predict the presence of eosinophilic inflammation of the airways.

 


Keywords: Asthma. Inflammation. Sputum. Eosinophils. Neutrophils.

 

6 - Relationship between functional and X-ray alterations in patients with cystic fibrosis

Relação entre alterações funcionais e radiológicas em pacientes com fibrose cística

Andréia Kist Fernandes, Felipe Mallmann, Ângela Beatriz John, Carlo Sasso Faccin, Paulo de Tarso Roth Dalcin, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2003;29(4):196-201

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Background: Cystic fibrosis (CF) is a disease marked by airway inflammation and airflow obstruction, resulting in air trapping in the lungs. Objective: To assess the associations between airflow limitation, pulmonary volume and X-ray findings in patients with cystic fibrosis. Method: A cross-sectional retrospective study. Review of spirometric, plethysmographic, and chest X-ray findings of outpatients (age ³ 16 years). The airflow findings were classified as within normal limits or as airflow obstruction: mild, moderate or severe obstructive alteration. Results: A total of 23 patients (15 male and eight female; mean age, 21 ± 5.9 years) were studied. Six of them were within normal limits, four had a mild, five had a moderate, and eight had a severe obstructive alteration. There was an association between airflow limitation and the increase of residual volume (p = 0.006) and also with the Brasfield score (p = 0.001), but not with the total lung capacity (p = 0.33). There was a correlation between residual volume and Brasfield score (r = 0,73, p = 0,002), but not with the total pulmonary capacity. Moreover, according to X-ray criteria, the air trapping was correlated only with the residual volume (p = 0.006). Conclusion: In patients with cystic fibrosis (age ³ 16 years), the progressive airflow limitation is accompanied by an increase in residual volume, while the total pulmonary capacity remains normal or tends to decrease. The X-ray score was associated with airflow limitation and residual volume, but not with total lung capacity.

 


Keywords: Cystic fibrosis. Pulmonary disease. Lung volume measurements. Radiography, thoracic.

 

7 - Mediastinal diseases: clinical and therapeutic aspects

Doenças mediastinais: aspectos clínicos e terapêuticos

Roberto Saad Júnior, Maria Elisa Ruffolo Magliari, Júlio Mott Ancona Lopez

J Bras Pneumol.2003;29(4):202-207

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Background: Mediastinal affections are common and encompass a great number of different diagnoses. Objective: To analyze the clinical aspects and the therapeutic response of 114 patients with mediastinal diseases treated at the Thoracic Surgery Department of Santa Casa de São Paulo Hospital, from 1979 and 1997. Method: The patients were grouped according to the benign or malignant nature of the disease, and the two groups were compared regarding gender, age bracket, symptomatology, topography of the lesion, mortality, and response to treatment. Results: Sixty-three patients had neoplasia: 31 benign and 32 malignant. Fifty-one cases were not neoplastic. No difference was found between the groups regarding gender or age bracket. Half of the patients were between 20 and 49 years of age. The anterior mediastinum was the most frequently affected compartment (66 patients), followed by the upper mediastinum (18 patients), the posterior mediastinum (16 patients), and the middle mediastinum (14 patients). The most frequent histological types were: benign thymus diseases (N = 40), mesenchymal tumors (N = 17), lymphomas (N = 15), neural tumors (N = 9), and germ cell tumors (N = 8). Malignant tumors were more frequently symptomatic (91%), and benign tumors were more frequent in asymptomatic patients (92%). The most frequent symptoms were related to myastenia gravis, followed by dyspnea and chest pain. Weight loss, anorexia and fever were significantly more frequent in patients with malignant neoplasias. Conclusions: Regarding the clinical aspects we can state that benign lesions were predominant, that mediastinal diseases were more prevalent in young adults, and that benign lesions were more frequent in asymptomatic patients. Treatment (clinical/surgical) was effective in most patients, benefiting approximately 90% of the patients with benign affections and 45% of the patients with malignant tumors. In 73% of the benign affections, surgical treatment was capable of achieving the cure. Mortality resulting from complications was 1.75%.

 


Keywords: Key words - Mediastinum. Mediastinal disease/epidemiology. Mediastinal neoplasms.

 

8 - Comparing peak and sustained values of maximal respiratory pressures in healthy subjects and chronic pulmonary disease patients

Comparação entre os valores de pico e sustentados das pressões respiratórias máximas em indivíduos saudáveis e pacientes portadores de pneumopatia crônica

J Bras Pneumol.2003;29(4):208-212

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Background: The measurement of maximal inspiratory and expiratory pressures is useful for the evaluation of pulmonary function. However, the methods to obtain them are not always properly described. Objective: To identify the difference between the peak pressure values (Ppeak, the highest pressure reached) and the sustained pressure (Pmaxs, the highest pressure sustained for one second) in MIP and MEP evaluation. Method: 55 healthy individuals and 50 patients who were taking part in a pulmonary rehabilitation program, all of them with chronic pulmonary disease, were studied by recording their best maximal inspiratory pressure and maximal expiratory pressure tests. The peak and sustained pressure values were compared and analyzed to determine whether there was a difference between them. Results: The maximum inspiratory pressure records of healthy individuals showed that the maximal peak inspiratory pressure and the maximal inspiratory pressure found were, respectively, 102 ± 33 cmH2O and 92 ± 29 cmH2O (p < 0.001), and those of the patients participating in the pulmonary rehabilitation program were 75 ± 23 cmH2O and 67 ± 22 cmH2O (p < 0.001). The recorded values of maximal expiratory pressure, peak and maximal were 119 ± 42 cmH2O and 110 ± 39 cmH2O (p < 0.001), respectively, for healthy subjects, and 112 ± 40 cmH2O and 103 ± 36 cmH2O (p < 0.001) for the patients. Conclusion: There is a significant difference between Ppeak and Pmaxs, that can lead to different interpretations in the evaluation of the respiratory muscle strength. To minimize interpretation errors, the authors suggest the use of devices which record both values (peak and sustained).

 


Keywords: Pulmonary function tests. Respiratory muscles strength. Maximal respiratory pressures.

 

9 - Development of an experimental model of neutrophilic pulmonary response induction in mice

Desenvolvimento de um modelo experimental de indução de resposta pulmonar neutrofílica em camundongos

Leonardo Araújo Pinto, Camila Camozzato, Monique Avozani, Denise Cantarelli Machado, Marcus Herbert Jones, Renato Tetelbom Stein, Paulo Márcio Condessa Pitrez

J Bras Pneumol.2003;29(4):213-216

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Background: Several lung diseases are characterized by a predominantly neutrophilic inflammation. A better understanding of the mechanisms of action of some drugs on the airway inflammation of such diseases may bring advances to the treatment. Objective: To develop a method to induce pulmonary neutrophilic response in mice, without active infection. Methods: Eight adult Swiss mice were used. The study group (n = 4) received an intranasal challenge with 1 x 1012 CFU/ml of Pseudomonas aeruginosa (Psa), frozen to death. The control group (n = 4) received an intranasal challenge with saline solution. Two days after the intranasal challenge, a bronchoalveolar lavage (BAL) was performed with total cell and differential cellularity counts. Results: The total cell count was significantly higher in the group with Psa, as compared to the control group (median of 1.17 x 106 and 0.08 x 106, respectively, p = 0.029). In addition to this, an absolute predominance of neutrophils was found in the differential cellularity of the mice that had received the Psa challenge. Conclusion: The model of inducing a neutrophilic pulmonary disease using frost-dead bacteria was successfully developed. This neutrophilic inflammatory response induction model in Swiss mice lungs may be an important tool for testing the anti-inflammatory effect of some antimicrobial drugs on the inflammation of the lower airways.

