Brazilian Journal of Pulmonology

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


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Year 2008 - Volume 34  - Number 1  (/January)


1 - Air pollution and our lung disease patients

Nossos doentes pneumopatas e a poluição atmosférica

Paulo Saldiva

J Bras Pneumol.2008;34(1):1

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2 - Advances in the radiological diagnosis of pulmonary nodules

Avanços no diagnóstico radiológico dos nódulos pulmonares

Edson Marchiori, Klaus Loureiro Irion

J Bras Pneumol.2008;34(1):2-3

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Original Article

3 - Evaluation of the knowledge of health professionals at a pediatric hospital regarding the use of metered-dose inhalers

Avaliação do conhecimento sobre o uso de inaladores dosimetrados entre profissionais de saúde de um hospital pediátrico

Fábio Pereira Muchão, Sílvia La Regina Rodrigues Perín, Joaquim Carlos Rodrigues, Cláudio Leone, Luiz Vicente Ribeiro Ferreira Silva Filho

J Bras Pneumol.2008;34(1):4-12

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Objective: To evaluate health professionals working at a tertiary pediatric hospital in terms of their knowledge regarding the practical use of metered-dose inhalers. Methods: Practical and written tests on the use of metered-dose inhalers were applied to physicians, physical therapists, nurses and nursing assistants. A score from 0 to 10 was assigned to each evaluation, and median scores were calculated for each professional category. Questions with higher and lower correct values were identified, and a descriptive comparison was made regarding the performance of the various professional categories. Statistical analysis was performed using the Kruskal-Wallis method for comparison of medians. A sequential logistic multiple regression analysis was also performed. Results: A total of 30 resident physicians or interns in the pediatrics department, 23 attending physicians, 29 physical therapists, 33 nurses and 31 nursing assistants were evaluated. Resident physicians, physical therapists and attending physicians performed significantly better than did nurses and nursing assistants. Only resident physicians had a median score greater than 6. Conclusions: The health professionals evaluated, particularly the nurses and nursing assistants, who are directly involved in the practical use of metered-dose inhalers, possess insufficient knowledge regarding the use of such inhalers.


Keywords: Metered dose inhalers; Inhalation spacers; Asthma; Education, public health professional.


4 - Malignant pleural mesothelioma: multidisciplinary experience in a public tertiary hospital

Mesotelioma pleural maligno: experiência multidisciplinar em hospital público terciário

Ricardo Mingarini Terra, Lisete Ribeiro Teixeira, Ricardo Beyruti, Teresa Yae Takagaki, Francisco Suso Vargas, Fabio Biscegli Jatene

J Bras Pneumol.2008;34(1):12-20

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Objective: To evaluate the experience in diagnosing and treating malignant pleural mesothelioma (MPM) accumulated over 5 years in a tertiary public hospital. Methods: The medical charts of the patients diagnosed with MPM between January of 2000 and February of 2005 were evaluated retrospectively. Results: Of the 17 patients analyzed, 14 were male and 3 were female. The mean age was 54.1 years (range, 13-75 years). The biopsy specimens for histopathological examination were obtained through thoracoscopy in 9 patients (53%), Cope needle in 5 (29.5%), and open pleural biopsy in 3 (17.5%). The following histological types were identified: epithelial, in 14 patients (82%); sarcomatoid, in 1 (6%); and biphasic, in 2 (12%). The therapeutic approaches used were as follows: multimodal (pleuropneumonectomy and adjuvant radiotherapy and chemotherapy) in 6 patients (35%); chemotherapy and radiotherapy in 6 (35%); radiotherapy alone in 3 (17.5%); and chemotherapy alone in 2 (12%). The mean survival was 11 months (range, 1-26 months). Conclusions: In the cases studied, an integrated multidisciplinary approach was used, and a highly complex hospital infrastructure was available for the diagnosis and treatment of MPM, as recommended in the literature. However, the mean survival was only 11 months, reflecting the aggressiveness of the disease.


Keywords: Mesothelioma; Pleura; Surgery; Diagnosis.


5 - Development of a modified Dumon stent for tracheal applications: an experimental study in dogs

Desenvolvimento de uma órtese de Dumon modificada para aplicações traqueais: um estudo experimental em cães

Rogério Gastal Xavier, Paulo Roberto Stefani Sanches, Amarilio Viera de Macedo Neto, Gabriel Kuhl, Samanta Bianchi Vearick, Marcelo Dall'Onder Michelon

J Bras Pneumol.2008;34(1):21-26

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Objective: To describe the development of a silicone stent and perform in vivo testing for biocompatibility/applicability in the normal canine trachea. Methods: Four different densities were tested in order to obtain the silicone prototypes. The pressure required for compression considering a contact area of 1 cm2, and a 30% reduction in diameter was calculated for each density. The best density was 70-75 Shore A hardness. Powdered barium sulfate was added to the silicone to make the stent radiopaque and easily identifiable in radiological imaging. This novel stent presents a corrugated external surface with discontinuous and protruding arcs resembling the tracheobronchial rings (for intercalation and fixation in the lumen of the lower airways), a highly polished inner surface and smooth extremities (to prevent friction-related damage). The prototype considered most appropriate in terms of rigidity and flexibility was bronchoscopically implanted in normal canine tracheas. After eight weeks, the animals were euthanized, and the tracheas were removed for anatomopathological analysis. Results: There were no postimplantation complications, and none had to be removed. After eight weeks, the devices were found to be well-positioned. Histopathology revealed a well-preserved epithelial basal membrane, foci of denuded epithelium, mild submucosal inflammatory infiltrate with scattered granulation tissue, vascular neoformation, and no microorganisms. Conclusions: The stent developed proved resistant to mechanical stress, biocompatible in the canine trachea and well-preserved at the study endpoint.


Keywords: Implants, experimental; Silicones; Biocompatible materials.


6 - Detection of pulmonary nodules by computer-aided diagnosis in multidetector computed tomography: preliminary study of 24 cases

Diagnóstico auxiliado por computador na detecção de nódulos pulmonares pela tomografia computadorizada com múltiplos detectores: estudo preliminar de 24 casos

Julia Capobianco, Dany Jasinowodolinski, Gilberto Szarf

J Bras Pneumol.2008;34(1):27-33

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Objectives: To evaluate the performance of a computer program designed to facilitate the detection of pulmonary nodules using multidetector computed tomography (MDCT) scans of the chest. Methods: We evaluated 24 consecutive MDCT scans of the chest at the Fleury Diagnostic Imaging Center during the period from October 7 to October 19 of 2006, using a 64-channel CT scanner. The study comprised 12 females and 12 males, ranging from 35 to 77 years of age (mean, 57.9 years). Double reading and a computer-aided diagnosis (CAD) system were used in order to perform two independent analyses of the data. The nodules found using both methods were recorded, and the data were compared. Results: The total sensitivity of CAD for the detection of nodules was 16.5%, increasing to 55% when nodules <4 mm in diameter were excluded. Sensitivity by diameter was 6.5% for nodules <4 mm, 45% for nodules of 4-6 mm, 100% for nodules of 6 mm-1 cm, and 0% for nodules >1 cm. More than 99% of true nodules detected by CAD were registered in the image double-reading process. Conclusions: In this preliminary 24-case study, the sensitivity of computer program tested was not significantly greater than that of the double-reading process that is routinely performed in this facility.


Keywords: Image interpretation, computer-assisted; Coin lesion, pulmonary; Tomography, X-ray computed.


7 - The effect of corticosteroids on the prevention of fat embolism syndrome after long bone fracture of the lower limbs: a systematic review and meta-analysis

O efeito do corticosteróide na prevenção da síndrome da embolia gordurosa após fratura de osso longo dos membros inferiores: revisão sistemática com meta-análise

Rodrigo Cavallazzi, Antonio César Cavallazzi

J Bras Pneumol.2008;34(1):34-41

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Objective: To analyze the available evidence regarding the effect that corticosteroids have on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture. Methods: In March of 2007, we performed a search of various electronic databases, including Medline, the Excerpta Medica database, the Cochrane Library, the Latin American and Caribbean Health Sciences Literature database and the Scientific Electronic Library Online. We selected randomized controlled trials that compared the effect of corticosteroids with that of placebo (or standard care) on the prevention of fat embolism syndrome after long bone fracture of the lower limbs or pelvic fracture. References from the studies included were also reviewed. Results: Six studies were included. The pooled relative risk for developing fat embolism syndrome was 0.16 (95% CI: 0.08-0.35) in the corticosteroid group as compared with the control group. The pooled relative risk for developing hypoxemia was 0.34 (95% CI: 0.19-0.59) in the corticosteroid group as compared with the control group. Conclusion: The analysis of evidence showed that corticosteroids decrease the risk of developing fat embolism syndrome and hypoxemia after long bone fracture of the lower limbs.


Keywords: Embolism, Fat; Adrenal Cortex Hormones; Meta-Analysis.


Brief Communication

8 - Anthropogenic air pollution and respiratory disease-related emergency room visits in Rio Branco, Brazil - September, 2005

Poluição atmosférica devido à queima de biomassa florestal e atendimentos de emergência por doença respiratória em Rio Branco, Brasil - Setembro, 2005

Márcio Dênis Medeiros Mascarenhas, Lúcia Costa Vieira, Tatiana Miranda Lanzieri, Ana Paula Pinho Rodrigues Leal, Alejandro Fonseca Duarte, Douglas Lloyd Hatch

J Bras Pneumol.2008;34(1):42-46

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Air pollution is a major public health problem in the Amazon forest and in large Brazilian cities. During September of 2005, high concentrations of smoke from biomass burning were observed in the city of Rio Branco. An ecological study was conducted to evaluate the relationship between daily concentrations of particulate matter < 2.5 μm (PM2.5) and the number of respiratory disease (RD)-related emergency room visits. Daily PM2.5 concentrations exceeded recommended air quality limits on 23 days. The incidence of RDs was higher among children < 10 years of age. There was a significant positive correlation between PM2.5 concentrations and asthma emergency room visits.


Keywords: Air pollution/adverse effects; Fires; Respiratory tract diseases/epidemiology; Asthma; Space-time clustering.


Ensaio Pictórico

9 - Diffuse abnormalities of the trachea: computed tomography findings

Alterações difusas da traquéia: aspectos na tomografia computadorizada

Edson Marchiori, Aline Serfaty Pozes, Arthur Soares Souza Junior, Dante Luiz Escuissato, Klaus Loureiro Irion, César de Araujo Neto, Jorge Luiz Barillo, Carolina Althoff Souza, Gláucia Zanetti

J Bras Pneumol.2008;34(1):47-54

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The aim of this pictorial essay was to present the main computed tomography findings seen in diffuse diseases of the trachea. The diseases studied included amyloidosis, tracheobronchopathia osteochondroplastica, tracheobronchomegaly, laryngotracheobronchial papillomatosis, lymphoma, neurofibromatosis, relapsing polychondritis, Wegener's granulomatosis, tuberculosis, paracoccidioidomycosis, and tracheobronchomalacia. The most common computed tomography finding was thickening of the walls of the trachea, with or without nodules, parietal calcifications, or involvement of the posterior wall. Although computed tomography allows the detection and characterization of diseases of the central airways, and the correlation with clinical data reduces the diagnostic possibilities, bronchoscopy with biopsy remains the most useful procedure for the diagnosis of diffuse lesions of the trachea.


Keywords: Thoracic diseases; Tracheal diseases; Tomography, X-ray computed; Trachea.


Case Report

10 - Mediastinal liposarcoma: a case report

Lipossarcoma de mediastino: relato de caso

Roberto Saad Junior, Vicente Dorgan Neto, Roberto Gonçalves, Márcio Botter, Leticia Cristina Dalledone Siqueira

J Bras Pneumol.2008;34(1):55-58

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Here, we describe the case of a 51-year-old female with mediastinal liposarcoma. Liposarcoma is the most common malignant mesenchymal neoplasm in adults, although a mediastinal location is extremely rare. It has a large volume and varied histologic subtypes. It is characterized by the compression of neighboring structures. Computed tomography and magnetic resonance imaging provide useful data for diagnosis. Tissue biopsy and histological typing are very important in determining the treatment and are needed for the final diagnosis. Radiotherapy and chemotherapy are ineffective treatment modalities. According to the literature, surgical resection is the treatment of choice. Long-term follow-up evaluation is indicated since there is a high rate of recurrence.


Keywords: Liposarcoma; Mediastinal neoplasms; Case reports [publication type].


11 - Bronchial thermoplasty: report on the first endoscopic treatment for asthma in Latin America*

Termoplastia brônquica: relato do primeiro tratamento endoscópico de asma na América Latina

Adalberto Sperb Rubin, Paulo Francisco Guerreiro Cardoso

J Bras Pneumol.2008;34(1):59-62

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Bronchial thermoplasty is a new bronchoscopic procedure that delivers radiofrequency energy to the airway and potentially reduces the smooth muscle-mediated bronchoconstriction. We report the case of a 48-year-old man with persistent moderate asthma submitted to bronchial thermoplasty. The treatment increased the forced expiratory volume in one second, increased the number of symptom-free days, reduced the use of relief medications, and improved the Juniper Asthma Quality of Life Scale score. In this patient, bronchial thermoplasty was well tolerated and safe. This was the first bronchial thermoplasty performed in Latin America. At 12 months after the procedure, the results were encouraging in terms of its potential benefits in patients with difficult-to-control asthma.


Keywords: Asthma/treatment; Respiratory function tests; Case reports [publication type].


Year 2008 - Volume 34  - Number 2  (/February)


1 - Pulmonary hypertension in chronic respiratory disorders: we need to learn more

Hipertensão pulmonar em pneumopatias crônicas: temos que aprender mais

Roberto F. P. Machado

J Bras Pneumol.2008;34(2):65-66

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Original Article

2 - Pulmonary histopathological alterations in patients with acute respiratory failure: an autopsy study

Alterações histopatológicas pulmonares em pacientes com insuficiência respiratória aguda: um estudo em autopsias

Alexandre de Matos Soeiro, Edwin Roger Parra, Mauro Canzian, Cecília Farhat, Vera Luiza Capelozzi

J Bras Pneumol.2008;34(2):67-73

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Objective: To present the pulmonary histopathological alterations found in the autopsies of patients with acute respiratory failure (ARF) and determine whether underlying diseases and certain associated risk factors increase the incidence of these histopathological patterns. Methods: Final autopsy reports were reviewed, and 3030 autopsies of patients > 1 year of age with an underlying disease and associated risk factors were selected. All had developed diffuse infiltrates and died of ARF-related pulmonary alterations. Results: The principal pulmonary histopathological alterations resulting in immediate death were diffuse alveolar damage (DAD), pulmonary edema, lymphocytic interstitial pneumonia (LIP) and alveolar hemorrhage. The principal underlying diseases were AIDS, bronchopneumonia, sepsis, liver cirrhosis, pulmonary thromboembolism, acute myocardial infarction (AMI), cerebrovascular accident, tuberculosis, cancer, chronic kidney failure and leukemia. The principal associated risk factors were as follows: age ≥ 50 years; arterial hypertension; congestive heart failure; chronic obstructive pulmonary disease; and diabetes mellitus. These risk factors and AIDS correlated with a high risk of developing LIP; these same risk factors, if concomitant with sepsis or liver cirrhosis, correlated with a risk of developing DAD; thromboembolism and these risk factors correlated with a risk of developing alveolar hemorrhage; these risk factors and AMI correlated with a risk of developing pulmonary edema. Conclusion: Pulmonary findings in patients who died of ARF presented four histopathological patterns: DAD, pulmonary edema, LIP and alveolar hemorrhage. Underlying diseases and certain associated risk factors correlated positively with specific histopathological findings on autopsy.


Keywords: Respiratory insufficiency; Autopsy; Lung diseases, interstitial; Pulmonary edema; Hemorrhage.


3 - Foreign body aspiration in children: clinical aspects, radiological aspects and bronchoscopic treatment

Aspiração de corpo estranho em crianças: aspectos clínicos, radiológicos e tratamento broncoscópico

Andrea de Melo Alexandre Fraga, Marcelo Conrado dos Reis, Mariana Porto Zambon, Ivan Contrera Toro, José Dirceu Ribeiro, Emilio Carlos Elias Baracat

J Bras Pneumol.2008;34(2):

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Objective: To describe the clinical manifestations and bronchoscopic treatment of foreign body aspiration in children under 14 years of age, correlating the clinical aspects with the bronchoscopic findings. Methods: A retrospective, descriptive study analyzing data related to children under 14 years of age undergoing bronchoscopy due to clinical suspicion of foreign body aspiration at the State University at Campinas Hospital das Clinicas from January of 2000 to December of 2005. Results: The sample consisted of 69 patients, ranging in age from 8 months to 12 years/7 months (75.4% under 3 years of age), 62.3% of whom were male. The principal complaint was sudden-onset cough (75.4%), auscultation was abnormal in 74%, and dyspnea was observed in 29%. Radiological abnormalities were seen in 88% of the cases. Aspirations were primarily into the right lung (54.8%), and 30.7% of the foreign bodies were of vegetal origin (principally beans and peanuts). In the follow-up period, 29% presented complications (most commonly pneumonia), which were found to be associated with longer aspiration time (p = 0.03). Mechanical ventilation was required in 7 children (10.1%), and multiple bronchoscopies were performed in 5 (7.2%). Conclusion: A history of sudden-onset choking and cough, plus abnormal auscultation and radiological findings, characterizes the profile of foreign body aspiration. In such cases, bronchoscopy is indicated. Longer aspiration time translates to a higher the risk of complications. The high prevalence of foreign bodies of vegetal origin underscores the relevance of prevention programs aimed at children younger than 3 years of age.


Keywords: Foreign bodies; Bronchoscopy; Pediatrics.


4 - Prevalence of pulmonary hypertension evaluated by Doppler echocardiography in a population of adolescent and adult patients with cystic fibrosis

Prevalência de hipertensão pulmonar avaliada por ecocardiografia Doppler em uma população de pacientes adolescentes e adultos com fibrose cística

Paula Maria Eidt Rovedder, Bruna Ziegler, Antônio Fernando Furlan Pinotti, Sérgio Saldanha Menna Barreto, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2008;34(2):83-90

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Objective: To determine the prevalence of pulmonary hypertension (PH) in patients with cystic fibrosis (CF), to compare clinical characteristics, radiographic scores, pulmonary function, and echocardiographic parameters in patients with and without PH, and to correlate echocardiographic findings with clinical characteristics, radiographic scores, and pulmonary function. Methods: This was a prospective, cross-sectional study involving clinically stable patients (aged 16 or older) enrolled in an adult CF program. The patients were submitted to clinical evaluation, Doppler echocardiography, pulmonary function tests, and chest X-rays. Results: Tricuspid regurgitant jet velocity (TRV) was obtained in 37 of the 40 patients studied. The prevalence of PH was 49% with a TRV cut-off of 2.5 m/s (18 patients) and 30% with a TRV cut-off of 2.8 m/s (11 patients). Peripheral oxygen saturation (SpO2) at rest, clinical score, forced expiratory volume in one second (FEV1), and forced vital capacity (FVC) were significantly lower in the group with PH. The TRV was found to correlate significantly with SpO2 at rest (p < 0.001), clinical score (p < 0.001), radiographic score (p = 0.030), FEV1 in liters (p < 0.001) and in % of predicted (p < 0.001), and FCV in liters (p = 0.008) and in % of predicted (p = 0.001). The single best predictor of TRV was SpO2 at rest (p < 0.001). Conclusion: The high prevalence of PH in the CF patients studied suggests that PH should be considered in the evaluation and follow-up treatment of such patients. The best predictor of PH was SpO2 at rest.


Keywords: Cystic fibrosis; Tricuspid valve/physiopathology; Hypertension, pulmonary; Echocardiography, Doppler.


5 - Smoking in a small city: an ethnographic study to serve as a base for the creation of a public health program

O tabagismo em um município de pequeno porte: um estudo etnográfico como base para geração de um programa de saúde pública

Thales Jenner de Oliveira Falcão, Iris do Céu Clara Costa

J Bras Pneumol.2008;34(2):91-97

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Objective: To outline the prevalence of smoking in the city of Parazinho, Brazil, with the objective of generating data on which to base a plan of action for smoking control programs in the city. Methods: A questionnaire was applied to 150 people (25.6% of whom were smokers) by community health agents during home visits. The questionnaire comprised 30 objective and subjective questions to collect social and biological information on smokers in urban and rural areas. Results: The data were analyzed using descriptive statistics, and the principal findings were as follows: the prevalence of smoking was higher among males (57.8%); most of the interviewees started smoking at an early age (45% before the age of 12); economic conditions constituted a contributing factor (66% of the smokers interviewed earned less than the minimum wage); most of the interviewees reported difficulty in kicking the habit (44.6% reported living with a smoker, and 80% had a friend who smoked); there was a high prevalence of tobacco-related diseases (56.6% had respiratory problems); and there was concomitant alcohol use in 52% of the smokers. Conclusion: This outline can be used in the generation of a local program of smoking prevention and control. Such a program is, in fact, under development. A team of professionals has received training in a 'minimal, intensive approach to the smoker', and a municipal outpatient clinic for the treatment of nicotine dependence has been inaugurated.


Keywords: Smoking/prevention & control; Questionnaires; Smoking/epidemiology.


6 - Tuberculous uveitis at a referral center in southeastern Brazil

Uveíte por tuberculose em um centro de referência no Sudeste do Brasil

Wesley Ribeiro Campos, Juliana Fulgêncio Henriques, Afrânio Lineu Kritski, André Curi, Rosita Tomishi Pimentel, Silvana Spindola de Miranda

J Bras Pneumol.2008;34(2):98-102

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Objective: To describe the occurrence of tuberculous uveitis (TBU) at a referral center in the state of Minas Gerais, Brazil. Methods: A total of 16 consecutive patients (≥15 years of age) who underwent diagnostic evaluation of uveitis between January of 2001 and July of 2004 at the Minas Gerais State Referral Center were selected for study. Demographic and clinical data, as well as data related to screening for toxoplasmosis, syphilis, and rheumatologic diseases, together with the results of tuberculin skin testing and HIV testing, were collected. Results: Of the16 patients evaluated, 11 (69%) were found to have TBU. A history of contact with pulmonary tuberculosis was reported by 8 (72%) of the 11 patients with TBU and by 1 (20%) of the 5 with non-TBU. Although the odds ratio for this association was 10.67 (95% CI: 0.59-398.66), the p value was borderline significant (p = 0.078). There was no difference between the patients with TBU and those with non-TBU in terms of the status of ocular inflammation or the tuberculin skin testing results. All of the patients were HIV negative and were monitored for two years. Conclusion: In this study, a history of contact with pulmonary tuberculosis proved to be useful in diagnosing TBU.


Keywords: Tuberculosis; Uveitis; Diagnosis; Brazil.


Brief Communication

7 - Brazilian examples of programs for the control of asthma

Exemplos brasileiros de programas de controle de asma

Alcindo Cerci Neto, Olavo Franco Ferreira Filho, Tatiara Bueno

J Bras Pneumol.2008;34(2):103-106

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The aim of this study was to determine which Brazilian programs demonstrate experience in asthma management. Data on and characteristics of those programs were obtained by electronic mail. The variables studied were related to the program itself, its patients and staff. Descriptive statistics were used in the study, which evaluated 17 programs. All programs received public funding, produced educational/training materials and had specialized physicians on staff. We concluded that the experience accumulated by all the programs can be used as one of the pillars of a national program for the control of asthma in Brazil.


Keywords: Programs; Asthma; Public health.


Review Article

8 - Cystic fibrosis in adults: diagnostic and therapeutic aspects

Fibrose cística no adulto: aspectos diagnósticos e terapêuticos

Paulo de Tarso Roth Dalcin, Fernando Antônio de Abreu e Silva

J Bras Pneumol.2008;34(2):107-117

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Once considered a childhood disease, cystic fibrosis is now also a disease of adults. Increased longevity has resulted in the aging of the cystic fibrosis population. The consequent age-related medical problems among adults with cystic fibrosis have increased medical care needs. These needs are being met by a growing number of non-pediatric pulmonologists and other non-pediatric specialists. The objective of this review was to summarize the current knowledge about diagnosis and treatment in adult cystic fibrosis. In most cases, the diagnosis is suggested by manifestations of chronic sinopulmonary disease and exocrine pancreatic insufficiency. The diagnosis is confirmed by a positive sweat test result. Adult patients may, however, present pancreatic sufficiency and atypical clinical features, sometimes in combination with normal or borderline sweat test results. In such cases, identifying cystic fibrosis mutations and measuring nasal potential difference can have diagnostic utility. The standard therapeutic approach to pulmonary disease includes the use of antibiotics, airway clearance, exercise, mucolytics, bronchodilators, oxygen therapy, anti-inflammatory agents and nutritional support. Appropriate application of these therapies results in most cystic fibrosis patients surviving into adulthood with an acceptable quality of life.


Keywords: Cystic fibrosis; Diagnosis; Therapeutics; Mucoviscidosis.


Case Report

9 - A very rare cause of dyspnea with a unique presentation on a computed tomography scan of the chest: macrophage activation syndrome

Uma rara causa de dispnéia com apresentação singular na tomografia computadorizada de tórax: síndrome de ativação macrofágica

Rodrigo Antônio Brandão-Neto, Alfredo Nicodemos Cruz Santana, Debora Lucia Seguro Danilovic, Fabíola Del Carlo Bernardi, Carmen Silvia Valente Barbas, Berenice Bilharinho de Mendonça

J Bras Pneumol.2008;34(2):118-120

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Macrophage activation syndrome is a rare and potentially life-threatening disease. It occurs due to immune dysregulation manifested as excessive macrophage proliferation, typically causing hepatosplenomegaly, pancytopenia and hepatic dysfunction. Here, we report an unusual case of macrophage activation syndrome presenting as dyspnea, as well as (reported here for the first time) high resolution computed tomography findings of an excavated nodule, diffuse ground glass opacities and consolidations (mimicking severe pneumonia or alveolar hemorrhage). The patient was successfully treated with human immunoglobulin. We recommend that macrophage activation syndrome be considered in the differential diagnosis of respiratory failure. Rapid diagnosis and treatment are essential to achieving favorable outcomes in patients with this syndrome.


Keywords: Macrophage activation; Lymphohistiocytosis, hemophagocytic; Tomography, X-ray computed; Lung diseases, interstitial.


10 - Management of recurrent distal tracheal stenosis using an endoprosthesis: a case report

Manejo da estenose traqueal distal recidivada por meio de endoprótese: relato de caso

André Germano Leite, Douglas Kussler

J Bras Pneumol.2008;34(2):121-125

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The authors report the case of a patient with recurrent distal tracheal stenosis after several tracheal resections. A T-Y tracheobronchial stent was inserted for the management of distal airway obstruction. The prosthesis was adapted based on the specifications obtained through a computed tomography scan of the chest with three-dimensional reconstruction.


Keywords: Tracheal stenosis; Prostheses and implants; Trachea/surgery; Case reports [publication type].


Letters to the Editor

11 - Bedside tracheostomy: practical considerations

Traqueostomia à beira do leito: considerações práticas

Ricardo Mingarini Terra, Angelo Fernandez, Ricardo Helbert Bammann

J Bras Pneumol.2008;34(2):126-

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Year 2008 - Volume 34  - Number 3  (/March)


1 - Histological diagnosis of lung cancer micrometastases

O diagnóstico histológico de micrometástases de tumores de pulmão

Simone Gusmão Ramos

J Bras Pneumol.2008;34(3):127-128

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Original Article

2 - Detection of micrometastases in pN0 non-small cell lung cancer: an alternative method combining tissue microarray and immunohistochemistry

Detecção de micrometástases em câncer de pulmão não-pequenas células estádio pN0: um método alternativo combinando imunohistoquímica e análise em microsséries

Maíra Rovigatti Franco, Edwin Roger Parra, Teresa Yae Takagaki, Fernando Augusto Soares, Vera Luiza Capelozzi

J Bras Pneumol.2008;34(3):129-135

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Objective: To present an alternative method of detecting micrometastases in lymph nodes previously testing negative for non-small cell lung cancer (NSCLC) by routine hematoxylin-eosin staining. Methods: A total of 77 hilar and mediastinal lymph nodes resected from 18 patients with NSCLC were investigated for the presence of micrometastases using a combination of microarray analysis and immunohistochemistry. Results: Micrometastases were detected by identifying cytokeratin- and chromogranin-positive cells in lymph node microarrays. Of the 18 patients initially staged as pN0 through routine hematoxylin-eosin staining, 9 (50%) were restaged as N1, and the prognoses were re-evaluated in terms of histological and clinical parameters. The comparison of the survival curves revealed that survival was higher in the patients without micrometastases than in those with micrometastases. In addition, in the multivariate analysis adjusted for age, gender, histological type, and restaging, the presence of micrometastases proved to be an independent predictor of survival. Among patients who had been previously staged as pN0, the risk of death was found to be 7-times greater for those later diagnosed with micrometastases than for those in whom no micrometastases were identified. Conclusion: The combination of microarray analysis and immunohistochemistry might represent a low-cost and less time-consuming alternative for identifying occult micrometastases and predicting prognoses in surgically resected patients with pN0 NSCLC. Larger randomized, prospective studies are needed in order to determine the accuracy of this method.


Keywords: Lung neoplasms; Microarray analysis; Chromogranin A; Survival analysis.


3 - The incidence of residual pneumothorax after video-assisted sympathectomy with and without pleural drainage and its effect on postoperative pain

Incidência de pneumotórax residual após simpatectomia torácica videotoracoscópica com e sem drenagem pleural e sua possível influência na dor pós-operatória

Alexandre Garcia de Lima, Giancarlo Antonio Marcondes, Ayrton Bentes Teixeira, Ivan Felizardo Contrera Toro, Jose Ribas Milanez de Campos, Fábio Biscegli Jatene

J Bras Pneumol.2008;34(3):136-142

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the incidence of residual pneumothorax after video-assisted thoracic sympathectomy, with and without postoperative pleural drainage, and to evaluate the possible influence of this type of pneumothorax on postoperative pain within the first 28 postoperative days. Methods: All patients presenting symptoms consistent with primary palmoplantar hyperhidrosis and treated at the Thoracic Surgery Outpatient Clinic of the State Hospital of Sumaré between July and December of 2006 were included. All were submitted to sympathectomy up to the third ganglion using video-assisted thoracoscopy and were randomized to receive or not receive postoperative pleural drainage for 3 h. Chest X-rays and low-dose computed tomography scans of the chest were performed on the first postoperative day in order to determine the incidence of residual pneumothorax. At different time points up to postoperative day 28, patient pain was assessed using a visual numeric scale and by measuring the quantity of opioid analgesics required. Results: This study comprised 56 patients, 27 submitted to bilateral pleural drainage and 29 not submitted to drainage. There was no statistical difference between the two groups in terms of the incidence of post-sympathectomy residual pneumothorax. Residual pneumothorax diagnosed through any of the methods did not influence pain within the first 28 postoperative days. Conclusion: Performing closed pleural drainage for 3 h immediately after video-assisted thoracic sympathectomy did not affect lung re-expansion or the incidence of residual pneumothorax. When residual pneumothorax was present, it did not affect pain within the first 28 postoperative days.


