Brazilian Journal of Pulmonology

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


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Year 2009 - Volume 35  - Number 1  (/January)


1 - Surgical treatment of emphysema

Tratamento cirúrgico do enfisema

José de Jesus Peixoto Camargo

J Bras Pneumol.2009;35(1):1-6

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Original Article

2 - Prevalence of asthma in children and adolescents in a city in the Brazilian Amazon region

Prevalência de asma em escolares e adolescentes em um município na região da Amazônia brasileira

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

J Bras Pneumol.2009;35(1):7-13

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Objective: To analyze the prevalence of asthma and asthma symptoms in students of two distinct age brackets residing in the city of Tangará da Serra, Brazil. Methods: Cross-sectional, population-based study of the prevalence of asthma in children from 6 to 7 years of age and adolescents from 13 to 14, using the standardized International Study of Asthma and Allergies in Childhood, phase 1 questionnaire, validated for use in Brazil. Students who responded affirmatively to question 2 (presence of wheezing in the preceding 12 months) were classified as suffering from asthma. Results: The study comprised 3,362 students, of whom 1,634 (48.6%) were children and 1,728 (51.4%) were adolescents. Of the 1,634 children, 816 (49.9%) were male and 818 (50.1%) were female. Of the 1,728 adolescents, 773 (45.0%) were male and 955 (55.0%) were female. The prevalence of asthma among the children was 25.2%, whereas that among the adolescents was 15.9% (χ2 = 8.34; p = 0.00). The children presented higher prevalences of the following symptoms of asthma than did the adolescents: wheezing ever (54.3%), nocturnal dry cough (43.9%), wheezing in the preceding 12 months (25.2%), and from 1 to 3 attacks of wheezing in the preceding 12 months (19.1%). There were no differences between the two groups regarding physician-diagnosed asthma (approximately 4.5%). There were no statistical differences regarding the prevalence of asthma by gender in the two groups. Conclusions: Tangará da Serra has a high prevalence of asthma in children and adolescents, and this result is compatible with other studies carried out in Brazil and Latin America using the same methodology.


Keywords: Asthma/epidemiology; Child; Adolescent.


3 - Therapeutic application of collateral ventilation with pulmonary drainage in the treatment of diffuse emphysema: report of the first three cases

Aplicação terapêutica da ventilação colateral com drenagem pulmonar no tratamento do enfisema pulmonar difuso: relato dos três primeiros casos

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

J Bras Pneumol.2009;35(1):14-19

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Objective: To report the results obtained in three patients with diffuse pulmonary emphysema during the pre- and post-operative periods following a new surgical technique: collateral ventilation with lung parenchyma drainage. Methods: Patients suffering from pulmonary failure and disabling dyspnea, despite having received the gold standard treatment, including pulmonary rehabilitation, were selected for the evaluation of pulmonary drainage. During the pre- and post-operative periods, patients were submitted to plethysmography and six-minute walk tests, as well as completing the following quality of life questionnaires: Medical Outcomes Study 36-item Short-Form Health Survey, Saint George's Respiratory Questionnaire, Eastern Cooperative Oncology Group Performance Status and Medical Research Council Scale. In all three cases, the post-operative follow-up period was at least 300 days. The tests were performed at the following time points: during the pre-operative period; between post-operative days 30 and 40; and on post-operative day 300. Data were analyzed using profile plots of the means. Results: When the results obtained in the pre-operative period were compared to those obtained at the two post-operative time points evaluated, improvements were observed in all parameters studied. Conclusions: The results suggest that the surgical technique proposed for the treatment of patients suffering from severe diffuse emphysema successfully reduces the debilitating symptoms of these patients, improving their quality of life considerably.


Keywords: Pulmonary emphysema; Lung diseases, obstructive; Lung, hyperlucent.


4 - Influence of lean body mass on cardiopulmonary repercussions during the six-minute walk test in patients with COPD

Influência da massa magra corporal nas repercussões cardiopulmonares durante o teste de caminhada de seis minutos em pacientes com DPOC

Nilva Regina Gelamo Pelegrino, Paulo Adolfo Lucheta, Fernanda Figueirôa Sanchez, Márcia Maria Faganello, Renata Ferrari, Irma de Godoy

J Bras Pneumol.2009;35(1):20-26

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Objective: Although lean body mass (LBM) has been associated with mortality in patients with COPD, its influence on functional limitation is not clear. The objective of this study was to analyze the cardiopulmonary variables in COPD patients with or without LBM depletion, prior to and after the six-minute walk test (6MWT). Methods: We evaluated COPD patients, 32 with LBM depletion and 36 without. All patients underwent clinical evaluation, spirometry, evaluation of body mass composition and 6MWT, as well as completing questionnaires related to quality of life and perception of dyspnea. Results: No significant differences in the severity of airway obstruction, perception of dyspnea and quality of life scores were found between the groups. The distance covered on the 6MWT was similar in COPD patients with and without LBM depletion (470.3 ± 68.5 m vs. 448.2 ± 89.2 m). However, patients with LBM depletion presented significantly greater differences between baseline and final values in terms of heart rate and Borg scale index for lower limb fatigue. There was a significant positive correlation between distance covered on the 6MWT and FEV1 (r = 0.381, p = 0.01).Conclusions: In the patients studied, functional exercise tolerance and quality of life were unaffected by LBM depletion. However, the patients with LBM depletion presented more pronounced lower limb fatigue during the 6MWT, which underscores the importance of the evaluation and treatment of systemic manifestations in COPD patients.


Keywords: Body mass index; Pulmonary disease, chronic obstructive; Exercise tolerance.


5 - Perception of disease severity in adult patients with cystic fibrosis

Percepção da gravidade da doença em pacientes adultos com fibrose cística

Paulo de Tarso Roth Dalcin, Greice Rampon, Lílian Rech Pasin, Sinara Corrêa Becker, Gretchem Mesquita Ramon, Viviane Ziebell de Oliveira

J Bras Pneumol.2009;35(1):27-34

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Objective: To evaluate the perception of disease severity in patients with cystic fibrosis (CF), investigating its relationship with clinical score, radiographic score, respiratory function tests, adherence to treatment and perception of self-care practices. Methods: Prospective, cross-sectional study involving CF patients treated in a program for adults with CF. The perception of disease severity, adherence to treatment and reported self-care practices were evaluated by means of questionnaires. Clinical data, Shwachman-Kulczycki clinical score, Brasfield radiographic score and spirometry were obtained for all of the patients. Results: Of the 38 patients studied, 3 (7.9%) patients rated their perception of health status as well below average; 5 (13.2%), as below average; 15 (39.5%), as average; 10 (26.3%), as above average; and 5 (13.2%), as well above average. The perception of disease severity correlated significantly with clinical score (r = 0.43, p = 0.007), FVC (r = 0.34, p = 0.034), FEV1 (r = 0.38, p = 0.019) and self-care practices (r = 0.33, p = 0.044), but not with degree of adherence (r = -0.03, p = 0.842) and radiographic score (r = 0.33, p = 0.51). Conclusions: The perception of disease severity correlated with objective measurements of disease severity (clinical score and respiratory function tests) and with reported self-care practices, but not with adherence to treatment.


Keywords: Severity of illness index; Cystic fibrosis; Patient compliance; Respiratory function tests.


6 - Pulmonary deposition of inhaled tobramycin prior to and after respiratory therapy and use of inhaled albuterol in cystic fibrosis patients colonized with Pseudomonas aeruginosa

Deposição pulmonar de tobramicina inalatória antes e após fisioterapia respiratória e uso de salbutamol inalatório em pacientes com fibrose cística colonizados por Pseudomonas aeruginosa

Milena Baptistella Grotta, Elba Cristina de Sá Camargo Etchebere, Antonio Fernando Ribeiro, Juliana Romanato, Maria Ângela Gonçalves de Oliveira Ribeiro, José Dirceu Ribeiro

J Bras Pneumol.2009;35(1):35-43

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Objective: To evaluate whether respiratory therapy followed by the use of inhaled albuterol modifies the pulmonary deposition of inhaled tobramycin in patients with cystic fibrosis (CF) and whether pulmonary deposition correlates with disease severity or genotype. Methods: A prospective study was carried out including patients with CF older than 6 years of age and colonized with Pseudomonas aeruginosa. Exclusion criteria were pulmonary exacerbation, changes in therapy between the study phases and FEV1 < 25%. All patients were submitted to pulmonary scintigraphy by means of a scintillation camera equipped with a low-energy all-purpose collimator in order to evaluate drug penetration following the administration of inhaled 99mTc-tobramycin, as well as to pulmonary perfusion with 99mTc-macroaggregated albumin (phase 1). One month later, the same procedure was performed following respiratory therapy and administration of inhaled albuterol (phase 2). Results: We included 24 patients (12 males) aged 5-27 years (mean ± SD: 12.85 ± 6.64 years). The Shwachman score (SS) was excellent/good in 8 patients, moderate/fair in 16 and poor in 0. Genotyping revealed that 7 patients were ΔF508 homozygotes, 13 were ΔF508 heterozygotes; and 4 presented other mutations. In all patients, lung deposition of tobramycin decreased in phase 2, especially in those with moderate/fair SS (p = 0.017) and in heterozygotes (p = 0.043). Conclusions: The use of a respiratory therapy technique and the administration of inhaled albuterol immediately prior to the use of inhaled tobramycin decreased the pulmonary deposition of the latter in CF patients, and this reduction correlates with disease severity and genotype.


Keywords: Cystic fibrosis; Tobramycin; Respiratory therapy; Albuterol; Radionuclide imaging.


7 - Prevalence of temporary social security benefits due to respiratory disease in Brazil

Prevalência de benefícios de seguridade social temporários devido a doença respiratória no Brasil

Simone de Andrade Goulart Ildefonso, Anadergh Barbosa-Branco, Paulo Rogério Albuquerque-Oliveira

J Bras Pneumol.2009;35(1):44-53

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Objective: To determine the prevalence of temporary social security benefits due to respiratory disease granted to employees, as well as the number of lost workdays and costs resulting from those in Brazil between 2003 and 2004. Methods: Cross-sectional study using data obtained from the Unified System of Benefits of the Brazilian Institute of Social Security (INSS, Instituto Nacional de Seguro Social) and the Brazilian Social Registry Database. Data regarding gender, age, diagnosis and type of economic activity, as well as type, duration and cost of benefits, were compiled. Results: Respiratory diseases accounted for 1.3% of the total number of temporary social security benefits granted by INSS, with a prevalence rate of 9.92 (per 10,000 employment contracts). Females and individuals older than 50 years of age were the most affected. Non-work-related benefits were more common than were work-related benefits. The most prevalent diseases were pneumonia, asthma and COPD, followed by laryngeal and vocal cord diseases. The most prevalent types of economic activity were auxiliary transportation equipment manufacturing, tobacco product manufacturing and computer-related activities. The mean duration of benefits was 209.68 days, with a mean cost of R$ 4,495.30 per occurrence. Respiratory diseases caused by exogenous agents demanded longer sick leave (mean, 296.72 days) and greater cost (mean, R$ 7,105.74). Conclusions: The most prevalent diseases were airway diseases and pneumonia. Workers from auxiliary transportation equipment manufacturing, tobacco product manufacturing and computer-related activities were the most affected. Diseases caused by exogenous agents demanded longer sick leaves and resulted in greater costs.