 


Keywords: Animal experimentation. Lung disesases. Inflammation. Neutrophils. Pseudomonas.

 

Case Report

10 - Diffuse alveolar hemorrhage resulting from pauci-immune pulmonary capillaritis

Hemorragia alveolar difusa por capilarite pulmonar pauci-imune

Andreia Salarini Monteiro, Gabriela Addor, David Henrique Nigri, Wilhermo Torres, Carlos Alberto de Barros Franco

J Bras Pneumol.2003;29(4):217-220

Abstract PDF PT

A 27 year-old female patient, cocaine user, presenting hemoptysis and progressive dyspnea with onset 48 hours prior to hospital admission, without any other signs or symptoms. Serum tests for infectious diseases, collagen disorders and vasculitis were negative. Urinalysis was type I. Computed tomography of the chest showed diffuse alveolar infiltrate, affecting mainly the lower left lobe. A thoracoscopic lung biopsy was performed to clarify the diagnosis. The histopathological findings showed capillaritis and diffuse intra-alveolar hemorrhage. Treated with steroid and cyclophosphamide pulse therapy, a good clinical and radiographical response was obtained. The recently described pauci-immune pulmonary capillaritis is characterized by the presence of isolated pulmonary capillaritis and negative serum testing for auto-immune diseases.

 


Keywords: Hemorrhage. Pulmonary alveoli/physiopathology.

 

11 - Silicosis associated with systemic lupus erythematosus

Associação de silicose e lúpus eritematoso sistêmico

Shirley Castro Holanda, Maria do Socorro T.M. Almeida, Antônio de Deus Filho

J Bras Pneumol.2003;29(4):221-224

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The hypothesis that exposure to silica might be associated with a wide range of autoimmune diseases including SLE (systemic lupus erythematosus) has been discussed over the last decade, but only few cases of silicosis and SLE were described in the literature. The authors report the case of a male patient in his fifth decade of life, with previous exposure to silica, who worked as a well digger for ten years. The patient's clinical picture started with articular symptoms, sporadic peaks of fever, anemia, positive antinuclear factor, peripheral (1/10) and homogeneous (1/500) standard, and productive cough. Computed tomography of the chest showed a diffuse interstitial process, bilateral nodules, para-aortic and para-tracheal hilar calcifications, compatible with pulmonary and ganglial silicosis. He developed acute respiratory distress syndrome (ARDS) and died.

 


Keywords: Systemic lupus erythematosus. Silicosis. Autoimmune diseases.

 

Review Article

12 - The value of cytology and pleural biopsy in the differential diagnostic of nonspecific pleural effusions

Valor de citologia e biópsia pleural no diagnóstico diferencial dos derrames pleurais indeterminados

Vera Luiza Capelozzi, Danieli Cheke da Rosa, Aloísio S. Felipe da Silva

J Bras Pneumol.2003;29(4):225-234

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A significant percentage of pleural effusions remains without a diagnostic explanation. In such circumstances, the anatomical-pathological result of nonspecific chronic pleuritis should be revised. This is an important issue, not only for the pathologist, but mainly for the pneumologist, who usually makes the clinical-pathological correlation during the routine practice. Although the existence of established criteria is accepted, they are certainly subjective and make the communication by means of a common language difficult, mainly among pathologists. The authors recently studied 311 pleural biopsies with histo-pathological diagnoses of chronic nonspecific pleuritis. All specimens were reviewed and the histo-pathological parameters quantified by stereology. The patients were stratified according to the final diagnosis of their disease, including cases of chronic renal failure, vasculitis, pancreatitis, tuberculosis, cancer, and congestive cardiac failure, in this case considering the pleura as normal. This procedure allowed us to obtain a discriminating model, whose morphological subcriteria classified almost 90% of the nonspecific chronic pleuritis biopsies, according to their final clinical diagnoses, which included true nonspecific chronic pleuritis or tuberculosis pleuritis, paraneoplastic pleuritis, or even normal pleura. By adding to this model the biochemistry or differential cytology of the pleural liquid, its classificatory power reaches 99% of correctness. This study represents the result of the experience acquired over several years in the histo-pathological interpretation of pleural biopsies, based on the correlation between morphology and biochemistry and cytology of the pleural fluid.

 


Keywords: Biopsy, needle. Pleura/pathology. Pleura/cytology. Pleural effusion.

 

13 - Lung tissue remodeling in the acute respiratory distress syndrome

Remodelamento do tecido pulmonar na síndrome do desconforto respiratório agudo

Alba Barros de Souza, Flavia Brandão dos Santos, Elnara Marcia Negri, Walter Araujo Zin, Patricia Rieken Macedo Rocco

J Bras Pneumol.2003;29(4):235-245

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Acute respiratory distress syndrome (ARDS) is characterized by diffuse alveolar damage, and evolves progressively with three phases: exsudative, fibroproliferative, and fibrotic. In the exudative phase, there are interstitial and alveolar edemas with hyaline membrane. The fibroproliferative phase is characterized by exudate organization and fibroelastogenesis. There is proliferation of type II pneumocytes to cover the damaged epithelial surface, followed by differentiation into type I pneumocytes. The fibroproliferative phase starts early, and its severity is related to the patient's prognosis. The alterations observed in the phenotype of the pulmonary parenchyma cells steer the tissue remodeling towards either progressive fibrosis or the restoration of normal alveolar architecture. The fibrotic phase is characterized by abnormal and excessive deposition of extracellular matrix proteins, mainly collagen. The dynamic control of collagen deposition and degradation is regulated by metalloproteinases and their tissular regulators. The deposition of proteoglycans in the extracellular matrix of ARDS patients needs better study. The regulation of extracellular matrix remodeling, in normal conditions or in several pulmonary diseases, such as ARDS, results from a complex mechanism that integrate the transcription of elements that destroy the matrix protein and produce activation/inhibition of several cellular types of lung tissue. This review article will analyze the ECM organization in ARDS, the different pulmonary parenchyma remodeling mechanisms, and the role of cytokines in the regulation of the different matrix components during the remodeling process.

 


Keywords: Respiratory distress syndrome. Pulmonary alveoli/lesions. Extracellular matrix. Cytokines/ultrastructure.

 

Upgrading

14 - Asma grave: uma questão de prescrição ou de diagnóstico?