Keywords: Hyperhidrosis; Sympathectomy; Pain, postoperative; Pneumothorax; Drainage; Pleura.


4 - The Brazilian Portuguese version of the London Chest Activity of Daily Living scale for use in patients with chronic obstructive pulmonary disease

Versão brasileira da escala London Chest Activity of Daily Living para uso em pacientes com doença pulmonar obstrutiva crônica

Marta Fioravante Carpes, Anamaria Fleig Mayer, Karen Muriel Simon, José Roberto Jardim, Rachel Garrod

J Bras Pneumol.2008;34(3):143 -151

Abstract PDF PT PDF EN Portuguese Text

Objective: To translate the London Chest Activity of Daily Living (LCADL) scale into Portuguese and to determine whether this version is reproducible in Brazilian patients with severe chronic obstructive pulmonary disease (COPD). Methods: The LCADL scale was translated into Portuguese and then back-translated into English. This pilot Brazilian Portuguese version was administered to 8 patients with COPD, and possible text-related problems were investigated. The principal problems were discussed with the authors of the original scale, and a final translated version was arrived at. At the study outset, two observers administered this final version (twice in one day) to 31 patients with COPD. One of those observers again administered the scale to the same patients 15-20 days later. At baseline, the patients were submitted to pulmonary function testing and to the six-minute walk test (6MWT). Results: The Brazilian Portuguese version of the LCADL scale demonstrated excellent reproducibility in the total score and in most of the questions, with an inter-rater Cronbach's alpha coefficient of 0.97 (95% CI: 0.89-0.97; p < 0.01) and an intra-rater Cronbach's alpha coefficient of 0.96 (95% CI: 0.83-0.96; p < 0.01). The total score presented a negative correlation with forced expiratory volume in one second in liters (r = −0.49; p < 0.05) and with distance covered on the 6MWT (r = −0.56; p < 0.05). Conclusion: The Brazilian Portuguese version of the LCADL scale is a reliable, reproducible, and valid instrument for evaluating dyspnea during activities of daily living in patients with severe COPD.


Keywords: Activities of daily living; Dyspnea; Diagnostic techniques and procedures; Reproducibility of results.


5 - Sputum examination in the clinical management of community-acquired pneumonia

Exame do escarro no manejo clínico dos pacientes com pneumonia adquirida na comunidade

Leonardo Gilberto Haas Signori, Maurício Weyh Ferreira, Luiz Carlos Hack Radünz Vieira, Karen Reetz Müller, Waldo Luís Leite Dias de Mattos

J Bras Pneumol.2008;34(3):152-158

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the frequency of the use of sputum examination in the clinical management of community-acquired pneumonia (CAP) in a general hospital and to determine whether its use has an impact on mortality. Methods: The medical records of CAP patients treated as inpatients between May and November of 2004 at the Nossa Senhora da Conceição Hospital, located in Porto Alegre, Brazil, were reviewed regarding the following aspects: age; gender; severity of pneumonia (Fine score); presence of sputum; sputum bacteriology; treatment history; change in treatment; and mortality. Results: A total of 274 CAP patients (134 males and 140 females) were evaluated. Using the Fine score to quantify severity, we classified 79 (28.8%) of those 274 patients as class II, 45 (16.4%) as class III, 97 (35.4%) as class IV, and 53 (19.3%) as class V. Sputum examination was carried out in 92 patients (33.6%). A valid sample was obtained in 37 cases (13.5%), and an etiological diagnosis was obtained in 26 (9.5%), resulting in a change of treatment in only 9 cases (3.3%). Overall mortality was 18.6%. Advanced age (above 65), CAP severity, and dry cough were associated with an increase in the mortality rate. Sputum examination did not alter any clinical outcome or have any influence on mortality. Conclusion: Sputum examination was used in a minority of patients and was not associated with any noticeable benefit in the clinical management of patients with CAP treated in a hospital setting.


Keywords: Pneumonia/etiology; Sputum; Diagnosis.


6 - Noncompliance with tuberculosis treatment involving self administration of treatment or the directly observed therapy, short-course strategy in a tuberculosis control program in the city of Carapicuíba, Brazil

Abandono do tratamento de tuberculose utilizando-se as estratégias tratamento auto-administrado ou tratamento supervisionado no Programa Municipal de Carapicuíba, São Paulo, Brasil

Amadeu Antonio Vieira, Sandra Aparecida Ribeiro

J Bras Pneumol.2008;34(3):159-166

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine treatment noncompliance rates among patients participating in a municipal tuberculosis control program and to identify the variables related to noncompliance depending on the type of treatment strategy used. Methods: A longitudinal non-concurrent cohort study was carried out involving two cohorts of patients participating in the Tuberculosis Control Program of the city of Carapicuíba, Brazil. The first cohort comprised 173 patients with tuberculosis treated from January 1, 2003 to December 31, 2003 using self administration of treatment, and the second comprised 187 patients with tuberculosis treated from July 1, 2004 to June 30, 2005 using the directly observed therapy, short-course strategy. Results: Noncompliance rates decreased from 13.3% (self administration of treatment) to 5.9% (directly observed therapy, short-course), a significant difference (p < 0.05). For the self administration of treatment strategy, the variables significantly associated with treatment noncompliance were as follows: being an unregistered worker (relative risk [RR] = 3.06); retreatment (RR = 2.73); alcoholism (RR = 3.10); and no investigation of contacts (RR = 8.94). For the directly observed therapy, short-course strategy, no variables were significantly associated with noncompliance. Conclusion: The directly observed therapy, short-course strategy decreased noncompliance rates and produced better treatment outcomes, even when the risk factors for noncompliance were the same.


Keywords: Tuberculosis; Self administration; Directly observed therapy; Treatment refusal.


7 - Adapting the Bird Mark 7 to deliver noninvasive continuous positive airway pressure: a bench study

Adaptação do Bird Mark 7 para oferta de pressão positiva contínua nas vias aéreas em ventilação não-invasiva: estudo em modelo mecânico

Beatriz Mayumi Kikuti, Karen Utsunomia, Renata Potonyacz Colaneri, Carlos Roberto Ribeiro de Carvalho, Pedro Caruso

J Bras Pneumol.2008;34(3):167-172

Abstract PDF PT PDF EN Portuguese Text

Objective: To test the efficiency of the Bird Mark 7 ventilator adapted to deliver continuous positive airway pressure (CPAP) in noninvasive positive pressure ventilation. Methods: This was an experimental study using a mechanical model of the respiratory system. A Bird Mark 7 ventilator was supplied with 400 and 500 kPa and tested at CPAP of 5, 10 and 15 cmH2O. The following variables were analyzed: difference between the preset CPAP and the CPAP actually attained CPAP (trueCPAP); area of airway pressure at the CPAP level employed (AREACPAP); and tidal volume generated. Results: Adapting the Bird Mark 7 to offer CPAP achieved the expected tidal volume in all situations of inspiratory effort (normal or high), ventilator pressure supply (400 or 500 kPa) and CPAP value (5, 10 or 15 cmH2O). At a CPAP of 5 or 10 cmH2O, the trueCPAP was near the preset level, and the AREACPAP was near zero. However, at a CPAP of 15 cmH2O, the value remained below the preset, and the AREACPAP was high. Conclusion: The efficiency of Bird Mark 7 adaptation in offering CPAP was satisfactory at 5 and 10 cmH2O but insufficient at 15 cmH2O. If adapted as described in our study, the Bird Mark 7 might be an option for offering CPAP up to 10 cmH2O in areas where little or no equipment is available.


Keywords: Ventilators, mechanical; Positive-pressure respiration; Continuous positive airway pressure.


Review Article

8 - Diagnosis of circadian rhythm sleep disorders

Diagnóstico dos transtornos do sono relacionados ao ritmo circadiano

Denis Martinez, Maria do Carmo Sfreddo Lenz, Luiz Menna-Barreto

J Bras Pneumol.2008;34(3):173-180

Abstract PDF PT PDF EN Portuguese Text

Insomnia and excessive sleepiness are common in the investigation of sleep-disordered breathing. Circadian rhythm sleep disorders are perhaps the most often overlooked conditions in the differential diagnosis of these symptoms. Circadian rhythm sleep disorders manifest as misalignment between the sleep period and the physical/social 24-h environmental cycle. The two most prevalent circadian rhythm sleep disorders are delayed sleep phase (common in adolescents) and advanced sleep phase (common in the elderly), situations in which the sleep period is displaced to a later or earlier time, respectively. It is important to keep these two disorders in mind, since they can be confused with insomnia and excessive sleepiness. However, there are nine possible diagnoses, and all nine are of clinical interest. Since light is the principal cue used in synchronizing the biological clock, blind individuals and night-shift/swing-shift workers are more prone to develop circadian rhythm sleep disorders. In this article, the new international classification of circadian rhythm sleep disorders is reviewed.


Keywords: Circadian rhythm; Sleep disorders; Sleep initiation and maintenance disorders; Sleep stages; Sleep apnea syndromes.


Case Report

9 - Chronic eosinophilic pneumonia secondary to long-term use of nitrofurantoin: high-resolution computed tomography findings

Pneumonia eosinofílica crônica secundária ao uso prolongado de nitrofurantoína: achados da tomografia computadorizada de alta resolução do tórax

Rosane Rodrigues Martins, Edson Marchiori, Sérgio Lopes Viana, Luiz Sérgio Pereira Grillo Júnior, Vera Luiza Capelozzi, Laércio Moreira Valença

J Bras Pneumol.2008;34(3):181-184

Abstract PDF PT PDF EN Portuguese Text

The authors report the case of a female patient who developed chronic eosinophilic pneumonia secondary to long-term use of nitrofurantoin for prophylaxis of recurrent urinary tract infections due to urethral stenosis. On high-resolution computed tomography scans, the pulmonary reaction to nitrofurantoin most commonly manifests as an interstitial-alveolar pattern in both lung bases. However, in this case, the alterations were most pronounced in the periphery of the upper lobes. In itself, this tomographic profile is strongly indicative of chronic eosinophilic pneumonia. The patient had previously been submitted to an open lung biopsy. The diagnosis of chronic eosinophilic pneumonia was confirmed through a review of the biopsy.


Keywords: Pneumonia; Pulmonary eosinophilia; Nitrofurantoin/adverse effects; Tomography, X-ray computed.


10 - Giant cell tumor of the rib occupying the entire hemithorax

Tumor de células gigantes costal ocupando todo o hemitórax

Samuel Zuínglio de Biasi Cordeiro, Paulo de Biasi Cordeiro, Aureliano Mota Cavalcanti Sousa, Deborah Cordeiro Lannes, Gustavo Soares de Moura Pierro

J Bras Pneumol.2008;34(3):185-188

Abstract PDF PT PDF EN Portuguese Text

The authors report the case of a 28-year-old female patient with a giant cell tumor originating from the rib. The tumor, measuring 25 × 17 cm, occupied the entire hemithorax and caused atelectasis of the left lung. This tumor was a benign mesenchymal neoplasm, which rarely affects the ribs. A thoracotomy involving en bloc resection of the chest wall and tumor was performed. Despite the large dimensions of the tumor, complete resection was possible, and lung function was restored.


Keywords: Neoplasms; Giant cells; Mesoderm; Thoracotomy; Medical records.


Year 2008 - Volume 34  - Number 4  (/April)


1 - Educational camp for children with asthma

Acampamento educacional para crianças asmáticas

A. Sonia Buist, Sandra R. Wilson

J Bras Pneumol.2008;34(4):189-190

PDF PT PDF EN Portuguese Text

Original Article

2 - Educational camp for children with asthma

Acampamento educacional para crianças asmáticas

Maria do Rosario da Silva Ramos Costa, Maria Alenita Oliveira, Ilka Lopes Santoro,Yara Juliano, José Rosado Pinto, Ana Luisa Godoy Fernandes

J Bras Pneumol.2008;34(4):191-195

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of a 5-day educational camp program for children with asthma in terms of improving their knowledge of asthma and enhancing their performance in the use of inhaled medication and in physical activities. Methods: Every day, the children received 20-min interactive educational sessions, the technique for using the metered-dose inhaler was reviewed, two peak flow readings were recorded, and the children performed physical activities that included breathing and relaxation exercises. A questionnaire regarding knowledge of asthma, as well as asthma triggers, asthma medications, misconceptions regarding asthma, and the use of spacers, was administered before and after the intervention. Correct use of inhaled medication and exercise-related symptoms were also evaluated before and after the intervention. Results: A total of 37 children with asthma, aged 8-10 years (15 females and 22 males), were included in this study. Of those, 25% showed an improvement in the level of knowledge of asthma after the educational camp program, as evidenced by the greater number of correct answers on three of the twelve questions analyzed (p < 0.05). The exercise-related dyspnea scores decreased significantly (p < 0.05). The ability to use inhaled medication correctly was significantly improved after the intervention (p < 0.05). Conclusions: The asthma educational camp program can improve knowledge about specific questions, encourage participation in physical activities, and improve the asthma management skills of children.


Keywords: Asthma; Asthma/prevention & control; Models, educational; Child.


3 - Prevalence of emotional and behavioral disorders in adolescents with asthma

Prevalência de transtornos emocionais e comportamentais em adolescentes com asma

Cristina Gonçalves Alvim, Janete Ricas, Paulo Augusto Moreira Camargos, Laura Maria Belizário de Lima Facury Lasmar, Cláudia Ribeiro de Andrade, Cássio da Cunha Ibiapina

J Bras Pneumol.2008;34(4):196-204

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of emotional and behavioral disorders in adolescents with asthma and to compare it with that of adolescents without asthma. Methods: A transversal study using the Strengths and Difficulties Questionnaire, administered to adolescents with or without asthma, ranging from 14 to 16 years of age and randomly selected from schools in the city of Belo Horizonte, Brazil. Results: The prevalence of emotional and behavioral disorders in adolescents with and without asthma was 20.4% (95% CI: 14.5-27.8%) and 9.0% (95% CI: 6.1-12.8%), respectively. Among adolescents with asthma, 56.6% (95% CI: 48.3-64.5%) presented normal scores, and 23.0% (95% CI 16.8-30.7%) presented borderline scores. Among adolescents without asthma, 75.0% (95% CI: 69.7-79.6%) presented normal scores, and 16.0% (95% CI: 12.2-20.7%) presented borderline scores. The median total score on the questionnaire was 14 and 12 among subjects with and without asthma, respectively (p < 0.01). In the final logistic regression model, adjusted for socioeconomic variables, the association between emotional/behavioral disorders and the following variables remained significant: being female (OR = 1.98; 95% CI: 1.10-3.56; p = 0.02) and having asthma (OR = 2.66; 95% CI: 1.52-4.64; p = 0.001). Conclusions: The prevalence of emotional and behavioral disorders is higher in adolescents with asthma than in those without asthma, underscoring the need for a holistic, interdisciplinary approach.


Keywords: Asthma; Epidemiology; Prevalence; Adolescent; Psychology; Behavioral symptoms.


4 - Thoracoscopy in the treatment of pleural empyema in pediatric patients

Toracoscopia no tratamento do empiema pleural em pacientes pediátricos

Davi Wen Wei Kang, José Ribas Milanez de Campos, Laert de Oliveira Andrade Filho, Fabiano Cataldi Engel, Alexandre Martins Xavier, Maurício Macedo, Karine Meyer

J Bras Pneumol.2008;34(4):205-211

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the results of thoracoscopy for the treatment of pleural empyema in pediatric patients. Methods: A retrospective study of 117 patients who underwent mediastinoscopy or video-assisted thoracoscopy for pleural empyema treatment. General anesthesia and single-lumen oral intubation were used. Surgery was indicated when there was pleural effusion and no clinical and radiological response to clinical treatment (antibiotics, physiotherapy and thoracocentesis) or severe sepsis, together with loculated pleural effusion (confirmed through ultrasound or computed tomography of the chest). Results: Between February of 1983 and July of 2006, 117 thoracoscopies were performed in patients ranging in age from 5 months to 17 years (mean, 4 years). Mean time for thoracic drainage was 9 days (range, 2-33 days), and mean period of hospitalization was 16.4 days (range, 4 to 49 days). One patient (0.8%) died after surgery, and persistent fistula was observed in 33 patients (28%). In 7 cases (6%), open thoracotomy with pulmonary decortication was performed due to the disposition of the empyema. Conclusions: Management of pleural empyema in this age bracket is still controversial, and surgical indication is often delayed, particularly when there are multiple loculations or severe sepsis. Early thoracoscopy yields a better clinical outcome for pediatric patients with pleural empyema, with apparent decreased morbidity and mortality, earlier chest tube removal, earlier hospital discharge and improved response to antibiotic therapy.


Keywords: Empyema, pleural; Pediatrics/instrumentation; Thoracoscopy; Thoracic surgery, video-assisted.


5 - Oxygen outflow delivered by manually operated self-inflating resuscitation bags in patients breathing spontaneously

Fluxo de saída de oxigênio fornecido por reanimadores manuais com balão auto-inflável em pacientes com ventilação espontânea

Armando Carlos Franco de Godoy, Ronan José Vieira, Ronan José Vieira Neto

J Bras Pneumol.2008;34(4):212-216

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the oxygen outflow delivered by seven different models of manually operated self-inflating resuscitation bags (with and without an oxygen reservoir connected), which were tested using different oxygen supply rates without manipulating the bag, by simulating their use in patients breathing spontaneously. Methods: The oxygen outflow was measured using a wall oxygen flow meter and a flow meter/respirometer attached to the bag, together with another flow meter/respirometer attached to the patient connection port. The resuscitation bags that allow the connection of an oxygen reservoir were tested with and without this device. All resuscitation bags were tested using oxygen supply rates of 1, 5, 10, and 15 L/min. Statistical analyses were performed using analysis of variance and t-tests. Results: The resuscitation bags that allow the connection of an oxygen reservoir presented a greater oxygen outflow when this device was connected. All resuscitation bags delivered a greater oxygen outflow when receiving oxygen at a rate of 15 L/min. However, not all models delivered a sufficient oxygen outflow even when the two previous conditions were satisfied. Conclusions: Of the resuscitation bags studied, those that allow the connection of an oxygen reservoir must have this reservoir connected to the bag when used as a source of oxygen in nonintubated spontaneously breathing patients. All of the models studied should receive oxygen at a rate ≥ 15 L/min. It is not safe to use manually operated self-inflating resuscitation bags for this purpose without knowing their characteristics.


Keywords: Oxygen/administration & dosage; Resuscitation; Equipment and supplies; Respiration; Intensive care.


6 - Evaluation of adenosine deaminase in the diagnosis of pleural tuberculosis: a Brazilian meta-analysis

Avaliação da adenosina desaminase no diagnóstico da tuberculose pleural: uma metanálise brasileira

Patrizio Morisson, Denise Duprat Neves

J Bras Pneumol.2008;34(4):217-224

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate Brazilian studies by summarizing the accuracy of adenosine deaminase in the diagnosis of the pleural tuberculosis, with the objective of lending support to the movement to make the test part of the routine in the investigation of pleural effusions. Methods: A search for Brazilian studies related to the determination of adenosine deaminase levels in the pleural liquid was carried out. These studies were evaluated and included in this study. The data were analyzed using summary receiver operating characteristic (SROC) curves, which enabled the studies to be collected and evaluated regarding the accuracy of the diagnosis. As for the global values of sensitivity and specificity, the Bayes' theorem was applied to calculate the post-test probabilities in different prevalences of the disease. Results: Twenty-five studies dating from 1987 to 2005 and including enough information to be used in the meta-analysis were identified. After evaluation, nine studies were included, totaling 1674 patients. According to the SROC curve, a sensitivity of 91.8% (95% CI: 89.8‑93.6%) and a specificity of 88.4% (95% CI: 86.0-90.5%) were found, with an area of 0.969 below the curve. The overall odds ratio was 112.0 (95% CI: 51.6-243.2). Considering a prevalence of tuberculosis of 50% (considered neutral), the post-test probability was 88.7% for a positive test and 91.5% for a negative test. Conclusion: Despite the differences found among studies, it is possible to conclude that the determination of adenosine deaminase levels has high accuracy in the diagnosis of the pleural tuberculosis and should be used as a routine test in its investigation.


Keywords: Pleural effusion; Tuberculosis; Diagnosis; Adenosine deaminase; Meta-analysis.


7 - Completeness of tuberculosis control program records in the case registry database of the state of Espírito Santo, Brazil: analysis of the 2001-2005 period

Completude dos dados do Programa de Controle da Tuberculose no Sistema de Informação de Agravos de Notificação no Estado do Espírito Santo, Brasil: uma análise do período de 2001 a 2005

Cláudia Maria Marques Moreira, Ethel Leonor Noia Maciel

J Bras Pneumol.2008;34(4):225-229

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the completeness of tuberculosis control program records for the 2001-2005 period in the case registry database of the state of Espírito Santo, Brazil. Methods: A descriptive study using secondary data analysis. The following variables were studied: race/color; educational level, supervised treatment, sputum culture at treatment outcome, HIV status, smear sputum microscopy at the sixth month of treatment and treatment outcome. Results: Using technical parameters of the case registry database of the Brazilian National Ministry of Health regarding the percentage of completeness of data on the reporting forms, the tuberculosis database of the state of Espírito Santo can be classified as fair to excellent. The state of Espírito Santo has 78 cities, 8 of which are considered priorities for tuberculosis control. For the variables studied, the cities not considered priorities presented better completeness of records than did those considered priorities, the exception being the variable treatment outcome, for which the percentage of completeness was comparable among all of the cities. Conclusions: Since the cities that are considered priorities accounted for 70.2% of the total number of reports, the responsible officials in those cities should improve the quality of those reports in terms of the completeness of forms and the updating of data, which are fundamental to the reliability of epidemiological analyses. That will make it possible to plan activities aimed at the prevention and control of tuberculosis in the state.


Keywords: Tuberculosis; Disease notification; Information systems; Databases as topic.


Review Article

8 - Allergic Rhinitis: epidemiological aspects, diagnosis and treatment

Rinite alérgica: aspectos epidemiológicos, diagnósticos e terapêuticos

Cássio da Cunha Ibiapina, Emanuel Savio Cavalcanti Sarinho, Paulo Augusto Moreira Camargos, Cláudia Ribeiro de Andrade, Álvaro Augusto Souza da Cruz Filho

J Bras Pneumol.2008;34(4):230-240

Abstract PDF PT PDF EN Portuguese Text

This study was a review of the literature on the epidemiological, clinical, diagnostic and therapeutic aspects of allergic rhinitis. Bibliographic searches were based on the information contained within the Medline, Latin American and Caribbean Health Sciences Literature and HighWire databases, covering the last thirty years and using the following search terms: 'allergic rhinitis', 'epidemiology', 'diagnosis' and 'treatment'. Sixty articles were selected. This study describes the increase in the prevalence of allergic rhinitis, its relationship with asthma, the diagnostic criteria and the treatment. The classification of allergic rhinitis and strategies for its treatment are presented. Therapeutic modalities presented and discussed include the administration of antihistamines, corticosteroids, immunotherapy, anti-leukotrienes, sodium cromoglycate and anti-IgE antibodies, as well as minimizing exposure to inhaled allergens. Finally, the importance of the management of allergic rhinitis in public health is emphasized.


Keywords: Rhinitis/therapy; Hypersensitivity; Epidemiology; Diagnosis.


Case Report

9 - Video-assisted thoracoscopic removal of foreign bodies from the pleural cavity

Videotoracoscopia para remoção de corpo estranho da cavidade pleural

Giovanni Antonio Marsico, André Luiz de Almeida, Dirceo Edson de Azevedo, Gustavo Carvalho Venturini, Alexandre Edson de Azevedo, Paula dos Santos Marsico

J Bras Pneumol.2008;34(4):241-244

Abstract PDF PT PDF EN Portuguese Text

Video-assisted thoracoscopy is a minimally invasive surgical technique. It is the procedure of choice for the treatment of certain lung and pleural diseases. It has been increasingly used in the acute phase of thoracic trauma. Another indication for its use, which is rarely described in the literature, is for the removal of retained intrathoracic foreign bodies. We report the cases of two hemodynamically stable gunshot victims in whom the bullet was removed from the pleural cavity through video-assisted thoracoscopy, thereby avoiding the need for thoracotomy.


Keywords: Thoracic injuries; Wounds, penetrating; Thoracic surgery, video-assisted; Foreign bodies.


10 - Treatment of pulmonary actinomycosis with levofloxacin

Tratamento da actinomicose pulmonar com levofloxacina

Diva de Fátima Gonçalves Ferreira, Joana Amado, Sofia Neves, Natália Taveira, Aurora Carvalho, Rosete Nogueira

J Bras Pneumol.2008;34(4):245-248

Abstract PDF PT PDF EN Portuguese Text

Actinomycosis is a chronic suppurative bacterial infection characterized by multiple abscesses, fistulous pathways, and fibrosis involving the face, neck, chest, and abdomen. It is caused by an anaerobic Gram-positive saprophytic bacterium ( Actinomyces). Primary actinomycosis of the lung is a rare disease that probably results from aspiration of oropharyngeal secretions. It can present as a chronic respiratory disease. The treatment of choice is antibiotic therapy with penicillin. The authors report the case of a 55-year-old female diagnosed with pulmonary actinomycosis and successfully treated with levofloxacin.


Keywords: Actinomycosis; Infection; Ofloxacin; Medical records.


Year 2008 - Volume 34  - Number 5  (/May)


1 - Challenges in lung transplantation

Desafios do transplante pulmonar

Fábio Biscegli Jatene, Paulo Manuel Pêgo-Fernandes

J Bras Pneumol.2008;34(5):249-250

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Original Article

2 - Low income as a protective factor against asthma in children and adolescents treated via the Brazilian Unified Health System

Baixa renda como fator de proteção contra asma em crianças e adolescentes usuários do Sistema Único de Saúde

Murilo Carlos Amorim de Britto, Emilses Fernandes de Carvalho Freire, Patrícia Gomes de Matos Bezerra, Rita de Cássia Coelho Moraes de Brito, Joakim da Cunha Rego

J Bras Pneumol.2008;34(5):251-255

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the role that low income plays in the development of asthma in children and adolescents. Methods: A case-control study using a questionnaire. Results: A total of 687 participants were studied at a tertiary hospital via the Brazilian Unified Health System. Ages ranged from 5 to 15 years, and 54.7% of the participants were male. Nearly half of the individuals (49.1%) lived in the metropolitan area of the city of Recife, and the remainder lived in the countryside. Most (98.1%) lived in concrete houses or apartments, with a mean of 5.7 rooms and 4.8 occupants per residence. Mean maternal level of education was 6.8 years of schooling. The median monthly per capita income was R$ 103.75 (Brazilian reals). The sample was stratified according to cut-off points related to the national minimum wage (R$ 350.00): <25% of minimum wage = very low income (39% of the sample); <50% of minimum wage = low income (37.3% of the sample); and ≥50% of minimum wage = satisfactory income (23.7% of the sample). There was no association between poverty and development of asthma. Conclusions: Poverty is not protective against asthma in children and adolescents treated via the Brazilian Unified Health System, as we might suppose based on the hygiene hypothesis. However, cohort studies are needed in order to confirm these findings.


Keywords: Asthma; Poverty; National health programs/Brazil; Child; Adolescent; Case-control studies.


3 - Complications related to lobectomy in living lobar lung transplant donors

Complicações relacionadas à lobectomia em doadores de transplante pulmonar intervivos

Spencer Marcantônio Camargo, José de Jesus Peixoto Camargo, Sadi Marcelo Schio, Leticia Beatriz Sánchez, José Carlos Felicetti, José da Silva Moreira, Cristiano Feijó Andrade

J Bras Pneumol.2008;34(5):256-263

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate post-operative complications in living lobar lung transplant donors. Methods: Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of post-operative complications and alterations in pulmonary function after lobectomy. Results: Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values. Conclusions: Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.


Keywords: Lung transplantation; Living donors; Pneumonectomy; Postoperative complications.


4 - High-resolution computed tomography in silicosis: correlation with chest radiography and pulmonary function tests

Tomografia computadorizada de alta resolução na silicose: correlação com radiografia e testes de função pulmonar

Agnaldo José Lopes, Roberto Mogami, Domenico Capone, Bernardo Tessarollo, Pedro Lopes de Melo, José Manoel Jansen

J Bras Pneumol.2008;34(5):264-272

Abstract PDF PT PDF EN Portuguese Text

Objective: To correlate tomographic findings with pulmonary function findings, as well as to compare chest X-ray findings with high-resolution computed tomography (HRCT) findings, in patients with silicosis. Methods: A cross-sectional study was conducted in 44 non-smoking patients without a history of tuberculosis. Chest X-ray findings were classified according to the International Labour Organization recommendations. Using a semiquantitative system, the following HRCT findings were measured: the full extent of pulmonary involvement; parenchymal opacities; and emphysema. Spirometry and forced oscillation were performed. Pulmonary volumes were evaluated using the helium dilution method, and diffusing capacity of the lung for carbon monoxide was assessed. Results: Of the 44 patients studied, 41 were male. The mean age was 48.4 years. There were 4 patients who were classified as category 0 based on X-ray findings and as category 1 based on HRCT findings. Using HRCT scans, we identified progressive massive fibrosis in 33 patients, compared with only 23 patients when X-rays were used. Opacity score was found to correlate most closely with airflow, DLCO and compliance. Emphysema score correlated inversely with volume, DLCO and airflow. In this sample of patients presenting a predominance of large opacities (75% of the individuals), the deterioration of pulmonary function was associated with the extent of structural changes. Conclusions: In the early detection of silicosis and the identification of progressive massive fibrosis, HRCT scans are superior to X-rays.


Keywords: Silicosis; Occupational diseases; Tomography, x-ray computed; Respiratory function tests.