Keywords: Respiratory tract diseases; Sick leave; Work; Workers' compensation; Social security.


8 - Clinical evolution of a group of patients with multidrug-resistant TB treated at a referral center in the city of Rio de Janeiro, Brazil

Evolução clínica de um grupo de pacientes com TB multirresistente atendidos em um centro de referência na cidade do Rio de Janeiro

Helio Ribeiro de Siqueira, Flávia Alvim Dutra de Freitas, Denise Neves de Oliveira, Angela Maria Werneck Barreto, Margareth Pretti Dalcolmo, Rodolpho Mattos Albano

J Bras Pneumol.2009;35(1):54-62

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Objective: To analyze the clinical characteristics and evolution of a group of patients with positive sputum cultures for multidrug-resistant (MDR) Mycobacterium tuberculosis and treated at a referral center in the city of Rio de Janeiro, Brazil. Methods: Based on the positive results in sputum cultures for MDR M. tuberculosis, 50 patients were selected, and their clinical data were obtained from the Brazilian Ministry of Health MDR-TB Database. The frequencies of noncompliance, relapses, failures and previous treatments for TB up to diagnosis of MDR-TB were compiled. The radiological patterns were classified as unilateral or bilateral, and with or without cavitation. Two years after the end of the standard treatment for MDR-TB, the outcome (cure, failure, noncompliance or death) for each patient was evaluated and reassessed every two years. The post-treatment follow-up period was eight years. Results: The mean number of previous treatments was 2.3 ± 0.9. The mean interval between the initial diagnosis and the development of MDR-TB was 2.0 ± 1.7 years. Two years after the initial treatment for MDR-TB, 2 patients had abandoned treatment, 8 had died, 18 had been cured, and 22 had presented treatment failure. The bivariate analysis showed that bilateral pulmonary involvement and cavitary pattern markedly reduced the chances for cure, with a relative risk of 1-0.6 (40%) and 1-0.7 (30%), respectively. At the end of the follow-up period, 2 patients had abandoned treatment, 9 had presented treatment failure, 17 had been cured, and 22 had died. Conclusions: Bilateral pulmonary involvement and cavity pattern greatly reduced the chances for cure of the patients with MDR-TB. Most patients who presented treatment failure died within the 8-year follow-up period.


Keywords: Tuberculosis, multidrug-resistant; Treatment outcome; Disease-free survival; Treatment refusal; Treatment failure.


9 - Prevalence of active and latent TB among inmates in a prison hospital in Bahia, Brazil

Prevalência de TB ativa e TB latente em internos de um hospital penal na Bahia

Antônio Carlos Moreira Lemos, Eliana Dias Matos, Carolina Nunes Bittencourt

J Bras Pneumol.2009;35(1):63-68

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Objective: To determine the prevalence of latent and active TB among detainees in a prison hospital in Bahia, Brazil. Methods: A cross-sectional study with prospective data collection was carried out comprising 237 inmates in the Bahia State Prison Hospital between July 2003 and April 2004. A standardized questionnaire was applied and completed by medical students. The detainees were systematically submitted to the following tests: tuberculin skin test, chest X-ray (anteroposterior), sputum smear microscopy and culture for mycobacteria. The events of interest were active TB and latent TB. Results: The mean age of the participants was 36.6 years, and 89.9% were male. Smoking and alcohol consumption were reported by 70.0% and 43.9% of the inmates, respectively. A history of treatment for TB was reported by 11.3% of the inmates. Of the inmates evaluated, 36.3% reported cough and 31.4% reported expectoration. Other less common symptoms were asthenia (in 26.2%), weight loss (in 23.1%), loss of appetite (in 17.7%), fever (in 11.3%) and hemoptysis (in 6.7%). Of the 86 inmates tested, none presented positive HIV serology. The prevalence of latent TB was 61.5% (96 of the 156 inmates submitted to tuberculin skin tests), whereas that of active TB was 2.5% (6 of the 237 inmates evaluated). The presence of cough was a determinant of active TB (prevalence ratio = 8.8; 95% CI: 1.04-73.9; p = 0.025). Conclusions: Active and latent TB are highly prevalent among inmates hospitalized in the Bahia State Prison Hospital. Our findings justify the need to implement public policies specifically directed towards the control of TB in this population.


Keywords: Tuberculosis; Prisons; Hospitals; Prevalence.


Brief Communication

10 - Design and evaluation of a device for collecting exhaled breath condensate

Diseño y evaluación de un equipo para obtener aire espirado condensado

Oscar Florencio Araneda Valenzuela, Maria Paulina Salazar Encina

J Bras Pneumol.2009;35(1):69-72

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In recent years, the analysis of exhaled breath condensate samples has been given great weight as a noninvasive methodology of studying physiology and lung diseases. The present study describes a device for measuring exhaled breath condensate that is affordable, easily constructed, portable and suitable for use in the field, as well as allowing the collection of simultaneous samples. The results obtained with this device in terms of the concentrations of pH, hydrogen peroxide and nitrite, metabolites related to inflammatory and oxidative damage, in exhaled breath condensate samples are comparable to those obtained with other devices previously described.


Keywords: Exhalation; Lung diseases; Equipment design.



11 - Psychometric properties of the Fagerström Test for Nicotine Dependence

As propriedades psicométricas do Teste de Fagerström para Dependência de Nicotina

Izilda Carolina de Meneses-Gaya, Antonio Waldo Zuardi, Sonia Regina Loureiro, José Alexandre de Souza Crippa

J Bras Pneumol.2009;35(1):73-82

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Objective: The Fagerström Test for Nicotine Dependence (FTND) is a screening instrument for physical nicotine dependence and is extensively used in various countries. The objective of the present report was to review articles related to the psychometric properties of the FTND. Methods: A systematic search for articles published up through December of 2007 was carried out in various electronic databases. The following search terms were used: "Fagerström Test for Nicotine Dependence"; "FTND"; "psychometric"; "validity"; "reliability"; "feasibility"; and "factors". We included articles published in English, Spanish or Portuguese and in which the psychometric properties of the FTND were evaluated. Results: Twenty-six studies related to the psychometric properties of the FTND were identified in the indexed literature. Analysis of the studies confirmed the reliability of the FTND for the assessment of nicotine dependence in different settings and populations. Conclusions: Further validation studies using previously validated instruments as a comparative measure are needed before the extensive use of the FTND can be justified on the basis of its psychometric qualities.


Keywords: Tobacco use disorder; Psychometrics; Tobacco; Reproducibility of results.


Review Article

12 - Tuberculosis in health professionals: a new perspective on an old problem

Tuberculose em profissionais de saúde: um novo olhar sobre um antigo problema

Ethel Leonor Noia Maciel, Thiago Nascimento do Prado, Juliana Lopes Fávero, Tiago Ricardo Moreira, Reynaldo Dietze

J Bras Pneumol.2009;35(1):83-90

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The objective of this review was to contribute to the debate on the nosocomial transmission of TB among health professionals in a country where TB is endemic. Prior to 1900, there was no reason to believe that health professionals interacting with TB patients were more susceptible to becoming infected with the bacillus than was the general population. Between 1920 and 1930, various studies showed significant findings regarding the rates of positive tuberculin skin tests among students in the area of health care. However, most clinicians remained skeptical about the susceptibility of health professionals to becoming infected with TB. In the various locales where the treatment of patients with TB has been implemented, health professionals have been described as an especially predisposed population to becoming infected with and developing active TB. It is urgent that the scientific community and health professionals become mobilized, recognizing themselves as a population at risk of developing TB, and that actions be taken in order to minimize the potential risks of acquiring the disease at locales where patients with TB are treated.


Keywords: Tuberculosis; Cross infection; Health personnel.


Case Report

13 - Repeat pulmonary thromboendarterectomy after recurrence of chronic thromboembolic pulmonary hypertension

Reoperação de tromboendarterectomia pulmonar em recidiva de tromboembolismo pulmonar crônico hipertensivo

Walter José Gomes, Carlos Jogi Imaeda, João Alessio Perfeito, Petrúcio Abrantes Sarmento, Rodrigo Caetano Souza, Vicente Forte

J Bras Pneumol.2009;35(1):91-94

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Pulmonary thromboendarterectomy has been established as the standard method for the treatment of chronic thromboembolic pulmonary hypertension, with excellent results. However, repeat pulmonary thromboendarterectomy due to recurrence of pulmonary embolism has never been reported in the Brazilian literature. Its safety and effectiveness remain obscure. We report the case of a patient presenting recurrence of chronic thromboembolic pulmonary hypertension five years after the first pulmonary thromboendarterectomy and requiring a second operation for resolution of the symptoms.


Keywords: Hypertension, pulmonary; Pulmonary embolism; Endarterectomy/methods.


14 - Chronic necrotizing pulmonary aspergillosis

Aspergilose pulmonar necrotizante crônica

Eduardo Felipe Barbosa Silva, Melânio de Paula Barbosa, Marco Antônio Alves de Oliveira, Rosane Rodrigues Martins, Jefferson Fontinele e Silva

J Bras Pneumol.2009;35(1):95-98

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Chronic necrotizing pulmonary aspergillosis is one of the forms of pulmonary aspergillosis typically found in mildly immunocompromised patients. We report the case of a female patient with complaints of chronic productive cough, fever and asthenia. She reported previous corticosteroid use. Computed tomography of the chest revealed consolidation with interposed cavitation in the right upper lobe. Fiberoptic bronchoscopy revealed purulent fluid within the tracheobronchial tree and an endobronchial exophytic lesion. The results of the biopsy of that lesion and the transbronchial biopsy were consistent with aspergillosis. Based on the clinical, radiological and histopathological findings, the patient was diagnosed with chronic necrotizing pulmonary aspergillosis. Treated with itraconazole, the patient presented a favorable clinical-radiological evolution.


Keywords: Aspergillosis; Lung diseases, fungal; Itraconazole. Resumo


15 - Extralobar pulmonary sequestration with hemothorax secondary to pulmonary infarction

Sequestro extralobar com hemotórax secundário a infarto pulmonar

Darcy Ribeiro Pinto Filho, Alexandre José Gonçalves Avino, Suzan Lúcia Brancher Brandão

J Bras Pneumol.2009;35(1):99-102

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Pulmonary sequestration is an uncommon condition that accounts for 0.5-6% of all pulmonary malformations and is typically diagnosed in childhood. Of the two forms of pulmonary sequestration, intralobar and extralobar, the latter is less frequently encountered. The current report describes the case of a 32-year-old female patient with chest and abdominal pain. Imaging (chest X-rays and computed tomography scans of the chest) revealed consolidation and pleural effusion. The initial thoracocentesis revealed hemothorax. Subsequent diagnostic video-assisted thoracoscopy revealed extralobar pulmonary sequestration. Consequently, the therapeutic decision was to make the conversion to thoracotomy in order to resect the lesion and safely ligate the intercostal vascular pedicle.


Keywords: Bronchopulmonary sequestration; Hemothorax; Pulmonary infarction.