Afrânio Kritski

J Bras Pneumol.2003;29(4):248-250

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Year 2003 - Volume 29  - Number 5  (September/October)

Editorial

1 - Bom para alguns, ótimo para outros

Sérgio Saldanha Menna Barreto

J Bras Pneumol.2003;29(5):251-

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Original Article

2 - Mediastinal tumors in children

Tumores do mediastino em crianças

José Carlos Fraga, Marcia Komlós, Eliziane Takamatu, Luciano Camargo, Fábio Contelli, Algemir Brunetto, Carlos Antunes

J Bras Pneumol.2003;29(5):253-257

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Background: Mediastinal tumors in children comprise a heterogeneous group of lesions that have a range of embryonic origins. They may present as benign cysts, as well as malignant lesions. Objective: To describe the diagnostic procedures, the treatments and outcomes of a group of children and adolescents with mediastinal tumors. Method: A retrospective analysis of twenty children and adolescents with mediastinal tumors who were treated at the Hospital de Clínicas de Porto Alegre from July, 1996 to July, 2002. All patients were submitted to some kind of surgical procedure: diagnostic, therapeutic, or both. Results: Twelve boys and eight girls were studied. Mean age at diagnosis was 6 years and 8 months (ranging from 3 months to 16 years). Fourteen tumors (70%) were located at the anterior, and six (30%) at the posterior mediastinum. Hodgkin and non-Hodgkin lymphomas were the most common tumors found in anterior mediastinum, whereas neuroblastoma was the most common among posterior malignancies. The most used surgical procedure for anterior tumors was Chamberlain anterior thoracotomy; posterolateral thoracotomy was usually performed for posterior tumors. Six patients died during the follow-up period but none of the deaths was considered related to the surgical procedure. Conclusion: Mediastinal tumors in children and adolescents represent an important cause of morbidity/mortality. The most common tumors at the anterior mediastinum were lymphomas, whereas at the posterior mediastinum the most common were neurogenic tumors. Surgery is an important step for the diagnosis and treatment of such lesions.

 


Keywords: Tumors. Mediastinum. Child. Lymphoma/surgery.

 

3 - Bronchiectasis: diagnostic and therapeutic features A study of 170 patients

Bronquiectasias: aspectos diagnósticos e terapêuticos Estudo de 170 pacientes

José da Silva Moreira, Nelson da Silva Porto, José de Jesus Peixoto Camargo, José Carlos Felicetti, Paulo Francisco Guerreiro Cardoso, Ana Luiza Schneider Moreira, Cristiano Feijó Andrade

J Bras Pneumol.2003;29(5):258-263

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Background: Bronchiectasis is a frequently found disease in medical practice in Brazil leading to significant morbidity and decrease in quality of life of the affected individuals. Objectives: To study diagnostic and therapeutic aspects in a series of hospitalized patients with bronchiectasis in a department of pulmonary diseases. Methods: Signs, symptoms, microbiological and radiographic data, and therapeutic results were studied in 170 hospitalized patients between 1978 and 2001 - females 62.4%, males 37.6%, and aged from 12 to 88 years (mean age 36.8 yrs). Previous history of pneumonia in childhood was detected in 52.5% of the patients, tuberculosis in 19.8%; 8.8% had bronchial asthma, and 2 had Kartagener's syndrome. Results: The most common symptoms were cough (100.0%), expectoration (96.0%) and pulmonary rales (66.0%). The pulmonary lesions were unilateral in 46.5% of the cases. Pneumococcus, H. influenzae or mixed flora were found in 85.0% of the examined sputa. All 170 patients received antibiotics and postural drainage, and 88 of them (younger and with a higher functional reserve) were also submitted to pulmonary resections (82 unilateral and 6 bilateral). Two deaths occurred, and repetitive hospitalizations were more frequent among the clinically treated patients. The follow up showed that most of the surgically treated patients had significant symptoms improvement and rarely needed to be re-hospitalized. Conclusions: In the majority of the patients, lung resection surgery improved permanently the prolonged bronchopulmonary symptoms of patients with bronchiectasis, differently from the patients who received only clinical treatment.

 


Keywords: Bronchiectasis/diagnosis. Bronchiectasis/therapy. Bronchiectasis/surgery. Bronchiectasis/complications. Tomography X-ray computed/methods. Inpatients. Retrospective studies.

 

4 - Smoking among school adolescents in Salvador (BA)

Tabagismo em amostra de adolescentes escolares de Salvador-Bahia

Adelmo Souza Machado Neto, Álvaro A. Cruz2

J Bras Pneumol.2003;29(5):264-272

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Background: Most tobacco users become addicted during adolescence. In Brazil, smoking prevalence among teenagers varies from 1% to 35%. Objective: To estimate the prevalence of smoking among teenagers, aged from 13 to 20, in fundamental and high school in Salvador, Bahia, Brazil. Method: Cross-sectional exploratory study. Thirty five hundred questionnaires were applied to students at fundamental and high school in five schools at the metropolitan region of Salvador (BA). Statistical analysis: descriptive and associative measurements (Prevalence Rate), Student's t and qui-square tests. Results: Smoking prevalence among teenagers in Salvador (BA) was 9.6%, considering 3,180 valid questionnaires. The frequency was higher in males (14%) than in females (6%). The prevalence increased with age. The mean age ± SD for tobacco initiation was 14 ± 2 years. Among the teenagers, 46% tried cigarettes, and 20% became addicted. The frequency was higher among teenagers whose parents were smokers. The mean ± SD number of daily cigarettes smoked by adolescent tobacco users (n = 132) was 7.4 (± 6.4) units per day, with a higher frequency among boys. Conclusion: Smoking prevalence in a selected set of adolescent students in Salvador (BA) was 9.6%, and it was higher among males. Parental smoking and cigarette experimentation were the major factor found to be associated to tobacco addiction among teenagers.

 


Keywords: Smoking/epidemiology. Adolescents. Students. Tobacco.

 

5 - Extended thymectomy through video assisted thoracic surgery and cervicotomy in the treatment of myasthenia

Timectomia estendida por cirurgia torácica videoassistida e cervicotomia no tratamento da miastenia

Eduardo Haruo Saito, Cláudio Higa, Rodolfo Acatauassu Nunes, Gérson C. Magalhães, Luiz Carlos Aguiar Vaz, Vicente Faria Cervante

J Bras Pneumol.2003;29(5):273-279

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Background: The relationship between myasthenia and the thymus is evident and the current treatment of this condition includes thymectomy. However, a revision of our experience with thymectomy has revealed the necessity of a more radical technique. Objective: To analyze, retrospectively, myasthenia gravis patients who underwent videothoracoscopic radical thymectomy, emphasizing the advantages and drawbacks of the methodology, pathological findings and results related to disease control. Material and methods: Twenty-one myasthenic patients (18 females and 3 males, aged 17 to 51 years), underwent videothoracoscopic bilateral thymectomy associated to transverse cervicotomy for removal of the thymus gland and surrounding tissues, and right and left pericardiac fat tissues. Those tissues were separately sent to pathology analysis. The mean time of follow-up was 39.2 months. Results: There were no intra-operative deaths. Two patients (9.5%) suffered vascular injury, and one patient (4.8%) presented a low level permanent dysphonia. Nineteen patients (90.4%) are doing well, with none or low dose medications. Pathology studies showed 10 hyperplastic thymuses, 6 with involution and 5 with normal aspect. Ectopic thymic tissue was found in six patients (28.6%). Conclusion: Videothoracoscopic radical thymectomy offered a good control of myasthenia gravis. Additionally, ectopic thymus tissue was removed from some patients.