5 - Effects of azathioprine on mucociliary clearance after bronchial section and anastomosis in a rat experimental model

Efeitos da azatioprina sobre a depuração mucociliar após secção e anastomose brônquica em um modelo experimental em ratos

Paulo Manuel Pêgo Fernandes, Marcelo Manzano Said, Rogério Pazetti, Luis Felipe Pinho Moreira, Fabio Biscegli Jatene

J Bras Pneumol.2008;34(5):273-279

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effects of azathioprine on the mucociliary system in a model of bronchial section and anastomosis in rats. Methods: Thirty-six male Wistar-Furth rats were submitted to left bronchial section and anastomosis and divided into two groups to receive either saline solution or azathioprine. After 7, 15 and 30 days of treatment, six animals from each group were killed, after which in situ mucociliary transport velocity, in vitro mucus transportability, and contact angle of mucus in the right (intact) and left (sectioned) bronchi were measured. Results: In situ mucociliary transport velocity was significantly lower in the sectioned bronchi than in the intact bronchi (p < 0.001). In situ mucociliary transport velocity was lower in the intact bronchi of the animals treated with azathioprine for 7 days (p < 0.05), and those bronchi presented full recovery after 30 days of treatment. The contact angle was higher in the mucus samples collected from the sectioned bronchi of the animals treated with saline solution for 30 days (p < 0.001), which is in accordance with the decreased in vitro mucus transportability observed in the same animals (p < 0.001). Conclusions: We conclude that, in the sectioned bronchi of rats, treatment with azathioprine causes only transitory impairment of mucociliary transport, whereas administration of saline solution impairs mucociliary transport for up to 30 days. In addition, azathioprine protects against alterations in mucus surface properties.


Keywords: Mucociliary clearance; Anastomosis, surgical; Immunosuppression; Lung.


6 - Comparison among pulmonary function test results, the Shwachman-Kulczycki score and the Brasfield score in patients with cystic fibrosis

Comparação entre provas de função pulmonar, escore de Shwachman‑Kulczycki e escore de Brasfield em pacientes com fibrose cística

Ivanice Duarte Freire, Fernando Antônio de Abreu e Silva, Manuel Ângelo de Araújo

J Bras Pneumol.2008;34(5):280-287

Abstract PDF PT PDF EN Portuguese Text

Objective: To study correlations among pulmonary function, chest radiology and clinical status in cystic fibrosis. Methods: A retrospective cross-sectional study was performed to evaluate chest X-rays and clinical charts of patients treated at the Hospital de Clínicas de Porto Alegre. Spirometry findings, Shwachman-Kulczycki (S-K) scores and Brasfield scores were analyzed. Results: The final sample consisted of 40 patients (mean age 9.72 ± 3.27). The following mean S-K scores were obtained: total, 80.87 ± 10.24; general activity, 24.75 ± 1.1; physical examination, 18.87 ± 4.59; nutrition, 21.87 ± 4.18; radiology, 15.37 ± 5.23. The mean Brasfield score was 18.2 ± 4. The pulmonary function test results, in percentage of predicted, were as follows: forced vital capacity (FVC), 82.99 ± 14.36%; forced expiratory volume in one second (FEV1), 83.62 ± 18.26%; and forced expiratory flow between 25 and 75% of FVC (FEF25-75), 74.63 ± 2.53%. The S-K score correlated moderately with FVC, whereas it correlated strongly with FEV1 and FEF25-75. The Brasfield score correlated strongly with the S-K total and radiology score, whereas it correlated moderately with pulmonary function. Physical examination correlated moderately with FVC, FEV1 and FEF25-75; as did nutrition with FEF25-75; and radiology with FEV1 and FEF25-75. General activity was the domain that had the greatest influence on the total S-K score. Conclusions: These two scoring systems are complementary, correlating with each other, as well as with pulmonary function tests. The radiology domain of the S-K scoring system is a good alternative to the Brasfield score.


Keywords: Cystic fibrosis; Spirometry; Lung/radiography.


7 - Prevalence of smoking among dentists in the Federal District of Brasília, Brazil

Prevalência do tabagismo entre dentistas do Distrito Federal

Gerlídia Araújo Rodrigues, Virgílio Galvão, Carlos Alberto de Assis Viegas

J Bras Pneumol.2008;34(5):288-293

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of smoking among dentists in the Federal District of Brasília, Brazil. Methods: A descriptive, cross-sectional survey, involving 446 dentists residing in the Federal District, was conducted in the second semester of 2004. Data regarding the smoking habit were obtained using a World Health Organization questionnaire that was translated and validated for use in Brazil by the Brazilian National Cancer Institute. Individuals who had smoked a minimum of one cigarette per day for at least 6 months prior to the study outset were classified as regular smokers. The distribution of frequencies was analyzed using descriptive statistics (means and standard deviations), as well as calculation of prevalence rates. The different variables were compared using the chi-square test, and values of p < 0.05 were considered statistically significant. Results: Of the dentists evaluated, 37% (42% of the males and 31.4% of the females) reported being smokers. Conclusions: The prevalence of smokers among dentists in the Federal District is above the national average for the adult population, which is approximately 32%. Although there was a predominance of males, the high number of female dentists who reported being smokers was a worrisome finding.


Keywords: Dentists; Smoking; Prevalence.


8 - Endotracheal tube cuff pressure alteration after changes in position in patients under mechanical ventilation

Alteração da pressão intra-cuff do tubo endotraqueal após mudança da posição em pacientes sob ventilação mecânica

Armando Carlos Franco de Godoy, Ronan José Vieira, Eduardo Mello De Capitani

J Bras Pneumol.2008;34(5):294-297

Abstract PDF PT PDF EN Portuguese Text

Objective: The purpose of this study was to investigate endotracheal tube cuff pressure (Pcuff) alteration in patients under mechanical ventilation after changes in position. Methods: All selected patients were initially placed in the 35° semi-Fowler position, with Pcuff adjusted to 20 mmHg, and randomly divided into two groups. Group A, in which patients were moved to the lateral decubitus position, facing away from the ventilator (measurement designated Pcuff A1), returned to the initial position (measurement designated Pcuff A2), moved to a lateral decubitus position, facing the ventilator (measurement designated Pcuff A3) and then returned to the initial position (measurement designated Pcuff A4); and Group B, in which patients were moved to the lateral decubitus position, facing the ventilator (measurement designated Pcuff B1), returned to the initial position (measurement designated Pcuff B2), moved to the lateral decubitus position; facing away from the ventilator (measurement designated Pcuff B3) and then returned to the initial position (measurement designated Pcuff B4). Results: The study comprised 70 patients, 31 allocated to group A and 39 allocated to group B. Values >22 mmHg were observed in 142(50.7%) of the 280 Pcuff measurements taken, and values <18 mmHg were observed in 14 (5%). When moved from the 35° semi-Fowler position to the lateral decubitus position, facing away from the ventilator, 58 (82.2%) of the patients presented mean Pcuff values in the higher range (>22 mmHg). Conclusions: Changes in body position can cause significant Pcuff variations in patients under mechanical ventilation.


Keywords: Pressure; Intubation, intratracheal; Posture; Supine position.


9 - Evaluation of surveillance of contacts of new tuberculosis cases in the state of Mato Grosso - Brazil

Avaliação da vigilância de contatos de casos novos de tuberculose no Estado de Mato Grosso - Brasil

Shaiana Vilella Hartwig, Eliane Ignotti, Beatriz Fátima Alves de Oliveira, Hellen Caroline de Oliveira Pereira, João Henrique Scatena

J Bras Pneumol.2008;34(5):298-303

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate surveillance of contacts of new tuberculosis cases in the state of Mato Grosso from 1999 to 2004. Methods: This was a descriptive epidemiological study based on data from the Tuberculosis Case Registry Database. The number of new tuberculosis cases, the number of contacts (estimated, investigated, and uninvestigated), and the tuberculosis incidence rate were analyzed by age bracket. The mean rate of contacts investigated for each case of tuberculosis by age bracket was calculated per year of study. The cases of pulmonary tuberculosis with and without contacts investigated were analyzed by sputum smear microscopy results. Results: In 2004, there were 41.3 cases of tuberculosis per 100,000 inhabitants in the state of Mato Grosso. The south-central region presented the highest incidence rate (57 cases/100,000 inhabitants) and a 15% rate of contacts investigated. Among those younger than 15 years, 63 contacts (60.5%) were investigated, whereas among those aged 15 or older, 389 (8.9%) were investigated. In 1999, the mean rate of contacts investigated statewide was 0.02 (0.5%), and, in 2004, it reached 0.42 (10.5%). The percentage of contacts investigated was 40% higher among the contacts of contagious cases (OR = 1.4; 95% CI: 1.08-1.83). Conclusions: The percentage of contacts investigated is very low, principally among adults. The adoption of the standards for investigation of tuberculosis contacts proposed by the Brazilian National Ministry of Health Department of Health Surveillance has not ensured that this group at highest risk of developing active tuberculosis be given priority at health care facilities in the state of Mato Grosso.


Keywords: Contact tracing; Epidemiologic surveillance; Tuberculosis/prevention & control.


10 - Methodology for characterizing proficiency in interpreting sputum smear microscopy results in the diagnosis of tuberculosis

Metodologia para caracterização de proficiência em leitura de resultados baciloscópicos para o diagnóstico da tuberculose

Francisco Duarte Vieira, Julia Ignez Salem, Antônio Ruffino-Netto, Susana Alles de Camargo, Regina Ruivo Ferro e Silva, Lúcia Cristina Corrêa Moura, Meire Jane Vilaça, José Vitor da Silva

J Bras Pneumol.2008;34(5):304-311

Abstract PDF PT PDF EN Portuguese Text

Objective: To propose a methodology for characterizing proficiency in sputum smear microscopy for acid-fast bacilli (AFB) in the diagnosis of tuberculosis and to determine the number of microscopies necessary to establish this proficiency, as well as the quality of the transcription of results, the causes of the discrepancies in the readings (rater or microscope used), and the criterion for classification of microscopy results that poses the most difficulty in characterizing proficiency. Methods: Four hundred sputum smear microscopies for the diagnosis of tuberculosis were analyzed through double-blind readings by six professionals who usually read/supervise microscopies performed in public health care facilities. The sample was stratified to obtain, at least, a reliability of 90% in the double-blind readings, an α error of 5%, and a precision of 3%. The results were analyzed using observed reliability and the kappa index. Results: Thirteen errors (0.27%) were found in the transcription of results. Reliability increased when the three distinct categories of positive results (AFB+, AFB++, and AFB+++) were grouped or when inconclusive results were excluded from the analysis. The quantification of the bacterial load was the classification criterion that posed the most difficulty in establishing proficiency. Using higher quality microscopes increased reliability. Reliability values stabilized only from the reading of 75 microscopies onward. Conclusions: Double-blind sputum smear microscopy readings using a panel containing 75 slides (36 negative, 4 inconclusive, and 35 positive) proved to be appropriate for characterizing proficiency in sputum smear microscopy for the diagnosis of tuberculosis when such proficiency is intended to reproduce laboratory routine.


Keywords: Tuberculosis; Microscopy; Reproducibility of results.


Review Article

11 - Hypercoagulability and lung cancer

Hipercoagulabilidade e câncer de pulmão

Felipe Costa de Andrade Marinho, Teresa Yae Takagaki

J Bras Pneumol.2008;34(5):312-322

Abstract PDF PT PDF EN Portuguese Text

The relationship between cancer and coagulopathy was suggested by Trousseau nearly 150 years ago. Later, it became more evident that oncologic patients are at a higher risk of experiencing thromboembolic events. This can be due to activation of the coagulation system either by neoplastic cells or by prescribed therapies (chemotherapy or surgical procedures). In fact, these events can constitute the first manifestation of cancer, and their recurrence, despite efficient anticoagulation, has been described. The coagulation system is normally activated in order to provide healing. In the presence of neoplasms, this complex system is activated as a response to multiple stimuli and seems to contribute to cancer progression. Activation of the coagulation system has a greater effect on metastatic foci than on the primary tumor. However, most cancer victims die from complications caused by metastasis, which underscores the importance of this theme. In this area, various mechanisms have been described, creating promising perspectives for future treatments. The current success in using low-molecular-weight heparins against small cell lung cancer is encouraging. Although the knowledge of those mechanisms is relatively incipient, many basic research and clinical studies are underway.


Keywords: Lung neoplasms; Thrombophilia.


Case Report

12 - Pulmonary complications of crack cocaine use: high-resolution computed tomography of the chest

Complicações pulmonares após uso de crack: achados na tomografia computadorizada de alta resolução do tórax

Alexandre Mançano, Edson Marchiori, Gláucia Zanetti, Dante Luiz Escuissato, Beatriz Cunha Duarte, Lourenço de Araujo Apolinário

J Bras Pneumol.2008;34(5):256-263

Abstract PDF PT PDF EN Portuguese Text

Here, we report high-resolution computed tomography (HRCT) findings in a patient who developed sudden hemoptysis, dyspnea and chest pain after smoking crack cocaine. Chest X-rays showed consolidations, primarily in the upper lobes, and HRCT scans showed ground glass attenuation opacities, consolidations and air-space nodules. A follow-up CT, after drug use discontinuation and administration of corticosteroids, showed partial resolution of pulmonary lesions and the appearance of cavitations. Clinical, imaging and laboratory findings led to a diagnosis of 'crack lung'.


Keywords: Crack cocaine/adverse effects; Cocaine-related disorders; Tomography, X-ray computed; Street drugs/adverse effects;


13 - Volumetric capnography as a noninvasive diagnostic procedure in acute pulmonary thromboembolism

Capnografia volumétrica como auxílio diagnóstico não-invasivo no tromboembolismo pulmonar agudo

Marcos Mello Moreira, Renato Giuseppe Giovanni Terzi, Mônica Corso Pereira, Tiago de Araújo Guerra Grangeia4, Ilma Aparecida Paschoal

J Bras Pneumol.2008;34(5):328-332

Abstract PDF PT PDF EN Portuguese Text

Pulmonary thromboembolism is a common condition. Its diagnosis usually requires pulmonary scintigraphy, computed angiotomography, pulmonary arteriography and, in order to rule out other diagnoses, the measurement of D-dimer levels. Due to the fact that these diagnostic methods are not available in most Brazilian hospitals, the validation of other diagnostic techniques is of fundamental importance. We describe a case of a woman with chronic pulmonary hypertension who experienced a pulmonary thromboembolism event. Pulmonary scintigraphy, computed angiotomography and pulmonary arteriography were used in the diagnosis. The D-dimer test result was positive. Volumetric capnography was performed at admission and after treatment. The values obtained were compared with the imaging test results.


Keywords: Thromboembolism; Hypertension, pulmonary; Capnography; Schistosomiasis.


14 - Lung adenocarcinoma, dermatomyositis, and Lambert-Eaton myasthenic syndrome: a rare combination

Adenocarcinoma pulmonar, dermatomiosite e síndrome miastênica de Lambert-Eaton: uma rara associação

Fernanda Manente Milanez, Carlos Alberto de Castro Pereira, Pedro Henrique Duccini Mendes Trindade, Ricardo Milinavicius, Ester Nei Aparecida Martins Coletta

J Bras Pneumol.2008;34(5):333-336

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The incidence of lung neoplasms is increasing in Brazil and in the world, probably as a result of the increase in smoking. Due to the greater number of cases, atypical presentations appear. We report the case of a 66-year-old hypertensive male smoker who presented progressive proximal muscular weakness and, in two months, evolved to dysphagia, dysphonia, and V-shaped skin lesions on the chest. A chest X-ray showed a spiculated pulmonary nodule in the right upper lobe. The biochemical analysis revealed elevated creatine kinase levels. After complementary tests and biopsies, the patient underwent right upper lobectomy. Histopathology showed a moderately differentiated adenocarcinoma. The overall analysis of the case and a review of the literature allow us to suggest that the clinical profile of the patient was a result of an overlap of two paraneoplastic syndromes (dermatomyositis and Lambert-Eaton myasthenic syndrome) secondary to lung adenocarcinoma.


Keywords: Lung neoplasms; Paraneoplastic syndromes; Dermatomyositis; Lambert-Eaton myasthenic syndrome; Adenocarcinoma.


Year 2008 - Volume 34  - Number 6  (/June)


1 - Childhood wheezing

Sibilância na infância

Dirceu Solé

J Bras Pneumol.2008;34(6):337-339

PDF PT PDF EN Portuguese Text

Original Article

2 - Evaluation of acute bacterial rhinosinusitis in asthma patients based on clinical parameters and imaging studies, together with ear, nose and throat examination

Avaliação da rinussinusite bacteriana aguda em pacientes asmáticos com base em parâmetros clínicos, exame otorrinolaringológico e estudo de imagem

Alecsandra Calil Moises Faure, Ilka Lopes Santoro, Luc Louis Maurice Weckx, Henrique Manoel Lederman, Artur da Rocha Correa Fernandes, Ana Luisa Godoy Fernandes

J Bras Pneumol.2008;34(6):340-346

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate paranasal sinuses in patients with stable or acute asthma in order to determine the prevalence of acute bacterial rhinosinusitis. Methods: A cross-sectional study including 30 patients with acute asthma (73% females) treated in the emergency room and 30 patients with stable asthma (80% females) regularly monitored as outpatients. All patients completed a questionnaire on respiratory signs and symptoms and were submitted to ear, nose and throat (ENT) examination, as well as to X-ray and computed tomography (CT) imaging of the sinuses. Results: Based on the clinical diagnosis, the prevalence of acute bacterial rhinosinusitis was 40% in the patients with acute asthma and 3% in those with stable asthma. The ENT examination findings and the imaging findings in isolation were not useful to confirm the diagnosis. Conclusions: In themselves, ENT examination findings, X-ray findings and CT findings were not useful for the diagnosis of acute bacterial rhinosinusitis. Our results provide further evidence that a clinical diagnosis of bacterial rhinosinusitis should be made with caution.


Keywords: Asthma; Sinusitis; Radiography; Tomography, X-ray computed; Endoscopy.


3 - Wheezing phenotypes from birth to adolescence: a cohort study in Pelotas, Brazil, 1993-2004

Padrões de sibilância respiratória do nascimento até o início da adolescência: coorte de Pelotas (RS) Brasil, 1993-2004

Adriana Muiño, Ana Maria Baptista Menezes, Felipe Fossati Reichert, Rodrigo Pereira Duquia, Moema Chatkin

J Bras Pneumol.2008;34(6):347-355

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the prevalence of wheezing patterns and their associations with independent variables. Methods: Cohort study of live births in 1993 in Pelotas, Brazil. A systematic subsample (20%) of the original cohort was evaluated at 6 months, 12 months and 4 years. At 10-12 years, 87.5% of the original cohort was contacted. Wheezing was categorized: transient, wheezing at 4 years but not at 10-12; persistent, wheezing at all evaluations; late-onset, wheezing at 10-12 years. Independent variables were analyzed: gender; skin color; family income; smoking/asthma during pregnancy; breastfeeding; respiratory infection/diarrhea (during the 1st year); family members with asthma/ allergy (at 4 years and at 10-12); physician-diagnosed rhinitis/eczema (at 10-12 years). Results: The subsample comprised 897 adolescents. Wheezing patterns were expressed as prevalence (95% CI): transient, 43.9% (40.7-47.2); persistent, 6.4% (4.8-8.0); and late-onset, 3.3% (2.2-4.5). The transient pattern was more common in children from low-income families, children breastfed for less time, children with a history of respiratory infections (during the 1st year) and children with asthma in the family (at 4 years). The persistent pattern was almost twice as common in males, in children whose mothers had asthma during pregnancy, in children with respiratory infections (during the 1st year) and in children with asthma in the family (at 4 and 10-12 years). The late-onset pattern was more prevalent among those with asthma in the family (at 10-12 years) and those diagnosed with rhinitis (at 10-12 years), being less prevalent among those reporting respiratory infections (during the 1st year) and those diagnosed with eczema (at 10-12 years). Conclusions: Knowledge of the associations of wheezing patterns allows us to adopt preventive and therapeutic measures.


Keywords: Respiratory sounds; Asthma; Epidemiology; Hypersensitivity.


4 - Symptoms of obstructive sleep apnea-hypopnea syndrome in children

Sintomas da síndrome de apnéia-hipopnéia obstrutiva do sono em crianças

Paloma Baiardi Gregório, Rodrigo Abensur Athanazio, Almir Galvão Vieira Bitencourt, Flávia Branco Cerqueira Serra Neves, Regina Terse5, Francisco Hora

J Bras Pneumol.2008;34(6):356-361

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the symptoms most frequently found in children with a polysomnographic diagnosis of obstructive sleep apneahypopnea syndrome (OSAHS). Methods: We evaluated 38 children consecutively referred to the sleep laboratory with suspicion of OSAHS between June of 2003 and December of 2004. The patients were submitted to a pre-sleep questionnaire and to polysomnography. Results: The mean age was 7.8 ± 4 years (range, 2-15 years), and 50% of the children were male. Children without apnea accounted for 7.9% of the sample. The obstructive sleep apnea observed in the remainder was mild in 42.1%, moderate in 28.9% and severe in 22.1%. Severe cases of apnea were most common among children under the age of six (pre-school age). In children with OSAHS, the most common symptoms were snoring and nasal obstruction, which were observed in 74.3 and 72.7% of the children, respectively. Excessive sleepiness and bruxism were seen in 29.4 and 34.3%, respectively, and reflux disease was seen in only 3.1%. Restless legs and difficulty in falling asleep were identified in 65 and 33%, respectively. All of the children diagnosed with severe OSAHS also presented snoring and bruxism. Conclusions: Snoring and nasal obstruction were the most common symptoms found in our sample of children and adolescents with OSAHS. In addition, OSAHS severity was associated with being in the lower age bracket.


Keywords: Obstructive sleep apnea; Polysomnography; Pediatrics; Snoring.


5 - Pulmonary involvement in Behcet's disease: a positive single-center experience with the use of immunosuppressive therapy

Acometimento pulmonar na doença de Behçet: uma boa experiência com o uso de imunossupressores

Alfredo Nicodemos Cruz Santana, Telma Antunes, Juliana Monteiro de Barros, Ronaldo Adib Kairalla, Carlos Roberto Ribeiro de Carvalho, Carmen Silvia Valente Barbas

J Bras Pneumol.2008;34(6):362-366

Abstract PDF PT PDF EN Portuguese Text

Objective: Behcet's syndrome, or Behcet's disease (BD), is a multisystem pathology, and survival is related to pulmonary involvement. However, it appears that different treatments correlate with different prognoses. The aim of this study was to evaluate clinical and tomographic evolution, as well as the survival, of patients with BD-related pulmonary involvement. Methods: A retrospective review of our experience with pulmonary manifestations in patients with BD treated at our institution between January 1, 1988 and April 30, 2006. The clinical, radiological, treatment and survival data were obtained from medical charts. Results: We identified 9 patients with BD-related pulmonary involvement. The mean age was 34 ± 11.5 years, and 7 of the patients were male. The radiological findings were as follows: pulmonary artery aneurysm (PAA) in 8 patients; pulmonary embolism in 3 (translating to an incidence of 5.11 cases/100 patient-years); alveolar hemorrhage in one; and pulmonary hypertension in one. The treatment consisted of immunosuppression with prednisone plus chlorambucil (or cyclophosphamide or mycophenolate mofetil) in all patients, with partial or complete resolution of the PAAs. One patient with a PAA and pulmonary hypertension also received sildenafil and warfarin, with good clinical and tomographic response (the first report in the English literature). In our sample, the mean duration of the follow-up period was 6.52 years. The three-year survival rate was 88.8%, as was the five-year survival rate. Conclusions: Patients with BD-related pulmonary involvement can present good survival with immunosuppressive therapy, and BD should be borne in mind as a possible cause of pulmonary hypertension and alveolar hemorrhage.


Keywords: Behcet Syndrome; Lung diseases, interstitial; Pulmonary circulation; Hypertension, pulmonary; Pulmonary embolism; Alveolar.


6 - Occupational exposure and occurrence of pneumoconioses in Campinas, Brazil, 1978-2003

Exposição ocupacional e ocorrência de pneumoconioses na região de Campinas (SP) Brasil, 1978-2003

Alessandro Vito Lido, Satoshi Kitamura, José Inácio Oliveira, Sérgio Roberto de Lucca, Valmir Antonio Zulian de Azevedo, Ericson Bagatin

J Bras Pneumol.2008;34(6):367-372

Abstract PDF PT PDF EN Portuguese Text

Objective: To develop and consolidate a comprehensive database on the occurrence of pneumoconioses in an industrialized region of Brazil, with a special focus on the activities most frequently related to these diseases. Methods: A retrospective, observational study was conducted in order to gather data on cases of pneumoconioses treated at the outpatient clinic of the State University at Campinas Hospital das Clínicas between 1978 and 2003. Individuals diagnosed with pneumoconiosis, based on their occupational history and on chest X-ray findings of abnormalities consistent with interstitial lung disease involving the parenchyma, in accordance with the 1980 and 2000 recommendations of the International Labour Organization, were included in the study. Results: A total of 1147 cases of pneumoconiosis were identified (1075 in males and 72 in females): 1061 cases of silicosis (92.5%); 51 cases of mixed-dust pneumoconiosis (4.45%); 15 cases of asbestosis (1.31%); 13 cases of phosphate rock-related pneumoconiosis (1.13%); and 7 cases of other types of pneumoconiosis (0.6%), including those related to exposure to coal, graphite and hard metals. The most common chest X-ray findings were 1/0, 1/1 or 1/2 profusion and small regular opacities (p, q or r), although 192 patients (16.74%) presented large opacities. There has been a substantial decline in the occurrence of the disease since the 1990s, and the duration of exposure was typically shorter than that observed in a study conducted in the United States. Conclusions: Our findings have been compiled into a comprehensive database for the investigation of pneumoconiosis in an industrialized area of Brazil. These data make it possible to conduct follow-up studies and develop health policies related to occupational respiratory disorders.


Keywords: Occupational medicine; Respiratory tract diseases/epidemiology; Pneumoconiosis; Epidemiology.


7 - Immediate bronchodilator response to formoterol in poorly reversible chronic obstructive pulmonary disease

Resposta broncodilatadora imediata ao formoterol em doença pulmonar obstrutiva crônica com pouca reversibilidade

Adalberto Sperb Rubin, Fábio José Fabrício de Barros Souza, Jorge Lima Hetzel, José da Silva Moreira

J Bras Pneumol.2008;34(6):373-379

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate, using pulmonary function tests, the effectiveness of formoterol as a bronchodilator at 30 min after its administration in patients with poorly reversible COPD. Methods: A prospective study including 40 COPD patients not responding to the short-acting bronchodilator used in the spirometric test-variation of less than 200 mL and less than 7% of predicted in forced expiratory volume in one second (FEV1). All patients were classified as having stage II, III, or IV COPD (Brazilian Thoracic Society/Global Initiative for Chronic Obstructive Lung Disease) and presented FEV1 ≤ 70% of predicted value. The patients were randomized into two groups of 20, with similar clinical characteristics, receiving, via a dry powder inhaler, either formoterol or a placebo. The pulmonary function testing (plethysmography) was repeated at 30 min after formoterol or placebo administration. Results: In the formoterol group, the mean values obtained for FEV1, inspiratory capacity, and forced vital capacity were significantly greater than those obtained in the placebo group (p = 0.00065, p = 0.05, and p = 0.017, respectively), whereas that obtained for airway resistance was significantly lower (p = 0.010). Less pronounced differences were observed for residual volume, vital capacity and specific airway conductance, which were lower, higher and higher, respectively, in the formoterol group. Conclusions: In COPD patients not responding to the short-acting bronchodilator used in the spirometric test, formoterol promoted significant improvement in lung function at 30 min after of administration. Further studies are required to confirm whether formoterol can also be used as a medication for immediate relief of symptoms in COPD.


Keywords: Chronic obstructive pulmonary disease; Respiratory function tests; Bronchodilator agents.


8 - Effects of manually assisted coughing on respiratory mechanics in patients requiring full ventilatory support

Efeitos da tosse manualmente assistida sobre a mecânica do sistema respiratório de pacientes em suporte ventilatório total

Katia de Miranda Avena, Antonio Carlos Magalhães Duarte, Sergio Luiz Domingues Cravo, Maria José Junho Sologuren, Ada Clarice Gastaldi

J Bras Pneumol.2008;34(6):380-386

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Objective: Manually assisted coughing (MAC) consists of a vigorous thrust applied to the chest at the beginning of a spontaneous expiration or of the expiratory phase of mechanical ventilation. Due to routine use of MAC in intensive care units, the objective of this study was to assess the effects of MAC on respiratory system mechanics in patients requiring full ventilatory support. Methods: We assessed 16 sedated patients on full ventilatory support (no active participation in ventilation). Respiratory system mechanics and oxyhemoglobin saturation were measured before and after MAC, as well as after endotracheal aspiration. Bilateral MAC was performed ten times on each patient, with three respiratory cycle intervals between each application. Results: Data analysis demonstrated a decrease in resistive pressure and respiratory system resistance, together with an increase in oxyhemoglobin saturation, after MAC combined with endotracheal aspiration. No evidence of alterations in peak pressures, plateau pressures or respiratory system compliance change was observed after MAC. Conclusions: The use of MAC alters respiratory system mechanics, increasing resistive forces by removing secretions. The technique is considered safe and efficacious for postoperative patients. Using MAC in conjunction with endotracheal aspiration provided benefits, achieving the proposed objective: the displacement and removal of airway secretions.


Keywords: Cough; Sputum; Respiratory mechanics; Respiration, artificial.


9 - Assessment of the quality of life of patients with lung cancer using the Medical Outcomes Study 36-item Short-Form Health Survey

Avaliação da qualidade de vida em pacientes com câncer de pulmão através da aplicação do questionário Medical Outcomes Study 36-item Short-Form Health Survey

Juliana Franceschini, Alecssandra Aparecida dos Santos, Inás El Mouallem, Sergio Jamnik, César Uehara, Ana Luisa Godoy Fernandes, Ilka Lopes Santoro

J Bras Pneumol.2008;34(6):387-393

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the quality of life of patients with lung cancer and to compare it with that of individuals without cancer. Methods: The Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) was administered to 57 patients diagnosed with lung cancer, treated at the Lung Cancer Outpatient Clinic of the Hospital São Paulo, and to a control group of 57 individuals recruited from the Extra Penha workout group. The Mann-Whitney test was used to compare the groups, domain by domain. The first model of logistic regression was adjusted for male gender, nonsurgical treatment, Karnofsky performance status and smoking, which were included as predictors. The second model was adjusted for each SF-36 domain in order to identify increases in the proportions of patients in stage IIIB or IV. Results: The lung cancer group and the control group presented the following mean scores, respectively, for the SF-36 domains: role limitations due to physical health problems, 29.39 ± 36.94 and 82.89 ± 28.80; role limitations due to emotional problems, 42.78 ± 44.78 and 86.55 ± 28.77; physical function, 56.49 ± 28.39 and 89.00 ± 13.80; vitality, 61.61 ± 23.82 and 79.12 ± 17.68; bodily pain, 62.72 ± 28.72 and 81.54 ± 19.07; general health, 62.51 ± 25.57 and 84.47 ± 13.47; emotional well-being, 68.28 ± 23.46 and 82.63 ± 17.44; and social functioning, 72.87 ± 29.20 and 91.67 ± 17.44. The logistic regression model showed that role limitations due to physical health problems, physical function and emotional well-being were predictors of stages IIIB and IV. Conclusions: The patients with lung cancer had a poorer quality of life, especially regarding physical aspects, than did the control subjects.