Year 2009 - Volume 35  - Number 2  (/February)


1 - Interfaces for noninvasive ventilation: Does it matter?

Interfaces para ventilação não-invasiva: Faz diferença?

Sean P. Keenan, Brent Winston

J Bras Pneumol.2009;35(2):103-105

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Original Article

2 - Semiquantitative echocardiographic evaluation of intrapulmonary vascular dilatations: correlation with evaluation of shunt levels and pulmonary function parameters

Avaliação semiquantitativa ecocardiográfica de dilatações vasculares intrapulmonares em candidatos a transplante hepático: correlação com avaliação de shunt e parâmetros funcionais pulmonares

Maria Angélica Pires Ferreira, Sérgio Saldanha Menna Barreto, Marli Maria Knorst, Mario Reis Álvares da Silva, Antonio Furlan Pinotti

J Bras Pneumol.2009;35(2):106-113

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Objective: To correlate semiquantitative evaluation of intrapulmonary vascular dilatations (IPVD) with quantitative evaluation of shunt levels, as well as to describe clinical and pulmonary function findings in a sample of liver disease patients with IPVD. Methods: Patients presenting transthoracic echocardiography (TTE) positivity for IPVD underwent clinical evaluation, pulmonary function tests and pulmonary shunt quantification (scintigraphy with technetium-99m-labeled macroaggregated albumin and blood gas analysis after pure oxygen breathing). Results: A total of 28 liver cirrhosis patients were studied (mean age, 47.5 years; 60.7% were Child-Pugh class B). A 4-point, ascending scale was used as a measure of IPVD intensity, which was scored as 1, 2, 3 and 4, respectively, in 13 (46.4%), 9 (32.1%), 2 (7.1%) and 4 (14.3%) of the patients. Patients were divided into a low-intensity group (scores 1 and 2) and a high-intensity group (scores 3 and 4). The mean shunt assessed using scintigraphy was 14.9% in the sample as a whole and was lower in the low-intensity group (11.7% vs. 26.3%; p = 0.01). The mean shunt by blood gas analysis was higher in the high-intensity group (8.3% vs. 16.3%; p < 0.001). Mean PaO2 was lower in the high-intensity group. There was a negative correlation between DLCO and IPVD severity (r = −0.406, p = 0.01). Conclusions: TTE is a safe, useful tool for assessing IPVD severity in liver disease patients. The IPVD intensity assessed using TTE correlated with the intrapulmonary shunt values obtained through the quantitative methods evaluated, as well as with pulmonary gas exchange abnormalities.


Keywords: Anoxia; Liver cirrhosis; Hepatopulmonary syndrome; Echocardiography.


3 - Risk factors and prophylaxis for venous thromboembolism in hospitals in the city of Manaus, Brazil

Fatores de risco e profilaxia para tromboembolismo venoso em hospitais da cidade de Manaus

Edson de Oliveira Andrade, Fábio Arruda Bindá, Ângela Maria Melo da Silva, Thais Ditolvo Alves da Costa, Marcélio Costa Fernandes, Márcio Costa Fernandes

J Bras Pneumol.2009;35(2):114-121

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Objective: To identify and classify risk factors for venous thromboembolism (VTE) in hospitalized patients, as well as to evaluate medical practices regarding prophylaxis for the disease. Methods: An observational cross-sectional study, carried out between January and March of 2006, involving inpatients at three hospitals in the city of Manaus, Brazil. Risk stratification for VTE was based on the criteria established by the Brazilian Society of Angiology and Vascular Surgery and by the International Union of Angiology. Clinical, surgical and medication-related risk factors were analyzed. The statistical analysis of the data obtained was conducted, adopting an alpha error of 5% and 95% CI. Qualitative data were analyzed using the chi-square test, whereas quantitative data were analyzed using Student's t-test. Results: Of the 1,036 patients included (total number of admissions, 1,051), 515 (49.7%) were male, and 521 (50.3%) were female. A total of 23 risk factors for VTE were identified (total number of occurrences, 2,319). The stratified risk for VTE was 50.6%, 16.6% and 30.8% among the admissions of high-, moderate- and low-risk cases, respectively. In 73.3% of the admissions, nonpharmacological prophylaxis was not employed at any point during the study period. In 74% of those classified as high- or moderate-risk cases, no prophylactic medications were administered. Conclusions: This study showed that, in the population studied, risk factors were common and that prophylactic measures were not employed in patients prone to developing VTE and its complications.


Keywords: Venous thromboembolism; Risk factors; Venous thrombosis/prevention & control.


4 - Expectations and patient satisfaction related to the use of thoracotomy and video-assisted thoracoscopic surgery for treating recurrence of spontaneous primary pneumothorax

Expectativas y satisfacción en el tratamiento del neumotórax espontáneo primario recurrente tratado por toracotomía o cirugía torácica video-asistida

Jorge Ramón Lucena Olavarrieta, Pául Coronel

J Bras Pneumol.2009;35(2):122-128

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Objective: To compare the outcomes of thoracotomy and video-assisted thoracoscopic surgery (VATS) in the treatment of recurrence of primary spontaneous pneumothorax. Methods: Medical records of patients presenting recurrence of primary spontaneous pneumothorax were retrospectively reviewed. Patients were divided into two groups: those who underwent conservative thoracotomy (n = 53, thoracotomy group); and those who underwent VATS (n = 47, VATS group). Results: Although there were no deaths in either group and the length of hospital stays was similar between the two, there was greater morbidity in the thoracotomy group. Patients in the thoracotomy group required more pain medication for longer periods than did those in the VATS group (p < 0.05). In the thoracotomy group, the rate of recurrence was 3%. Pain was classified as insignificant at one month after the operation by 68% of patients in the VATS group and by only 21% of those in the thoracotomy group (p < 0.05). At three years after the surgical procedure, 97% of the VATS group patients considered themselves completely recovered from the operation, compared with only 79% in the thoracotomy group (p < 0.05). Chronic or intermittent pain, requiring the use of analgesics more than once a month, was experienced by 90% of the thoracotomy group patients and 3% of the VATS group patients. In addition, 13% of the thoracotomy group patients required clinical pain management. Conclusions: We recommend VATS as the first-line surgical treatment for patients with recurrent primary spontaneous pneumothorax.


Keywords: Thoracoscopy; Thoracic surgery, video-assisted; Recurrence; Pneumothorax.


5 - Long-term repercussions of a pulmonary rehabilitation program on the indices of anxiety, depression, quality of life and physical performance in patients with COPD

Repercussões tardias de um programa de reabilitação pulmonar sobre os índices de ansiedade, depressão, qualidade de vida e desempenho físico em portadores de DPOC

Rossane Frizzo de Godoy, Paulo José Zimermann Teixeira, Benno Becker Júnior, Maurício Michelli, Dagoberto Vanoni de Godoy

J Bras Pneumol.2009;35(2):129-136

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Objective: To assess the 24-month effects of a pulmonary rehabilitation program (PRP) on anxiety, depression, quality of life and physical performance of COPD patients. Methods: Thirty patients with COPD (mean age, 60.8 ± 10 years; 70% males) participated in a 12-week PRP, which included 24 physical exercise sessions, 24 respiratory rehabilitation sessions, 12 psychotherapy sessions and 3 educational sessions. All patients were evaluated at baseline (pre-PRP), at the end of the treatment (post-PRP) and two years later (current) by means of four instruments: the Beck Anxiety Inventory; the Beck Depression Inventory; Saint George's Respiratory Questionnaire; and the six-minute walk test (6MWT). Results: The comparison between the pre-PRP and post-PRP values revealed a significant decrease in the levels of anxiety (pre-PRP: 10.7 ± 6.3; post-PRP: 5.5 ± 4.4; p = 0.0005) and depression (pre-PRP: 11.7 ± 6.8; post-PRP: 6.0 ± 5.8; p = 0.001), as well as significant improvements in the distance covered on the 6MWT (pre-PRP: 428.6 ± 75.0 m; post-PRP: 474.9 ± 86.3 m; p = 0.03) and the quality of life index (pre-PRP: 51.0 ± 15.9; post-PRP: 34.7 ± 15.1; p = 0.0001). There were no statistically significant differences between the post-PRP and current evaluation values. Conclusions: The benefits provided by the PRP in terms of the indices of anxiety, depression and quality of life, as well as the improved 6MWT performance, persisted throughout the 24-month study period.


Keywords: Pulmonary disease, chronic obstructive; Rehabilitation; Exercise; Quality of life; Anxiety; Depression.


6 - Nutritional, clinical and socioeconomic profile of patients with cystic fibrosis treated at a referral center in northeastern Brazil

Perfil nutricional, clínico e socioeconômico de pacientes com fibrose cística atendidos em um centro de referência no nordeste do Brasil

Isabel Carolina da Silva Pinto, Cristiane Pereira da Silva, Murilo Carlos Amorim de Britto

J Bras Pneumol.2009;35(2):137-143

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the profile of patients with cystic fibrosis (CF). Methods: A prospective, cross-sectional study involving CF patients ≤ 18 years of age, evaluated between March and July of 2006 at a referral center in northeastern Brazil. Nutritional assessment was performed using Z scores for height/age (H/A), weight/age (W/A) and weight/height (W/H), as well as %weight/height (%W/H) and body composition measurements. Socioeconomic and clinical data were obtained. Results: Twenty-one patients were evaluated, 12 (57.1%) of whom were female. Mean age at diagnosis was 3.8 ± 3.9 years. The principal features at diagnosis were respiratory infection (85.7%), steatorrhea (66.7%) and nutritional deficit (47.6%). The mean Z scores for W/A, H/A and W/H were 0.73 ± 0.28, 0.34 ± 0.21 and 0.73 ± 0.35, respectively. Mean %W/H was 94.52 ± 1.58. The percentage of malnourished children assessed by Z score differed from that assessed by %W/H (nutritional deficit in 66.7% and 33.3%, respectively; p > 0.05). Socioeconomic status, clinical status and Shwachman score were better among well-nourished patients than among those classified as malnourished (p < 0.05 for Shwachman score). Conclusions: Normal nutritional status was identified based on nutritional indicators (W/A, H/A and W/H), whereas nutritional deficit was identified by assessing body composition. Socioeconomic factors proved favorable, especially maternal education and per capita income. Age at diagnosis was higher than that reported in the literature, although the Shwachman score and the incidence of respiratory infections demonstrated that the patients presented good clinical status.


Keywords: Cystic fibrosis; Nutritional assessment; Symptoms, clinical; Socioeconomic factors.