 


Keywords: Thorax. Surgery, video-assisted. Myastenia gravis. Thymectomy.

 

6 - Management of massive hemoptysis with the rigid bronchoscope and cold saline lavage

Controle da hemoptise maciça com broncoscopia rígida e soro fisiológico gelado

Giovanni Antonio Marsico, Carlos Alberto Guimarães, Jorge Montessi, Antonio Miguel Martins da Costa, Levi Madeira

J Bras Pneumol.2003;29(5):280-286

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Background: Massive hemoptysis is a high morbidity and high mortality condition, independently of the treatment administered. A variety of methods are used to control the acute bleeding. The instillation of iced saline solution through a rigid bronchoscope was described in 1980. Objective: To establish the efficacy of repeated instillations of iced saline solution (4oC) using a rigid bronchoscope for the acute control of massive hemoptysis. Method: A group of 94 patients with massive hemoptysis was treated with rigid bronchoscopy and lavage with iced saline solution of the actively bleeding lung. The absence of bleeding recurrence within the following 15 days was considered a therapeutic success. The causes of hemoptysis included: pulmonary tuberculosis: 78 (83%), among which 48 had active disease, and 30 had tuberculosis sequelae, bronchiectasis (6), lung cancer (5), intracavitary aspergilloma (3), and unknown (2). The bleeding site was found in 93 patients (99%). The mean saline volume used in the bronchoscopy was 528 mL, ranging from 160 mL to 2,500 mL. Results: All patients stopped bleeding during the procedure. Fifteen patients were submitted to some kind of procedure (surgery, embolization, or radiation therapy) within 15 days, and the efficacy of lavage could not be assessed. Twenty of the 79 patients followed-up for more than 15 days had recurrence of hemoptysis. Cold saline lavage was repeated once in 13 patients, twice in 6 patients, and 3 times in one patient. Conclusion: The control of tracheobronchial hemorrhage through bronchoscopy and lavage with iced saline is an effective procedure and can be repeated in case of re-bleeding. It is a safe procedure, and allows the definitive treatment to occur in better clinical conditions.

 


Keywords: Hemoptysis. Tuberculosis. Bronchoscopy.

 

7 - Effects of a physical exercises program designed to increase thoracic mobility in patients with chronic obstructive pulmonary disease

Efeitos de programa de exercícios físicos direcionado ao aumento da mobilidade torácica em pacientes portadores de doença pulmonar obstrutiva crônica

Elaine Paulin, Antonio Fernando Brunetto, Celso Ricardo Fernandes Carvalho

J Bras Pneumol.2003;29(5):287-294

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Background: Chronic obstructive pulmonary disease is detrimental to lung mechanics and peripheral muscles. The physical programs developed for this condition are usually targeted to an improvement on aerobics capacity. Programs that approach specifically the changes in thoracic mobility and thoracic muscles are rare. Objective: To assess the effects of a physical exercise program designed to increase chest wall mobility on functional and psychosocial capacity in moderate to severe chronic obstructive pulmonary disease patients. Methods: Thirty patients with moderate to severe chronic obstructive pulmonary disease were studied. They were randomized to 2 groups: control group (CG) and treated group (TG). The CG was submitted to an educational program and the TG was submitted to an educational program plus a physical exercise program aiming to increase chest wall mobility. Variables included spirometry, thoracic mobility, quality of life, anxiety and depression levels and a six minute walk test (6MWT). Results: After 2 months of training, only the TG presented improvements on chest wall mobility (from 4.20 ± 0.58 cm to 5.27 ± 0.58 cm; p = 0.05) and 6MWT (from 469.73 ± 31.99 m to 500.60 ± 27.38 m; p = 0.01). It was also observed that the TG presented improvement on the St. George's Respiratory Questionnaire (SGRQ) score, Chronic Respiratory Questionnaire (CRQ), and Beck's depression scale after 2 months of treatment. Pulmonary function did not improve either in the CG or in the TG group. Conclusion: Our results suggest that exercises aimed to the increasing of chest wall mobility improve thoracic mobility, quality of life, submaximal exercise capacity, and reduce dyspnea and depression symptoms in chronic obstructive pulmonary disease patients.

 


Keywords: COPD. Thoracic mobility. Quality of life. Capacity of exercise. Dyspnea.

 

Upgrading

8 - Study about the ability of the pulmonary aerostasia, in animal model, using differents parenchymal pulmonary types of the sutures

Estudo sobre a eficácia da aerostasia pulmonar, em modelo animal, utilizando diferentes tipos de suturas

Darcy Ribeiro Pinto Filho

J Bras Pneumol.2003;29(5):295-301

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Background: The search for an ideal procedure to accomplish aerostasis, after partial surgical resection of the lung parenchyma, remains a practical challenge for the thoracic surgeon. Objective: The objective of this study was to compare the ability of four types of parenchymal pulmonary sutures in preventing air leaks, using a porcine model with incremental endobronchial pressures. Method: Ex vivo experimental study in porcine lungs (n = 5) at the Laboratory of Experimental Surgery of the Universidade de Caxias do Sul. Four different parenchymal pulmonary types of suture were analyzed: type 1 (absorbable suture), type 2: (stapled suture), type 3 (stapled suture with bovine pericardium) and type 4 (stapled suture with biologic glue). The surgical sutures (n = 40) were exposed to different intrabronchial pressure levels, varying from 10 cmH2O to 60 cmH2O. The presence of air leaks along the suture line was verified through the water seal maneuver. Results: The mean intrabronchial pressure level needed to cause suture line air leaks for each type were: type 1 (n = 10): 29 cmH2O; type 2 (n = 10): 38.5 cmH2O; type 3 (n = 10): 44 cmH2O; and type 4 (n = 10): 51.4 cmH2O. The comparison between the mean intrabronchial pressure level of type 1 and of types 2 and 3 sutures was statistically significant, respectively: p = 0.04 and p = 0.01. However, the comparison between types 2, 3 and 4 did not show statistic significance (p > 0.05). Conclusions: The pulmonary suture covered by biologic glue demonstrated more resistance to incremental levels of intrabronchial pressure. Parenchymal pulmonary sutures using stapled suture exclusively or stapled with bovine pericardium or biologic glue demonstrated an increased ability to avoid air leaks if compared to absorbable sutures in a model of porcine lung with incremental levels of intrabronchial pressure. There were no differences between stapler exclusively or stapler and bovine pericardium or biologic glue.

 


Keywords: Experimental study. Thoracic surgery. Biologic glue. Staplers.