Keywords: Lung neoplasms; Quality of life; Health status.


10 - Treatment outcome and laboratory confirmation of tuberculosis diagnosis in patients with HIV/AIDS in Recife, Brazil

Desfecho do tratamento e confirmação laboratorial do diagnóstico de tuberculose em pacientes com HIV/AIDS no Recife, Pernambuco, Brasil

Magda Maruza, Ricardo Arraes de Alencar Ximenes, Heloísa Ramos Lacerda

J Bras Pneumol.2008;34(6):394-403

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the frequency of unfavorable outcome (death or default and treatment failure) between tuberculosis (TB)/HIV co-infected patients treated for TB after laboratory confirmation of the diagnosis and TB/HIV co-infected patients who were so treated without diagnostic confirmation. Methods: A retrospective cohort of TB/HIV co-infected patients who started TB treatment between July of 2002 and June of 2004 at an HIV/AIDS referral center in Recife, Brazil. The main exposure variable, laboratory confirmation of TB, was adjusted for three different sets of variables: sociodemographic variables; HIV/AIDS-related variables; and TB-related variables. In order to evaluate the statistical significance of the results, we calculated odds ratios, with 95% confidence intervals, and p values (from chi-square tests and likelihood ratio tests). Results: A total of 262 patients were studied. No association was found between laboratory confirmation of the diagnosis of TB at treatment outset and unfavorable outcome, even after adjustment for confounders. In the final multiple logistic regression model, the following variables remained: the presence of other opportunistic diseases; CD4 lymphocyte count below 50 cells/mm3; viral load between 10,000 and 100,000 copies/mL; dyspnea; the disseminated form of TB; and change in the TB treatment regimen due to adverse reactions or intolerance. Conclusions: Our results suggest that TB treatment in TB/HIV co-infected patients without etiologic confirmation of TB, at the discretion of experienced physicians in referral centers, did not increase the risk of unfavorable outcomes. In addition, it allowed the identification of groups that should be closely monitored due to a greater risk of unfavorable outcomes.


Keywords: Tuberculosis; Diagnosis; Therapeutics; Treatment outcome; HIV infections.


11 - Accuracy of inpatient and outpatient gastric lavage in the diagnosis of pulmonary tuberculosis in children

Acurácia do lavado gástrico realizado em ambiente hospitalar e ambulatorial no diagnóstico da tuberculose pulmonar em crianças

Ethel Leonor Noia Maciel, Reynaldo Dietze, Renata Peres Lyrio, Solange Alves Vinhas, Moises Palaci, Rodrigo Ribeiro Rodrigues, Claudio Jose Struchiner

J Bras Pneumol.2008;34(6):404-411

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare gastric lavage (GL) performed in inpatients with GL performed in outpatients in terms of its accuracy in diagnosing pulmonary tuberculosis (TB) in children. Methods: A prospective study was carried out in the state of Espírito Santo, Brazil, from 1999 to 2003. A total of 230 children suspected of having TB (103 inpatients and 127 outpatients) were selected to undergo GL. Those thus diagnosed with TB (n = 53) were divided into two groups: inpatient GL (n = 30) and outpatient GL (n = 23). All 53 children were monitored for 6 months in order to evaluate the accuracy of the diagnosis. Accuracy was determined based on any change in diagnosis, cure rate, and the percentage of positive cultures in the two groups studied. Results: The cure rate was 100% in both groups, and there was no change in diagnosis in the 53 children studied. No significant difference was found between the two groups studied in terms of detection of Mycobacterium tuberculosis (RR = 1.47; 95% CI: 0.95-2.27; p = 0.095), although the outpatient group presented a greater rate of positive cultures. Conclusions: Our results show that the accuracy of GL performed in an inpatient setting is similar to that of GL performed in an outpatient setting. This indicates that hospitalization is required only in more severe cases in which GL cannot be performed as an outpatient procedure.


Keywords: Gastric lavage; Tuberculosis; Diagnosis.


Review Article

12 - Role of nitric oxide in the control of the pulmonary circulation: physiological, pathophysiological, and therapeutic implications

Papel do óxido nítrico na regulação da circulação pulmonar: implicações fisiológicas, fisiopatológicas e terapêuticas

Carlos Alan Dias-Junior, Stefany Bruno de Assis Cau, José Eduardo Tanus-Santos

J Bras Pneumol.2008;34(6):412-419

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Nitric oxide (NO) is an endogenous vasoactive compound that contributes to pulmonary vascular homeostasis and is produced by three nitric oxide synthase (NOS) isoforms-neuronal NOS (nNOS); inducible NOS (iNOS); and endothelial NOS (eNOS)-all three of which are present in the lung. Studies using pharmacological inhibitors or knockout mice have shown that eNOS-derived NO plays an important role in modulating pulmonary vascular tone and attenuating pulmonary hypertension. However, studies focusing on the role of iNOS have shown that this isoform contributes to the pathophysiology of acute lung injury and acute respiratory distress syndrome. This review aimed at outlining the role played by NO in the control of pulmonary circulation, both under physiological and pathophysiological conditions. In addition, we review the evidence that the L-arginine-NO-cyclic guanosine monophosphate pathway is a major pharmacological target in the treatment of pulmonary vascular diseases.


Keywords: Nitric oxide; Arginine; Nitric oxide synthase; Cyclic GMP; Pulmonary circulation.


Case Report

13 - Negative-pressure pulmonary edema and hemorrhage associated with upper airway obstruction

Edema e hemorragia pulmonar por pressão negativa associados à obstrução das vias aéreas superiores

Ricardo Kalaf Mussi, Ivan Felizardo Contrera Toro

J Bras Pneumol.2008;34(6):420-424

Abstract PDF PT PDF EN Portuguese Text

Negative-pressure pulmonary edema accompanied by hemorrhage as a manifestation of upper airway obstruction is an uncommon problem that is potentially life-threatening. The principal pathophysiological mechanism involved is the generation of markedly negative intrathoracic pressure, which leads to an increase in pulmonary vascular volume and pulmonary capillary transmural pressure, creating a risk of disruption of the alveolar-capillary membrane. We report the case of an adult male with diffuse alveolar hemorrhage following acute upper airway obstruction caused by the formation of a cervical and mediastinal abscess resulting from the insertion of a metallic tracheal stent. The patient was treated through drainage of the abscess, antibiotic therapy, and positive pressure mechanical ventilation. This article emphasizes the importance of including this entity in the differential diagnosis of acute lung injury after procedures involving upper airway instrumentation.


Keywords: Hemorrhage; Pulmonary edema; Airway obstruction; Abscess; Prostheses and implants.


14 - A rare case of pneumothorax: metastatic adamantinoma

Caso raro de pneumotórax: adamantinoma metastático

Roberto Gonçalves, Roberto Saad Júnior, Vicente Dorgan Neto, Marcio Botter

J Bras Pneumol.2008;34(6):425-429

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Here, we describe two cases of lung metastasis of adamantinoma of long bones, a low-grade bone neoplasm that rarely metastasizes. In both cases, the clinical presentation of the metastases was characterized by spontaneous pneumothorax secondary to tumor cavitation, a phenomenon described in only three of the studies reviewed in the literature. Clinical, radiological, and anatomopathological findings, as well as the procedures adopted in the two cases, are described.


Keywords: Adamantinoma; Pneumothorax; Neoplasm metastasis; Medical records.


Special Article

15 - Therapeutic application of collateral ventilation in diffuse pulmonary emphysema: study protocol presentation

Aplicação terapêutica da ventilação colateral no enfisema pulmonar difuso: apresentação de um protocolo

Roberto Saad Júnior, Vicente Dorgan Neto, Marcio Botter, Roberto Stirbulov, Jorge Rivaben, Roberto Gonçalves

J Bras Pneumol.2008;34(6):430-434

Abstract PDF PT PDF EN Portuguese Text

We present a protocol to test a new surgical procedure for the treatment of patients with diffuse lung emphysema who, after having received the golden standard treatment (pulmonary rehabilitation), continue to present respiratory failure with disabling dyspnea. Ten patients with severe lung hyperinflation will be evaluated. The method proposed is designed to create alternative expiratory passages for air trapped in the emphysematous lung by draining the lung parenchyma, thereby establishing communication between the alveoli and the external environment. The ten patients selected will be required to meet the inclusion criteria and to give written informed consent. Those ten patients will be included in the study pending the approval of the Ethics in Research Committee of the São Paulo Santa Casa School of Medicine, São Paulo, Brazil. The protocol we will employ in order to evaluate the proposed procedure is feasible and will show whether debilitated patients suffering from diffuse pulmonary emphysema can benefit from this procedure, which could represent an alternative to lung transplant or lung volume reduction surgery, the only options currently available.


Keywords: Pulmonary emphysema; Pulmonary disease, chronic obstructive; Lung, hyperlucent.


Year 2008 - Volume 34  - Number 7  (/July)


1 - Sleepiness and sleep apnea: a disastrous partnership

Sonolência e apnéia do sono: uma parceria desastrosa

Francisco Hora de Oliveira Fontes

J Bras Pneumol.2008;34(7):435-436

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Original Article

2 - Development and assessment of a multimedia computer program to teach pleural drainage techniques

Desenvolvimento e avaliação de um programa multimídia de computador para ensino de drenagem pleural

João Aléssio Juliano Perfeito, Vicente Forte, Roseli Giudici, José Ernesto Succi, Jae Min Lee, Daniel Sigulem

J Bras Pneumol.2008;34(7):437-444

Abstract PDF PT PDF EN Portuguese Text

Objective: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. Methods: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple-choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. Results: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple-choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. Conclusions: The computer program developed at the Federal University of São Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.


Keywords: Teaching; Thoracic surgery; Multimedia; Drainage; Pleural diseases.


3 - Effects of quercetin on bleomycin-induced lung injury: a preliminary study

Efeitos da quercetina na lesão pulmonar induzida por bleomicina: um estudo preliminar

José Antônio Baddini Martinez, Simone Gusmão Ramos, Mônica Souza Meirelles, Adalberto Valladas Verceze, Maurício Rodrigues de Arantes, Hélio Vannucchi

J Bras Pneumol.2008;34(7):445-452

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the effects of quercetin in a model of bleomycin-induced pulmonary inflammation and fibrosis. Methods: Seventynine adult male hamsters were randomized to receive intratracheal (IT) instillations and intraperitoneal (IP) injections in four configurations: IP vehicle/IT saline (VS group, n = 16); IP quercetin/IT saline (QS group, n = 16); IP vehicle/IT bleomycin (VB group, n = 27); and IP quercetin/ IT bleomycin (QB group, n = 20). Quercetin and bleomycin were administered at 30 mg/kg/day and 10 U/kg, respectively. Quercetin was started/discontinued 3 days before/14 days after the IT instillations. Results: The mortality rate was significantly higher in the VB group than in the other groups (44% vs. VS: 0%; QS: 0%; and QB: 15%). Lung levels of thiobarbituric acid reactive substances (× 10−2 nmol/mg) were significantly higher in the VB group (6.6 ± 1.3 vs. VS: 5.5 ± 0.8; QS: 2.5 ± 0.6; and QB: 5.8 ± 0.6). Lung levels of reduced glutathione (× 10−2 nmol/mg) were significantly lower in the VB/QB groups than in the VS/QS groups (28.9 ± 13.8/28.6 ± 14.8 vs. 43.9 ± 16.0/51.1 ± 20.3), whereas those of hydroxyproline (mg/g) were significantly higher (201.6 ± 37.3/177.6 ± 20.3 vs. 109.6 ± 26.1/117.5 ± 32.0).Mean lung septal thickness (μm) was greatest in the VB group (16.9 ± 3.2 vs. VS: 3.0 ± 0.3; QS: 3.3 ± 0.2; and QB: 5.2 ± 1.1). Conclusions: In a hamster model of lung injury, quercetin exhibited anti-inflammatory effects that are related, at least in part, to its antioxidant properties.


Keywords: Pulmonary fibrosis; Bleomycin; Flavonoids; Lipid peroxidation.


4 - Experimental models for assessment of pulmonary alterations in hepatopulmonary syndrome

Modelos experimentais para avaliação das alterações pulmonares na síndrome hepatopulmonar

Rafael Vercelino1, Juliana Tieppo, Luiz Albeto Forgiarini Junior, Alexandre Simões Dias, Claudio Augusto Marroni, Norma Possa Marroni

J Bras Pneumol.2008;34(7):453-460

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Objective: The aim of this study was to identify the best experimental model in which to observe the pulmonary alterations characterizing hepatopulmonary syndrome (HPS). Methods: Male Wistar rats, with mean weight of 250 g, were used in four experimental models: inhaled carbon tetrachloride; intraperitoneal carbon tetrachloride; partial portal vein ligation; and bile duct ligation (BDL). The animals in all groups were divided into control and experimental subgroups. The following variables were measured: transaminase levels; blood gases; lipoperoxidation, using thiobarbituric acid reactive substances (TBARS) and chemiluminescence; and levels of superoxide dismutase (SOD) anti-oxidant activity. Anatomopathological examination of the lung was also performed. Results: There were statistically significant differences between the BDL control and BDL experimental groups: aspartate aminotransferase (105.3 ± 43 vs. 500.5 ± 90.3 IU/L); alanine aminotransferase (78.75 ± 37.7 vs. 162.75 ± 35.4 IU/L); alkaline phosphatase (160 ± 20.45 vs. 373.25 ± 45.44 IU/L); arterial oxygen tension (85.25 ± 8.1 vs. 49.9 ± 22.5 mmHg); and oxygen saturation (95 ± 0.7 vs. 73.3 ± 12.07%). Lipoperoxidation and antioxidant activity also differed significantly between the two BDL groups (control vs. experimental): TBARS (0.87 ± 0.3 vs. 2.01 ± 0.9 nmol/mg protein); chemiluminescence (16008.41 ± 1171.45 vs. 20250.36 ± 827.82 cps/mg protein); and SOD (6.66 ± 1.34 vs. 16.06 ± 2.67 IU/mg protein). The anatomopathological examination confirmed pulmonary vasodilatation in the BDL model. In the other models, there were no alterations that were characteristic of HPS. Conclusions: The data obtained suggest that the BDL model can be used in future studies involving hepatic alterations related to oxidative stress and HPS.


Keywords: Hepatopulmonary syndrome; Lung; Oxidative stress; Rats.


5 - Chronic bacterial infection and echocardiographic parameters indicative of pulmonary hypertension in patients with cystic fibrosis

Infecção bacteriana crônica e indicadores ecocardiográficos de hipertensão pulmonar em pacientes com fibrose cística

Paula Maria Eidt Rovedder, Bruna Ziegler, Lilian Rech Pasin, Antônio Fernando Furlan Pinotti, Sérgio Saldanha Menna Barreto, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2008;34(7):461-467

Abstract PDF PT PDF EN Portuguese Text

Objectives: To examine the relationship between chronic bacterial infection and pulmonary hypertension, using Doppler echocardiography, in patients with cystic fibrosis (CF). Methods: A prospective cross-sectional study involving CF patients (≥ 16 years of age) admitted to a program for adults with the disease. The study included 40 patients with a mean age of 23.7 ± 6.3 years. Patients were submitted to clinical evaluation, Doppler echocardiography, pulmonary function tests, chest X-rays and sputum cultures of Pseudomonas aeruginosa and Burkholderia cepacia. Results: In terms of the following variables, no significant differences were found between P. aeruginosapositive patients and P. aeruginosa-negative patients: clinical score (p = 0.472); forced expiratory volume in one second (FEV1; p = 0.693); radiological score (p = 0.760); tricuspid regurgitant jet velocity (TRV, p = 0.330); diameter of the right ventricle (DRV, p = 0.191); and right ventricular/pulmonary artery (RV/PA) systolic acceleration time (SAT, p = 0.330). B. cepacia-positive patients presented significantly lower FEV1 than did B. cepacia-negative patients (p = 0.011). No significant differences were found between B. cepacia-positive patients and B. cepacia-negative patients regarding the following variables: clinical score (p = 0.080); radiological score (p = 0.760); TRV (p = 0.613); DRV (p = 0.429); and RV/PA SAT (p = 0.149). Conclusions: Chronic infection with P. aeruginosa or B. cepacia presented no association with pulmonary hypertension in adult CF patients. Pulmonary function was worse in B. cepacia-positive patients than in P. aeruginosa-positive patients.


Keywords: Cystic fibrosis; Bacterial infections; Hypertension, pulmonary; Echocardiography, Doppler.


6 - Airflow limitation in brazilian caucasians: FEV1/FEV6 vs. FEV1/FVC

Limitação ao fluxo aéreo em brasileiros da raça branca: VEF1/VEF6 vs. VEF1/CVF

André Luis Pinto Soares, Sílvia Carla Sousa Rodrigues, Carlos Alberto de Castro Pereira

J Bras Pneumol.2008;34(7):468-472

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Objective: To evaluate the use of the forced expiratory volume in one second/forced expiratory volume in six seconds (FEV1/FEV6) ratio as an alternative to the FEV1/forced vital capacity (FVC) ratio in the detection of mild airway obstruction. Methods: Reference equations for the Brazilian population in 2006 were used in order to determine the lower limits of normality for the FEV1/FEV6 and FEV1/FVC ratios. The spirometry findings of 155 patients from 20 to 84 years of age were analyzed. All of the patients presented the following: a < 15% difference between predicted and observed FEV1/FVC ratio; an FEV1 ≥ 60% of predicted; and an exhalation time of at least 6 s. The Brazilian Thoracic Society criteria for acceptability and reproducibility in spirometry were met. Results: Mean values (± SD) for FEV1/FEV6 and FEV1/FVC were 73 ± 4% and 75 ± 3%, respectively. Using the FEV1/FVC ratio, we identified airflow obstruction in 61 patients, compared with only 46 patients when we used the FEV1/FEV6 ratio, showing a sensitivity of 75% (p < 0.001). Conclusions: The FEV1/FEV6 ratio has poor sensitivity and should not be used to replace the FEV1/FVC ratio in the diagnosis of mild airway obstruction.


Keywords: Forced expiratory volume; Vital capacity; Airway obstruction; Spirometry; Respiratory function tests.


7 - Value of [18F]-FDG-PET/CT as a predictor of cancer in solitary pulmonary nodule

Valor do FDG[18F]-PET/TC como preditor de câncer em nódulo pulmonar solitário

Rafael de Castro Martins, Sérgio Altino de Almeida, Antônio Alexandre de Oliveira Siciliano, Maria Carolina Pinheiro Pessoa Landesmann, Fabrício Braga da Silva, Carlos Alberto de Barros Franco, Lea Mirian Barbosa da Fonseca

J Bras Pneumol.2008;34(7):473-480

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Objective: To determine the diagnostic accuracy of positron emission tomography/computed tomography (PET/CT) using fluorine- 18‑deoxyglucose ([18F]-FDG) for the evaluation of a solitary pulmonary nodule (SPN). Methods: Prospective analysis of 53 consecutive patients submitted to PET/CT between March 2005 and May 2007 for the evaluation of an SPN. Of those, 32 met the criteria for inclusion in the present study. The lesions were evaluated for location, size, radiotracer uptake and maximum standardized uptake value (SUV). The FDG-PET/CT results were correlated with other predictors of malignancy (age, gender, smoking status, nodule size and nodule location). The definitive diagnosis was established through histopathology or through clinical/radiological follow-up for at least one year. Results: Fourteen malignant SPNs were found. Through analysis of the receiver operating characteristic curve, we established an SUV of 2.5 as the most appropriate cut-off point, since it correctly identified 13 of the 14 malignant SPNs. The results below that point revealed one false positive for neoplasia out of a total of 14. The semiquantitative method presented a sensitivity of 92.9%, specificity of 72.2%, positive predictive value of 72.2%, negative predictive value of 92.9% and accuracy of 81.2%. The multivariate analysis showed a statistically significant association with SPN malignancy only for nodule location in the upper lobes (p = 0.048) and SUV (p = 0.007). Conclusions: The results obtained suggest that the SUV of [18F]-FDG is a useful predictor of neoplasia in SPN, with a high negative predictive value, which allows malignancy to be safely ruled out, showing its relevance in the diagnostic approach to pulmonary nodules.


Keywords: Positron-emission tomography; Coin lesion, pulmonary; Lung neoplasms.


8 - Reversal of digital clubbing in surgically treated lung cancer patients

Regressão do hipocratismo digital em pacientes com câncer de pulmão tratados cirurgicamente

José da Silva Moreira, Marlene Hass, Ana Luiza Schneider Moreira, James de Freitas Fleck, José de Jesus Peixoto Camargo

J Bras Pneumol.2008;34(7):481-489

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Objective: To objectively evaluate the reversal of digital clubbing (DC) in a series of surgically treated lung cancer patients, and to review the literature on the subject. Methods: Sixty-one patients with non-small cell lung cancer-40 with and 21 without DC-were treated by pulmonary resection. Eleven (18%) received additional postoperative radiation therapy. Preoperatively, as well as on postoperative days 7, 18, and 90, the hyponychial angle (HA) and the distal phalangeal depth/interphalangeal depth (DPD/IPD) ratio were determined on profile shadow projections of the index fingers. A review of the literature on reversal of DC (1954-2007) was also performed. Results: From the preoperative period to postoperative day 90, HA decreased from 200.5 ± 5.0° to 193.3 ± 6.8° (p < 0.001), and the DPD/IPD ratio decreased from 1.014 ± 0.051 mm to 0.956 ± 0.045 mm (p < 0.001) in the group of 40 patients with DC. The HA and the DPD/IPD ratio decreased in 33 (82.5%) but remained the same in 7 (1.7%), 6 with unfavorable evolution. In the 21 patients without DC, HA (184.5 ± 5.5°) and the DPD/IPD ratio (0.937 ± 0.046 mm) remained unchanged after surgery. In the literature (1954-2007), we found 52 cases, 5 of which were lung cancer cases, in which reversal of DC, observed in several clinical conditions, was explicitly reported. Conclusion: In most lung cancer patients, DC resolves after effective surgical treatment of the tumor, as can occur in patients with other conditions.


Keywords: Osteoarthropathy, secondary hypertrophic; Lung neoplasms; Pulmonary surgical procedures.


9 - Obstructive sleep apnea-hypopnea syndrome: association with gender, obesity and sleepiness-related factors

Síndrome das apnéias-hipopnéias obstrutivas do sono: associação com gênero e obesidade e fatores relacionados à sonolência

Marli Maria Knorst, Fábio José Fabrício de Barros Souza, Denis Martinez

J Bras Pneumol.2008;34(7):490-496

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Objective: To study the effects that gender and obesity have on excessive daytime sleepiness (EDS) in individuals with obstructive sleep apnea-hypopnea syndrome (OSAHS), as well as to identify factors associated with EDS in such individuals. Methods: A total of 300 consecutive patients who completed the clinical evaluation satisfactorily and whose polysomnography showed an apnea-hypopnea index (AHI) > 10 events/hour of sleep were selected from a sleep clinic population for inclusion in the study. Results: Mean age was 47 ± 11 years, and mean AHI was 52.1 ± 29.2 events/hour of sleep. Females presented higher mean age, lower EDS scores and less time in apnea . Mean EDS score was 14.7 ± 7.2. The EDS score correlated best with body movements (r = 0.43; p < 0.01), respiratory events during sleep (r = 0.40; p < 0.01), duration of apnea (r = 0.40; p < 0.01), peripheral oxygen saturation (SpO2; r = -0.38; p < 0.01) and AHI (r = 0.37; p < 0.01). Mean body mass index (BMI) was 30.2 ± 5.3 kg/m2. Overweight, obesity and morbid obesity were observed in 41, 44 and 5.3% of cases, respectively. Disease severity correlated most strongly with BMI (r = 0.51; p < 0.01). Conclusions: Higher mean age, lower EDS scores and less time spent in sleep apnea time in apnea were associated with being female. Fragmented sleep, number/duration of respiratory events during sleep, SpO2 levels and obesity were associated with sleepiness. The BMI had a significant effect on OSAHS severity.


Keywords: Sleep apnea, obstructive; Sleep apnea syndromes; Polysomnography; Sleep stages; Obesity.


10 - Lung donor profile in the state of São Paulo, Brazil, in 2006

Perfil do doador de pulmão disponibilizado no estado de São Paulo, Brasil, em 2006

Paulo Manuel Pêgo Fernandes, Marcos Naoyuki Samano, Jader Joel Machado Junqueira, Daniel Reis Waisberg, Gustavo Sousa Noleto, Fabio Biscegli Jatene

J Bras Pneumol.2008;34(7):497-505

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the rate at which lungs available for transplantation in the state of São Paulo in 2006 were utilized and to determine the lung donor profile in the same period. Methods: A retrospective study of 497 clinical charts of lung tissue donors from January to December of 2006. Results: According to the clinical charts, lungs were not offered for transplant in 149 cases (30%), which were therefore excluded from the study. Among the 348 lung donors eligible for inclusion in the study, the mean age was 37.4 ± 16.1 years, and 56.9% were males. The main causes of brain death among the donors were stroke (in 40.5%), skull-brain trauma (in 34.2%) and subarachnoid hemorrhage (in 10.9%). The great majority of these lung donors (90.5%) received vasoactive agents, and 13.5% presented cardiopulmonary arrest. The mean donor leukocyte count was 15,008 ± 6,467 cells/mm3, 67.8% of the donors received anti-bacterial agents, and 26.1% presented lung infection. Nearly 40% of the lung donors presented chest X-ray abnormalities. Only 4.9% of the lung donors were accepted, representing 28 lungs (allograft utilization rate of 4%). The causes for donor exclusion were gas exchange alterations (in 30.1%), infection (in 23.7%) and distance (in 10.9%). Conclusions: The lung utilization rate in the state of São Paulo is low when compared to mean rates worldwide. In addition, more than half of the donor pool was excluded due to altered gas exchange or pulmonary infection. The combination of better care of the potential donor and more flexible selection criteria could increase allograft utilization.


Keywords: Lung transplantation; Donor selection; Tissue donors.


11 - Directly observed therapy using home-based supervisors for treating tuberculosis in Vitória, Brazil

Tratamento supervisionado em pacientes portadores de tuberculose utilizando supervisores domiciliares em Vitória, Brasil

Ethel Leonor Noia Maciel, Ana Paula Silva, Waleska Meireles, Karina Fiorotti, David Jamil Hadad, Reynaldo Dietze

J Bras Pneumol.2008;34(7):506-513

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the use of family members as supervisors of directly observed therapy (DOT) in patients with tuberculosis.Methods: This was a prospective descriptive study involving patients diagnosed with pulmonary tuberculosis. The sample comprised 98 patients. A standardized protocol was implemented in order to train the patient and their families. After the training, the patient was allowed to choose either a family member or a health care worker as a supervisor. Absolute and relative frequencies were used in descriptive data analysis. Results: A family member supervisor was chosen by 94 patients (96%). The cure rate was 99%. The partner was chosen by 49% of the patients, and other family members were chosen by 28%. The heath care team needed to take over DOT in 3% of the cases. Regular attendance at follow-up appointments was 67%. It was observed that 24% of the problems in this DOT model referred to the family supervisor forgetting to administer the medication or to the patient forgetting to take it; 39% of the patients forgot to take the medication for one day, and 31% forgot to take it for two days. There was change of supervisor in 9% of the sample, medication was lost by the patient sometime during treatment in 9%, and patient drug intolerance occurred in 8%. Conclusions: DOT supervised by a family member has proven an effective and low-cost technique. However, compliance is not due to one single factor but to the combination of strategies adopted: bus passes; educational measures and especially the individualized approach.


Keywords: Directly observed therapy; Tuberculosis; Patient compliance.


Review Article

12 - Alpha-1 antitrypsin deficiency: diagnosis and treatment

Deficiência de alfa-1 antitripsina: diagnóstico e tratamento

Aquiles A Camelier, Daniel Hugo Winter, José Roberto Jardim, Carlos Eduardo Galvão Barboza, Alberto Cukier, Marc Miravitlles

J Bras Pneumol.2008;34(7):514-527

Abstract PDF PT PDF EN Portuguese Text

Alpha-1 antitrypsin deficiency is a recently identified genetic disease that occurs almost as frequently as cystic fibrosis. It is caused by various mutations in the SERPINA1 gene, and has numerous clinical implications. Alpha-1 antitrypsin is mainly produced in the liver and acts as an antiprotease. Its principal function is to inactivate neutrophil elastase, preventing tissue damage. The mutation most commonly associated with the clinical disease is the Z allele, which causes polymerization and accumulation within hepatocytes. The accumulation of and the consequent reduction in the serum levels of alpha-1 antitrypsin cause, respectively, liver and lung disease, the latter occurring mainly as early emphysema, predominantly in the lung bases. Diagnosis involves detection of low serum levels of alpha-1 antitrypsin as well as phenotypic confirmation. In addition to the standard treatment of chronic obstructive pulmonary disease, specific therapy consisting of infusion of purified alpha-1 antitrypsin is currently available. The clinical efficacy of this therapy, which appears to be safe, has yet to be definitively established, and its cost-effectiveness is also a controversial issue that is rarely addressed. Despite its importance, in Brazil, there are no epidemiological data on the prevalence of the disease or the frequency of occurrence of deficiency alleles. Underdiagnosis has also been a significant limitation to the study of the disease as well as to appropriate treatment of patients. It is hoped that the creation of the Alpha One International Registry will resolve these and other important issues.


Keywords: alpha 1-antitrypsin; Emphysema; Pulmonary disease, chronic obstructive.


Case Report

13 - Primary tracheobronchial amyloidosis

Amiloidose traqueobrônquica primária

Gustavo Chatkin, Mauríco Pipkin, José Antonio Figueiredo Pinto, Vinicius Duval da Silva, José Miguel Chatkin

J Bras Pneumol.2008;34(7):528-531

Abstract PDF PT PDF EN Portuguese Text

Amyloidosis is a disease characterized by extracellular deposition of fibrillar protein in organs and tissues. Primary tracheal amyloidosis is rare. We report here a case of a 55-year-old man with tracheal amyloidosis hospitalized for acute respiratory insufficiency and with a history of recent episodes of pneumonia. Chest X-ray and chest computed tomography showed tracheal obstruction due to a tumor. A passage was created in order to relieve the symptoms. Histological examination (Congo red staining) revealed amyloid deposits but no evidence of neoplasia. Although this is a rare clinical condition, its importance is discussed regarding the differential diagnosis of tracheal tumors and the repercussions for therapeutic decision-making.


Keywords: Amyloidosis; Respiratory insufficiency; Congo red; Airway obstruction.