7 - Effectiveness of a photogrammetric model for the analysis of thoracoabdominal respiratory mechanics in the assessment of isovolume maneuvers in children

Efetividade de um modelo fotogramétrico para a análise da mecânica respiratória toracoabdominal na avaliação de manobras de isovolume em crianças

Denise da Vinha Ricieri, Nelson Augusto Rosário Filho

J Bras Pneumol.2009;35(2):144-150

Abstract PDF PT PDF EN Portuguese Text

Objective: To test the applicability of a geometric model, adapted to the supine position, for the analysis of respiratory mechanics regarding changes in lateral thoracoabdominal areas in children with asthma. Methods: Nineteen children (mean age, 11.26 ± 1.28 years) performed isovolume maneuvers (IVMs) after maximal inspiration, followed by glottal closure and alternation of airflow between the abdominal and thoracic compartments. The maneuvers were recorded in a digital video camera placed perpendicularly to the movement plane, and the images of interest were selected. The geometric model was traced on each image based on surface landmarks of anatomical references. The traced areas were calculated using a computer program, and the results were converted into metric units (cm2) using a surface landmark of a known area. Relative contributions (RCs) of the subcompartments in relation to their original compartments and to the chest wall (CW) were calculated. Results: The model was based on 55 thoracic IVM images and 55 abdominal IVM images. Areas and subareas were compared between the maneuvers. There were significant differences in all subcompartments (p < 0.001). All of the RCs were significantly different for the CW (p < 0.001) but not for the ratios between the subcompartments and their original compartments. Conclusions: This geometric model, applied in children and adapted to the supine position, was effective in profiling changes in the thoracoabdominal silhouette during the IVMs, and the selected subdivisions were useful for the identification of areas contributing the most and the least to CW composition.


Keywords: Photogrammetry; Respiratory mechanics; Image processing, computer-assisted.


8 - Comparison between PEF values obtained from a population sample in the city of São Carlos, Brazil, and reference values

Comparação de valores de PFE em uma amostra da população da cidade de São Carlos, São Paulo, com valores de referência

Cilso Dias Paes, Bruna Varanda Pessoa, Maurício Jamami, Valéria Amorim Pires Di Lorenzo, Kamilla Tays Marrara

J Bras Pneumol.2009;35(2):151-156

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the reference values for PEF suggested by other authors in 1963, 1989 and 2001 (for populations in the USA, England and Cuba, respectively) with those obtained from a population sample in the city of São Carlos, Brazil, and to determine whether there is concordance among them. Methods: A total of 243 volunteers (123 females and 120 males; 20-70 years of age) participated in the study. The PEF measurements were performed with the volunteer standing, using a nose clip, by means of a portable peak flow meter. These measurements were compared with the reference values using the Friedman test and Dunn's post-hoc test (p < 0.05). Results: Significant differences were found in all age groups from both genders regarding the values predicted in 1989; the same occurred in the 20-30 and 31-40 age groups (both genders), as well as in the 61-70 age group (females only), regarding those predicted in 2001, as well as in the 20-30 age group (males only) regarding those predicted in 1963. Conclusions: The values predicted in 1963 are appropriate for a population of individuals with the same characteristics as the study sample, except for males in the 20-30 age group. Our study is relevant due to the fact that our sample was larger than that evaluated in the 1963 study. The majority of the values predicted in 1989 and 2001 overestimated the PEF values obtained in our study, proving to be inappropriate for the population studied.


Keywords: Reference values; Respiratory function tests; Airway obstruction; Peak expiratory flow rate.


9 - Characteristics of patients with lung cancer in the city of Manaus, Brazil

Características de pacientes com câncer de pulmão na cidade de Manaus

Fernando Luiz Westphal, Luis Carlos de Lima, Edson Oliveira Andrade, José Corrêa Lima Netto, Andrei Salvioni da Silva, Bruna Cecília Neves de Carvalho

J Bras Pneumol.2009;35(2):157-163

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the characteristics of patients with lung cancer. Methods: A retrospective descriptive study of patients receiving a histopathological diagnosis of lung cancer between 1995 and 2002 in the city of Manaus, Brazil. Data were collected from the medical archives of three hospitals. Statistical analyses were carried out, and survival curves were generated by means of an actuarial estimator. Results: Of the 352 patients selected, 262 (74.4%) were male and 90 (25.6%) were female. The mean age was 62 years. The following histological types were identified: squamous cell carcinoma, 62.8%; adenocarcinoma, 24.7%; small cell carcinoma, 9.1%; and large cell carcinoma, 3.4%. The most common stages were stages IIIB and IV, in 45% and 21.5%, respectively. Of the total sample, 73.4% were submitted to treatment. Of these, 51.4% underwent radiotherapy; 16.6%, surgery; 15.8%, chemotherapy; and 16.2%, radiotherapy in association with chemotherapy. Cumulative survival rates were low: three-year survival was 6.5%, and five-year survival was 3.5%. Conclusions: In this group of patients with lung cancer, survival rates were considerably lower than those reported in the literature. This might be attributable to the limited access to the specialized health care system and the advanced stage of the disease at diagnosis.


Keywords: Lung neoplasms; Neoplasm staging; Survival.


10 - Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation

Influência das máscaras facial total, facial e nasal nos efeitos adversos agudos durante ventilação não-invasiva

Marcelo Alcantara Holanda, Ricardo Coelho Reis, Georgia Freire Paiva Winkeler, Simone Castelo Branco Fortaleza, José Wellington de Oliveira Lima, Eanes Delgado Barros Pereira

J Bras Pneumol.2009;35(2):164-173

Abstract PDF PT PDF EN Portuguese Text

Objective: Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. Methods: This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. Results: The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. Conclusions: The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.


Keywords: Intermittent positive-pressure ventilation; Masks/adverse effects; Respiratory insufficiency;Equipment failure analysis.


Brief Communication

11 - Incidence of TB diagnosed in the emergency room of a teaching hospital in southeastern Brazil

Incidência de TB diagnosticada no pronto-atendimento de um hospital escola na região sudeste do Brasil

Silvana Spíndola de Miranda, Ana Rita de Paiva Toledo, Simone Rodrigues Ribeiro, Izabela Magalhães Campos, Petra Maria de Oliveira Duarte Sthur, Afrânio Lineu Kritski

J Bras Pneumol.2009;35(2):174-178

Abstract PDF PT PDF EN Portuguese Text

In this study, we analyzed the number of TB cases in an emergency room (ER) and the susceptibility profile of Mycobacterium tuberculosis strains. Patients were selected from among those treated at the Hospital das Clínicas, in the city of Belo Horizonte, Brazil. Between 2002 and 2005, 240 TB patients were identified. Of those, 117 patients (48.7%) were diagnosed in the ER, 72 (61.5%) presenting positive sputum smear microscopy. Drug susceptibility testing was carried out in 90 strains, of which 80 (89%) were sensitive, 9 (10%) were resistant, and 1 (1%) was multidrug resistant. The incidence of positive smear sputum microscopy and resistant TB strains was high, which calls for the immediate adoption of TB control measures in the ER.


Keywords: Tuberculosis; Disease transmission, infectious; Drug resistance.


Review Article

12 - Pulmonary arterial hypertension and thyroid disease

Hipertensão arterial pulmonar e doenças da tireoide

Denise Rossato Silva, Marcelo Basso Gazzana, Ângela Beatriz John, Débora Rodrigues Siqueira, Ana Luiza Silva Maia, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2009;35(2):179-185

Abstract PDF PT PDF EN Portuguese Text

Recent studies have suggested an association between pulmonary arterial hypertension (PAH) and thyroid diseases (hypothyroidism and hyperthyroidism). This combination has a good prognosis, because the increase in the pulmonary artery pressure is usually slight and reverses after the treatment of the thyroid disease. Although the exact mechanism involved in the pathogenesis of this combination has not yet been established, it has been hypothesized that thyroid hormones and autoimmunity have a direct influence. Due to the high prevalence of thyroid disease in patients with PAH, thyroid function tests should be considered in the investigation of every patient with PAH. In this review, we describe the prevalence of PAH in patients with thyroid diseases and the prevalence of thyroid disease in patients with PAH, as well as addressing the principal effects that thyroid diseases have on the respiratory system. In addition, we report the treatment effects in patients with these diseases.


Keywords: Hypertension, pulmonary; Graves disease; Hyperthyroidism; Hypothyroidism; Thyroid hormones; Echocardiography.


Case Report

13 - A rare case of synchronous malignant thoracic tumors

Um caso raro de tumores torácicos malignos sincrônicos

Benoit Jacques Bibas, Marcos Madeira, Rodrigo Gavina, Leonardo Hoehl-Carneiro, Sergio Sardinha

J Bras Pneumol.2009;35(2):186-189

Abstract PDF PT PDF EN Portuguese Text

Malignant neurogenic mediastinal tumors in adults are uncommon and extremely aggressive. We report the case of a 61-year-old male patient with the simultaneous occurrence of malignant mediastinal schwannoma and bronchioloalveolar carcinoma. Although bronchioloalveolar carcinoma is present in 4-7% of the resected synchronous thoracic tumors, this association has never been reported in the literature. However, it is a common finding in patients presenting apparently inflammatory infiltrates and ground-glass opacities, as in the case presented here.


Keywords: Mediastinal neoplasms; Nerve sheath neoplasms; Neurilemmoma; Neoplasms, multiple primary; Adenocarcinoma, bronchiolo-alveolar.


14 - Small cell carcinoma in Pancoast syndrome

Carcinoma de pequenas células na síndrome de Pancoast

Jefferson Fontinele e Silva, Melânio de Paula Barbosa, Cláudio Luiz Viegas

J Bras Pneumol.2009;35(2):190-193

Abstract PDF PT PDF EN Portuguese Text

Pancoast syndrome consists of signs and symptoms resulting from a tumor affecting the pulmonary apex and adjacent structures. The process is typically caused by a neoplasm. The majority of cases of Pancoast syndrome are caused by bronchogenic carcinoma. The most commonly found histologic subtypes are adenocarcinoma and epidermoid carcinoma. There have been very few reports of small cell lung carcinoma in the genesis of Pancoast syndrome. We describe the case of a patient with Pancoast syndrome caused by small cell lung carcinoma and discuss the aspects related to the diagnosis and treatment.


Keywords: Pancoast syndrome; Small cell lung carcinoma; Lung neoplasms.


15 - Simultaneous bilateral spontaneous pneumothorax in an adult patient with cystic fibrosis

Pneumotórax espontâneo simultâneo bilateral em um paciente adulto com fibrose cística

Kamlesh Mohan, Martin James Ledson, Martin John Walshaw, Edson Marchiori

J Bras Pneumol.2009;35(2):194-196

Abstract PDF PT PDF EN Portuguese Text

Pneumothorax is a common complication in cystic fibrosis and is associated with worsening of lung function. However, bilateral simultaneous pneumothorax in cystic fibrosis is a rare condition. We describe the case of a 17-year-old female with cystic fibrosis who presented with spontaneous pneumothorax. Clinically, she presented right-sided chest pain and progressive breathlessness. The pneumothorax failed to resolve after the initial treatment (chest drainage). However, the patient was later successfully treated with additional chest drainage and talc pleurodesis. We also discuss the etiology and management of pneumothorax in patients with cystic fibrosis, since pneumothorax is associated with increased morbidity and mortality among such patients.


Keywords: Cystic fibrosis/physiopathology; Pneumothorax; Pleurodesis.