 

Case Report

9 - Sildenafil for treatment of pulmonary hypertension in association with systemic lupus erythematosus and anti-phospholipid syndrome

Sildenafil no tratamento da hipertensão pulmonar associada a lúpus eritematoso sistêmico e síndrome antifosfolipídio

Eduardo José do Rosário e Souza, Junia Rios Garib, Nasim Michel Garib, Paulo Madureira de Pádua

J Bras Pneumol.2003;29(5):302-304

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Severe pulmonary hypertension is a debilitating disease with short life expectancy that often affects young people. Pleuropulmonary complications of systemic lupus erythematosus occur in 50-70% of patients. Severe symptomatic pulmonary hypertension in systemic lupus erythematosus is rare and carries a bad prognosis because a fatal outcome can occur within months. The authors describe, for the first time, a patient with systemic lupus erythematosus with severe pulmonary hypertension and secondary antiphospholipid syndrome who responded favorably to oral sildenafil, after unsuccessful use of prednisone, intravenous cyclophosphamide, warfarin and diltiazem.

 


Keywords: Vasodilator agents/therapeutic use. Lupus erythematosuos systemic. Antiphospholipid antibodies. Phosphodiesterase inhibitors.

 

10 - Resolution of right-to-left shunt after primary pulmonary hypertension treatment with sildenafil

Resolução do "shunt" direita-esquerda após uso do sildenafil como tratamento de hipertensão pulmonar primária

Sérgio Marques da Silva, Carla Bastos Valeri, Humberto Bassit Bogossian, Carlos Jardim, Sérgio Eduardo Demarzo, Rogério Souza

J Bras Pneumol.2003;29(5):305-308

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Primary pulmonary hypertension is a rare, progressive disease with high mortality rates. The treatment of primary pulmonary hypertension is still based on high-cost drugs, not yet available in developing countries. Recently, the use of sildenafil as an alternative drug for primary pulmonary hypertension treatment has been reported. It is reported a case of a 21 year-old female patient with primary pulmonary hypertension, who presented an acute worsening of symptoms and decrease of oxygen saturation. The investigation revealed the existence of a patent oval foramen not previously seen, with right-to-left shunt. Sildenafil treatment was instituted in escalating doses. After 40 days of treatment, the echocardiogram showed resolution of the shunt, concomitant to oxygenation improvement. The authors believe that sildenafil is a feasible alternative for primary pulmonary hypertension treatment, although larger clinical trials are necessary to determine its clinical safety and efficacy.

 


Keywords: Pulmonary hypertension/therapy. Vasodilator agents/administration & dosage.

 

Review Article

11 - Hantavirus pulmonary and cardiovascular syndrome

Síndrome pulmonar e cardiovascular por hantavírus

Mariangela Pimentel Pincelli, Carmen Sílvia Valente Barbas, Carlos Roberto Ribeiro de Carvalho, Luiza Terezinha Madia de Souza, Luís Tadeu Moraes Figueiredo

J Bras Pneumol.2003;29(5):309-324

Abstract PDF PT

Hantavirus pulmonary and cardiovascular syndrome is a recently identified and often fatal disease, which presents as acute respiratory distress syndrome (ARDS). Since the first outbreak, in Nov/Dec 1993, in Juquitiba, Brazil, 226 cases have been registered by FUNASA (National Health Foundation).(4) The disease occurs in previously healthy subjects, presenting with fever and symptoms similar to the common cold, and may rapidly evolve to pulmonary edema, respiratory failure and shock. Hemoconcentration and thrombocytopenia are common features, and the typical radiological finding is a bilateral diffuse interstitial infiltrate that evolves to alveolar consolidations in parallel to the worsening of the clinical condition. Initially, mortality was around 75%, but it declined to approximately 35% in the last few years. Patients who survive usually recover completely, about a week after the onset of the respiratory symptoms. The causal agent is a previously unrecognized hantavirus whose natural reservoirs are rodents of the family Muridae, sub-family Sigmodontinae. Specific antiviral treatment for hantavirus pulmonary and cardiovascular syndrome has not yet been well established, and the efficacy of ribavirin is currently being studied. Intensive care, including mechanical ventilation and invasive hemodynamic monitoring, is required for the more severe presentations of the disease. These measures may improve the prognosis and survival of patients with hantavirus pulmonary and cardiovascular syndrome if started early in the course of the disease.

 


Keywords: Hantavirus pulmonary syndrome/diagnoses. Hantavirus infections/diagnoses. Brazil.

 

12 - Inhaled nitric oxide: clinical application

Óxido nítrico inalatório: considerações sobre sua aplicação clínica

Gisele Limongeli Gurgueira, Werther Brunow de Carvalho

J Bras Pneumol.2003;29(5):325-331

Abstract PDF PT

The objective of this paper is to report some clinical and therapeutic aspects of inhaled nitric oxide in pediatrics. Some references were obtained from Medline® using the keywords: inhaled nitric oxide and pediatrics, and critical care. Other sources were the University library and personal files. Along the last decade, clinical trials with inhaled nitric oxide demonstrated only a few specific areas of proven efficacy and a variety of possible adverse events. Toxicity related to inhaled nitric oxide included metahemoglobinemia, cytotoxic pulmonary effects, excess production of nitrogen dioxide and peroxynitrite, and injury to the pulmonary surfactant system. The administration of inhaled nitric oxide to patients with severe left ventricular dysfunction and pulmonary hypertension should be cautious, since vasodilatation may increase pulmonary blood flow and lead to excessive preload. Some studies showed the clinical effects related to abrupt nitric oxide withdrawal, including rebound pulmonary hypertension. Current literature supports the therapeutic use of inhaled nitric oxide in persistent pulmonary hypertension of the newborn (gestational age ³ 34 weeks) to improve oxygenation and avoid extracorporeal oxygenation; and in congenital cardiopathy accompanied by pulmonary hypertension, especially in the immediate postoperative period. To date, research in pediatrics and multicentre trials in adults with inhaled nitric oxide therapy have failed to show mortality reduction or decrease the amount of time under mechanical ventilation for acute respiratory distress syndrome and acute lung injury. This indication needs further investigations. Persistent pulmonary hypertension is the most important indication for inhaled nitric oxide. The Food and Drug Administration has not approved inhaled nitric oxide in acute respiratory distress syndrome for adults and children.

 


Keywords: Nitric oxide/therapeutic use. Pediatrics. Pulmonary hypertension. Critical care.

 

Year 2003 - Volume 29  - Number 6  (November/December)

Editorial

1 - O espírito do Jornal de Pneumologia

Geraldo Lorenzi-Filho

J Bras Pneumol.2003;29(6):335-

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2 - Prevendo a sobrevida da fibrose pulmonar idiopática: estamos melhorando?

Harold R. Collard, Talmadge E. King Jr.