14 - Chronic thromboembolic pulmonary hypertension: diagnostic limitations

Hipertensão pulmonar associada ao tromboembolismo pulmonar crônico: limitações diagnósticas

Bruno Arantes Dias, Carlos Jardim, André Hovnanian, Caio Júlio César Fernandes, Rogério Souza

J Bras Pneumol.2008;34(7):532-536

Abstract PDF PT PDF EN Portuguese Text

Chronic thromboembolic pulmonary hypertension is the only potentially curable form of pulmonary hypertension, assuming that surgical treatment is possible. However, there are hindrances to making a definitive, noninvasive diagnosis. We present the case of a 40-year-old female patient with idiopathic pulmonary arterial hypertension, confirmed in 1994. This patient developed thrombi in pulmonary vessels (as an overlap syndrome) mimicking chronic thromboembolic pulmonary hypertension. The identification of these conditions, which present high intraoperative mortality and unsatisfactory surgical resolution, is quite difficult in clinical practice. We discuss the current approach to candidate selection for surgical treatment of chronic thromboembolic pulmonary hypertension and the possible repercussions of inappropriate selection.


Keywords: Hypertension, pulmonary/diagnosis; Hypertension, pulmonary/therapy; Pulmonary embolism; Endarterectomy.


15 - Mitral valve obstruction by tumor embolus as a cause of irreversible cardiac arrest during right pneumonectomy

Obstrução de valva mitral por embolização tumoral per-operatória (pneumectomia direita) com parada cardíaca irreversível

Rui Haddad, Carlos Henrique Ribeiro Boasquevisque, Tadeu Diniz Ferreira, Mario Celso Martins Reis, Fernando D'Imperio Teixeira

J Bras Pneumol.2008;34(7):537-540

Abstract PDF PT PDF EN Portuguese Text

A 26-year-old patient with a voluminous primary pulmonary hemangiopericytoma in the right lung, diagnosed through previous surgical biopsy, presented irreversible cardiac arrest during the hilar dissection portion of a right pneumonectomy. The patient did not respond to resuscitation efforts. Autopsy showed total obstruction of the mitral valve by a tumor embolism. In cases of large lung masses with hilar involvement, as in the case presented, we recommend preoperative evaluation using transesophageal echocardiography, magnetic resonance imaging or angiotomography. If injury to the pulmonary vessels or atrial cavities is detected, surgery with extracorporeal circulation should be arranged in order to allow resection of the intravascular or cardiac mass, together with pulmonary resection. We recommend that care be taken in order to recognize and treat this problem in patients not receiving a preoperative diagnosis.


Keywords: Embolism; Heart arrest; Pneumonectomy.


Letters to the Editor

16 - Surgical treatment of pleural empyema in children

O tratamento cirúrgico do empiema pleural em crianças

Cristiano Feijó Andrade, Helena Teresinha Mocelin, Gilberto Bueno Fischer

J Bras Pneumol.2008;34(7):541-544

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17 - Authors' reply: "Surgical treatment of pleural empyema in children".

Resposta dos autores : "O tratamento cirúrgico do empiema pleural em crianças".

Davi Wen Wei Kang, José Ribas Milanez de Campos

J Bras Pneumol.2008;34(7):

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Year 2008 - Volume 34  - Number 8  (/August)


1 - Understanding and preventing asthma-related deaths

Entendendo e prevenindo as mortes relacionadas à asma

Rogelio Pérez-Padilla, Luis Torre-Bouscoulet

J Bras Pneumol.2008;34(8):545-

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Original Article

2 - Factors associated with mortality in patients hospitalized in Spain and Latin America for acute severe asthma in 1994, 1999, and 2004

Fatores associados à mortalidade em pacientes hospitalizados por asma aguda grave em 1994, 1999 e 2004 na Espanha e América Latina

Gustavo Javier Rodrigo, Vicente Plaza, Santiago Bardagí Forns, Miguel Perpiñá Tordera, Jorge Salas

J Bras Pneumol.2008;34(8):546-551

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate, for the first time, the characteristics of patients with acute asthma who died during hospitalization in Spain and Latin America, as well as to evaluate factors associated with asthma mortality. Methods: A retrospective review of hospital records of 3,038 patients with asthma (aged 15-69 years) admitted to nineteen tertiary care hospitals in Spain and in eight Latin-American countries in 1994, 1999, and 2004. Results: There were 25 deaths (0.8% of all hospitalized patients) during the three years studied. Although there was a tendency towards a reduction in in-hospital mortality (from 0.97% in 1994 to 0.69% in 2004), there were no significant differences in terms of year or geographic area. Intensive care unit admissions and cases of out of hospital cardiopulmonary arrest increased the mortality rates to 8.3% and 24.7%, respectively. The multivariate analysis showed that gender (female; OR = 25.5; 95% CI: 2.6-246.8), out of hospital cardiopulmonary arrest (OR = 22.5; 95% CI: 4.4-114.7), and arterial pH < 7.3 during hospitalization (OR = 1.0; 95% CI: 1.1-3.4) were strongly associated with asthma mortality. Conclusions: Our study on mortality in patients hospitalized for acute severe asthma showed that deaths occurred almost exclusively in female patients and in patients who suffered out of hospital cardiopulmonary arrest, confirming previous findings from studies conducted in developed countries.


Keywords: Asthma/mortality; Asthma/epidemiology; Hospitalization; Hospital mortality.


3 - Inspiratory muscle training and respiratory exercises in children with asthma

Treinamento muscular inspiratório e exercícios respiratórios em crianças asmáticas

Elisângela Veruska Nóbrega Crispim Leite Lima, Willy Leite Lima, Adner Nobre, Alcione Miranda dos Santos, Luciane Maria Oliveira Brito, Maria do Rosário da Silva Ramos Costa

J Bras Pneumol.2008;34(8):552-558

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of the present study was to evaluate the effects that inspiratory muscle training (IMT) and respiratory exercises have on muscle strength, peak expiratory flow (PEF) and severity variables in children with asthma. Methods: This was a randomized analytical study involving 50 children with asthma allocated to one of two groups: an IMT group, comprising 25 children submitted to IMT via an asthma education and treatment program; and a control group, comprising 25 children who were submitted only to monthly medical visits and education on asthma. The IMT was performed using a pressure threshold load of 40% of maximal inspiratory pressure (MIP). The results were evaluated using analysis of variance, the chi-square test and Fisher's exact test, values of p > 0.05 being considered significant. Results: In the comparative analysis, pre- and post-intervention values of MIP, maximal expiratory pressure (MEP) and PEF increased significantly in the IMT group: MIP from −48.32 ± 5.706 to −109.92 ± 18.041 (p < 0.0001); MEP from 50.64 ± 6.55 to 82.04 ± 17.006 (p < 0.0001); and PEF from 173.6 ± 50.817 to 312 ± 54.848 (p < 0.0001). In the control group, however, there were no significant differences between the two time points in terms of MIP or MEP, although PEF increased from 188 ± 43.97 to 208.80 ± 44.283 (p < 0.0001). There was a significant improvement in the severity variables in the IMT group (p < 0.0001). Conclusions: Programs involving IMT and respiratory exercises can increase mechanical efficiency of the respiratory muscles, as well as improving PEF and severity variables.


Keywords: Breathing exercises; Asthma/therapy; Asthma/rehabilitation.


4 - Use of a one-way flutter valve drainage system in the postoperative period following lung resection

Utilização da válvula unidirecional de tórax como sistema de drenagem no pós-operatório de ressecções pulmonares

Nelson de Araujo Vega, Hugo Alejandro Vega Ortega, Alfio José Tincani, Ivan Felizardo Contrera Toro

J Bras Pneumol.2008;34(8):559-566

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate pleural drainage using a one-way flutter valve following elective lung resection. Methods: This was a prospective study, with descriptive analysis, of 39 lung resections performed using a one-way flutter valve to achieve pleural drainage during the postoperative period. Patients less than 12 years of age were excluded, as were those submitted to pneumonectomy or emergency surgery, those who were considered lost to follow-up and those in whom water-seal drainage was used as the initial method of pleural drainage. Lung expansion, duration of the drainage, hospital stay and postoperative complications were noted. Results: A total of 36 patients were included and analyzed in this study. The mean duration of pleural drainage was 3.0 ± 1.6 days. At 30 days after the surgical procedure, chest X-ray results were considered normal for 34 patients (95.2%). Postoperative complications occurred in 8 patients (22.4%) and were related to the drainage system in 3 (8.4%) of those. Conclusions: The use of a one-way flutter valve following elective lung resection was effective, was well tolerated and presented a low rate of complications.


Keywords: Drainage; Postoperative complications; Thoracic surgery.


5 - Systemic effects of nocturnal hypoxemia in patients with chronic obstructive pulmonary disease without obstructive sleep apnea syndrome

Efeitos sistêmicos da hipoxemia noturna em pacientes com doença pulmonar obstrutiva crônica sem síndrome da apnéia obstrutiva do sono

Paulo de Tarso Guerrero Mueller, Marcílio Delmondes Gomes, Carlos Alberto de Assis Viegas, José Alberto Neder

J Bras Pneumol.2008;34(8):567-574

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the effects of nocturnal hypoxemia in patients with chronic obstructive pulmonary disease without obstructive sleep apnea syndrome. Methods: We studied 21 patients-10 desaturators and 11 nondesaturators-submitted to arterial blood gas analysis, polysomnography, spirometry, cardiopulmonary exercise testing (cycle ergometer), and hand-grip dynamometry, as well as measurements of maximal inspiratory pressure, maximal expiratory pressure, and C-reactive protein (CRP) levels. Patients with arterial oxygen tension > 60 mmHg were included; those with an apnea-hypopnea index > 5 events/hour of sleep were excluded. Maximal oxygen uptake, maximal power, systolic blood pressure, diastolic blood pressure (DBP), and maximal heart rate were measured during exercise in order to detect hemodynamic alterations. Patients presenting CRP levels above 3 mg/L were considered CRP-positive. Results: Minimal peripheral oxygen saturation during sleep was significantly higher among nondesaturators (p = 0.03). More desaturators presented CRP > 3 mg/L (p < 0.05). No differences were observed in terms of any variables, However, mean peripheral oxygen saturation during sleep correlated with DBP and maximal inspiratory pressure (p < 0.001 and p = 0.001, respectively). Conclusions: Although nocturnal hypoxemia does not reduce exercise capacity or hand-grip strength in patients with mild/moderate COPD, its effect on maximal exercise DBP seems to depend on the degree of hypoxemia. In addition, there is a positive relationship between maximal inspiratory pressure and mean peripheral oxygen saturation during sleep, as well as evidence of pronounced inflammatory activation in patients with nocturnal hypoxemia.


Keywords: Pulmonary disease, chronic obstructive; Exercise test; Anoxia; Respiratory function tests.


6 - Analysis of hospitalizations for respiratory diseases in Tangará da Serra, Brazil

Análise das internações por doenças respiratórias em Tangará da Serra - Amazônia Brasileira

Antonia Maria Rosa, Eliane Ignotti, Sandra de Souza Hacon, Hermano Albuquerque de Castro

J Bras Pneumol.2008;34(8):575-582

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze hospitalizations for respiratory diseases among children under 15 years of age in an area with high levels of environmental pollution. Methods: A cross-sectional study of hospitalizations due to respiratory diseases of patients residing in the city of Tangará da Serra, located in the state of Mato Grosso (Brazilian Amazon region), from 2000 to 2005. Data on hospital admissions were obtained from the Brazilian Unified Health Care System and from Brazilian Institute of Geography and Statistics population estimates. Results: In 2005, the rate of hospitalization for respiratory diseases among children under 15 years of age in the microregion of Tangará da Serra was 70.1/1,000 children. Between 2000 and 2005, there were 12,777 such admissions, of which 8,142 (63.7%) were for respiratory diseases. During the dry season (May to October), the rate of admissions for respiratory diseases was 10% higher than during the rainy season (November to April). The principal causes of admission included pneumonia (90.7%) and respiratory insufficiency (8.5%). Admissions of children under 5 years of age for pneumonia were 4 times the expected number for the city. Children under 12 months of age were the most frequently hospitalized, with an average increase of 32.4 admissions per 1,000 children per year. Conclusions: Tangará da Serra presented a high number of pediatric admissions for respiratory diseases. Therefore, it is logical to consider it a priority area for investigation and monitoring of the environmental risk factors for such diseases.


Keywords: Respiratory tract diseases; Pneumonia; Hospitalization; Climate; Air pollution/Brazil.


7 - Ischemic preconditioning by selective occlusion of the pulmonary artery in rats

Pré-condicionamento isquêmico por oclusão seletiva da artéria pulmonar em ratos

Eduardo Sperb Pilla, Giovani Schirmer Vendrame, Pablo Gerardo Sánchez, Gustavo Grun, Eduardo Fontena, Luiz Alberto Forgiarini Júnior, Norma Anair Possa Marroni, Cristiano Feijó Andrade, Paulo Francisco Guerreiro Cardoso

J Bras Pneumol.2008;34(8):583-589

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Objective: To evaluate the effect of lung ischemic preconditioning (IPC) on normothermic ischemia/reperfusion (I/R) injury in a rat model, quantifying the production of reactive oxygen species. Methods: Forty-seven male Wistar rats were randomized into four groups: control, sham, I/R and IPC. Control group animals were anesthetized and killed by decapitation, after which pneumonectomy was performed and the left lungs were stored in liquid nitrogen. Sham, IPC and I/R group rats were anesthetized, tracheostomized, ventilated, anticoagulated and submitted to left thoracotomy with dissection of the left pulmonary artery for clamping. Sham group rats underwent dissection of the left pulmonary artery, I/R group rats underwent 30 min of total hilar clamping, and IPC group rats underwent 5-min clamping of the left pulmonary artery followed by 30 min of total hilar clamping. Lungs were reperfused for 90 min and ventilated with the same parameters, with additional positive end-expiratory pressure of 1 cmH2O. Hemodynamic and blood gas values were obtained prior to thoracotomy, prior to total hilar clamping, after 30 min of reperfusion and after 90 min of reperfusion. Lipid peroxidation was determined by measuring levels of thiobarbituric acid reactive substances. Results: There were no significant differences among the groups in terms of the levels of thiobarbituric acid reactive substances. Nor were there any significant differences among the sham, I/R and IPC groups in terms of arterial oxygen tension, arterial carbon dioxide tension or hemodynamic values. Conclusions: In an in situ I/R rat model, 5-min IPC of the left pulmonary artery does not attenuate I/R injury.


Keywords: Ischemia; Reperfusion; Organ preservation; Reactive oxygen species.


8 - Descriptive study of the frequency of nontuberculous mycobacteria in the Baixada Santista region of the state of São Paulo, Brazil

Estudo descritivo da freqüência de micobactérias não tuberculosas na Baixada Santista

Liliana Aparecida Zamarioli, Andréa Gobetti Vieira Coelho, Clemira Martins Pereira, Ana Carolina Chiou Nascimento, Suely Yoko Mizuka Ueki, Erica Chimara

J Bras Pneumol.2008;34(8):590-594

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Objective: The present study aims at describing the frequency of nontuberculous mycobacteria (NTM) species identified through laboratory testing of samples collected from non-sterile sites (sputum), as well as its frequency in HIV-infected and non-HIV-infected individuals in the Baixada Santista region of the state of São Paulo, Brazil, in the period from 2000 to 2005. Methods: Retrospective analysis of sputum smear microscopy results and culture was conducted based on the records on file at the Instituto Adolfo Lutz-Santos, the regional tuberculosis laboratory. Results: We analyzed 194 NTM strains isolated from 125 individuals, of whom 73 (58.4%) were HIV-negative and 52 (41.6%) were HIV-positive. Thirteen different species were identified: Mycobacterium kansasii; M. avium complex; M. fortuitum; M. peregrinum; M. gordonae; M. terrae; M. nonchromogenicum; M. intracellulare; M. flavescens; M. bohemicum; M. chelonae; M. shimoidei; and M. lentiflavum. In 19.2% of the cases, the bacteriological diagnosis was confirmed by isolation of the same species in at least two consecutive samples. Conclusions: Our results show the importance of including systematic identification of NTM in the laboratory routine, and that its integration into the clinical routine could improve the characterization of the disease, thereby informing the planning of effective control measures in specific populations, such as individuals presenting tuberculosis/HIV co-infection.


Keywords: Mycobacteria, atypical; Laboratory techniques and procedures; HIV; Tuberculosis.


9 - Lung cancer: histology, staging, treatment and survival

Câncer de pulmão: histologia, estádio, tratamento e sobrevida

Fabiola Trocoli Novaes, Daniele Cristina Cataneo, Raul Lopes Ruiz Junior, Júlio Defaveri, Odair Carlito Michelin, Antonio José Maria Cataneo

J Bras Pneumol.2008;34(8):595-600

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Objective: To analyze principal histological types of lung cancer, as well as the staging, treatment and survival of lung cancer patients. Methods: This was a retrospective study based on the analysis of medical charts of patients treated at the Botucatu School of Medicine Hospital das Clínicas over a six-year period. Results: From January of 2000 to January of 2006, 240 patients with lung cancer, most (64%) of whom were male, were treated. The most common histological type was squamous cell carcinoma (37.5%), followed by adenocarcinoma (30%), neuroendocrine carcinoma (19.6%) and large cell carcinoma (6.6%). Only 131 patients (54.6%) were treated. Of those, 52 patients (39.7%) received only chemotherapy, 32 (24.4%) were treated with chemotherapy combined with radiotherapy, and 47 (35.9%) were submitted to surgery alone or surgery accompanied by chemotherapy, with or without radiotherapy. Only 27 patients (20.6%) were submitted to surgery alone. Concerning staging, 34.4% presented stage IV at the time of diagnosis, 20.6% presented stage IIIB, 16.8% presented stage IIIA, and the remaining 28.2% were classified as stage I or II. Five-year survival was 65% for those in stage I and 25% for those in the remaining stages. Conclusions: Of the various histological types, the most common was squamous cell carcinoma and the least common was large cell carcinoma. Most cases presented advanced stages at the moment of diagnosis, and less than 30% of the cases presented early stages. This accounts for the low survival rate and the small number of patients submitted to surgical treatment alone, the majority being submitted to chemotherapy alone.


Keywords: Carcinoma, bronchogenic; Lung neoplasms/histology; Lung neoplasms/drug therapy; Lung neoplasms/radiotherapy; Surgery; Survival.


10 - Tuberculosis-related mortality in the state of Espírito Santo, Brazil, 1985-2004

Mortalidade específica por tuberculose no estado do Espírito Santo, no período de 1985 a 2004

Cláudia Maria Marques Moreira, Eliana Zandonade, Reynaldo Dietze, Ethel Leonor Noia Maciel

J Bras Pneumol.2008;34(8):601-606

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Objective: The purpose of this study was to describe tuberculosis-related mortality in Espírito Santo, Brazil, evaluating its tendencies in relation to clinical presentation, gender and age bracket. Methods: We conducted a retrospective, descriptive study based on secondary data. For the 1985-2004 period, we investigated all deaths of residents of Espírito Santo in which tuberculosis was given as the underlying cause, as reported in the Brazilian National Mortality Database. Results: The adjusted mortality rates for all forms of tuberculosis paralleled the overall mortality rates in the state, decreasing from 5.6/100,000 inhabitants in 1985 to 2.0/100,000 inhabitants in 2004. Pulmonary tuberculosis was the predominant form of the disease (89.7% of tuberculosis-related deaths) throughout the period studied, and the male/ female mortality rate ratio ranged from 1.1 in 1998 to 3.19 in 2004. Conclusions: We observed a decrease in the mortality rates in all age brackets. Predominance of the pulmonary form, male gender and advanced age was similar to that of overall tuberculosis-related mortality in Brazil.


Keywords: Tuberculosis/epidemiology; Mortality; Information systems.


11 - Epidemiological profile of tuberculosis cases reported among health care workers at the University Hospital in Vitoria, Brazil

Perfil epidemiológico dos casos notificados de tuberculose entre os profissionais de saúde no Hospital Universitário em Vitória (ES) Brasil

Thiago Nascimento do Prado, Heleticia Scabelo Galavote, Ana Paula Brioshi, Thamy Lacerda, Geisa Fregona, Valdério do Valle Detoni, Rita de Cássia Duarte Lima, Reynaldo Dietze, Ethel Leonor Noia Maciel

J Bras Pneumol.2008;34(8):607-613

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Objective: To describe the epidemiological profile of tuberculosis cases reported among health care workers in the Tuberculosis Control Program of the Cassiano Antonio of Moraes University Hospital in Vitoria, Brazil. Methods: A retrospective descriptive study of secondary data was conducted between 2002 and 2006. Results: Twenty-five cases of health care workers with tuberculosis were reported: 8 in nursing technicians (32%); 4 in doctors (16%); 3 in nurses (12%); 2 in radiology technicians (8%) and 8 in professionals from other categories (32%). Of those 25 health care workers, 14 (56%) were male and 11 (44%) were female. The incidence of the disease was highest among those from 35 to 39 years of age. The predominant clinical presentation was extrapulmonary (12 cases, 48%), followed by pulmonary (11 cases, 44%) and a combination of the two (2 cases, 8%). Regarding comorbidities, AIDS, alcoholism and smoking, respectively, were present in 33.3% of the study population. Outcomes were as follows: 22 cases of cure (88%); 2 transfers (8%); and 1 death (4%). The proportion of health care workers diagnosed with tuberculosis in the period studied was 2.53%. Conclusions: The results show the need for heath care workers who work in the tuberculosis control program to fill out the field "professional occupation" on the tuberculosis case registry database reporting forms. In addition, this situation draws attention to the need to implement an occupational tuberculosis control program.


Keywords: Health profile; Tuberculosis/epidemiology; Health personnel; Prevalence.


Review Article

12 - Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Métodos empregados na verificação da adesão à corticoterapia inalatória em crianças e adolescentes: taxas encontradas e suas implicações para a prática clínica

Nulma Souto Jentzsch, Paulo Augusto Moreira Camargos

J Bras Pneumol.2008;34(8):614-621

Abstract PDF PT PDF EN Portuguese Text

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis. Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil. The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.


Keywords: Patient compliance; Asthma/therapy; Asthma/prevention & control.


Case Report

13 - Adult respiratory distress syndrome due to fat embolism in the postoperative period following liposuction and fat grafting

Síndrome da angústia respiratória do adulto por embolia gordurosa no período pós-operatório de lipoaspiração e lipoenxertia

André Nathan Costa, Daniel Melo Mendes, Carlos Toufen, Gino Arrunátegui, Pedro Caruso, Carlos Roberto Ribeiro de Carvalho

J Bras Pneumol.2008;34(8):622-625

Abstract PDF PT PDF EN Portuguese Text

Fat embolism is defined as mechanical blockage of the vascular lumen by circulating fat globules. Although it primarily affects the lungs, it can also affect the central nervous system, retina, and skin. Fat embolism syndrome is a dysfunction of these organs caused by fat emboli. The most common causes of fat embolism and fat embolism syndrome are long bone fractures, although there are reports of its occurrence after cosmetic procedures. The diagnosis is made clinically, and treatment is still restricted to support measures. We report the case of a female patient who developed adult respiratory distress syndrome due to fat embolism in the postoperative period following liposuction and fat grafting. In this case, the patient responded well to alveolar recruitment maneuvers and protective mechanical ventilation. In addition, we present an epidemiological and pathophysiological analysis of fat embolism syndrome after cosmetic procedures.


Keywords: Respiratory distress syndrome, adult; Embolism, fat; Lipectomy.


14 - Castleman's disease accompanied by pleural effusion

Doença de Castleman associada a derrame pleural

Valéria Góes Ferreira Pinheiro, Geórgea Hermógenes Fernandes, Lia Cavalcante Cezar, Newton de Albuquerque Alves, Dalgimar Beserra de Menezes

J Bras Pneumol.2008;34(8):626-630

Abstract PDF PT PDF EN Portuguese Text

Castleman's disease is a rare disorder of the lymphoid tissue. We report the case of a female patient with bilateral otosclerosis, no respiratory symptoms, and pleural effusion discovered as an incidental finding on a chest X-ray. Computed tomography of the chest revealed a mediastinal mass. The biopsy findings demonstrated that it was a plasmacytic variant of Castleman's disease. The patient underwent mediastinal mass resection. This resulted in near-total resolution of the effusion, which remained as a small loculation within the left pleural space.


Keywords: Giant lymph node hyperplasia; Pleural effusion; Case reports.


15 - Mediastinal teratoma with malignant degeneration

Teratoma de mediastino com degeneração maligna

Fabiano Alves Squeff, Eduardo Salvador Gerace, Roberto Saad Júnior, Márcio Botter, Roberto Gonçalves, Juliana Fracalossi Paes

J Bras Pneumol.2008;34(8):631-634

Abstract PDF PT PDF EN Portuguese Text

Here, we report the case of a patient with a slowly-progressing anterior mediastinal teratoma submitted to surgical resection. The anatomopathological examination of the sample revealed malignant degeneration to carcinoid tumor. Such evolution is very rare, and we have found only three related studies in the literature. We describe the clinicopathological features of the tumor and discuss the treatment administered. The evolution was satisfactory, and the patient was submitted to oncological treatment.


Keywords: Mediastinal neoplasms; Teratoma; Carcinoid tumor; Mediastinum/surgery.


Letters to the Editor

16 - The fortitude of Vicente Forte and his living art dedicated to medicine in Brazil

O sertão de Vicente Forte e sua vivente obra dedicada à medicina brasileira

Geraldo Roger Normando Júnior

J Bras Pneumol.2008;34(8):635-636

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Year 2008 - Volume 34  - Number 9  (/September)


1 - Wood stoves: a source of enjoyment and a potential hazard

Fogão a lenha: um passatempo agradável, uma rotina perigosa

Irma de Godoy

J Bras Pneumol.2008;34(9):637-638

PDF PT PDF EN Portuguese Text

Original Article

2 - Reduction in the number of asthma-related hospital admissions after the implementation of a multidisciplinary asthma control program in the city of Londrina, Brazil

Redução do número de internações hospitalares por asma após a implantação de programa multiprofissional de controle da asma na cidade de Londrina

Alcindo Cerci Neto, Olavo Franco Ferreira Filho, Tatiara Bueno, Maria Amélia Talhari

J Bras Pneumol.2008;34(9):639-645

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the relationship between the reduction in the number of asthma-related hospital admissions and the changes occurring after the intervention performed in the health care system of the city of Londrina, Brazil. Methods: In 2003, an intervention was performed in the local health care system (Family Health Clinics). The steps adopted were as follows: development of a protocol based on the III Brazilian Consensus on Asthma Management; access to free inhaled corticosteroids for patients; training of health professionals; and implementation of educational measures, especially for the community. The authorizations for hospital admissions of patients diagnosed with asthma alone between 2002 and 2005 in the city of Londrina were analyzed. Results: The mean age was 14.3 ± 0.5 years, without gender predominance. The number of hospital admissions fell more markedly in 2005 than in the previous years studied. This decline was more pronounced at the Family Health Clinics where professional training occurred earlier. The post-intervention (2004-2005) rate of asthma-related hospital admissions (120/100,000 inhabitants) was significantly lower than the pre-intervention (2002-2003) rate (178/100,000 inhabitants; p < 0.01). Conclusions: The admission curve showed a tendency toward a reduction after 2003, and, aside from the intervention performed, no other factors that would explain the results obtained were identified. The rate at which the number of hospital admissions decreased was in direct proportion to the length of time elapsed since the intervention (greater decreases over time). We conclude that the intervention performed in the local health care system was responsible for the data presented.


Keywords: Asthma; Hospitalization; Public health.


3 - Clinical phenotypes of severe asthma

Fenótipos clínicos de asma grave

Roseliane de Souza Araújo Alves, Flávia de Almeida Filardo Vianna, Carlos Alberto de Castro Pereira

J Bras Pneumol.2008;34(9):646-653

Abstract PDF PT PDF EN Portuguese Text

Objective: To characterize clinical phenotypes of severe asthma. Methods: A total of 111 patients were retrospectively evaluated at a specialized outpatient clinic. A systematic protocol for patient evaluation and follow-up was applied. Treatment compliance and control of the disease at the end of follow-up were defined by clinical and functional data. Patients who did not meet asthma control criteria after six months despite compliance with treatment and correct use of medication were characterized as treatment-resistant. Phenotypes were determined by factorial analysis and compared using various tests. Results: At the end of follow-up, 88 patients were considered treatment compliant and 23 were considered noncompliant. Factorial analysis of the compliant patients identified four phenotypes: phenotype 1 (28 patients) comprised patients who were treatment-resistant, more often presenting nocturnal symptoms and exacerbations, as well as more often using rescue bronchodilators; phenotype 2 (48 patients) comprised patients with persistent airflow limitation, lower ratios of forced expiratory volume in one second/forced vital capacity at baseline, more advanced age and longer duration of symptoms; phenotype 3 (42 patients) comprised patients with allergic rhinosinusitis who were nonsmokers and presented predominantly reversible airflow obstruction; and phenotype 4 (15 patients) comprised cases with a history of aspirin intolerance to acetylsalicylic acid associated with near-fatal asthma. Conclusions: A significant number of patients with severe asthma are noncompliant with treatment. Although many patients with severe asthma have persistent airflow obstruction, the most relevant clinical phenotype comprises patients who are resistant to the typical treatment.


Keywords: Asthma; Asthma/prevention & control; Asthma/treatment.


4 - Aggressive treatment using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy

Tratamento agressivo com retalho muscular e/ou omentopexia nas infecções do esterno e mediastino anterior em pós-operatório de esternotomia

Alexandre Heitor Moreschi, Amarilio Vieira de Macedo Neto, Gilberto Venossi Barbosa, Mauricio Guidi Saueressig

J Bras Pneumol.2008;34(9):654-660

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of an aggressive treatment approach using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy on mortality, as compared to that of a conservative treatment approach. Methods: Data were collected prior to, during and after the surgical procedures. Group A (n = 44) included patients submitted to conservative treatment- debridement together with resuture or continuous irrigation with polyvinylpyrrolidone-iodine solutions, or even with second-intention wound healing (retrospective data). Group B (n = 9) included patients in whom infection was not resolved with conservative treatment, and who therefore underwent aggressive treatment (intermediate phase). Group C (n = 28) included patients primarily submitted to aggressive treatment (prospective data). Results: Postoperative hospital stays were shorter in the patients submitted to aggressive treatment (p < 0.046). There were 7 deaths in group A, 1 in group B, and 2 in group C. However, the classical level of significance of α = 0.05 was not reached. Conclusion: Aggressive treatment also proved to be effective when the infection was not resolved with conservative treatment. These findings demonstrate that the proposed treatment provides excellent results.


Keywords: Surgical flaps; Osteomyelitis; Mediastinitis; Thoracic surgery.