Year 2009 - Volume 35  - Number 3  (/March)


1 - Smoking and asthma control

Tabagismo e controle da asma brônquica

Carlos Alberto de Assis Viegas

J Bras Pneumol.2009;35(3):197-198

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Original Article

2 - Evaluation of criteria for the diagnosis of asthma using an epidemiological questionnaire

Avaliação de critérios para o diagnóstico de asma através de um questionário epidemiológico

Neusa Falbo Wandalsen, Cássia Gonzalez, Gustavo Falbo Wandalsen, Dirceu Solé

J Bras Pneumol.2009;35(3):199-205

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate criteria for the diagnosis of asthma in an epidemiological survey. Methods: Adolescents (13-14 years of age) and legal guardians of schoolchildren (6-7 years of age) in the city of Santo André, Brazil, completed the International Study of Asthma and Allergies in Childhood (ISAAC) standard written questionnaire. Affirmative responses regarding wheezing within the last 12 months, asthma ever, bronchitis ever (question added at the end of the questionnaire), as well as the overall ISAAC score above the predefined cutoff points, were considered indicative of asthma. Results: The legal guardians of 2,180 schoolchildren and 3,231 adolescents completed the questionnaires properly. Depending on the criterion adopted, the prevalence of asthma ranged from 4.9% to 26.8% for the schoolchildren and from 8.9% to 27.9% for the adolescents. The criteria with the lowest and highest prevalences were, respectively, physician-diagnosed asthma and physician-diagnosed bronchitis. When compared with other criteria, physician-diagnosed bronchitis showed concordance levels between 71.9% and 79.4%, positive predictive values between 0.16 and 0.63 and poor concordance (kappa: 0.21-0.46). Strong concordance levels were found only between wheezing within the last 12 months and the overall ISAAC score (kappa: 0.82 and 0.98). Conclusions: The prevalence of asthma varied significantly, depending on the criterion adopted, and there was poor concordance among the criteria. Wheezing within the last 12 months and the overall ISAAC score are the best criteria for the diagnosis of asthma, whereas the question regarding bronchitis ever did not improve the questionnaire. Modifications in this instrument can make it difficult to draw comparisons and should therefore be carefully evaluated.


Keywords: Asthma; Bronchitis; Diagnosis; Epidemiology; Child; Adolescent.


3 - Incidence of asthma symptoms and decreased pulmonary function in young amateur swimmers

Frequência de sintomas de asma e de redução da função pulmonar entre crianças e adolescentes nadadores amadores

Iara Nely Fiks, Leonardo Carlos Araujo Santos, Telma Antunes, Raquel Calvo Gonçalves, Celso Ricardo Fernandes de Carvalho, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2009;35(3):206-212

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the incidence of asthma symptoms in young amateur swimmers, and to describe the clinical treatment of the children with asthma in a private sports club in the city of São Paulo, Brazil. Methods: The study included 171 amateur swimmers, ranging from 6 to14 years of age. All of the participants or their legal guardians were asked to complete the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, and 119 were submitted to pulmonary function testing at rest. Results: The overall incidence of asthma symptoms (ISAAC score ≥ 6) among the swimmers was 16.8%. Of the 119 swimmers submitted to spirometry, 39 (32.7%) presented spirometric alterations (FEV1/FVC < 0.75). Among those with an ISAAC score ≥ 6, there were 10 (31.2%) who stated that they were receiving no asthma treatment. Of those who reported receiving pharmacological treatment, 24% made use of bronchodilators but not of corticosteroids. Conclusions: The incidence of asthma symptoms and pulmonary function alterations among amateur swimmers within the 6-14 age bracket was high. In addition, a relevant proportion of these athletes were receiving no treatment.


Keywords: Asthma/therapy; Asthma/diagnosis; Child; Swimming; Exercise.


4 - Compensatory sweating after thoracoscopic sympathectomy: characteristics, prevalence and influence on patient satisfaction

Hiperhidrose compensatória após simpatectomia toracoscópica: características, prevalência e influência na satisfação do paciente

Carlos Alberto Almeida de Araújo, Ítalo Medeiros Azevedo, Maria Angela Fernandes Ferreira, Hylas Paiva da Costa Ferreira, Jorge Lúcio Costa de Medeiros Dantas, Aldo Cunha Medeiros

J Bras Pneumol.2009;35(3):213-220

Abstract PDF PT PDF EN Portuguese Text

Objective: This prospective study aimed at investigating predictive factors for compensatory sweating after thoracoscopic sympathectomy. Methods: From 2000 to 2002, 80 patients (53 females and 27 males) underwent thoracoscopic sympathectomy to treat hyperhidrosis. Patient ages ranged from 12 to 56 years, and the mean post-operative follow-up period was 42.51 ± 5.98 months. Patient satisfaction with the results was evaluated through the use of a rating scale. The procedure was performed bilaterally: at the T2 level for facial hyperhidrosis; at the T3-T4 level for axillary hyperhidrosis; and at the T3 level for palmar hyperhidrosis. Results: Post-operatively, 68 patients (85.0%) presented compensatory sweating, which was classified as mild in 23 (33.8%), moderate in 23 (33.8%) and severe in 22 (32.4%). Considering the final surgical results, 70 patients (87.5%) were satisfied with the outcome of the operation, whereas 10 patients (12.5%) were dissatisfied. The level of patient satisfaction varied according to gender, age, body mass index (BMI) and extent of denervation. The compensatory sweating was more severe on the abdomen and back than on the legs. Conclusions: Although compensatory sweating, which is a common adverse effect of sympathectomy, occurred in the majority of cases, the level of patient satisfaction was high. The best candidates for thoracoscopic sympathectomy are young adult women with a BMI ≤ 24.9 kg/m2.


Keywords: Sympathectomy; Hyperhidrosis; Thoracoscopy; Postoperative complications;Thoracic surgery, video-assisted.


5 - Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil

Prevalência de pectus carinatum e pectus excavatum em escolares de Manaus

Fernando Luiz Westphal, Luiz Carlos de Lima, José Corrêia Lima Neto, Altair Rodrigues Chaves, Vítor Lazarini dos Santos Júnior, Brena Luize Cunha Ferreira

J Bras Pneumol.2009;35(3):221-226

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of congenital anterior chest wall deformities in 11- to 14-year-old students. Methods: Students participating in the study were recruited from public schools in the city of Manaus, Brazil. The statistically significant sample (precision, 1%; 95% CI) comprised 1,332 students. Pectus deformities were identified by physical examination of the chest, and the individuals with one of these deformities completed a questionnaire regarding heredity and symptoms resulting from the chest abnormality. Results: The mean age of the participants was 11.7 years. The prevalence of pectus abnormalities was 1.95% (pectus excavatum: 1.275%; pectus carinatum: 0.675%). Of the 26 students with a pectus deformity, 17 (65.4%) had pectus excavatum, and 18 (69.2%) were male. Concomitant scoliosis was observed in 3 cases (11.5%). A family history of pectus was reported by 17 students (65.4%), and 17 (65.4%) reported chest pain, dyspnea or palpitations. Conclusions: In this study, the prevalence of pectus deformities (1.95%) was lower than that reported in other studies conducted in Brazil (3.6-4.9%) but was higher than that reported in the literature (mean, 1%).


Keywords: Musculoskeletal abnormalities; Prevalence; Funnel chest.


6 - Postintubation injuries and open surgical tracheostomy: should we always perform isthmectomy?

Sequelas pós-intubação e traqueostomia cirúrgica aberta: devemos sempre fazer a istmectomia?

Alexandre Garcia de Lima, Ariovaldo Marques, Ivan Felizardo Contrera Toro

J Bras Pneumol.2009;35(3):227-233

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the influence of the surgical team (general surgery or thoracic surgery) and the surgical technique (with or without isthmectomy) on the incidence of postintubation injuries in the airways of tracheostomized patients. Methods: Between January 1st and August 31st, 2007, 164 patients admitted to the adult intensive care unit and tracheally intubated for more than 24 h were studied prospectively at the Sumaré State Hospital, located in the city of Sumaré, Brazil. When tracheostomy was necessary, these patients were randomly assigned to thoracic or general surgery teams. All of the patients were submitted to fiberoptic tracheoscopy for decannulation or late evaluation of the airway. Results: Of the 164 patients in the study, 90 (54.88%) died (due to causes unrelated to the procedure), 67 (40.85%) completed follow-up, and 7 (4.27%) were lost to follow-up. Of the 67 patients who completed follow-up, 32 had undergone tracheostomy (21 by the general surgery team and 11 by the thoracic surgery team), and 22 had been submitted to isthmectomy (11 by the general surgery team and 11 by the thoracic surgery team). There was no difference between the surgical teams in terms of the incidence of stoma complications. However, there was a significant difference when the surgical techniques (with or without isthmectomy) were compared. Conclusions: Not performing isthmectomy in parallel with tracheostomy leads the surgeon to open the tracheal stoma more distally than expected. In such cases, there were more stoma complications.


Keywords: Tracheostomy; Intensive care units; Tracheal stenosis.


7 - Video-assisted thoracoscopy for the diagnosis of diffuse parenchymal lung disease

A videotoracoscopia no diagnóstico das doenças difusas do parênquima pulmonar

Renato Tadao Ishie, João José de Deus Cardoso, Rafael José Silveira, Lucas Stocco

J Bras Pneumol.2009;35(3):234-241

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the role of video-assisted thoracoscopy in the diagnosis of diffuse parenchymal lung diseases. Methods: The medical charts of patients suspected of having diffuse parenchymal lung disease were retrospectively reviewed, as were the results of the anatomopathological examination of lung biopsy specimens collected through video-assisted thoracoscopy. Results: Of the 48 patients included in the study, 25 (52.08%) were female and 23 (47.92%) were male. The mean age was 58.77 years (range, 20-76 years). A total of 54 biopsy fragments were submitted to anatomopathological examination: 24 (44.44%) from the lingula; 10 (18.52%) from the left lower lobe; 7 (12.96%) from the right middle lobe; 6 (11.11%) from the right lower lobe; 5 (9.26%) from the left upper lobe; and 2 (3.71%) from the right upper lobe. The mean duration of thoracic drainage was 2.2 days. Adverse events included conversion to thoracotomy, in 2 patients (4.17%), and residual pneumothorax, in 1 (2.08%). The definitive diagnosis was made in 46 patients (95.83%), and idiopathic interstitial pneumonia was the predominant diagnosis (in 54.18%). The most common diagnoses were usual interstitial pneumonia (in 29.27%), nonspecific interstitial pneumonia (in 16.67%) and hypersensitivity pneumonia (in 12.50%). Conclusions: Lung biopsy through video-assisted thoracoscopy is a safe, effective and viable procedure for the diagnosis of diffuse parenchymal lung diseases.


Keywords: Lung diseases, interstitial; Thoracoscopy; Diagnosis.