J Bras Pneumol.2003;29(6):336-337

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3 - Perfil dos pacientes portadores de Mycobacterium SP

Afrânio Lineu Kritski

J Bras Pneumol.2003;29(6):338-339

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Original Article

4 - Lung disease caused by Mycobacterium kansasii

Pneumopatia causada por Mycobacterium kansasii

Nelson Morrone, Maria do Carmo Cruvinel, Nelson Morrone Junior, José Antonio dos Santos Freire, Lilia Maria Lima de Oliveira, Carla Gonçalves

J Bras Pneumol.2003;29(6):341-349

Abstract PDF PT

Background: Mycobacterium kansasii is a nontuberculous mycobacterium that can colonize the lungs and cause pulmonary infection. Objective: To report authors' study of 6 patients with pulmonary disease caused by M. kansasii infection in a series of 6 patients diagnosed over 5 years. Method: Between June 1995 and June 2000, 1,349 patients diagnosed with tuberculosis were admitted to the Ipiranga Ari Nogueira da Silva Sanitarium. M. kansasii was identified in the sputum cultures of six (0.44%) of these patients. Results: Patient ages ranged from 25 to 77 years, 5 of the 6 were male, and all presented symptomatic chronic lung disease. All patients tested negative for HIV. Chest radiographs confirmed a history of lung disease; all presented thin walled cavities and adjacent pleural thickening was seen in 2. All patients were initially treated with isoniazid-rifampin-pyrazinamide. In 2 patients, intolerance to pyrazinamide necessitated the substitution of pyrazinamide with ethambutol. Based on the culture results, pyrazinamide was also replaced by ethambutol in 2 other patients. All patients were treated for 9 months or longer, and only one patient suffered recurrence of the disease. After being considered cured of the M. kansasii infection, 1 patient died of respiratory insufficiency due to silicosis. Conclusions: Mycobacteriosis due to M. kansasii was found only rarely and may be attributable to the characteristics of our patients. Therapy with isoniazid, rifampin and pyrazinamide with eventual replacement of the latter by ethambutol was shown to be effective.

 


Keywords: Mycobacterium kansaii. Lung diseases. Respiratory insufficiency.

 

Editorial

4 - Quem espera nem sempre alcança

Daniel Deheinzelin

J Bras Pneumol.2003;29(6):340-

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Original Article

6 - Factors associated with inadequate treatment in a group of patients with multidrug-resistant tuberculosis

Fatores associados aos tratamentos inadequados em grupo de portadores de tuberculose multirresistente

Elizabeth Clara Barroso, Rosa Maria Salani Mota, Maria Filomena Martiniano Morais, Creusa Lima Campelo, Joana Brasileiro Barroso, Jorge Luis Nobre Rodrigues

J Bras Pneumol.2003;29(6):350-357

Abstract PDF PT

Background: Multidrug resistant tuberculosis is a threat to tuberculosis control worldwide. In many studies, it has been suggested that inadequate treatment is a risk factor for the development of multidrug resistent tuberculosis. Objective: To identify the factors associated with inadequate treatment in a group of patients with multidrug resistent tuberculosis. Method: The authors identified all drug sensitivity test for tuberculosis performed at the Central Laboratory of the state of Ceará from 1990 to 1999. Retrospective and prospective analysis was performed, comparing the characteristics of adequately treated patients with those of inadequately treated patients. Multidrug resistance was defined as resistance to 2 drugs (rifampin and isoniazid) or more, using the Cox proportional hazards model. Results: Of the 1,500 sensitivity test performed at the Central Laboratory of Public Health of the state of Ceará, 266 revealed multidrug-resistant strains. Of those 266 patients, the authors were able to identify only 153, of whom 19 were excluded. Thus, our sampling consisted of 134 patients. Univariate analysis demonstrated that the significant factors associated with inadequate treatment were: noncompliance with the treatment, extreme poverty, drug intolerance, mistakes in the management of the patients, lack of medication being supplied by the health service, two or more previous treatments, pronounced lung cavities and bilateral lesions on chest X-rays. They found a further association (p < 0.0010) between alcoholism or smoking and noncompliance with the treatment. In the multivariate analysis, the factors associated with an outcome of inadequate treatment were: two or more previous treatments (p < 0.0001, OR = 5.9; CI 95%: 2.5-13.7), pronounced cavitation (p < 0.0217, OR = 2.7; CI 95%: 1.2-6.1) and bilateral chest X-ray lesions (p < 0.0226, OR = 3.2; CI 95%: 1.4-7.4) Conclusion: In the study, the authors observed that factors related to inadequate treatment are wide-ranging. An attempt at better control of the disease is warranted, especially in those patients with pronounced cavitation or bilateral lesions in chest X-rays. And those with 2 or more previous treatments.

 


Keywords: Tuberculosis, multidrug-resistant. Risk factors.

 

7 - Delay in the diagnosis and surgical treatment of lung cancer

Retardo no diagnóstico e no tratamento cirúrgico do câncer de pulmão

Marli Maria Knorst, Rodrigo Dienstmann, Luciane Pankowski Fagundes

J Bras Pneumol.2003;29(6):358-364

Abstract PDF PT

Background: Lung cancer is the leading cause of cancer-related death worldwide. Objective: To determine the time spent diagnosing, staging and surgically treating lung cancer in a university hospital. Method: Between January 1990 and December 1998, 69 (53 male, 16 female) patients were diagnosed with lung cancer and underwent surgery. The hospital records of these patients were reviewed to evaluate clinical and histological data, dates of outpatient visits, hospital admission, tests and procedures, as well as to determine if the patients were examined as inpatients or as outpatients. Results: The 15 patients investigated as outpatients were designated as group I, the 28 examined as both inpatients and outpatients as group II, and the 26 investigated as inpatients as group III. Age ranged from 43 to 79 years (mean ± SD; 61 ± 10). Of the 69 patients, 43 were smokers and 23 were ex-smokers. The mean time from onset of symptoms to the first outpatient visit was 110 days and 33 days from the first outpatient visit until diagnosis. There was a lapse of 25 days between diagnosis and surgery. The mean total elapsed time between the first outpatient visit and surgery was 58 days. The mean total time was 72 days for group I, 72 days for group II, and 35 days for group III (p < 0.01). There was no significant difference regarding total time in relation to the different stages of the disease (p = 0.16). Conclusions: The results show that patients waited too long before seeking medical assistance and that medical treatment of lung cancer was further delayed when patients were examined in an outpatient setting.

 


Keywords: Lung neoplasm/surgery. Disease progression.