5 - Surgical treatment of 60 patients with pulmonary malformations: What have we learned?

Tratamento operatório de 60 pacientes com malformações pulmonares: O que aprendemos?

Altair da Silva Costa Júnior, João Aléssio Juliano Perfeito, Vicente Forte

J Bras Pneumol.2008;34(9):661-666

Abstract PDF PT PDF EN Portuguese Text

Objective: To retrospectively analyze the medical charts of patients with pulmonary malformations submitted to surgical treatment and to investigate the clinical evolution prior to the definitive diagnosis. Methods: We analyzed the medical charts of patients with pulmonary malformations operated on at the São Paulo Hospital-Federal University of São Paulo/Paulista School of Medicine-from 1969 to 2004. Each medical chart was analyzed as to the following aspects: clinical profile; diagnosis; previous treatment; surgical treatment; and nosocomial complications. The inclusion criteria were having received a diagnosis of pulmonary malformation, having undergone pulmonary resection, and chart data being complete. Results: The analysis of the medical charts revealed that 60 patients diagnosed with pulmonary malformations-27 cases of bronchogenic cyst, 14 cases of congenital lobar emphysema, 10 cases of pulmonary sequestration, and 9 cases of cystic adenomatoid malformation-underwent surgery. Ages ranged from 4 days to 62 years (mean, 17.9 years). There was a predominance of males (55%). Ninety-two percent of the patients presented symptoms (mean duration, 15.37 months). Of the 60 patients undergoing surgery, 27 (45%) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23%, and mortality was 3.3%. Surgical times ranged from 1 to 8 h (mean, 3.2 h). Conclusions: Misdiagnosis or delayed diagnosis of pulmonary malformations resulted in unnecessary treatments and hospitalizations, as well as in frequent, recurrent infectious complications. We believe that the definitive treatment is surgery, which is curative and has low morbidity and mortality rates.


Keywords: Bronchogenic cyst; Bronchopulmonary sequestration; Cystic adenomatoid malformation of lung, congenital; Respiratory tract infections; Thoracic surgery.


6 - Comparative study of respiratory symptoms and lung function alterations in patients with chronic obstructive pulmonary disease related to the exposure to wood and tobacco smoke

Estudo comparativo de sintomas respiratórios e função pulmonar em pacientes com doença pulmonar obstrutiva crônica relacionada à exposição à fumaça de lenha e de tabaco

Maria Auxiliadora Carmo Moreira, Maria Rosedália de Moraes, Daniela Graner Schwartz Tannus Silva, Thayssa Faria Pinheiro, Huber Martins Vasconcelos Júnior, Lanucy Freita de Lima Maia, Daine Vargas do Couto

J Bras Pneumol.2008;34(9):661-666

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe and analyze clinical symptoms and spirometric alterations of patients with chronic obstructive pulmonary disease (COPD) and history of exposure to wood and tobacco smoke. Methods: We retrospectively evaluated data related to 170 patients distributed into 3 groups: 34 exposed only to wood smoke, 59 patients exposed only to tobacco smoke and 77 patients exposed to both. Results: The groups did not differ significantly in terms of age (p = 0.225) or degree of exposure, considering each type of exposure in isolation or in combination (p = 0.164 and p = 0.220, respectively). Females predominated in the group exposed to wood smoke. There were no differences among the groups regarding respiratory symptoms (p > 0.05), and moderate dyspnea predominated in the three groups (p = 0.141). The group exposed to wood smoke presented higher percentages of forced expiratory volume in one second/forced vital capacity ratio and of forced expiratory volume in one second (p < 0.05). Positive results on bronchodilator testing occurred more frequently in the group exposed to tobacco smoke. The percentage of severe and extremely severe obstruction was significantly higher in the group exposed to tobacco smoke (44.1%) than in that exposed to wood smoke (11.8%; p = 0.006). Conclusions: Respiratory symptoms and pulmonary function alterations consistent with COPD were observed in the groups of patients exposed to wood smoke. However, those alterations were not as significant as the alterations observed in the groups exposed to tobacco smoke. This study emphasizes the importance of prospective studies in evaluating the risk of wood-smoke-related COPD in Brazil, as well as the need for preventive measures in this area.


Keywords: Pulmonary disease, chronic obstructive; Smoking; Air pollution, indoor; Smoke.


7 - Comparison of spirometric changes in the response to bronchodilators of patients with asthma or chronic obstructive pulmonary disease

Comparação da variação de resposta ao broncodilatador através da espirometria em portadores de asma ou doença pulmonar obstrutiva crônica

Isabella Correia Silvestri, Carlos Alberto de Castro Pereira, Sílvia Carla Sousa Rodrigues

J Bras Pneumol.2008;34(9):675-682

Abstract PDF PT PDF EN Portuguese Text

Objective: Making the differential diagnosis between asthma and chronic obstructive pulmonary disease (COPD) based on the response to inhaled bronchodilators by means of spirometry is controversial.The objective of this study was to identify the most useful spirometric variables in order to distinguish between asthma and COPD. Methods: Retrospective study conducted from April of 2004 to January of 2006, comparing the spirometric parameters of 103 nonsmoking patients with asthma to those of 108 patients with COPD who were smokers for more than 10 pack-years. All of the patients included in the study were older than 40 and presented stable disease at the time of the test. Results: Initial forced expiratory volume in one second (FEV1) was the same in the two groups (pre-bronchodilator FEV1 = 51%). However, patients with COPD were older (66 ± 9 years vs. 59 ± 11 years, p < 0.001) and more frequently male (73% vs. 27%, p < 0,001).After the use of the bronchodilator, the median absolute difference in FEV1 was 0.25 L (range, −0.09 to 1.13 L) in patients with asthma and 0.09 L (range, −0.1 to 0.73 L) in those with COPD (p < 0.001).The highest sensitivity (55%), specificity (91%) and likelihood ratio (6.1) for asthma diagnosis was obtained when the percentage increase in postbronchodilator FEV1 in relation to the predicted FEV1 (Δ%predFEV1) was equal to or greater than 10%.Isolated significant increases in forced vital capacity were more common in patients with COPD. Conclusions: In patients over the age of 40 and presenting obstructive lung disease, a Δ%predFEV1 ≥ 10% is the best spirometric parameter to distinguish asthma from COPD.


Keywords: Spirometry; Respiratory function tests; Lung diseases, obstructive.


8 - Community-acquired staphylococcal pneumonia

Pneumonia estafilocócica adquirida na comunidade

José Wellington Alves dos Santos, Douglas Zaione Nascimento, Vinicius André Guerra, Vanessa da Silva Rigo, Gustavo Trindade Michel, Tiago Chagas Dalcin

J Bras Pneumol.2008;34(9):683-689

Abstract PDF PT PDF EN Portuguese Text

Objective: Staphylococcal pneumonia typically presents high rates of morbidity and mortality. It typically occurs in cases of influenza (airborne transmission) or during episodes of bacteremia (blood-borne transmission). Methods: A retrospective and descriptive study was conducted in patients admitted to our hospital between January of 1992 and December of 2003. All of he patients included had been diagnosed with community-acquired pneumonia caused by Staphylococcus aureus. All were older than 14 years of age, and none were intravenous drug users. Results: Community-acquired pneumonia was identified in 332 cases, of which 24 (7.3%) were identified as cases of staphylococcal pneumonia. Age ranged from 14 to 89 years. Fifteen patients were male, and nine were female. Twelve patients met the criteria for severe pneumonia. Chest X-rays showed unilateral consolidation in 14 cases, bilateral consolidation in 10, pleural effusion in 15, rapid radiological progression of pulmonary lesions in 14, cavitation in 6 and pneumothorax in 1. Most of the patients presented comorbidities, of which diabetes mellitus was the most common. Twelve patients presented complications such as empyema and septic shock. Four patients died, translating to a mortality rate of 16.6% in our sample. Conclusions: The clinical presentation of pneumonia caused by S. aureus is similar to that of pneumonia caused by other etiological agents. Radiological findings, epidemiological data and risk factors provide important clues to the diagnosis. These factors are important for clinical suspicion, since S. aureus is not typically addressed in empirical treatment.


Keywords: Staphylococcal pneumonia; Staphylococcal infections; Community-acquired infections.


9 - Impact of heated humidification with automatic positive airway pressure in obstructive sleep apnea therapy

Impacto da umidificação aquecida com pressão positiva automática em vias aéreas na terapia do síndroma de apneia obstrutiva do sono

Sara Moreira da Silva Trindade Salgado, José Pedro Correia Fernandes Boléo-Tomé, Cristina Maria Sardinha Canhão, Ana Rita Tavares Dias, Joana Isaac Teixeira, Paula Maria Gonçalves Pinto, Maria Cristina de Brito Eusébio Bárbara Prista Caetano

J Bras Pneumol.2008;34(9):690-694

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the impact that heated humidification instituted in the beginning of automatic positive airway pressure (APAP) therapy has on compliance with and the side effects of the treatment. Methods: Thirty-nine treatment-naïve patients with obstructive sleep apnea were randomized into two groups to receive APAP using one of two modalities: with heated humidification (APAPwith group); and without heated humidification (APAPw/o group).Patients were evaluated at 7 and 30 days after APAP initiation. The following parameters were analyzed: compliance with treatment (mean number of hours/night); side effects (dry nose or mouth, nasal obstruction and rhinorrhea); daytime sleepiness (Epworth sleepiness scale score) and subjective comfort (visual analog scale score). Patients were also evaluated in terms of residual apnea-hypopnea index (AHI), as well as mean pressures and leaks registered in the ventilators. Results: There were no differences between the two groups in terms of mean age (APAPwith: 57.4 ± 9.2; APAPw/o: 56.5 ± 10.7 years), AHI (APAPwith: 28.1 ± 14.0; APAPw/o: 28.8 ± 20.5 events/hour of sleep), baseline Epworth score (APAPwith: 11.2 ± 5.8; APAPw/o: 11.9 ± 6.3) and initial nasal symptoms. Compliance was similar in both groups (APAPwith: 5.3 ± 2.4; APAPw/o: 5.2 ± 2.3 h/night). There were no differences in any of the other parameters analyzed. Conclusions: The introduction of heated humidification at the beginning of APAP therapy provided no advantage in terms of treatment compliance or side effects of treatment.


Keywords: Humidity; Positive-pressure respiration/adverse effects; Patient compliance.


10 - Profile of smokers seeking a smoking cessation program

Perfil dos fumantes que procuram um centro de cessação de tabagismo

Sergio Ricardo Santos, Maria Stela Gonçalves, Fernando Sergio Studart Leitão Filho, José Roberto Jardim

J Bras Pneumol.2008;34(9):695-701

Abstract PDF PT PDF EN Portuguese Text

Objective: To define the profile of smokers who seek professional assistance through a smoking cessation program and to compare smoker profiles among males, females and elderly people. Methods: Two-hundred and three smokers were prospectively evaluated. The participants completed questionnaires related to smoking history, history of psychiatric disorders, depression, anxiety and nicotine dependence as well as a general self-report questionnaire. Results: In this sample, 58.6% of the individuals were female (119). The mean age was 45.3 ± 12.0 years, with no statistically significant difference between genders (p = 0.391). The majority of the individuals in the sample (84.2%) presented socioeconomic class C or above. Sixty-three percent had at least a high school education. Depression was more often referred to by women, and the difference between genders was borderline significant (p = 0.069). However, when depression was evaluated using the Beck Depression Inventory, there was no statistically significant difference between genders and between elderly and nonelderly people. Conclusions: In the profile of the smokers who sought assistance, we identified aspects (such as being female and having been diagnosed with depression) that are known predictors of treatment failure. This shows the importance of carrying out a complete pre-evaluation of the profile of a smoker who seeks a smoking cessation program. Thus, procedures can be adopted prior to and during the treatment of the smoker, with the objective of increasing treatment success rates.


Keywords: Anxiety; Depression; Smoking.


Brief Communication

11 - Assessing the impact that external factors have on respiratory mechanics assessed using a specific photogrammetric model

Impacto de fatores externos sobre a mecânica respiratória avaliada por um modelo fotogramétrico específico: biofotogrametria

Denise da Vinha Ricieri, Nelson Augusto Rosário Filho

J Bras Pneumol.2008;34(9):702-706

Abstract PDF PT PDF EN Portuguese Text

This is a report on a methodological adaptation of the photogrammetric technique, which is used in other medical specialties, for use in analyzing respiratory movements. Photogrammetry and a model of photogrammetry designated biofotogrametria para análise da mecânica respiratória (BAMER, photogrammetric analysis of respiratory mechanics) were tested under previously described pathophysiological conditions: post-exercise dynamic hyperinflation using positive end-expiratory pressure. The BAMER model identified an increase in the thoraco-abdominal area following exercise using positive end-expiratory pressure. These results are comparable to those obtained with more robust systems of respiratory kinematics. The use of photogrammetry has value in many areas, since it produces quantitative data, being particularly relevant in pediatrics, in which monitoring resources are scarce.


Keywords: Biomechanics; Photogrammetry; Respiratory mechanics; Thoracic wall.


Review Article

12 - Oral hygiene with chlorhexidine in preventing pneumonia associated with mechanical ventilation

Higiene bucal com clorexidina na prevenção de pneumonia associada à ventilação mecânica

Carolina Contador Beraldo, Denise de Andrade

J Bras Pneumol.2008;34(9):707-714

Abstract PDF PT PDF EN Portuguese Text

Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs), and oral antiseptic is used as a preventive measure. We reviewed meta-analyses and randomized clinical trials indexed in the Medical Literature Analysis and Retrieval System and Cumulative Index to Nursing and Allied Health Literature databases regarding the topical use of chlorhexidine in the prevention of VAP. Eight publications were analyzed. In seven (87.5%) chlorhexidine diminished the colonization of the oropharynx, and in four (50%) there was a reduction of VAP. Chlorhexidine seems to reduce colonization, thus reducing the incidence of VAP.


Keywords: Pneumonia, ventilator-associated; Oral hygiene; Chlorhexidine.


Special Article

13 - High-resolution computed tomography patterns of diffuse interstitial lung disease with clinical and pathological correlation

Padrões tomográficos das doenças intersticiais pulmonares difusas com correlação clínica e patológica

Brett Elicker, Carlos Alberto de Castro Pereira, Richard Webb, Kevin O. Leslie

J Bras Pneumol.2008;34(9):715-744

Abstract PDF PT PDF EN Portuguese Text

High-resolution computed tomography (HRCT) is the radiological imaging technique best suited to revealing changes in lung structure. Various HRCT findings, taken together, can represent typical patterns. These patterns, in conjunction with the anatomical distribution of findings and with clinical data, can narrow the differential diagnosis of diffuse interstitial lung disease and, in many cases, indicate the correct diagnosis with a high degree of accuracy. The most common HRCT patterns seen in cases of diffuse interstitial lung diseases are the nodular pattern, linear/reticular opacities, cystic lesions, ground-glass opacities and consolidations. This article reviews the correlations between HRCT patterns and pathologic findings, summarizing the most common causes, as well as detailing the methods of investigation employed in order to diagnose the most common types of chronic diffuse lung disease.


Keywords: Lung diseases, interstitial/pathology; Tomography, X-Ray computed; Diagnostic techniques, respiratory system.


Case Report

14 - Cutaneous leukocytoclastic vasculitis accompanied by pulmonary tuberculosis

Vasculite leucocitoclástica cutânea associada à tuberculose pulmonar

Maurício Carvalho, Robson Luiz Dominoni, Denise Senchechen, Artur Furlaneto Fernandes, Ismael Paulo Burigo, Eloisa Doubrawa

J Bras Pneumol.2008;34(9):745-748

Abstract PDF PT PDF EN Portuguese Text

We report the case of a 50-year-old male with a rare combination: pulmonary tuberculosis and cutaneous leukocytoclastic vasculitis. The patient sought emergency treatment presenting with headache, arthralgia, cutaneous rash, and weight loss (4 kg) in the last 20 days. A chest X-ray, performed in a previous outpatient visit, revealed cavitation in the middle and upper lobes of the right lung, as confirmed by computed tomography. Sputum smear microscopy (Ziehl-Neelsen staining) was positive in three consecutive samples, and the result of the skin lesion biopsy was consistent with cutaneous leukocytoclastic vasculitis. The patient was therefore diagnosed with cutaneous leukocytoclastic vasculitis accompanied by pulmonary tuberculosis. Our objective was to describe a combination rarely reported in the medical literature and to discuss the possible pathogenic mechanisms of this combination.


Keywords: Vasculitis, hypersensitivity; Tuberculosis; Hypersensitivity.


15 - Pulmonary veno-occlusive disease: diagnostic and therapeutic alternatives

Doença veno-oclusiva pulmonar: alternativas diagnósticas e terapêuticas

Carlos Eduardo Galvão Barboza, Carlos Viana Poyares Jardim, André Luís Dressler Hovnanian, Bruno Arantes Dias, Rogério Souza

J Bras Pneumol.2008;34(9):749-752

Abstract PDF PT PDF EN Portuguese Text

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension. Surgical biopsy was usually required for diagnostic confirmation. However, the morbidity, mortality and limited benefit of this procedure have generated discussion regarding noninvasive diagnostic techniques. We present the case of a female patient with progressive dyspnea, hypoxemia and pulmonary hypertension, the last diagnosed via catheterization. Computed tomography revealed septal thickening and diffuse micronodules. Bronchoalveolar lavage revealed occult alveolar hemorrhage. Treatment with an endothelin antagonist was started, resulting in symptomatic and functional improvement. Occult alveolar hemorrhage differentiates PVOD from idiopathic pulmonary hypertension. We believe that this finding, in combination with characteristic tomographic findings, is sufficient to establish a diagnosis of PVOD.


Keywords: Hypertension, pulmonary; Pulmonary veno-occlusive disease; Bronchoalveolar lavage; Receptors, endothelin/antagonists & inhibitors.


Year 2008 - Volume 34  - Number 10  (/October)


1 - Tuberculosis/HIV co-infection

Co-infecção tuberculose/HIV

Antônio Carlos Moreira Lemos

J Bras Pneumol.2008;34(10):753-755

PDF PT PDF EN Portuguese Text

Original Article

2 - Evaluation of the Asthma Control Questionnaire validated for use in Brazil

Avaliação do Questionário de Controle da Asma validado para uso no Brasil

Mylene Leite, Eduardo Vieira Ponte, Jaqueline Petroni, Argemiro D`Oliveira Júnior, Emílio Pizzichini, Álvaro Augusto Cruz

J Bras Pneumol.2008;34(10):756-763

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate whether the Portuguese version of the Asthma Control Questionnaire (ACQ) is a valid instrument to measure asthma control in adult outpatients in Brazil. Methods: We selected 278 outpatients diagnosed with asthma. All of the patients completed the questionnaire, underwent spirometry and were clinically evaluated by a physician in order to characterize the control of the disease in the first visit. The questionnaire was evaluated in three versions, with 5, 6 and 7 questions, respectively, and scores of 0.75 and 1.50 were used as cut-off points. Results: Of the 278 patients, 77 (27.7%) had intermittent asthma, 39 (14.0%) had mild persistent asthma, 40 (14.4%) had moderate persistent asthma and 122 (43.9%) had severe persistent asthma. The sensitivity of ACQ to identify uncontrolled asthma ranged from 77% to 99%, and the specificity ranged from 36% to 84%. The positive predictive value ranged from 73% to 90%, and the negative predictive value ranged from 67% to 95%. The positive likelihood ratio ranged from 1.55 to 4.81, and the negative likelihood ratio ranged from 0.03 to 0.27. In the 5- and 6-question versions of the ACQ, the intraclass correlation coefficient was 0.92. These two versions were both responsive to clinical changes in the patients. Conclusions: All three versions of the ACQ satisfactorily discriminated between patients with uncontrolled asthma and those with controlled asthma. The 5- and 6-question versions also presented good reliability and responsiveness. Therefore, the ACQ is a valid tool for evaluating asthma control in adult outpatients in Brazil.


Keywords: Asthma; Therapeutics; Diagnosis; Questionnaires; Reproducibility of results.


3 - Asthma and lung function in a birth cohort at 6-7 years of age in southern Brazil

Asma e função pulmonar aos 6-7 anos de idade em uma coorte de nascimentos no Sul do Brasil

Moema Nudilemon Chatkin, Ana Maria Baptista Menezes, Silvia Elaine Cardozo Macedo, Edgar Fiss

J Bras Pneumol.2008;34(10):

Abstract PDF PT PDF EN Portuguese Text

Objective: Asthma and respiratory symptoms are common in children, and many studies have shown associations between childhood symptoms and impaired lung function in adult life. The aim of the present study was to investigate the association of various respiratory symptoms with wheezing patterns (persistent, early, and late-onset) and lung function, as well as to determine whether lung function was associated with atopy or with demographic, socioeconomic, environmental, and gestational factors, in a birth cohort at 6-7 years of age. Methods: The target population consisted of children aged 6-7 years from a birth cohort of 5,304 children born in southern Brazil in 1993. For this follow-up evaluation, 532 of those children were randomly selected, and a sub-sample was submitted to spirometry and skin prick tests. A questionnaire was administered to the parent(s) or legal guardian(s) of each child. Results: Spirometric values were lower in the children with respiratory symptoms or asthma. Mean forced expiratory volume in one second/forced vital capacity ratio (FEV1/FVC ratio) was lower in children with any of the following: current wheezing and asthma; asthma ever; four or more episodes of wheezing within the preceding 12 months; sleep disturbance due to wheezing; and exercise-induced wheezing. Persistent wheezing was associated with lower FEV1/FVC ratio. After multiple linear regression, exercise-induced wheezing was also associated with reduced FEV1/FVC ratio. Nonwhite skin color and wheezing severe enough to limit speech were associated with lower FEV1. Conclusions: Children with persistent wheezing and symptoms of severe asthma have impaired lung function at 6-7 years of age.


Keywords: Asthma; Respiratory function tests; Respiratory sounds; Signs and symptoms, respiratory.


4 - Prevalence of gastroesophageal reflux in lung transplant candidates with advanced lung disease

Prevalência de refluxo gastroesofágico em pacientes com doença pulmonar avançada candidatos a transplante pulmonar

Gustavo Almeida Fortunato, Mirna Mota Machado, Cristiano Feijó Andrade, José Carlos Felicetti, José de Jesus Peixoto Camargo, Paulo Francisco Guerreiro Cardoso

J Bras Pneumol.2008;34(10):772-778

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the esophageal function profile and the prevalence of gastroesophageal reflux (GER) in lung transplant candidates. Methods: From July of 2005 to November of 2006, a prospective study was conducted involving 55 candidates for lung transplantation at the Santa Casa de Misericórdia Hospital in Porto Alegre, Brazil. Prior to transplantation, patients underwent outpatient stationary esophageal manometry and 24-h esophageal pH-metry using one and two electrodes. Results: Abnormal esophageal manometry was documented in 80% of the patients, and 24% of the patients presented pathological acid reflux. Digestive symptoms presented sensitivity and specificity for GER of 50% and 61%, respectively. Of the patients with chronic obstructive pulmonary disease, 94% presented abnormal esophageal manometry, and 80% presented lower esophageal sphincter hypotonia, making it the most common finding. Patients with bronchiectasis presented the highest prevalence of GER (50%). Conclusions: In patients with advanced lung disease, GER is highly prevalent. In the population studied, digestive symptoms of GER were not predictive of pathological acid reflux. The role that GER plays in chronic rejection should be examined and clarified in future studies.


Keywords: Gastroesophageal reflux; Lung transplantation; Manometry; Esophageal pH monitoring.


5 - Idiopathic pulmonary fibrosis and emphysema in smokers

Fibrose pulmonar idiopática simultânea a enfisema em pacientes tabagistas

Denise Rossato Silva, Marcelo Basso Gazzana, Sérgio Saldanha Menna Barreto, Marli Maria Knorst

J Bras Pneumol.2008;34(10):779-786

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the clinical and functional findings recently reported in the medical literature for patients diagnosed with emphysema involving the upper lobes and idiopathic pulmonary fibrosis (IPF) involving the lower lobes. Methods: Eleven patients with emphysema and IPF were identified retrospectively. All of the patients underwent high-resolution computed tomography of the lung and pulmonary function tests. Results: Of the 11 patients, 8 were male and 3 were female. The mean age was 70.7 ± 7.2 years (range, 61-86 years). All of the patients were smokers (mean smoking history, 61.5 ± 43.5 pack-years). The mean values of forced vital capacity (FVC), forced expiratory volume in one second (FEV1) and FEV1/FVC were 72.1 ± 12.7%, 68.2 ± 11.9% and 74.4 ± 10.8, respectively. Lung volumes were normal in 7 patients. A restrictive pattern was observed in 3 patients, and hyperinflation was present in one. The diffusing capacity was moderatelyto- severely reduced in all of the patients (mean, 27.7% ± 12.9% of predicted). Ten of the 11 patients performed the six-minute walk test. The mean distance covered was 358.4 ± 143.1 m, and 9 of the 10 patients presented desaturation ≥ 4%. Echocardiographic findings suggestive of pulmonary hypertension were present in 4 patients (mean systolic pulmonary artery pressure, 61.8 mmHg; range, 36-84 mmHg). Conclusions: The concomitant presence of emphysema and IPF causes characteristic changes on pulmonary function tests. The most significant finding is a discrepancy between diffusing capacity and spirometry results.


Keywords: Pulmonary emphysema; Pulmonary fibrosis; Lung Diseases, interstitial; Anoxia; Hypertension, pulmonary.


6 - Immunohistochemical study of lung remodeling in mice exposed to cigarette smoke

Estudo imunohistoquímico do remodelamento pulmonar em camundongos expostos à fumaça de cigarro

Samuel Santos Valença, Luís Cristóvão Porto

J Bras Pneumol.2008;34(10):787-795

Abstract PDF PT PDF EN Portuguese Text

Objective: Various studies of emphysema involve long-term exposure of animals to cigarette smoke, focusing on the cell type involved in the protease/antiprotease imbalance and on extracellular matrix degradation. In emphysema, increased expression of metalloproteinases is associated with cytokines, and evidence suggests that the matrix metalloproteinase-12 (MMP-12) plays an important role. Our objective was to investigate tissue inhibitor of metalloproteinase-2 (TIMP-2), tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) detection by immunohistochemical methods in mouse lung. Methods: Male C57BL/6 mice were exposed 3 times a day to the smoke of 3 cigarettes over a period of 10, 20, 30 or 60 days in an inhalation chamber (groups CS10, CS20, CS30 and CS60, respectively). Controls were exposed to the same conditions in room air. Results: A progressive increase in the number of alveolar macrophages was observed in the bronchoalveolar lavage fluid of the exposed mice. The mean linear intercept, an indicator of alveolar destruction, was greater in all exposed groups when compared to control group. In the CS10, CS20 and CS30 mice, the immunohistochemical index (II) for MMP-12 increased in parallel with a decrease in II for TIMP-2 in the CS10, CS20 and CS30 mice. The II for the cytokines TNF-α and IL-6 was greater in all exposed groups than in the control group. Emphysema, with changes in volume density of collagen and elastic fibers, was observed in the CS60 group. Conclusions: These findings suggest that cigarette smoke induces emphysema with major participation of TNF-α and IL-6 without participation of neutrophils.


Keywords: Macrophages, alveolar; Emphysema; Tissue inhibitor of metalloproteinase-2; Interleukin-6.


7 - Airway resistance in children measured using the interrupter technique: reference values

Resistência de vias aéreas em crianças medida pela técnica do interruptor: valores de referência

Viviane Viegas Rech, Paula Cristina Vasconcellos Vidal, Hilário Teixeira de Melo Júnior, Renato Tetelbom Stein, Paulo Márcio Condessa Pitrez, Marcus Herbert Jones

J Bras Pneumol.2008;34(10):796-803

Abstract PDF PT PDF EN Portuguese Text

Objective: The interrupter technique is used for determining interrupter resistance (Rint) during quiet breathing. This noninvasive method requires minimal cooperation and can therefore be useful in evaluating airway obstruction in uncooperative children. To date, no reference values have been determined for Rint in a Brazilian population. The objective of this study was to define a prediction equation for airway resistance using the interrupter technique for healthy children aged 3-13 years. Methods: This was a prospective, cross-sectional study involving preschool and school children in Porto Alegre, Brazil, in whom Rint was measured during peak expiratory flow. Results: ­One-hundred and ninety-three children were evaluated. Univariate analysis using linear regression showed that height, weight and age correlated significantly and independently with Rint. Multiple regression with height, weight, age and gender as variables resulted in a model in which only height and weight were significant, independent predictors of Rint. Collinearity was identified among height, weight and age. ­Conclusions: Reference values and an equation for calculating Rint in healthy children were obtained and are adjusted for height.


Keywords: Respiratory function tests; Airway resistance; Diagnostic techniques, respiratory system; Airway obstruction/diagnosis; Reference values.


8 - Using electron microscopy and multivariate cluster analysis to determine diagnosis and prognosis in cases of neuroendocrine lung carcinoma

Diagnóstico e prognóstico dos tumores pulmonares neuroendócrinos mediante microscopia eletrônica e análise multivariavel de agrupamento

Cecília Aparecida Vaiano Farhat, Edwin Roger Parra, Andrew V. Rogers, Silvia Nagib Elian, Mary N. Sheppard, Vera Luiza Capelozzi

J Bras Pneumol.2008;34(10):804-811

Abstract PDF PT PDF EN Portuguese Text

Objective: To establish reproducible electron microscopic criteria for identifying the four major types of neuroendocrine tumors of the lung: carcinoid; atypical carcinoid; large cell neuroendocrine carcinoma; and small cell carcinoma. Methods: Measurements were made on electron micrographs using a digital image analyzer. Sixteen morphometric variables related to tumor cell differentiation were assessed in 27 tumors. The examination under electron microscopy revealed that all of the tumors could be classified as belonging to one of the four categories listed above. Cluster analysis of the morphometry variables was used to group the tumors into three clusters, and Kaplan-Meier survival function curves were employed in order to draw correlations between each cluster and survival. Results: All three clusters of neuroendocrine carcinomas were found to be associated with survival curves, demonstrating the prognostic significance of electron microscopic features. The tumors fell into three well-defined clusters, which represent the spectrum of neuroendocrine differentiation: typical carcinoid (cluster 1); atypical carcinoid and large cell neuroendocrine carcinoma (cluster 2); and small cell carcinoma (cluster 3). Cluster 2 represents an intermediate step in neuroendocrine carcinogenesis, between typical carcinoid tumors and small cell carcinomas. Conclusions: Our findings confirm that electron microscopy is useful in making the diagnosis and prognosis in cases of lung tumor.


Keywords: Neuroendocrine tumors/lung; Microscopy, electron; Cluster analysis; Survival analysis.