8 - Nutritional profile of lung transplant candidates

Perfil nutricional de pacientes candidatos ao transplante de pulmão

Sabrina Monteiro Pereira de Souza, Miyoko Nakasato, Maria Lúcia Mendes Bruno, Alessandra Macedo

J Bras Pneumol.2009;35(3):242-247

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the nutritional profile of lung transplant candidates. Methods: A retrospective cross-sectional study involving lung transplant candidates at a public hospital in the city of São Paulo, Brazil. Data related to gender, age and underlying lung disease were compiled for the participants. For the assessment of the nutritional profile of the patients, body mass index (BMI), mid-arm muscle circumference (MAMC), waist circumference and triceps skinfold thickness (TST) were determined during the first outpatient visit. Results: We included 117 patients, 69 of which (59%) were male. The mean age of the participants was 42.5 ± 15.2 years. The most prevalent underlying disease, seen in 29 patients (24.8%), was pulmonary emphysema. The nutritional profile was considered normal in 48.3% of the patients with pulmonary emphysema, 55% of those with cystic fibrosis, 56% of those with bronchiectasis and 50% of those with other lung diseases. The majority (51.7%) of the patients with pulmonary fibrosis were classified as overweight. The TSTs indicated that the risk of depletion was highest (64.7%) among the patients with cystic fibrosis, followed by those with bronchiectasis (52.6%). Conclusions: Patients with pulmonary fibrosis presented the highest BMIs, although the corresponding TSTs and MAMCs were normal. Patients with cystic fibrosis and bronchiectasis presented the highest prevalence of nutritional depletion, based on TST and MAMC.


Keywords: Lung transplantation; Nutritional status; Body mass index.


9 - Correlation between clinical parameters and health-related quality of life in women with COPD

Correlação entre parâmetros clínicos e qualidade de vida relacionada à saúde em mulheres com DPOC

Nilton Maciel Mangueira, Isabel Lucena Viega, Melissa de Almeida Melo Maciel Mangueira, Alcimar Nunes Pinheiro, Maria do Rosário da Silva Ramos Costa

J Bras Pneumol.2009;35(3):248-255

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Objective: To correlate health-related quality of life (HRQL) of women with COPD with clinical parameters and with the six-minute walk distance (6MWD; six-minute walk test). Methods: Cross-sectional study involving 30 female patients diagnosed with mild or moderate COPD treated at the Respiratory Outpatient Clinic of the Presidente Dutra University Hospital. Patients completed the Saint George's Respiratory Questionnaire (SGRQ) and were evaluated in terms of respiratory pressures, spirometry parameters and 6MWD. Descriptive statistical analysis was carried out, as were Student's t-tests for dependent variables, together with Pearson's and Spearman's correlation coefficients for numerical and ordinal variables, respectively. Results: According to the SGRQ total scores, HRQL was impaired, to some extent, in most of the participants. Most SGRQ total scores were between the second and the third quartiles, reflecting poor HRQL. The participants also presented poor functional capacity. Mean 6MWD (317.7 m), inspiratory muscle strength (−53.48 cmH2O) and expiratory muscle strength (69.5 cmH2O) were all below reference values. We found that HRQL was not correlated with body mass index or pulmonary function. However, HRQL presented a negative linear correlation with age, MIP and 6MWD, as well as a positive correlation with the sensation of dyspnea and fatigue. Conclusions: In this study, HRQL, determined using the SGRQ, was severely impaired in COPD patients, who presented severe limitations in functional capacity, breath control and personal life.


Keywords: Quality of life; Pulmonary disease, chronic obstructive; Women.


Brief Communication

10 - Noninvasive determination of inspiratory pressure in patients with spinal cord injury: what is the best method?

Determinação não-invasiva da pressão inspiratória em pacientes com lesão medular traumática: qual é o melhor método?

Andrea Ponte Rocha, Sergio Ricardo Menezes Mateus, Thomas Anthony Horan, Paulo Sérgio Siebra Beraldo

J Bras Pneumol.2009;35(3):256-260

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The aim of the study was to evaluate the performance of sniff nasal inspiratory pressure (SNIP) and MIP in individuals with spinal cord injury. We evaluated 26 patients with spinal cord injury. Mean FVC in those with tetraplegia was 52 ± 19% of predicted, compared with 78 ± 23% of predicted in those with paraplegia (p < 0.05). In contrast, the percentage of predicted SNIP was lower in those with tetraplegia than in those with paraplegia (p < 0.05). In all participants, SNIP correlated significantly with the level of the injury (r = 0.489; 95% CI: 0.125‑0.737). The impact that the greater discriminatory power of SNIP has on the diagnosis of impaired pulmonary function in spinal cord-injured patients should be investigated further.


Keywords: Spinal cord injuries; Respiratory function tests; Respiratory muscles; respiratory paralysis.


11 - Prevalence of active and passive smoking in a population of patients with asthma

Prevalência de tabagismo ativo e passivo em uma população de asmáticos

Sérvulo Azevedo Dias-Júnior, Regina Carvalho Pinto, Luciene Angelini, Frederico Leon Arrabal Fernandes, Alberto Cukier, Rafael Stelmach

J Bras Pneumol.2009;35(3):261-265

Abstract PDF PT PDF EN Portuguese Text

Smoking causes an intense inflammatory reaction in the airways and is associated with worse clinical outcomes in patients with asthma. The objective of this study was to determine the prevalence of active and passive smoking in a population of patients with asthma. The sample of asthma patients (n = 100) consisted of 47 nonsmokers, 33 former smokers, 17 passive smokers and 3 active smokers. Most had moderate or severe asthma. Mean exhaled CO was 9.34 ppb in smokers, 4.19 ppb in passive smokers, 3.98 ppb in nonsmokers and 3.98 ppb in former smokers. We conclude that the prevalence of exposure to tobacco smoke is high among asthma patients.


Keywords: Smoking; Asthma; Prevalence.


Review Article

12 - Computed tomography findings of postoperative complications in lung transplantation

Achados tomográficos nas complicações pós-operatórias do transplante pulmonar

Bruno Hochhegger, Klaus Loureiro Irion, Edson Marchiori, Rodrigo Bello, José Moreira, José Jesus Camargo

J Bras Pneumol.2009;35(3):266-274

Abstract PDF PT PDF EN Portuguese Text

Due to the increasing number and improved survival of lung transplant recipients, radiologists should be aware of the imaging features of the postoperative complications that can occur in such patients. The early treatment of complications is important for the long-term survival of lung transplant recipients. Frequently, HRCT plays a central role in the investigation of such complications. Early recognition of the signs of complications allows treatment to be initiated earlier, which improves survival. The aim of this pictorial review was to demonstrate the CT scan appearance of pulmonary complications such as reperfusion edema, acute rejection, infection, pulmonary thromboembolism, chronic rejection, bronchiolitis obliterans syndrome, cryptogenic organizing pneumonia, post-transplant lymphoproliferative disorder, bronchial dehiscence and bronchial stenosis.


Keywords: Tomography, X-ray computed; Lung transplantation; Postoperative complications.


Case Report

13 - Pulmonary and extrapulmonary coccidioidomycosis: three cases in an endemic area in the state of Ceará, Brazil

Coccidioidomicose pulmonar e extrapulmonar: três casos em zona endêmica no interior do Ceará

Ricardo Hideo Togashi, Fernando Moreira Batista Aguiar, Dalton Barros Ferreira, Camille Matos de Moura, Monique Teixeira Montezuma Sales, Nikaelle Ximenes Rios

J Bras Pneumol.2009;35(3):275-279

Abstract PDF PT PDF EN Portuguese Text

Coccidioidomycosis, a fungal illness acquired by the inhalation of arthroconidia of Coccidioides sp., was first described in 1894. Coccidioidomycosis is mainly restricted to areas with arid climate, alkaline soil and low rainfall. Consequently, most of the reported cases in Brazil have occurred in the northeastern region. We report three cases of pulmonary coccidioidomycosis occurring between 2005 and 2006 in an endemic area in the state of Ceará, Brazil. The three patients were immunocompetent adult males, hunters of armadillos (Dasypus novemcinctus), with complaints of cough, fever, dyspnea and pleuritic pain. All three patients presented pulmonary involvement, and one also presented cutaneous lesions. Chest X-rays and CT scans of the patients revealed characteristic coccidioidomycosis lesions. The diagnosis was confirmed by serological testing. All of the patients evolved to cure after antifungal treatment.


Keywords: Coccidioidomycosis; Lung diseases, fungal; Coccidioides.


14 - Mucoepidermoid carcinoma of the trachea mimicking asthma

Carcinoma mucoepidermoide da traqueia mimetizando asma brônquica

Ricardo Kalaf Mussi, Ivan Felizardo Contrera Toro, Mônica Corso Pereira

J Bras Pneumol.2009;35(3):280-284

Abstract PDF PT PDF EN Portuguese Text

In cases of recent asthma in which clinical control with the usual treatment (corticosteroids and bronchodilator) is unsatisfactory, it is important to consider other diagnoses, such as congestive heart failure, gastroesophageal reflux or other forms of airway obstruction. We report the case of a female patient with mucoepidermoid carcinoma of the trachea mimicking asthma. The patient presented cough and wheezing, as well as abnormal spirometry results with an obstructive pattern that was responsive to bronchodilators. One year later, the patient presented clinical and spirometric worsening. The chest X-ray revealed no abnormalities. A CT scan showed a vegetative lesion obstructing the tracheal lumen and located 1 cm from the carina. Fiberoptic bronchoscopy showed a finding similar to a bronchial carcinoid tumor. The anatomopathological diagnosis made after surgical resection was low-grade mucoepidermoid carcinoma, without lymph node involvement. Although the flow-volume curve was not suggestive of upper airway obstruction, the spirometry performed after the surgery showed a significant reduction in the degree of obstruction and greater reversibility after bronchodilator use. There was no evidence of recurrence of the disease or of the symptoms after a two-year follow-up period.


Keywords: Bronchial hyperreactivity; Carcinoma, mucoepidermoid; Trachea; Asthma; Lung diseases, obstructive.


15 - Osteitis after BCG vaccination

Osteíte por BCG

André Fukunishi Yamada, Juliana Barbosa Pellegrini, Luciana Menezes Cunha, Artur da Rocha Corrêa Fernandes

J Bras Pneumol.2009;35(3):285-289

Abstract PDF PT PDF EN Portuguese Text

The authors report the case of a 21-month-old boy with an osteolytic lesion in the proximal region of the right humerus. Based on the clinical history and histological findings, the authors suspected osteitis following BCG vaccination. Symptoms remitted after antituberculosis therapy was initiated, and the patient presented radiological improvement. The authors describe this uncommon entity in pediatric practice and call attention to possible complications of BCG vaccination.


Keywords: Infant; Osteitis; BCG vaccine; Tuberculosis.