 

8 - Profile and follow-up of patients with Mycobacterium sp. at the Hospital das Clínicas da Universidade Federal de Minas Gerais

Perfil e seguimento dos pacientes portadores de Mycobacterium sp. do Hospital das Clínicas da Universidade Federal de Minas Gerais

Giselle Carvalho Froes, Rosane Luiza Coutinho, Marcelo Nardy de Ávila, Leandra Rocha Cançado, Silvana Spíndola de Miranda

J Bras Pneumol.2003;29(6):365-370

Abstract PDF PT

Background: Surveys of patients diagnosed with mycobacteriosis, taken at the Laboratory of Mycobacteriology of the Hospital das Clínicas da Universidade Federal de Minas Gerais, have shown that lack of information concerning diagnosis prevented 42% from initiating treatment. Objective: To evaluate the profile of patients with mycobacterial infection attending the Hospital das Clínicas da Universidade Federal de Minas Gerais. To describe the follow up of those patients and compare it to the guidelines made by the National Program for the Control of Tuberculosis. Methods: The files of patients diagnosed with mycobacterium infection during 2002 were selected from the archives of the Laboratory of Mycobacteriology of the Hospital das Clínicas da Universidade Federal de Minas Gerais. An active search for these patients was carried out and follow-up exams were then performed. Results: Of the 66 patients selected, 62 (94%) were positive for Mycobacterium tuberculosis and 4 (6%) had nontuberculous mycobacteriosis. Another 4 (6%) had been transferred to other institutions. Of the remaining 58, 37 (63%) had been cured, 1 (2%) had refused treatment, 9 (16%) were not found and 11 (19%) had died. Of the 11 deaths, 7 (64%) had tested positive for HIV. Conclusion: Patients failed to receive treatment not due to lack of diagnosis, but to inadequate structure, low awareness levels of all parties, and lack of tuberculosis control organization at the hospital level. Due to the high number of HIV-positive patients, the number of patients cured was lower than that required by the National Health Ministry. Deaths were attributed to HIV infection and lack of knowledge about the disease. In order to identify and address the problems associated with clinical laboratory practice, laboratory professionals must work in concert with their clinical counterparts when carrying out operational research on tuberculosis.

 


Keywords: Tuberculosis/diagnosis. Mycobacterium infections/complications.

 

9 - Histological features and survival in idiopathic pulmonary fibrosis

Achados histológicos e sobrevida na fibrose pulmonar idiopática

Ester Nei Aparecida Martins Coletta, Carlos Alberto de Castro Pereira, Rimarcs Gomes Ferreira, Adalberto Sperb Rubin, Lucimara Sonja Villela, Tatiana Malheiros, João Norberto Stávale

J Bras Pneumol.2003;29(6):371-378

Abstract PDF PT

Background: Idiopathic pulmonary fibrosis was recently redefined as usual interstitial pneumonia of unknown etiology. Consequently, the prognostic value of histological findings needs to be reassessed. Objective: To correlate clinical, functional and histological findings with survival in patients with idiopathic pulmonary fibrosis. Method: Patients (n = 51; mean age: 66 ± 8 years; gender: 21 females/30 males) were evaluated. Of the 51, 26 were smokers or ex-smokers. Duration of symptoms, forced vital capacity and smoking habits were recorded. All patients presented usual interstitial pneumonia verified through histology. Degree of honeycombing, established fibrosis, desquamation, cellularity, myointimal thickening of blood vessels and number of fibroblastic foci were graded according to the semiquantitative method. Results: Median duration of symptoms was 12 months and initial forced vital capacity was 72 ± 21%. Cox multivariate analysis revealed that survival correlated inversely and significantly (p < 0.05) with duration of symptoms and fibroblastic foci score, as well as with myointimal thickening of blood vessels. Limited numbers of fibroblastic foci, as well as myointimal thickening involving less than 50% of blood vessels, were predictive of greater survival. No correlation with survival was found for gender, age, forced vital capacity, inflammation or degree of cellularity. Conclusion: Semiquantitative analysis of lung biopsies yields relevant prognostic information regarding patients with usual interstitial pneumonia.

 


Keywords: Pulmonary fibrosis. Lung diseases, interstitial. Survival analysis.

 

10 - Influence of oral L-carnitine supplementation combined with physical training on exercise tolerance in patients with chronic obstructive pulmonary disease

Efeitos da suplementação oral de L-carnitina associada ao treinamento físico na tolerância ao exercício de pacientes com doença pulmonar obstrutiva crônica

Audrey Borghi Silva, Valéria Amorim Pires Di Lorenzo, Maurício Jamami, Luciana Maria Malosá Sampaio, Aureluce Demonte, Leonardo Cardello, Dirceu Costa

J Bras Pneumol.2003;29(6):379-385

Abstract PDF PT

Background: Patients with chronic obstructive pulmonary disease usually present intolerance to physical exertion due to ventilatory limitation. L-carnitine has been used to enhance aerobic capacity in patients with chronic diseases, but no study seems to be available for this patient population. Objective: To evaluate the influence of L-carnitine supplementation (2 g/day) in chronic obstructive pulmonary disease patients undergoing physical training three times a week for six weeks. Method: Patients (mean age 69 ± 7 years, n = 30) with stable chronic obstructive pulmonary disease and < 65% of predicted forced expiratory volume in 1 second (FEV1) were separated into three groups of 10 patients each. Group 1 (G1, n = 10) received physical training and L-carnitine (2 g/day), group 2 (G2, n = 10) received physical training and placebo, and group 3 (G3, n = 10) received only L-carnitine (2 g/day). Spirometry and a 6-minute walking distance test were performed before and after intervention. Plasma levels of free carnitine were measured at the beginning and end of the study. Results: A significant increase in walking distance was found only in G1 and G2 (421 ± 100 to 508 ± 80.7 and 496 ± 78.7 to 526 ± 64.3 respectively). In addition, heart rates during physical training sessions were found to be significantly lower in G1 when compared to G2. There were no significant changes in spirometric variables, oxygen saturation or dyspnea in any group. Plasma levels of free L-carnitine were found to increase only in G3 (59.2 ± 13.8 to 102.3 ± 15.3 mmol/L). Conclusion: Oral L-carnitine supplementation combined with physical training may improve tolerance to physical exertion in chronic obstructive pulmonary disease patients.

 


Keywords: Chronic obstructive pulmonary disease. Carnitine/therapeutic use. Spirometry/methods. Exercise. Walking.

 

11 - Interference of nail polish colors and time on pulse oximetry in healthy volunteers

Interferência da coloração de esmaltes de unha e do tempo na oximetria de pulso em voluntários sadios

Mara Harumi Miyake, Solange Diccini, Ana Rita de Cássia Bettencourt

J Bras Pneumol.2003;29(6):386-390

Abstract PDF PT

Background: Pulse oximetry is a noninvasive method to measure the saturation of peripheral oxyhaemoglobin (SpO2). It's usually used in emergency, intensive care and operating room units. Pulse oximeter readings have limited accuracy in the presence of methemoglobin, carboxyhemoglobin, anaemia, peripheral vasoconstriction, nail polish, fluorescent light, and motion. Objectives: To evaluate the interferences of the color of nail polishes and time on SpO2 in healthy individuals. Methods: Sixty-one healthy female volunteers, ages ranging from 18 to 32 years. The nail polish colors used to evaluate SpO2 were: base coat on the little finger, light pink on the ring finger, sparkling light pink on the medium finger and red on the thumb. The index finger was used as control and thus, did not receive nail polish. The time for each color was evaluated every minute until 5 minutes were completed. Results: When the SpO2 measurement was compared with the control, the base coat (p = 0.56), light pink (p = 0.56) and sparkling light pink (p = 0.37) colors didn't present statistically significant differences. Only the red presented a significant variation (p < 0,001), however it was within normal parameters. SpO2 didn't vary significantly with time. Conclusion: Despite the difference found with the red color, all the SpO2 values achieved were inside the normal range for a healthy individual. Pulse oximeter readings are not significantly affected by the color of nail polish in relation to time.