9 - Extramedullary hematopoiesis: findings on computed tomography scans of the chest in 6 patients

Hematopoese extramedular: achados em tomografia computadorizada do tórax de 6 pacientes

Edson Marchiori, Dante Luiz Escuissato, Klaus Loureiro Irion, Gláucia Zanetti, Rosana Souza Rodrigues, Gustavo de Souza Portes Meirelles, Bruno Hochhegger

J Bras Pneumol.2008;34(10):812-816

Abstract PDF PT PDF EN Portuguese Text

Objective: To present findings on computed tomography scans of the chest indicative of extramedullary hematopoiesis in six patients. Methods: We retrospectively analyzed computed tomography scans of six adult patients-five males and one female-with a mean age of 36.5 years. Two radiologists independently reviewed the scans, and a consensus was reached in discrepant cases. Results: The most common finding in the scans was lower paravertebral masses with heterogeneous content (four patients). The scans of two patients showed a solitary parietal and pleural mass. Conclusions: There are findings in computed tomography scans that are highly suggestive of extramedullary hematopoiesis, especially when those findings correlate with underlying blood diseases. Such findings, in most of the cases, allow physicians to dispense with histopathological confirmation.


Keywords: Tomography, X-ray computed; Hematopoiesis, extramedullary; Mediastinum/physiopathology; Anemia, sickle cell.


10 - Alterations in peak inspiratory pressure and tidal volume delivered by manually operated self-inflating resuscitation bags as a function of the oxygen supply rate

Alterações da pressão de pico inspiratório e do volume corrente fornecidos por reanimadores manuais com balão auto-inflável em função do fluxo de entrada de oxigênio utilizado

Armando Carlos Franco de Godoy, Ronan José Vieira, Eduardo Mello De Capitani

J Bras Pneumol.2008;34(10):817-821

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess possible alterations in the tidal volume and peak inspiratory pressure delivered by seven models of manually operated self-inflating resuscitation bags as a function of the oxygen supply rate used. Methods: The resuscitation bags tested were the following: Oxigel, models A and B; CE Reanimadores; ProtecSolutions; Missouri; Axmed; and Narcosul. For the measurements, a wall oxygen flow meter, a flow meter/respirometer, a resuscitation bag, a sensor (Tracer 5 unit), and a test lung were connected. In addition, the Tracer 5 unit was connected to a notebook computer. Oxygen supply rates of 1, 5, 10, and 15 L/min were used. Results: The tidal volume delivered by the Oxigel model A resuscitation bag when receiving oxygen at a rate of 15 L/min was approximately 99% greater than that delivered when receiving oxygen at a rate of 1 L/min. Similarly, peak inspiratory pressure was approximately 155% greater. Under the same conditions, the tidal volume delivered by the Narcosul resuscitation bag was 48% greater, and peak inspiratory pressure was 105% greater. The remaining resuscitation bags tested showed no significant alterations in the tidal volume or peak inspiratory pressure delivered. Conclusions: Under the resistance and compliance conditions used, the resuscitation bags in which the oxygen inflow is directed to the interior of the bag had the patient valve stuck at the inspiratory position when receiving oxygen at a rate ≥ 5 L/min, significantly increasing the tidal volume and peak inspiratory pressure delivered. This did not occur with the resuscitation bags in which the oxygen inflow is directed to the exterior of the bag.


Keywords: Oxygen/administration & dosage; Resuscitation; Equipment and supplies; Pulmonary ventilation; Intensive care.


11 - Mycobacterium tuberculosis and nontuberculous mycobacterial isolates among patients with recent HIV infection in Mozambique

Doença pulmonar por Mycobacterium tuberculosis e micobactérias não-tuberculosas entre pacientes recém-diagnosticados como HIV positivos em Moçambique, África

Elizabete Abrantes Nunes, Eduardo Mello De Capitani, Elizabete Coelho, Alessandra Costa Panunto, Orvalho Augusto Joaquim, Marcelo de Carvalho Ramos

J Bras Pneumol.2008;34(10):822-828

Abstract PDF PT PDF EN Portuguese Text

Objective: Mycobacteriosis is frequently diagnosed among HIV-infected patients. In Mozambique, where few patients are under antiretroviral therapy and the prevalence of tuberculosis is high, there is need for better characterization of mycobacteria at the species level, as well as for the identification of patterns of resistance to antituberculous drugs. Methods: We studied a sample of 503 HIV-infected individuals suspected of having pulmonary tuberculosis. Of those 503, 320 tested positive for mycobacteria through sputum smear microscopy or culture of bronchoalveolar lavage fluid. Results: Acid-fast bacilli were observed in the sputum of 73% of the individuals presenting positive cultures. Of 277 isolates tested, only 3 were nontuberculous mycobacteria: 2 were identified as Mycobacterium avium and one was identified as M. simiae. Strains initially characterized as M. tuberculosis complex through polymerase chain reaction restriction analysis (PRA) of the hsp65 gene were later confirmed as such through PRA of the gyrB gene. Among the M. tuberculosis isolates, resistance patterns were as follows: to isoniazid, 14%; to rifampin, 6%; and multidrug resistance, 5%. Previously treated cases showed significantly higher rates of resistance to first-line antituberculous drugs. The most common radiological pattern was interstitial infiltrate (in 67%), followed by mediastinal lymph node enlargement (in 30%), bronchiectasis (in 28%), miliary nodules (in 18%) and cavitation (in 12%). Patients infected with nontuberculous mycobacteria presented clinical profiles indistinguishable from those of other patients. The median CD4 lymphocyte count in this group was 134 cells/mm3. Conclusions: There is a strong association between tuberculosis and AIDS in Mozambique, as expected in a country with a high prevalence of tuberculosis. Although drug resistance rates are high, the isoniazid-rifampin regimen continues to be the appropriate choice for initial therapy.


Keywords: Tuberculosis; Mycobacteria, atypical; HIV; Acquired immunodeficiency syndrome; Drug Resistance, Multiple; Mozambique.


Review Article

12 - Cystic fibrosis-related dyslipidemia

Dislipidemia relacionada à fibrose cística

Crésio de Aragão Dantas Alves, Daniela Seabra Lima

J Bras Pneumol.2008;34(10):829-837

Abstract PDF PT PDF EN Portuguese Text

This article aims to review the physiopathology, diagnosis and treatment of cystic fibrosis-related dyslipidemia (CFD). Bibliographic searches of the Medline and Latin American and Caribbean Health Sciences Literature databases were made (year range, 1987-2007), and the most representative papers on the theme were selected. The characteristic symptoms of CFD are hypertriglyceridemia-with or without hypocholesterolemia-and essential fatty acid deficiency. The principal CFD risk factors are pancreatic insufficiency, high-carbohydrate diet, liver diseases, inflammatory state and corticosteroid therapy. There are no specific recommendations regarding screening, which is typically performed based on the diagnosis, and at regular intervals, and more frequently in individuals belonging to high-risk groups. Treatment includes a balanced diet, micronutrient supplementation, and regular physical exercise according to individual tolerance. In the great majority of the cases, CFD-related hypertriglyceridemia does not reach values for which the use of hypolipidemic drugs is indicated. We conclude that there are few articles in the literature regarding the frequency, etiology and management of CFD. Preventive and therapeutic recommendations for hypertriglyceridemia are extrapolated from studies in individuals without cystic fibrosis. Further research is necessary to investigate the association of essential fatty acid deficiency and the physiopathology of cystic fibrosis. Since hypertriglyceridemia is an important risk factor for coronary artery disease, prospective studies will contribute for a better understanding of the natural history of this condition and define how to prevent and treat it.


Keywords: Cystic fibrosis; Dyslipidemias; Hypertriglyceridemia; Fatty Acids, nonesterified.


Brief Communication

13 - Testing pulmonary vasoreactivity

Teste de vasorreatividade pulmonar

Edmundo Clarindo Oliveira, Carlos Faria Santos Amaral, Marco Antonio Moura, Frederico Thadeu Assis Figueiredo Campos, Helder Machado Pauperio

J Bras Pneumol.2008;34(10):838-844

Abstract PDF PT PDF EN Portuguese Text

Pulmonary arterial hypertension is classified as idiopathic or secondary (associated with collagenoses, heart disease, portal hypertension, pulmonary thromboembolism, and pulmonary vascular diseases). Pulmonary vasoreactivity should be tested in order to define the best treatment option. Of the many drugs that have been used to test pulmonary vasoreactivity, inhaled nitric oxide is the best choice, due to its specific pulmonary effect and very short half-life (5-10 s). The results of this test identify candidates for heart surgery among patients with congenital heart disease and candidates for the use of calcium antagonists among patients with other forms of pulmonary arterial hypertension. Performing and interpreting the results of such tests are a great responsibility, since mistakes can lead to incorrect treatment decisions, resulting in the death of patients.


Keywords: Hypertension, pulmonary/diagnosis; Nitric oxide/diagnostic use; Administration, inhalation.


Guidelines SBPT

14 - Smoking cessation guidelines - 2008

Diretrizes para cessação do tabagismo - 2008

Jonatas Reichert, Alberto José de Araújo, Cristina Maria Cantarino Gonçalves, Irma de Godoy, José Miguel Chatkin, Maria da Penha Uchoa Sales, Sergio Ricardo Rodrigues de Almeida Santos e Colaboradores

J Bras Pneumol.2008;34(10):845-880

Abstract PDF PT PDF EN Portuguese Text

These guidelines are an up-to-date and comprehensive tool to aid health professionals in treating smokers, recommending measures and strategies for managing each case based on clinical evidence. Written in a simplified and objective manner, the text is divided into two principal sections: Evaluation and Treatment. The sections both present comments on and levels of evidence represented by the references cited, as well as some proposals for the reduction of damage and for intervening in specific and still poorly explored situations, such as relapse, passive smoking, physician smoking, and tobacco use in specific environments.


Keywords: Smoking/adverse effects; Smoking cessation/methods; Guideline.


Case Report

15 - Primary tracheobronchial amyloidosis

Amiloidose traqueobrônquica primária

José Wellington Alves dos Santos, Ayrton Schneider Filho, Alessandra Bertolazzi, Gustavo Trindade Michel, Lauro Vinícius Schvarcz da Silva, Carlos Renato Melo, Vinícius Dallagasperina Pedro, Daniel Spilmann, Juliana Kaczmareck Figaro

J Bras Pneumol.2008;34(10):881-884

Abstract PDF PT PDF EN Portuguese Text

Tracheobronchial amyloidosis is an uncommon localized form of amyloidosis, characterized by amyloid deposits restricted to the trachea, main bronchi and segmental bronchi. We present the case of a retired 67-year-old man with long-term progressive dyspnea, wheezing and chest pain. A diagnosis of tracheobronchial amyloidosis was made after the third fiberoptic bronchoscopy and histological confirmation through Congo red staining of tissue samples.


Keywords: Amiloidose/traquéia; Broncoscopia; Doenças da traquéia/diagnóstico.


16 - Pregnancy in a patient with severe pulmonary alveolar microlithiasis

Gravidez em paciente com microlitíase alveolar pulmonar grave

José Osmar Bezerra de Souza Filho, Cristiane Maria Cavalcante Silveira, Aline Barreto da Cunha, Valéria Goes Ferreira Pinheiro, Francisco Edson de Lucena Feitosa, Marcelo Alcântara Holanda

J Bras Pneumol.2008;34(10):885-888

Abstract PDF PT PDF EN Portuguese Text

Pulmonary alveolar microlithiasis (PAM) is a rare disease that affects both lungs. It is characterized by the presence of small calculi (calcium phosphate) within the alveolar spaces. We report the case of a 26-year-old female whose diagnosis was based on characteristic findings on chest X-rays and high-resolution computed tomography scans. The patient, 28 weeks pregnant, was rehospitalized 10 months after the diagnosis, presenting hypoxemic acute respiratory failure and severe restrictive ventilatory defect on spirometry. After 32 completed weeks of gestation (228 days), she was submitted to cesarean section, and the outcome was successful for mother and newborn. PAM has a variable clinical course. It is suggestive of an autosomal recessive inheritance pattern and has been associated with positive family history. The etiology of PAM is unclear, and many authors speculate that there is a local enzymatic defect responsible for the intra-alveolar accumulation of calcium. Reports of patients with PAM who become pregnant are exceptional, and this is the first case described in Brazil. The course of this disease is usually slow and progressive, and patients typically die of cardiorespiratory failure. The present case illustrates the need to offer female patients, especially those with advanced disease, genetic counseling and orientation regarding the risks of pregnancy. Currently, the only effective therapy is lung transplantation.


Keywords: Pulmonary alveoli; Pregnancy; Respiratory insufficiency.


Year 2008 - Volume 34  - Number 11  (/November)


1 - Induced sputum cell counts in medical practice

O escarro induzido na prática médica

Elcio Oliveira Vianna

J Bras Pneumol.2008;34(11):889-890

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Original Article

2 - Influence of a DNA-hsp65 vaccine on bleomycin-induced lung injury

Influência do biofármaco DNA-hsp65 na lesão pulmonar induzida por bleomicina

Adriana Ignacio de Padua, Célio Lopes Silva, Simone Gusmão Ramos, Lúcia Helena Faccioli, José Antônio Baddini Martinez

J Bras Pneumol.2008;34(11):891-899

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effects of immunization with a DNA-hsp65 vaccine in an experimental model of pulmonary fibrosis. Methods: A total of 120 male C57BL/6 mice were distributed into four groups: SS, injected with saline (placebo) and then receiving intratracheal (IT) instillation of saline; SB, injected with saline (placebo) and then receiving IT instillation of bleomycin; PB, treated with plasmid only, without bacterial genome, and then receiving IT instillation of bleomycin; and BB, treated with the vaccine and then receiving IT instillation of bleomycin. Bleomycin was instilled 15 days after the last immunization, and the animals were killed six weeks thereafter. The left and right lungs were removed, the former for morphological analysis and the latter for hydroxyproline measurements. Results: The proportion of deaths within the first 48 h after the IT instillation (deaths attributed to the surgical procedure) was higher in the SB group than in the SS group (57.7% vs. 11.1%). The mean area of pulmonary interstitial septa was greater in the SB and PB groups (53.1 ± 8.6% and 53.6 ± 9.3%, respectively) than in the SS and BB groups (32.9 ± 2.7% and 34.3 ± 6.1%, respectively). The mean area of interstitial septa stained by picrosirius was greater in the SB, PB and BB groups than in the SS group (8.2 ± 4.9%, 7.2 ± 4.2% and 6.6 ± 4.1%, respectively, vs. 2.0 ± 1.4%). The total hydroxyproline content in the lung was significantly lower in the SS group (104.9 ± 20.9 pg/lung) than in the other groups (SB: 160.4 ± 47.8 pg/lung; PB: 170.0 ± 72.0 pg/lung; and BB: 162.5 ± 39.7 pg/lung). Conclusions: Immunization with the DNA-hsp65 vaccine reduced the deposition of noncollagen matrix in a model of bleomycin-induced lung lesion.


Keywords: Pulmonary fibrosis; Bleomycin; Collagen.


3 - Prevalence of allergic bronchopulmonary aspergillosis in patients with cystic fibrosis in the state of Bahia, Brazil

Prevalência de aspergilose broncopulmonar alérgica em pacientes com fibrose cística na Bahia, Brasil

Ana Cláudia Costa Carneiro, Antônio Carlos Moreira Lemos, Sérgio Marcos Arruda, Maria Angélica Pinheiro Santos Santana

J Bras Pneumol.2008;34(11):900-906

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of allergic bronchopulmonary aspergillosis (ABPA) in patients with cystic fibrosis treated at a referral center in the state of Bahia, Brazil. Methods: A cross-sectional study, with prospective data collection, carried out at the Cystic Fibrosis Referral Center of Bahia of the Octávio Mangabeira Specialized Hospital. We evaluated 74 patients diagnosed with cystic fibrosis, older than six years of age, treated between December 9, 2003 and March 7, 2005. We analyzed the following variables: gender, age, forced vital capacity, forced expiratory volume in one second, pharmacodynamic response, chest X-ray findings, facial sinus X-ray findings, wheezing, cultures for Aspergillus spp., total immunoglobulin E (IgE), specific IgE for Aspergillus fumigatus and immediate skin test reactivity to A. fumigatus antigen. Results: Of the 74 patients, 2 were diagnosed with ABPA. We found total IgE levels > 1,000 IU/mL in 17 (23%), positive immediate skin reactivity to A. fumigatus antigen in 19 (25.7%) and wheezing in 60 (81.1%). Conclusions: The prevalence of ABPA was 2.7%. The high levels of total IgE, high incidence of wheezing and high rate of immediate skin test reactivity to A. fumigatus antigen suggest that these patients should be carefully monitored due to their propensity to develop ABPA.


Keywords: Cystic fibrosis; Aspergillosis, allergic bronchopulmonary; Immunoglobulin E/diagnostic use; Hypersensitivity, immediate/diagnosis; Gliotoxin.


4 - Pulmonary function and respiratory muscle strength in chronic renal failure patients on hemodialysis

Função pulmonar e força muscular respiratória em pacientes com doença renal crônica submetidos à hemodiálise

Demetria Kovelis, Fábio Pitta, Vanessa Suziane Probst, Celeide Pinto Aguiar Peres, Vinicius Daher Alvares Delfino, Altair Jacob Mocelin, Antônio Fernando Brunetto

J Bras Pneumol.2008;34(11):907-912

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate pulmonary function and respiratory muscle strength in chronic renal failure patients, correlating these variables with hemodialysis-related weight fluctuation; to study the correlation between the duration of hemodialysis and potential respiratory alterations. Methods: Seventeen patients (median age, 47 years; interquartile range, 41-52 years), submitted to three weekly hemodialysis sessions for a median of 27 months (interquartile range, 14-55) were evaluated. Twelve of the patients were male. The patients underwent spirometry. Maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP) were measured prior to and after the first hemodialysis session of the week. Body weight was quantified prior to and after each of the three weekly sessions. Results: Before the first hemodialysis session of the week, 8 patients presented mild restrictive defect, which normalized after the session in 2 of those patients. After dialysis, there was a significant increase in forced vital capacity (p = 0.02) and a significant decrease in body weight (p = 0.0001). Weight fluctuation over 3 days without hemodialysis tended to correlate with the variation in forced vital capacity in the first weekly session (r = 0.47; p = 0.055). Duration of hemodialysis correlated with predialysis MIP (r = −0.3; p = 0.03) and MEP (r = −0.63; p = 0.006). Conclusions: More pronounced weight gain in the interdialytic period is associated with worsening of lung function, which is almost fully reversible by hemodialysis. In addition, longer duration of hemodialysis is associated with decreased respiratory muscle strength.


Keywords: Spirometry; Respiratory muscles/physiopathology; Kidney failure, chronic; Renal dialysis.


5 - Determination of the inflammatory component of airway diseases by induced sputum cell counts: use in clinical practice

Determinação do componente inflamatório das doenças das vias aéreas através do escarro induzido: utilização na prática clínica

Pablo Moritz, Leila John Marques Steidle, Manuela Brisot Felisbino, Túlia Kleveston, Marcia Margaret Menezes Pizzichini, Emilio Pizzichini

J Bras Pneumol.2008;34(11):913-921

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the usefulness of determining the inflammatory component of airway diseases (inflammometry) by induced sputum cell counts, as well as its influence on treatment decisions in a tertiary facility for the treatment of respiratory diseases. Methods: We analyzed 151 sputum samples from 132 consecutive patients referred for clinical sputum induction by five pulmonologists between July of 2006 and February of 2007. A structured questionnaire related to the reasons for requesting the test and to the therapeutic decision making based on test results was completed by each attending physician upon receiving the test results. Induced sputum was obtained and processed according to a technique previously described. Results: The principal motives for ordering the test were inhaled corticosteroid dose titration in patients with moderate-to-severe asthma (in 54.3%), investigation of chronic cough (in 30.5%), and monitoring airway inflammation in patients with bronchiectasis (in 7.3%) or chronic obstructive pulmonary disease (in 6%). Of the 82 patients with asthma, 47 (57%) presented eosinophilic bronchitis (>3% eosinophils). Nonasthmatic eosinophilic bronchitis was diagnosed in 9 (19%) of the 46 patients with chronic cough. Neutrophilic bronchitis (>65% neutrophils) was found in 13 patients, of which 5 had asthma, 2 had chronic cough, and 6 had chronic obstructive pulmonary disease/bronchiectasis. Based on the induced sputum results, the corticosteroid dose was modified in 48 asthma patients (64.7%). Conclusions: The systematic application of inflammometry using induced sputum cell counts can be beneficial for patients with airway diseases, particularly those with asthma or chronic cough.


Keywords: Sputum; Asthma; Bronchitis.


6 - Gene probes versus classical methods in the identification of mycobacteria

Estudo comparativo entre um sistema de sonda genética e métodos clássicos na identificação das micobactérias

Andréa Gobetti Vieira Coelho, Liliana Aparecida Zamarioli, Clemira Martins Pereira Vidal Reis, Ana Carolina Chiou Nascimento, Juliana dos Santos Rodrigues

J Bras Pneumol.2008;34(11):922-926

Abstract PDF PT PDF EN Portuguese Text

Objective: The emergence of tuberculosis/HIV co-infection and the increase in the number of cases of infection with nontuberculous mycobacteria (NTM) require rapid laboratory test results in the isolation and identification of mycobacteria. The objective of this study was to evaluate the identification of mycobacteria by means of gene probes in comparison with that obtained using classical biochemical methods. Methods: Between 2002 and 2004, 178 mycobacterial cultures, all testing positive for acid-fast bacilli, were analyzed. Samples were obtained from clinical specimens of patients with respiratory symptoms or with clinical suspicion of pulmonary tuberculosis/mycobacteriosis who were treated in the greater metropolitan area of Santos. Results: The gene probe identified 137 samples (77%) as Mycobacterium tuberculosis complex and 41 (23%) as NTM. Discordant results between the methods (3%) were obtained only in the year of implementation (2002). When comparing the methods, the sensitivity, specificity, positive predictive value and negative predictive value of the gene probe method were 98%, 93%, 98% and 93%, respectively. Conclusions: Despite the cost, the identification of mycobacteria using the molecular technique is faster: maximum 3 h vs. 28-30 days for classical methods. The use of gene probes is a validated molecular technique. It is fast, easy to use and readily available on the market. It has high specificity and sensitivity, which justifies its implementation and routine use in referral laboratories, since it facilitates the diagnosis providing agile clinical interventions.


Keywords: Mycobacterium tuberculosis; Tuberculosis/diagnosis; Mycobacterium/classification; DNA probes.


7 - Factors associated with cigarette experimentation among adolescents

Fatores associados à experimentação do cigarro em adolescentes

Maristela Prado e Silva, Regina Maria Veras Gonçalves da Silva, Clovis Botelho

J Bras Pneumol.2008;34(11):927-935

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the prevalence of and factors associated with smoking experimentation among adolescents. Methods: Cross-sectional study, using a specific questionnaire to interview 2,883 students from 7th to 10th grade in schools located in the urban area of the city of Cuiabá, in the state of Mato Grosso, Brazil. Prevalence was estimated, and the principal factors related to cigarette experimentation were analyzed. Subsequently, a hierarchical logistic model was used to describe the chances of cigarette experimentation related to the variables being investigated. Results: The prevalence of cigarette experimentation was 30.2%. In the final model of the analysis, the main variables related to cigarette experimentation were low maternal level of education (OR = 2.44; 95% CI: 1.72-3.47); low socioeconomic level (OR = 1.39; 95% CI: 1.01-1.93); studying in a public school (OR = 1.56; 95% CI: 1.22-2.00); being in 10th grade (OR = 3.45; 95% CI: 2.63-4.54); attending school in the evening (OR = 2.44; 95% CI: 1.85-3.22); having divorced parents (OR = 1.23; 95% CI: 1.02-1.49); having been held back for one school year (OR = 2.17; 95% CI: 1.78-2.70); having friends who smoke (OR = 3.75; 95% CI: 2.99-4.70) having a sibling who smokes (OR = 2.44; 95% CI: 1.82-3.27); and being older (age 17-19 years) (OR = 2.44; 95% CI: 1.39-4.17). Conclusions: A high proportion of adolescents have experimented with smoking. After adjusting for confounding variables, the factors most strongly associated with cigarette experimentation were maternal level of education, age of the adolescent, attending school in the evening, having been held back for one school year and having a sibling who smokes. Preventive measures must be directed at adolescents in schools in order to control smoking.


Keywords: Smoking; Adolescent; Students; Risk factors.


8 - Smoking among hospitalized patients in a general hospital

Tabagismo em pacientes internados em um hospital geral

Maria Vera Cruz de Oliveira, Tatiana Riera de Oliveira, Carlos Alberto de Castro Pereira, Alexandre Vidal Bonfim, Fernando Studart Leitão Filho, Larissa Rego Voss

J Bras Pneumol.2008;34(11):936-941

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the frequency of smoking among hospitalized patients in a general hospital, and to evaluate their profile. Methods: A random representative sample of 111 patients, classified as nonsmokers, former smokers or smokers, was evaluated. The smokers were submitted to the Fagerström test and measurement of expired carbon monoxide. Expired carbon monoxide higher than 6 ppm was considered a significant indicator of recent smoking. Results: Of the 111 patients in the sample, 60 (54%) were female. The mean age was 70 years. Of the 111 patients, 56 (51%) had never smoked, 36 (32%) were former smokers, and 19 (17%) were smokers. All of the smokers were male. The smokers were younger (58 ± 17 years) than the nonsmokers (68 ± 12 years) and the former smokers (73 ± 14 years)-ANOVA: F = 6.57 (p = 0.002). Among the smokers, the mean tobacco intake was 43 pack-years and the mean Fagerström score was 5.0. Of the 19 smokers, 11 (58%) had respiratory symptoms and 3 had withdrawal symptoms. The mean expired carbon monoxide in the smokers was 5.0 ppm. Expired carbon monoxide levels were higher than 6 ppm in 8 (42%) of the smokers. There was a higher prevalence of smokers in some wards: 70% of all smokers were hospitalized on only five wards. Conclusions: In a large tertiary hospital, 17% of the hospitalized patients were smokers, and 7% had smoked within the last 8 h. The smokers were younger men, hospitalized on specific wards.


Keywords: Smoking; Hospitalization; Carbon monoxide/diagnostic use.


9 - Cytokines and acute phase serum proteins as markers of inflammatory regression during the treatment of pulmonary tuberculosis

Citocinas e proteínas de fase aguda do soro como marcadores de regressão da resposta inflamatória ao tratamento da tuberculose pulmonar

Eliana Peresi, Sônia Maria Usó Ruiz Silva, Sueli Aparecida Calvi, Jussara Marcondes-Machado

J Bras Pneumol.2008;34(11):942-949

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Objective: To evaluate the pattern of pro-inflammatory cytokines, anti-inflammatory cytokines and the acute phase response (APR) as markers of the response to treatment of pulmonary tuberculosis. Methods: Twenty-eight patients with pulmonary tuberculosis were evaluated at three time points: pretreatment (T0), treatment month 3 (T3) and treatment month 6 (T6). Levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukine-10 (IL-10) and transforming growth factor-beta (TGF-β) were determined using ELISA in the supernatant of peripheral blood mononuclear cell and monocyte culture. Levels of total protein, albumin, globulins, C-reactive protein (CRP), alpha-1-acid glycoprotein (AAG) and erythrocyte sedimentation rate (ESR) were also determined. All of these parameters were also evaluated, only once, in a group of healthy controls. Results: In relation to controls, patients presented cytokine levels and APR that were higher at T0, lower at T3 and either lower (TNF-α, IL-10, TGF-β, AAG and ESR) or normal (IFN-γ and CRP) at T6. Conclusions: For individuals with negative smear sputum microscopy, CRP, AAG and ESR are potential markers of pulmonary tuberculosis and of the need for treatment; CRP (T0 > T3 > T6 = reference) can also be a marker of treatment response. In the patients, the Th0 profile (IFN-γ, IL-10, TNF-α and TGF-β), inducer of and protector against inflammation, predominated at T0, whereas the Th2 profile (IL-10, TNF-α and TGF-β), protecting against the harmful pro-inflammatory effect of the remaining TNF-α, predominated at T6. The behavior of IFN-γ (T0 > T3 > T6 = controls) suggests its use as a marker of treatment response.


Keywords: Acute-phase proteins; Cytokines; Mycobacterium tuberculosis; Tuberculosis/therapy.


10 - Nontuberculous mycobacteria isolated in São José do Rio Preto, Brazil between 1996 and 2005

Isolamento de micobactérias não-tuberculosas em São José do Rio Preto entre 1996 e 2005

Heloisa da Silveira Paro Pedro, Maria Izabel Ferreira Pereira, Maria do Rosário Assad Goloni, Suely Yoko Mizuka Ueki, Erica Chimara

J Bras Pneumol.2008;34(11):950-955

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the incidence of nontuberculous mycobacteria and the range of species isolated between 1996 and 2005 at a regional branch of the Adolfo Lutz Institute-located in the city of São José do Rio Preto, Brazil-and to show the importance of laboratory testing. Methods: Mycobacteria were isolated from pulmonary and extrapulmonary specimens and identified through phenotyping and molecular methods (polymerase chain reaction-restriction enzyme analysis). Results: We isolated 317 nontuberculous mycobacterium strains: ­Mycobacterium avium complex, 182 (57.4%); M. gordonae, 33 (10.4%); M. fortuitum, 25 (7.9%); M. chelonae, 8 (2.5%); M. terrae complex, 8 (2.5%); M. kansasii, 7 (2.2%); and less frequent species, 54 (17%). During this period, 72 cases (33.3%) were characterized as mycobacteriosis, according to bacteriological criteria established by the American Thoracic Society in 2007. Of those 72 cases, 56 were attributed to M. avium complex. Of those 56, 29 (51.8%) were characterized as disseminated disease. Six cases were attributed to M. fortuitum, 3 to M. gordonae, 2 to M. chelonae, 1 to M. abscessus, 1 to M. kansasii, 1 to M. intracellulare, 1 to M. malmoense and 1 to ­Mycobacterium ssp. Conclusions: These results show the importance of the bacteriological diagnosis, since identification of the species enables early and appropriate treatment.


Keywords: Mycobacteria, atypical/isolation & purification; Mycobacteria, atypical/classification; Diagnostic techniques and procedures.


Brief Communication

11 - Bronchoscopy for foreign body removal: where is the delay?

Broncoscopia para remoção de corpo estranho: onde está o atraso?