Letters to the Editor

16 - Adherence to treatment in patients with cystic fibrosis

Adesão ao tratamento em pacientes com fibrose cística

Jefferson Veronezi, Daiane Scortegagna

J Bras Pneumol.2009;35(3):290-291

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Author's reply

17 - Author's reply

Resposta dos autores

Paulo de Tarso Roth Dalcin

J Bras Pneumol.2009;35(3):291-292

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Year 2009 - Volume 35  - Number 4  (/April)


1 - Asthma, a chronic disease whose manifestations go beyond respiratory distress, physical limitation and impaired quality of life

Asma, uma doença crônica cujas manifestações vão além do desconforto respiratório, limitação física e redução da qualidade de vida

Ana Luisa Godoy Fernandes

J Bras Pneumol.2009;35(4):293-294

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Original Article

2 - Prevalence of developmental defects of enamel in children and adolescents with asthma

Prevalência do desenvolvimento de defeitos no esmalte dentário em crianças e adolescentes com asma

Rodrigho Pelisson Guergolette, Cássia Cilene Dezan, Wanda Terezinha Garbelini Frossard, Flaviana Bombarda de Andrade Ferreira, Alcindo Cerci Neto, Karen Barros Parron Fernandes

J Bras Pneumol.2009;35(4):295-300

Abstract PDF PT PDF EN Portuguese Text

Objective: This study aimed to evaluate the prevalence of developmental defects of enamel (DDEs) in relation to asthma severity, symptom onset and pharmacological treatment in pediatric asthma patients. Methods: Children and adolescents (68 asthma patients and 68 controls), 5-15 years of age and residents of the city of Londrina, Brazil, were enrolled in the study. Medical and dental histories were collected through the use of a structured questionnaire. Each participant underwent a dental examination in which the examiner employed the DDE index. Results: Of the 68 asthma group subjects, 61 (89.7%) presented dental enamel defects, compared with only 26 (38.2%) of those in the control group. Using multivariate logistic regression analysis, we estimated the risk of DDEs in permanent dentition to be 11 times higher in pediatric subjects with asthma than in those without (OR = 11.88, p = 0.0001). The occurrence of dental enamel defects correlated with greater asthma severity (p = 0.0001) and earlier symptom onset (p = 0.0001). However, dental enamel defects did not correlate with the initiation of treatment (p = 0.08) or the frequency of medication use (p = 0.93). Conclusions: Pediatric patients with severe, early-onset asthma are at increased risk of dental enamel defects and therefore require priority dental care.


Keywords: Asthma/prevention & control; Bronchodilator agents; Adrenal cortex hormones/therapeutic use; Dental enamel; Amelogenesis.


3 - Asthma and COPD according to the pulmonologist

A asma e a DPOC na visão do pneumologista

Hisbello da Silva Campos, Antonio Carlos Moreira Lemos

J Bras Pneumol.2009;35(4):301-309

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate how pulmonologists view the impact that asthma and COPD has on their patients, as well as how they treat these diseases. Methods: Survey including 227 pulmonologists participating in the VI Brazilian Congress on Asthma, II Brazilian Congress on COPD and II Brazilian Congress on Smoking, all of which were held in 2007. Results: According to the answers given by the pulmonologists, COPD is a public health problem of equal or greater importance than asthma, and COPD causes various disruptions in the lives of patients and their family members. When prescribing an inhalation device, pulmonologists feel that simplicity of use is more important than is the cost. There was a slight preference for the Aeroliser® and Diskus® systems. The budesonide-formoterol combination was the therapeutic regimen most often cited for the continued treatment of symptomatic asthma, whereas tiotropium bromide was the most often cited medication for the treatment of COPD. Selection of the therapeutic regimen for asthma and COPD is primarily influenced by the results of therapeutic trials published in the literature. Conclusions: The opinions of pulmonologists on the topics under study are in concordance with data in the specialized literature.


Keywords: Questionnaires; Asthma; Pulmonary disease, chronic obstructive; Physician's practice patterns; Brazil.


4 - Evaluation of diagnostic criteria for severe asthma described in a public health directive regulating the free distribution of medications for the maintenance treatment of asthma

Avaliação dos descritores de asma grave em pacientes incluídos na portaria de saúde pública que regulamenta a distribuição gratuita de medicamentos para o tratamento de manutenção da asma

Maria Amélia Carvalho da Silva Santos, Ana Luisa Godoy Fernandes, Mara Marta Amorim, Patrícia Bueno Lima, Sonia Maria Faresin, Ilka Lopes Santoro

J Bras Pneumol.2009;35(4):310-317

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the capacity of the criteria described in Complementary Directive SAS/MS 12, issued on November 12, 2002, to identify patients with severe asthma, describing and comparing clinical, functional and treatment data of such patients. Methods: This was a nested case-control study using a structured database for adult asthma outpatients. We defined cases as asthma patients who met the inclusion criteria described in the directive, defining controls as those who did not. We collected and compared data related to the following: demographic characteristics; history of asthma; medications in use; comorbidities; history of tobacco use; number of exacerbations within the last 12 months, asthma-related hospitalizations and intensive care unit admissions within the last 12 months; spirometry; and sputum cytology. Results: The case and control groups consisted of 29 and 31 patients, respectively. The number of asthma exacerbations and emergency room visits within the last 12 months, as well as the number of patients that received at least one pulse of oral corticosteroids, was significantly higher in the case group than in the control group. In addition, prebronchodilator FVC was lower among the cases than among the controls. Furthermore, cytology revealed that eosinophil counts were significantly higher in the induced sputum of cases than in that of controls. Conclusions: The criteria described in the directive are suited to stratifying patients with severe asthma.


Keywords: Asthma; Budesonide; Combined modality therapy.


5 - Comparative study of two quality of life questionnaires in patients with COPD

Estudo comparativo entre dois questionários de qualidade de vida em pacientes com DPOC

Andréa Sória Buss, Luciano Müller Correa da Silva

J Bras Pneumol.2009;35(4):318-324

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare two quality of life questionnaires-the Saint George's Respiratory Questionnaire (SGRQ) and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36)-in patients with COPD, focusing on the discriminative properties of the questionnaires and correlating their domains with the following variables: Modified Medical Research Council Dyspnea Scale score; Beck Depression Inventory score; visual analog scale general health perception; Mini-Mental State Examination score; and a COPD clinical score developed specifically for the study. Methods: We interviewed 30 COPD patients between May and September of 2006. For the SF-36 and SGRQ, scores (total and domain) were compared and correlated. Results: With the exception of the pain domain, all of the SF-36 domains correlated significantly with the SGRQ total score (r = −0.5 to −0.69; p < 0.01). Of the SGQR domains, only the symptoms domain correlated significantly with all of the variables studied (p < 0.05). Conclusions: The majority of the expected correlations between the SGRQ and the SF-36 were observed, as were those expected between the two questionnaires and the other variables studied. The SGRQ, notably the symptoms domain, presented better discriminative properties than did the generic SF-36 questionnaire. The SF-36 is not an appropriate instrument for determining the affective state of COPD patients.


Keywords: Pulmonary disease, chronic obstructive; Quality of life; Data collection.


6 - Bronchodilation in COPD: beyond FEV1-the effect of albuterol on resistive and reactive properties of the respiratory system

Broncodilatação na DPOC: muito além do VEF1-efeito do salbutamol nas propriedades resistivas e reativas do sistema respiratório

Gerusa Marítimo da Costa, Alvaro Camilo Dias Faria, Ana Maria Gonçalves Tavares Di Mango, Agnaldo José Lopes, José Manoel Jansen, Pedro Lopes de Melo

J Bras Pneumol.2009;35(4):325-333

Abstract PDF PT PDF EN Portuguese Text

Objective: Current debates on the bronchodilator response in COPD patients and whether the variation in FEV1 can be considered as an indicator of complete reversibility in such patients motivated us to conduct this study. The objective of the study was to determine the effect of albuterol on the resistive and reactive properties of the respiratory system in COPD patients. Methods: We evaluated 70 patients with COPD, divided into two groups based on spirometry findings: bronchodilator (BD)-negative (n = 39); and BD-positive (n = 31). We used the forced oscillation technique (FOT) to evaluate the following parameters: resistance at the intercept (R0), associated with the total resistance of the respiratory system; mean resistance (Rm), associated with central airway resistance; dynamic compliance (Cdyn); and the slope of resistance (S) and mean reactance (Xm), both of which are associated with the homogeneity of the respiratory system. Results: The use of albuterol resulted in significant reductions in R0 (p < 0.00002) and Rm (p < 0.0002). There were also significant increases in S (p < 0.0001), Cdyn (p < 0.0001) and Xm (p < 0.00004). These modifications occurred in both groups, the changes in FOT parameters being greater than those observed for spirometric parameters. Conclusions: The use of albuterol improved the resistive and reactive properties of the respiratory system of the COPD patients under study. These changes occurred regardless of the FEV1-based classification, thereby indicating that the use of this parameter in isolation might not suffice to identify the physiological effects involved.


Keywords: Pulmonary disease, chronic obstructive; Bronchodilator agents; Spirometry; Albuterol.


7 - Association of MBL2, TGF-β1 and CD14 gene polymorphisms with lung disease severity in cystic fibrosis

Associação entre os polimorfismos dos genes MBL2, TGF-β1 e CD14 com a gravidade da doença pulmonar na fibrose cística

Elisangela Jacinto de Faria, Isabel Cristina Jacinto de Faria, José Dirceu Ribeiro, Antônio Fernando Ribeiro, Gabriel Hessel, Carmen Sílvia Bertuzzo

J Bras Pneumol.2009;35(4):334-342

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify associations between genetic polymorphisms (in the MBL2, TGF-β1 and CD14 genes) and the severity of the lung disease in patients with cystic fibrosis (CF), as well as between the presence of ΔF508 alleles and lung disease severity in such patients. Methods: This was a cross-sectional cohort study, based on clinical and laboratory data, involving 105 patients with CF treated at a university hospital in the 2005-2006 period. We included 202 healthy blood donors as controls for the determination of TGF-β1 and CD14 gene polymorphisms. Polymorphisms in the MBL2 and TGF-β1 genes at codon 10, position +869, were genotyped using the allele-specific PCR technique. The C-159T polymorphism in the CD14 gene was genotyped using PCR and enzymatic digestion. Results: Of the 105 CF patients evaluated, 67 presented with severe lung disease according to the Shwachman score. The MBL2 gene polymorphisms were not associated with disease severity in the CF patients. Analysis of the T869C polymorphism in the TGF-β1 gene showed an association only between TC heterozygotes and mild pulmonary disease. Although patients presenting the TT genotype of the C159T polymorphism in the CD14 gene predominated, there was no significant difference regarding lung disease severity. Conclusions: There was an association between the TC genotype of the T869C polymorphism (TGF-β1) and mild pulmonary disease in CF patients. In the CD14 gene, the TT genotype seems to be a risk factor for pulmonary disease but is not a modulator of severity. We found no association between being a ΔF508 homozygote and presenting severe lung disease.


Keywords: Cystic fibrosis; Polymorphism, genetic; Severity of illness index; Mannose-binding lectin; Transforming growth factor beta.


8 - Bronchoalveolar lavage analysis in victims of severe facial burns

Análise do lavado broncoalveolar em vítimas de queimaduras faciais graves

Eucir Rabello, Vera Flores Batista, Patrícia Martins Lago, Renata de Azevedo Gameiro Alvares, Cesônia de Assis Martinusso, José Roberto Lapa e Silva

J Bras Pneumol.2009;35(4):343-350

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze bronchoalveolar lavage (BAL) specimens of burn victims who inhaled smoke, in order to identify alterations associated with mortality or survival. Methods: Eighteen victims of facial burns were submitted to BAL up to 24 h after the event. We investigated cell and protein content, including TNF-α, HLA-DR, CD14, CD68 and iNOS. Results: Of the 18 patients submitted to bronchoscopy, 8 (44.4%) died during the follow-up period. The mean age of patients who died was significantly higher (44.7 vs. 31.5 years). On average, the patients who died had burns covering 60.1% of the total body surface area, compared with 26.1% in the survivors (p < 0.0001). Of the 18 patients submitted to bronchoscopy, 11 (61.1%) showed endoscopic signs of smoke inhalation injury, and 4 (36.4%) of those 11 died. Of the 7 patients with no signs of smoke inhalation injury, 4 (57.1%) died. The mean number of ciliated epithelial cells in the BAL fluid was significantly higher in the patients who died than in the survivors (6.6% vs. 1.4%; p = 0.03). There were no significant differences between the groups in terms of any of the other parameters evaluated. Conclusions: The total body surface area burned was a predictive factor for mortality. Increased numbers of ciliated epithelial cells in the BAL fluid, denoting bronchial epithelial desquamation, were associated with higher mortality in patients with facial burns.