 


Keywords: Nail polish. Oxygen saturation. Pulse oximetry.

 

Case Report

12 - Idiopathic bronchocentric granulomatosis in a nonasthmatic young woman

Granulomatose broncocêntrica idiopática em jovem não asmática

José Wellington Alves dos Santos, Carlos Renato Mello, Gustavo Trindade Michel, Claudius Wladimir Cornelius de Figueiredo, Jader Miletho, Alessandro Zordan

J Bras Pneumol.2003;29(6):391-394

Abstract PDF PT

Bronchocentric granulomatosis is histopathologically defined as being characterized by necrotizing granulomatous inflammation centered in the bronchi or bronchioles, which can be idiopathic or associated with infectious, immunologic or neoplastic diseases. This paper reports the case of a 26 year old nonasthmatic young woman with a 1-month history of chest pain, fever and productive cough. Chest radiography and computerized tomography were performed, and an open-lung biopsy was submitted to histological analysis. Radiographs and tomographs revealed consolidation and cavitation in the lingula. Transbronchial needle aspiration showed nonspecific inflammatory lesions, and no etiologic agent was identified. Histological examination of the specimen obtained by open-lung biopsy was consistent with idiopathic bronchocentric granulomatosis. The patient responded positively to prednisone therapy, and no relapse was documented.

 


Keywords: Bronchocentric granulomatosis. Bronchi. Allergic bronchopulmonary aspergillosis. Prednisone/therapeutic use.

 

13 - Interstitial pneumonia in a patient undergoing treatment with leflunomide: drug-induced toxicity?

Pneumonite intersticial em paciente sob tratamento com leflunomide: toxicidade da droga?

Jonatas Reichert, Adriane Reichert, Luci Iolanda Bendhack, Lucia de Noronha, Dante Escuissato, Acir Rachid Filho

J Bras Pneumol.2003;29(6):395-400

Abstract PDF PT

Leflunomide is an anti-rheumatic drug with immunomodulating effects. Granulomatous interstitial pneumonia has never been described in association with the use of this drug. We report the case of a 33-year-old female patient who presented with chest pain, weight loss and pulmonary infectious syndrome during the fifth month of monotherapy with leflunomide for rheumatoid arthritis, which advanced to respiratory insufficiency in the sixth month. Radiologic findings revealed pulmonary intersticial infiltrates, as well as bilateral alveolar infiltrates (mainly in the upper and medium lobes) and scattered micronodules. However, no mediastinal abnormalities were detected. Leflunomide was suspended. After resolution of the infection, interstitial reticulonodular lesions persisted, predominantly in the upper 2/3 of the right lung and in the center of the left lung, interspersed with a ground-glass pattern in the superior lobes. Surprisingly, pulmonary biopsy revealed tuberculoid granulomas without caseous necrosis. A thorough etiological investigation was carried out, but no etiologic agent was identified. After four months, the condition spontaneously and completely disappeared. This profile suggests that the pulmonary complications seen in this case were the result of leflunomide use.

 


Keywords: Lung diseases, interstitial/chemically induced. Lung/drugs effects.

 

14 - Alveolar hemorrhage associated with lupus nephritis

Hemorragia alveolar associada a nefrite lúpica

Ricardo Henrique de Oliveira Braga Teixeira, Marcel Hiratsuka, Flávia Calderini Rosa, Rogério Souza, Carlos Roberto Ribeiro de Carvalho

J Bras Pneumol.2003;29(6):401-404

Abstract PDF PT

Alveolar hemorrhage leading to respiratory failure is uncommon. Various etiologies have been reported, including systemic lupus erythematosus, which generally presents as pulmonary-renal syndrome. It is believed that the pathogenesis of microangiopathy is related to deposits of immune complexes that lead to activation of cellular apoptosis. The authors report two cases of alveolar hemorrhage and respiratory failure, both requiring mechanical ventilation. The two cases had opposite outcomes after pharmacological therapy. The presence of anti-glomerular basement membrane antibodies in one of the cases demonstrates the multiplicity of physiopathological mechanisms that may be involved. This multiplicity of mechanisms provides a possible explanation for the heterogeneous responses to the available treatments.

 


Keywords: Lupus erythematosus systemic/etiology. Lupus nephritis/etiology. Respiratory insufficiency/complications.

 

Review Article

15 - Phosphodiesterase inhibitors: new perspectives on an old therapy for asthma?

Inibidores de fosfodiesterases: novas perspectivas de uma antiga terapia na asma?

Hisbello Campos, Debora Xisto, Walter A. Zin, Patricia R.M. Rocco

J Bras Pneumol.2003;29(6):405-412

Abstract PDF PT

Asthma is a chronic inflammatory disease characterized by varying degrees of airflow obstruction and diverse clinical manifestations. As knowledge of asthma pathogenesis has increased, treatment has evolved. Airway inflammation, modulated by genetic and environmental factors, results in altered airway architecture (airway remodeling). Inflammation in asthma is typically multicellular in nature, involving mast cells, neutrophils, eosinophils, and T lymphocytes, as well as muscle and epithelial cells. Various cytokines and chemokines play roles in orchestrating the inflammatory process. Recognition of the critical role played by airway inflammation, which is an indicator of the degree of asthma severity, has shifted the treatment toward either prevention or the inhibition of inflammatory markers. In light of this, new drug formulations have been considered. In addition to the b2 agonists, theophylline, and corticosteroids currently being used, the second generation of selective phosphodiesterase inhibitors has shown promising results. Recent studies suggest that these drugs may soon offer a novel alternative in the treatment of asthma.

 


Keywords: Phosphodiesterase inhibitors/therapeutic use. Inflammation mediators. Asthma/pathology.

 

16 - Chronic cough in non-smokers: diagnostic approach

Abordagem diagnóstica da tosse crônica em pacientes não-tabagistas

Márcia Jacomelli, Rogério Souza, Wilson Leite Pedreira Júnior

J Bras Pneumol.2003;29(6):413-420

Abstract PDF PT

Cough is the main physiological mechanism responsible for the clearance of secretions from airways, acting as an important defense mechanism. However, the presentation of chronic cough is one of the most important causes for patients to seek medical attention all over the world, thus the significance of the correct recognition of all the factors related to the process of cough. Among those factors, some are of extreme importance, since they may be present in almost 95% of the cases: post-nasal drip syndrome, asthma and gastroesophageal reflux disease. The main step for a successful therapy for chronic cough is a rational and progressive diagnostic approach, narrowing the list of possible diagnosis and allowing the institution of a treatment with a better cost-effectiveness. The proposal of an algorithm focusing on the most common causes of chronic cough may be helpful in this initial approach.

 


Keywords: Chronic cough. Diagnostic algorithm. Asthma. Postnasal drip syndrome. Gastroesophageal reflux disease.

 

 


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