Alexandre Garcia de Lima, Nelson Alves dos Santos, Elen Renate Figueira Rocha, Ivan Felizardo Contrera Toro

J Bras Pneumol.2008;34(11):956-958

Abstract PDF PT PDF EN Portuguese Text

This was a retrospective analysis of the medical charts of 145 patients treated at the Bronchoscopy and Thoracic Surgery Clinic of the Hospital das Clínicas da Universidade Estadual de Campinas (HC-Unicamp, State University of Campinas Hospital das Clínicas) over a period of 10 years. There was a significant difference related to the site of first medical visit (HC-Unicamp versus other institutions) in terms of the time elapsed between the suspicion of bronchial aspiration and the actual respiratory endoscopic examination. However, no significant difference was found in the rate of positive results. The low number of referral centers that provide emergency respiratory endoscopy can negatively influence the treatment of patients under suspicion of bronchial aspiration, jeopardizing the overall recovery in the mid- and long-term.


Keywords: Airway obstruction; Respiratory aspiration; Bronchoscopy.


Review Article

12 - Tuberculosis and silicosis: epidemiology, diagnosis and chemoprophylaxis

Tuberculose e silicose: epidemiologia, diagnóstico e quimioprofilaxia

Carlos Eduardo Galvão Barboza, Daniel Hugo Winter, Márcia Seiscento, Ubiratan de Paula Santos, Mário Terra Filho

J Bras Pneumol.2008;34(11):959-966

Abstract PDF PT PDF EN Portuguese Text

Silicosis, the most prevalent of the pneumoconioses, is caused by inhalation of crystalline silica particles. Silica-exposed workers, with or without silicosis, are at increased risk for tuberculosis and nontuberculous mycobacteria-related diseases. The risk of a patient with silicosis developing tuberculosis is higher (2.8 to 39 times higher, depending on the severity of the silicosis) than that found for healthy controls. Various regimens for tuberculosis chemoprophylaxis in patients with silicosis have been studied, all of which present similar efficacy and overall risk reduction to about one half of that obtained with placebo. Long-term regimens have potential side effects (particularly hepatotoxicity). In addition, the use of such regimens can jeopardize adherence to treatment. The current guidelines recommend that tuberculin skin tests be performed, and, if positive, that chemoprophylaxis be instituted. There are several possible regimens, varying in terms of the drugs prescribed, as well as in terms of treatment duration. We recommend the use of isoniazid at 300 mg/day (or 10 mg/kg/day) for six months for patients with silicosis, as well as for healthy patients with periods of exposure to silica longer than 10 years and strongly positive tuberculin skin test results (induration ≥ 10 mm). Nevertheless, further studies are necessary so that indications, drugs, doses and duration of chemoprophylaxis regimens can be more properly defined.


Keywords: Silicosis; Tuberculosis; Diagnostic techniques and procedures; Chemoprevention.


Guidelines SBCT

13 - Guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis

Diretrizes para a prevenção, diagnóstico e tratamento da hiperidrose compensatória

Roberto de Menezes Lyra, José Ribas Milanez de Campos, Davi Wen Wei Kang, Marcelo de Paula Loureiro, Marcos Bessa Furian, Mário Gesteira Costa, Marlos de Souza Coelho

J Bras Pneumol.2008;34(11):967-977

Abstract PDF PT PDF EN Portuguese Text

With the objective of establishing guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis, consensus meetings were held. Attendees included a general surgeon and thoracic surgeons affiliated with the Brazilian Society of Thoracic Surgery. The topics addressed were those that would ostensibly broaden multidisciplinary knowledge. Based on recent guidelines for the prevention, diagnosis and (clinical and surgical) treatment of compensatory hyperhidrosis, as well as on a review of the medical literature, the participants prepared a preliminary text, whose recommendations were revised and subsequently approved by all of the participants. The consensus text was posted on the Internet, becoming the object of further corrections and revisions prior to taking on its present form.


Keywords: Hyperhidrosis/therapy; Hyperhidrosis/surgery; Sympathectomy/methods; Postoperative complications; Thoracic surgery, video‑assisted.


Case Report

14 - Gynecomastia: a rare adverse effect of isoniazid

Ginecomastia: um efeito colateral raro da isoniazida

Nelson Morrone, Nelson Morrone Junior, Alessandra Garcia Braz, José Antonio Freire Maia

J Bras Pneumol.2008;34(11):978-981

Abstract PDF PT PDF EN Portuguese Text

We report the case of a patient who twice developed gynecomastia following tuberculosis treatment. An 18-year-old male developed painful bilateral gynecomastia after three months of treatment with the isoniazid-rifampin-pyrazinamide regimen. Partial resolution of gynecomastia was achieved at the end of treatment. The patient was retreated with the same regimen eight years later, and gynecomastia recurred after six months of treatment. Hormone levels were normal, and a mammogram revealed bilateral gynecomastia. The isoniazid was discontinued, and the gynecomastia was partially resolved by the end of treatment. Four years later, gynecomastia was not detected. We conclude that isoniazid-related gynecomastia completely resolves when the medication is discontinued. Therefore, pharmacological and surgical treatment should be avoided.


Keywords: Isoniazid/adverse effects; Gynecomastia/chemically induced; Tuberculosis.


15 - Cystic lymphangioma of the mediastinum

Linfangioma cístico do mediastino

Filipa Maria Arruda Viveiros Correia, Bárbara Seabra, Ana Rego, Raquel Duarte, José Miranda

J Bras Pneumol.2008;34(11):982-984

Abstract PDF PT PDF EN Portuguese Text

Cystic lymphangioma is a rare congenital benign tumor. It results from focal proliferation of well-differentiated lymphatic tissue originating from abnormal development of the lymphatic system. Most cystic lymphangiomas occur in the primitive lymph sacs of children or young adults. They generally appear in the neck (75%) and axillary region (20%). Only 1% are located in the mediastinum. Acquired lymphangiomas, which are principally seen in middle-aged adults, are caused by a process of chronic lymphatic obstruction secondary to surgery, chronic infection, or radiation. Here, we present the case of a 50-year-old male with cystic lymphangioma of the mediastinum, detected on a routine chest X-ray.


Keywords: Lymphangioma, cystic; Mediastinum; Incidental findings.


16 - Pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease and bronchiectasis

Nocardiose pulmonar em portador de doença pulmonar obstrutiva crônica e bronquiectasias

Miguel Abidon Aidê, Silvia Soares Lourenço, Edson Marchiori, Gláucia Zanetti, Pedro Juan José Mondino

J Bras Pneumol.2008;34(11):985-988

Abstract PDF PT PDF EN Portuguese Text

We report the case of a patient with chronic obstructive pulmonary disease and bronchiectasis, chronically using corticosteroids, who acquired pulmonary nocardiosis, which presented as multiple cavitated nodules. The principal symptoms were fever, dyspnea and productive cough with purulent sputum. Chest X-ray and computed tomography of the chest revealed nodules, some of which were cavitated, in both lungs. Sputum smear microscopy and culture revealed the presence of Nocardia spp. The patient was treated with imipenem and cilastatin, which produced an excellent clinical response.


Keywords: Pulmonary disease, chronic obstructive; Nocardia infections; Bronchiectasis.


Letters to the Editor

17 - The use of animals in experimental studies

O uso de animais em estudos experimentais

Sami Karapolat

J Bras Pneumol.2008;34(11):989-

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18 - Authors' reply:

Resposta do autor

José Antonio Baddini Martinez

J Bras Pneumol.2008;34(11):990-

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Year 2008 - Volume 34  - Number 12  (/December)


1 - The Brazilian Journal of Pulmonology and the Internet

O Jornal Brasileiro de Pneumologia e a Internet

José Antônio Baddini Martinez

J Bras Pneumol.2008;34(12):991-992

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2 - Respiratory manifestations and esophageal diseases

Manifestações respiratórias e doenças esofágicas

Elie Fiss

J Bras Pneumol.2008;34(12):993-994

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Original Article

3 - Predictors of adherence to treatment in patients with severe asthma treated at a referral center in Bahia, Brazil

Preditores da adesão ao tratamento em pacientes com asma grave atendidos em um centro de referência na Bahia

Pablo de Moura Santos, Argemiro D'Oliveira Júnior, Lúcia de Araújo Costa Beisl Noblat, Adelmir Souza Machado, Antonio Carlos Beisl Noblat, Álvaro Augusto Cruz

J Bras Pneumol.2008;34(12):995-1002

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To determine the rate of adherence to treatment with inhaled corticosteroids in patients with severe asthma, to identify predictive factors for adherence and to evaluate the relationship between adherence to treatment and parameters of clinical and functional response. Methods: Prospective cohort study of patients enrolled in the Program for the Control of Asthma and Allergic Rhinitis in the state of Bahia, Brazil. The study comprised 160 patients with severe asthma, monitored for 180 days in order to evaluate adherence (dependent variable) to the prescribed inhaled corticosteroid. Independent variables were assessed at baseline and for a six-month follow-up period by means of interviews and the completion of a standardized questionnaire. Patients recorded the missed doses in a diary. Results: Of the 160 patients, 158 completed the study. Adherence rate was 83.8%. Of the 158 patients, 112 (70.9%) were considered adherent (cut-off point: 80% of prescribed doses administered). There was a significant association between asthma control and adherence to treatment. Predictors of poor adherence were adverse effects, living far from the referral center, limited resources to pay for transportation and dose schedule. Other factors, such as depressive symptoms, religion and economic status, were not associated with poor adherence. Conclusions: Adherence to asthma treatment was high and was associated with the clinical response to treatment, in a sample of patients with severe asthma enrolled in a public program that provides free medication and the assistance of a multiprofessional specialized team in a referral center.


Keywords: Asthma; Directly observed therapy; Treatment outcome; Patient compliance; Pharmacy.


4 - Influence of pleural drainage on postoperative pain, vital capacity and six-minute walk test after pulmonary resection.

Influência do dreno pleural sobre a dor, capacidade vital e teste de caminhada de seis minutos em pacientes submetidos à ressecção pulmonar

Vanessa Pereira de Lima, Daniela Bonfim, Thais Telles Risso, Denise de Moraes Paisani, Julio Flavio Fiore Junior, Luciana Dias Chiavegato, Sonia Maria Faresin.

J Bras Pneumol.2008;34(12):1003-1007

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. Methods: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. Results: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p= 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). Conclusions: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.


Keywords: Thoracic surgery; Exercise test; Respiratory function tests; Pain, postoperative.


5 - Validation of the Modified Pulmonary Functional Status and Dyspnea Questionnaire and the Medical Research Council scale for use in Brazilian patients with chronic obstructive pulmonary disease

Validação do Modified Pulmonary Functional Status and Dyspnea Questionnaire e da escala do Medical Research Council para o uso em pacientes com doença pulmonar obstrutiva crônica no Brasil

Demetria Kovelis, Nicoli Oldemberg Segretti, Vanessa Suziane Probst, Suzanne Claire Lareau, Antônio Fernando Brunetto, Fábio Pitta

J Bras Pneumol.2008;34(12):1008-1018

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To determine the validity and reproducibility of two subjective instruments to assess limitations in activities of daily living (ADLs) in patients with chronic obstructive pulmonary disease (COPD) in Brazil: the Pulmonary Functional Status and Dyspnea ­Questionnaire ‑ ­Modified version (PFSDQ-M) and the Medical Research Council (MRC) scale. Methods: Thirty patients with COPD (age, 67 ± 10 years; males, 17; forced expiratory volume in one second, 42% ± 13% of predicted) completed the Portuguese-language versions of the two instruments on two occasions, one week apart. The PFSDQ-M has three components: influence of dyspnea on ADLs, influence of fatigue on ADLs and change experienced by the patient with ADLs. The MRC scale is simple, with only five items, in which patients report the degree to which dyspnea limits their performance of ADLs. The traditional Saint George's Respiratory Questionnaire (SGRQ), previously validated for use in Brazil, was used as a validation criterion. Results: The test-retest reliability (intraclass correlation coefficient) of the PFSDQ-M was 0.93, 0.92 and 0.90 for the dyspnea, fatigue and change components, respectively, compared with 0.83 for the MRC scale. Bland-Altman plots showed good test-retest concordance for the PFSDQ-M. The components of the PFSDQ-M and the MRC scale correlated significantly with all of the domains and the total score on the SGRQ (0.49 < r < 0.80; p < 0.01 for all). Conclusions: The Portuguese-language versions of the PFSDQ-M and the MRC scale proved reproducible and valid for use in patients with COPD in Brazil.


Keywords: Pulmonary disease, chronic obstructive; Activities of daily living; Validation studies.


6 - Determination of alpha 1-antitrypsin levels and of the presence of S and Z alleles in a population of patients with chronic respiratory symptoms

Avaliação da concentração de alfa 1-antitripsina e da presença dos alelos S e Z em uma população de indivíduos sintomáticos respiratórios crônicos

Heliane Guerra Serra, Carmen Sílvia Bertuzzo, Mônica Corso Pereira, Cláudio Lúcio Rossi, Walter Pinto Júnior, Ilma Aparecida Paschoal

J Bras Pneumol.2008;34(12):1019-1025

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To determine the levels of alpha-1 antitrypsin (AAT) and the presence of S and Z alleles in patients with chronic respiratory symptoms. Methods: Patients with chronic cough and dyspnea were submitted to clinical evaluation, pulmonary function tests, high-resolution computed tomography, nephelometric determination of AAT and determination of S and Z alleles by polymerase chain reaction. Smoking and AAT levels were considered the dependent variables. Results: Of the 89 patients included in the study, 44 were female. The mean age was 51.3 ± 18.2 years. The S and Z alleles were detected in 33.3% and 5.7%, respectively, and the gene frequency was 0.16 and 0.028, respectively. Two patients were SZ heterozygotes (AAT levels ≤ 89 mg/dL). The patients were divided into groups based on AAT level: ≤ 89 mg/­dL (deficiency, no group); 90-140 mg/dL (intermediate, Group 1, n = 30); and ≥ 141 mg/dL (normal, Group 2, n = 57). The frequency of smokers was the same in both groups, although tobacco intake was greater in Group 2. The S allele was present in 13 and 14 patients in Groups 1 and 2, respectively, whereas the Z allele was present in 2 and 1 patient in the same groups. There was no difference in the results of pulmonary function tests or in the frequency of bronchiectasis or emphysema between the two groups. Spirometric values and AAT levels were similar in smokers and nonsmokers. Bronchiectasis was more common in nonsmokers, and emphysema was more common in smokers. Conclusions: Thirty patients presented AAT levels lower than the mean values found in patients with the MM or MS genotype, and this fact could not be explained by an increased frequency of S and Z alleles.


Keywords: Alpha 1-antitrypsin; Emphysema: Lung diseases; Alleles.


7 - Influence of oscillating positive expiratory pressure and the forced expiratory technique on sputum cell counts and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease.

Influência da técnica de pressão expiratória positiva oscilante e da técnica de expiração forçada na contagem de células e quantidade do escarro induzido em portadores de asma ou doença pulmonar obstrutiva crônica

Ana Lúcia Bernardo de Carvalho Morsch, Maria Marta Amorim, Andréa Barbieri, llka Lopes Santoro, Ana Luisa Godoy Fernandes

J Bras Pneumol.2008;34(12):1026-1032

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To evaluate whether respiratory therapy techniques influence the number of cells within and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease (COPD). Methods: Randomized clinical trial, in which patients with asthma or COPD under intervention (n = 16 and 10, respectively) were compared with control groups (n = 16 and 10). Patients in the asthma/intervention (A/I) and COPD/intervention (C/I) groups were submitted to oscillating positive expiratory pressure maneuvers for 5 min, followed by 10 forced expiratory technique sequences. These patients were also submitted to an induced sputum protocol with inhaled hypertonic saline (3%, 4% or 5%; A/I group) or inhaled isotonic saline (C/I group). The asthma/control (A/C) and COPD/control (C/C) groups were submitted only to the standard induced sputum protocol. Results: The final mean weight of the sputum samples was significantly greater in the A/I group than in the A/C group (2,767.25 ± 998.08 mg vs. 1,689.17 ± 1,189.96 mg; p = 0.03). The mean/median total cell counts (×106/mL) were higher in the A/I and C/I groups than in the A/C and C/C groups (4.06/0.95 and 0.63/0.39, p = 0.05, vs. 5.08/1.77 and 0.64/0.40, p = 0.02). There were no statistically significant differences among the groups in terms of cell viability. Conclusions: The use of respiratory therapy techniques can increase sputum sample weight in asthma patients, as well as increasing total cell counts in patients with asthma or COPD.


Keywords: Asthma; Pulmonary disease, obstructive chronic; Sputum; Physical therapy modalities.


8 - Laboratorial validation of an automated assay for the determination of adenosine deaminase activity in pleural fluid and cerebrospinal fluid

Validação laboratorial de um método automatizado de dosagem da atividade de adenosina desaminase em líquido pleural e em líquido cefalorraquidiano

Márcia Cristina Feres, Maria Cristina De Martino, Suely Maldijian, Fernando Batista, Alexandre Gabriel Júnior, Sérgio Tufik

J Bras Pneumol.2008;34(12):1033-1039

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: The incidence of tuberculosis worldwide has emphasized the need for better assays designed to diagnose the disease, principally the extrapulmonary form. The objective of the present study was to validate the performance of an automated method for the determination of adenosine deaminase (ADA) activity in pleural fluid (PF) and cerebrospinal fluid (CSF), comparing it with a conventional method (the modified Giusti method). Methods: In total, 134 samples were selected from among those tested in our laboratory: 94 PF samples and 40 CSF samples. The ADA activity was determined using the two methods. Inter- and intra-assay precision was determined, linear regression analysis was performed, simple concordance tests were conducted, and the means of the differences were calculated. Results: The correlation coefficients for PF and CSF samples were, respectively, 0.96 and 0.95. Inter-assay precision was determined using 21 replicates at 3 different activity levels: low, medium and high. The percentage coefficient of variation (%CV) was, respectively, 5.9, 8.1 and 5.8 for PF samples, compared with 21.9, 18.6 and 13.8 for CSF samples. Intra-assay precision in %CV was 1.3 and 11.7, respectively, for PF and CSF samples. The concordance between the methods in PF and CRF samples was, respectively, 96.8% and 100%, considering the reference values for the diagnosis of TB to be 40 U/L (conventional) and 30 U/L (automated) in PF samples, versus 9 U/L (for both methods) in CSF samples. Conclusions: The results validate the use of the automated method of determining ADA activity in PF and CSF samples as an alternative to the conventional method.


Keywords: Adenosine deaminase; Tuberculosis/diagnosis; Pleural effusion; Cerebrospinal fluid.


9 - Esophageal manometry and 24-h esophageal pH-metry in a large sample of patients with respiratory symptoms

Esofagomanometria e pHmetria esofágica de 24 h em uma ampla amostra de pacientes com manifestações respiratórias

Mirna da Mota Machado, Paulo Francisco Guerreiro Cardoso, Iana Oliveira e Silva Ribeiro, Idílio Zamin Júnior, Rene Jacobsen Eilers

J Bras Pneumol.2008;34(12):1040-1048

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate the esophageal motor profile of patients with respiratory symptoms referred to a digestive motility referral center for esophageal function testing. Methods: The results of esophageal manometry and 24-h esophageal pH-metry were analyzed. The inclusion criterion was presenting respiratory symptoms, with or without accompanying digestive symptoms. Results: Of the 1,170 patients included in the study, 602 (51.5%) reported having digestive and respiratory symptoms (DRS group), and 568 (48.5%) reported having only respiratory symptoms (RS group). Asthma was diagnosed in 142 patients in the RS group (RS-A subgroup) and in 201 of those in the DRS group (DRS-A subgroup). Of the 346 cases of esophageal dysmotility, hypomotility was found in 175 (14.3% and 15.6% in the DRS and RS groups, respectively), and lower esophageal sphincter (LES) hypotonia was found in 411 (40.3% and 30.2%, respectively). Hypotonia correlated with GERD. Exposure of the distal esophagus to acid was markedly abnormal in the supine position. The prevalence of GERD in the sample as a whole, the RS-A/DRS-A subgroups and the RS-A subgroup alone was 39.8%, 44.0% and 35.2%, respectively. Conclusions: Hypotonic LES was the most common abnormality and correlated with GERD. Although GERD was more evident in the DRS group, approximately one third of the patients in the RS group also presented GERD (silent GERD). The findings suggest that GERD can be an extrapulmonary cause of chronic respiratory symptoms unresponsive to conventional therapy.


Keywords: Gastroesophageal reflux; Signs and symptoms, respiratory; Asthma; Esophageal pH monitoring; Manometry.


10 - Adverse effects of tuberculosis treatment: experience at an outpatient clinic of a teaching hospital in the city of São Paulo, Brazi

Efeitos adversos no tratamento da tuberculose: experiência em serviço ambulatorial de um hospital-escola na cidade de São Paulo

Denise Eri Onodera Vieira, Mauro Gomes

J Bras Pneumol.2008;34(12):1049-1055

Abstract PDF PT PDF EN Portuguese Text

Abstract Objectives: To determine the frequency of adverse effects related to the use of the tuberculosis treatment regimen designated Regimen I and the need for regimen alterations due to these effects. Methods: A retrospective analysis of 329 medical charts of patients who were treated with Regimen I and discharged after cure between March 2000 and April 2006 was carried out at the Tuberculosis Outpatient Clinic, Department of Pulmonology of the Santa Casa de Misericórdia de São Paulo Hospital in the city of São Paulo, Brazil. Adverse effects and the timing of their appearance, as well as subsequent modifications in the treatment regimen, were investigated. Results: We included 297 patients, 146 (49.1%) of whom presented one or more adverse effects related to antituberculosis medications. The frequency of minor side effects was 41.1%, and that of major side effects was 12.8%. The most common reactions were those involving the gastrointestinal tract (40.3%) and the skin (22.1%). Adverse effects were more common in the first and second months of treatment (58.4%). Modification of the treatment regimen was necessary in 11 cases (3.7% of the total sample). Drug-induced hepatitis was the adverse effect that demanded the most regimen changes. Conclusions: In this group of patients, the frequency of adverse effects related to treatment with Regimen I was 49.1%. However, in most of the cases, it was not necessary to modify the treatment regimen due to side effects.


Keywords: Tuberculosis/therapy; Antitubercular agents/adverse effects; Hepatitis, toxic.


11 - Conventional and molecular techniques in the diagnosis of pulmonary tuberculosis: a comparative study

Métodos convencionais e moleculares para o diagnóstico da tuberculose pulmonar: um estudo comparativo

Stella Sala Soares Lima, Wanessa Trindade Clemente, Moisés Palaci, Reinaldo Vieira Rosa, Carlos Maurício de Figueiredo Antunes, José Carlos Serufo

J Bras Pneumol.2008;34(12):1056-1062

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To compare four laboratory methods in the diagnosis of pulmonary tuberculosis. Methods: Respiratory secretion specimens were collected from 160 patients suspected of having pulmonary tuberculosis. Direct testing for Mycobacterium tuberculosis was carried out using Ziehl-Neelsen staining, auramine staining, culture on Löwenstein-Jensen (LJ) medium and polymerase chain reaction (PCR). The strains isolated were identified by means of a radiometric method using p-nitro-alpha-acetylamino-beta-hydroxypropiophenone (NAP) and classical methods. The sensitivity of the methods was compared to the gold standard for the diagnosis of pulmonary tuberculosis, based on clinical, radiological and microbiological criteria. Results: Of the 160 patients, 142 were diagnosed with pulmonary tuberculosis according to the gold standard. The sensitivity of Ziehl-Neelsen staining, auramine staining, culture on LJ medium and PCR was 54.2%, 58.4%, 67.6% and 77.5%, respectively, when compared with the diagnostic criterion adopted. All four methods presented 100% specificity. In the identification of mycobacteria, there was high (96.8%) concordance between PCR and the radiometric method using NAP. The sensitivity of PCR was 50.8% in samples with negative sputum smear microscopy results and 98.8% in those with positive results. The sensitivity of PCR was lower in specimens with negative results in sputum smear microscopy and culture than in those with positive results (25.6% and 99.0%, respectively). Conclusions: We found PCR to be a promising method for the diagnosis of pulmonary tuberculosis, even in paucibacillary specimens. Simultaneous identification and faster results are additional advantages of this method.


Keywords: Tuberculosis, pulmonary/diagnosis; Culture media; Polymerase chain reaction; Sputum/microbiology.


Brief Communication

12 - Molecular diversity of Mycobacterium tuberculosis strains in a slum area of Rio de Janeiro, Brazil

Diversidade molecular de cepas de Mycobacterium tuberculosis em uma região de favela da cidade do Rio de Janeiro

Joycenea Matsuda Mendes, Silvia Maria Almeida Machado, Maria Cristina Lourenço, Rosa Maria Carvalho Ferreira, Leila de Souza Fonseca, Maria Helena Feres Saad

J Bras Pneumol.2008;34(12):1063-1068

Abstract PDF PT PDF EN Portuguese Text

This retrospective molecular study involving restriction fragment length polymorphism, using insertion sequence 6110 as a marker, was conducted in order to provide an initial insight into the genetic diversity of Mycobacterium tuberculosis strains isolated in the slums of the Complexo de Manguinhos, located in the city of Rio de Janeiro, Brazil. Of the 67 strains evaluated, 23 (34.3%) were found to belong to clusters (total clusters, 10). Household and social chains of transmission were associated with clustering, in 20% and 60%, respectively. Living in the Conjunto Habitacional Programado 2 slum was associated with clustering. Although not significant, it is relevant that 26% of the clustered strains presented primary resistance. These findings, although possibly underestimating the prevalence due to the failure to analyze all strains, could help improve the local tuberculosis control program.


Keywords: Tuberculosis; Epidemiology, molecular; Mycobacterium tuberculosis/transmission; Polymorphism, Restriction Fragment Length.


Review Article

13 - Noncigarette forms of tobacco use

Formas não habituais de uso do tabaco

Carlos Alberto de Assis Viegas

J Bras Pneumol.2008;34(12):1069-1073

Abstract PDF PT PDF EN Portuguese Text

There are many preparations for tobacco use, which can be classified as smoking or smokeless tobacco. Among the noncigarette preparations that produce smoke, we cite cigars, pipes and narghiles. Smokeless tobacco can be found in preparations for chewing or for being absorbed by nasal and oral mucosae (snuff). However, all tobacco products deliver nicotine to the central nervous system, and there is a confirmed risk of dependence. In addition, there is no safe form of tobacco use, and tobacco users have a significantly increased risk of morbidity and premature mortality due to tobacco-related diseases.


Keywords: Smoking; Tobacco; Tobacco, smokeless; Tobacco industry; Nicotine.


Case Report

14 - Kikuchi-Fujimoto disease

Doença de Kikuchi-Fujimoto

Rogério Gastal Xavier, Denise Rossato Silva, Mauro Waldemar Keiserman, Maria Francisca Torres Lopes

J Bras Pneumol.2008;34(12):1074-1078

Abstract PDF PT PDF EN Portuguese Text

Kikuchi-Fujimoto disease is characterized by fever and lymphadenopathy, usually localized in the cervical region. This disease principally affects young females. It can be confused with lymphoma, adenocarcinoma metastasis and tuberculosis. We report two cases of Kikuchi‑Fujimoto disease. In the first case, a 28-year-old female had been treated for tuberculosis one year prior and presented with a clinical and histological profile consistent with Kikuchi-Fujimoto disease. The second patient, a 58-year-old female, initially received treatment for Wegener's granulomatosis and, subsequently, for tuberculosis. Histopathological examination followed by immunohistochemical analysis confirmed the diagnosis of Kikuchi-Fujimoto disease in both cases. After the definitive diagnosis had been made, both patients were treated symptomatically, and both presented clinical improvement within one month. Subsequently, the latter patient developed systemic lupus erythematosus.


Keywords: Fever; Lymph nodes; Rare diseases; Tuberculosis, lymph node; Histiocytic necrotizing lymphadenitis; Lupus erythematosus, systemic.


15 - Septic pulmonary embolism secondary to jugular thrombophlebitis: a case of Lemierre's syndrome

Embolia pulmonar séptica secundária à tromboflebite jugular: um caso de síndrome de Lemierre

Denise Rossato Silva, Marcelo Basso Gazzana, Ricardo Albaneze, Paulo de Tarso Roth Dalcin, Josi Vidart, Nei Gulcó

J Bras Pneumol.2008;34(12):1079-1083

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Abstract Lemierre's syndrome is characterized by acute oropharyngeal infection, complicated by internal jugular venous thrombosis secondary to septic thrombophlebitis, and by metastatic infections in various distant organs-most commonly in the lungs. We report a case of Lemierre's syndrome in a 56-year-old female who presented with right-sided neck mass and fever. Right internal jugular venous thrombosis was demonstrated on an ultrasound. A computed tomography scan of the chest revealed multiple opacities throughout both lungs. An open surgical biopsy was performed due to suspicion of pulmonary metastases. Anatomopathological examination revealed septic emboli in lung parenchyma. Retrospectively, the patient reported a history of pharyngitis two weeks prior to hospitalization. After the diagnosis had been made, the patient was treated with broad-spectrum antibiotics (cefuroxime for 7 days and azithromycin for 5 days; subsequently, because fever persisted, cefepime for 7 days). One month later, a computed tomography scan of the chest revealed resolution of the opacities.


Keywords: Pulmonary embolism; Lung abscess; Thrombophlebitis; Jugular veins; Pharyngitis.


Case Series

16 - Laryngotracheobronchial papillomatosis: findings on computed tomography scans of the chest

Papilomatose laringotraqueobrônquica: aspectos em tomografia computadorizada de tórax

Edson Marchiori, Cesar de Araujo Neto, Gustavo Souza Portes Meirelles, Klaus Loureiro Irion, Gláucia Zanetti, Israel Missrie, Juliana Sato

J Bras Pneumol.2008;34(12):1084-1089

Abstract PDF PT PDF EN Portuguese Text

Abstract Objective: To present the findings of computed tomography (CT) scans of the chest in patients with laryngotracheobronchial papillomatosis. Methods: We retrospectively analyzed CT scans of eight patients, five males and three females, ranging from 5 to 18 years of age with a mean age of 10.5 years. Images were independently reviewed by two radiologists. In discrepant cases, a consensus was reached. Results: The most common CT findings were intratracheal polypoid lesions and pulmonary nodules, many of which were cavitated. Conclusions: In patients with laryngotracheobronchial papillomatosis, the most common tomographic finding was the combination of intratracheal polypoid lesions and multiple pulmonary nodules, many of which were cavitated.


Keywords: Tomography, X-ray computed; Papilloma; Tracheal neoplasms.





J Bras Pneumol.2008;34(12):1090

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Index of Issues

18 - SUBJECT INDEX FOR V.34 (1-12)


J Bras Pneumol.2008;34(12):1091-1095

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Index of Authors

19 - AUTHOR INDEX FOR V.34 (1-12)


J Bras Pneumol.2008;34(12):1096-1103

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Relationship of Reviewers

20 - REVIEWERS - 2008


J Bras Pneumol.2008;34(12):1104-1108

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