Keywords: Burns; Smoke inhalation injury; Bronchoalveolar lavage; Epithelial cells; Macrophages;Tumor necrosis factor-alpha.


9 - Mycobacterium tuberculosis infection among community health workers involved in TB control

Infecção por Mycobacterium tuberculosis entre agentes comunitários de saúde que atuam no controle da TB

Patrícia Marques Rodrigues, Tiago Ricardo Moreira, Andressa Karla Luz de Moraes, Rafael da Cruz Araújo Vieira, Reynaldo Dietze, Rita de Cassia Duarte Lima, Ethel Leonor Noia Maciel

J Bras Pneumol.2009;35(4):351-358

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the incidence of Mycobacterium tuberculosis infection, using tuberculin skin test, among community health agents (CHAs) monitoring TB patients in the city of Cachoeiro de Itapemirim, Brazil. Methods: We included 30 CHAs acting in the Family Health Program and 30 of their family members residing in the same household. The tuberculin skin test results of each CHA were compared with those of the corresponding family member. Results: Of the 30 CHAs, 27 (90.0%) were female, compared with 23 (76.7%) of the 30 family members (p = 0.299). The mean age of the CHA group and of the family member group was, respectively, 36.8 and 39.7 years. No statistically significant difference was found between the groups regarding the level of education. Regarding M. tuberculosis exposure, the same number of participants in the two groups reported having known or had contact with a TB patient (17 individuals; 56.7%). There was a statistically significant difference regarding positive tuberculin skin test results (26.7% in the CHA group and 3.3% in the family member group; p = 0.011). Conclusions: M. tuberculosis infection was significantly higher among CHAs than among their family members, fueling the debate on the occupational risk involved in the activities of these professionals.


Keywords: Community health aides; Tuberculosis; Tuberculin test.


10 - Juvenile household contacts aged 15 or younger of patients with pulmonary TB in the greater metropolitan area of Vitória, Brazil: a cohort study

Comunicantes domiciliares jovens de pacientes com TB pulmonar na região da grande Vitória (ES): um estudo de coorte

Ethel Leonor Noia Maciel, Luiza Werner Heringer Vieira, Lucília Pereira Dutra Molina, Rosana Alves, Thiago Nascimento do Prado, Reynaldo Dietze

J Bras Pneumol.2009;35(4):359-366

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare clinical, radiological and laboratory aspects of household contacts, aged 15 or younger, of patients presenting a positive culture for Mycobacterium tuberculosis. Methods: This was a cohort study comparing children and adolescents (≤ 15 years of age) who were household contacts of TB cases presenting positive sputum smear and positive culture results (exposed group, n = 100) or negative sputum smear and positive culture results (unexposed group, n = 55). All of the contacts were evaluated via the TB control program of a university hospital in the city of Vitória, Brazil, between July of 2003 and December of 2006. Results: Of the 155 minors evaluated, 87 (56.1%) were female and 68 (43.9%) were male. Of those 155, 28 (18%) were aged 5 or younger, 62 (40%) were aged 5-9, and 65 (42%) were aged 10-15. Symptoms of the disease were found in 17 (17%) of the 100 contacts in the exposed group and in 9 (16%) of the 55 in the unexposed group (p = 0.86). Chest X-rays showed alterations in 20 (21%) and 2 (4%) of the contacts in the exposed and unexposed groups, respectively (RR = 6.9; p = 0.004). In the exposed and unexposed groups, respectively, 35 (38%) and 10 (18%) of the contacts presented positive results on the tuberculin skin test (RR = 2.8; p = 0.01). Of the 100 contacts in the exposed group, 5 (5%) were diagnosed with TB, which was not diagnosed in any of those in the unexposed group (p = 0.08). Conclusions: Although no significant difference was found between the two groups regarding the incidence of TB, it is of note that there is a greater risk of becoming infected with M. tuberculosis if the bacterial load of the index case is high.


Keywords: Tuberculosis; Mycobacterium tuberculosis; Tuberculosis, pulmonary; Child; Adolescent.


11 - Intrahospital transport of patients on invasive ventilation: cardiorespiratory repercussions and adverse events

Transporte intra-hospitalar de pacientes sob ventilação invasiva: repercussões cardiorrespiratórias e eventos adversos

Lea Tami Suzuki Zuchelo, Paulo Antônio Chiavone

J Bras Pneumol.2009;35(4):367-374

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the occurrence of cardiorespiratory alterations and to identify adverse events during the intrahospital transport of patients on invasive ventilation. Methods: A prospective observational non-randomized study was conducted at two tertiary hospitals between April of 2005 and December of 2006. We included patients on invasive ventilation who required intrahospital transport during the study period. Exclusion criteria were as follows: being under suspicion of brain death; being submitted to alternate periods of mechanical ventilation/nebulization via a T-piece; and being transported to the operating room. Prior to and after transport, we evaluated blood gas analysis results, vital signs, use of medications by means of a continuous infusion pump, parameters regarding the mechanical ventilator, duration of transport, transport distance and number of professionals involved. Results: We included 48 patients in a total of 58 intrahospital transports. Relevant cardiorespiratory alterations were identified in 39 transports, totaling 86 episodes, as well as 16 adverse events related to equipment or personnel failure, such as problems related to batteries and to miscommunication. Conclusions: During the intrahospital transport of patients on invasive ventilation, cardiorespiratory alterations were common (67.2%), and adverse events occurred in 75.7% of the transports.


Keywords: Patient transfer; Intensive care; Respiration, artificial; Ventilators, mechanical.


Review Article

12 - Role of immunohistochemistry in the diagnosis of lung cancer

Papel da imuno-histoquímica no diagnóstico do câncer de pulmão

Vera Luiza Capelozzi

J Bras Pneumol.2009;35(4):375-382

Abstract PDF PT PDF EN Portuguese Text

The role of immunohistochemistry is to recognize antigens and, consequently, to identify and classify specific cells within a cell population whose morphology is heterogenous or apparently homogenous. The visualization of the antigen-antibody complex is made possible through the addition of either a fluorochrome conjugate or an enzyme to the antibody, which is then viewed under microscopy. Immunohistochemistry can be used in the routine diagnosis of lung cancer, in order to identify biological markers (diagnostic and prognostic). The essential immunohistochemistry panels will be discussed in this review.


Keywords: Immunohistochemistry; Tumor markers, biological; Lung neoplasms.


Case Report

13 - Ectopic thyroid in the anterior mediastinum

Tireoide ectópica no mediastino anterior

Maria José Araújo da Cunha Guimarães, Carla Manuela Silva Valente, Lèlita Santos, Manuel Fontes Baganha

J Bras Pneumol.2009;35(4):383-387

Abstract PDF PT PDF EN Portuguese Text

Ectopic thyroid is a rare condition, and its location in the anterior mediastinum is even rarer, there having been only 5 reported cases in the past 30 years. Here, we describe 2 clinical cases and present a review of the literature regarding the etiology, embryology and clinical manifestations of ectopic thyroid.


Keywords: Thyroid dysgenesis; Mediastinum; Goiter.


14 - Chylothorax after surgical treatment of right-sided thoracic outlet syndrome

Fístula linfática após tratamento cirúrgico de síndrome do desfiladeiro torácico à direita

Luiz Felipe Lopes Araujo, Alexandre Heitor Moreschi, Guilherme Baroni de Macedo, Laura Moschetti, Eduardo Lopes Machado, Maurício Guidi Saueressig

J Bras Pneumol.2009;35(4):388-391

Abstract PDF PT PDF EN Portuguese Text

Chylothorax as a complication of the surgical treatment of thoracic outlet syndrome is a quite rare event. We report a case of right-sided chylothorax and present a brief review on the treatment of postoperative chylothorax.


Keywords: Chylothorax; Thoracic outlet syndrome; Cervical rib syndrome; Postoperative complications.


15 - Lung pseudotumor as the initial presentation of Wegener's granulomatosis

Pseudotumor pulmonar como apresentação inicial de granulomatose de Wegener

Marcelo Fouad Rabahi, Ludmila Bertti Coelho, Eliza de Oliveira Borges, Marcella Stival Lemes, Weniskley Mendes de Castro, Siderley de Souza Carneiro

J Bras Pneumol.2009;35(4):392-395

Abstract PDF PT PDF EN Portuguese Text

Wegener's granulomatosis is a multisystemic inflammatory illness of unknown etiology, characterized by vasculitis of small and medium caliber vessels. The most common clinical manifestations involve the upper respiratory tract, lungs and kidneys. Common alterations in imaging studies include pulmonary opacities and bilateral multiple nodules, cavitations occurring in 50% of the cases. Treatment includes corticosteroids and immunosuppressants. We describe an atypical case of a 61-year-old man initially investigated due to suspicion of a unilateral lung tumor, which proved to be, in fact, a case of Wegener's granulomatosis.


Keywords: Wegener's Granulomatosis; Vasculitis; Diagnosis, differential; Lung neoplasms.


Letters to the Editor

16 - To convince and to inform: ethical issues in public health campaigns

Convencer e informar: questões éticas nas campanhas de saúde pública

Alexandre Amaral Rodrigues

J Bras Pneumol.2009;35(4):396-398

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Author's reply

17 - Author's reply

Resposta dos autores

Carlos Alberto de Assis Viegas

J Bras Pneumol.2009;35(4):397-398

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Year 2009 - Volume 35  - Number 5  (/May)


1 - Influenza and scientific articles

Influenza e publicações científicas

José Antônio Baddini Martinez

J Bras Pneumol.2009;35(5):399-400

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2 - Assessment of exercise capacity in pulmonary hypertension

Avaliação da capacidade de exercício na hipertensão pulmonar

Sérgio Saldanha Menna Barreto

J Bras Pneumol.2009;35(5):401-403

PDF PT PDF EN Portuguese Text

Original Article

3 - Accuracy of clinical examination findings in the diagnosis of COPD

Acurácia do exame clínico no diagnóstico da DPOC

Waldo Luís Leite Dias de Mattos, Leonardo Gilberto Haas Signori, Fernando Kessler Borges, Jorge Augusto Bergamin, Vivian Machado

J Bras Pneumol.2009;35(5):404-408

Abstract PDF PT PDF EN Portuguese Text

Objective: Simple diagnostic methods can facilitate the diagnosis of COPD, which is a major public health problem. The objective of this study was to investigate the accuracy of clinical variables in the diagnosis of COPD. Methods: Patients with COPD and control subjects were prospectively evaluated by two investigators regarding nine clinical variables. The likelihood ratio for the diagnosis of COPD was determined using a logistic regression model. Results: The study comprised 98 patients with COPD (mean age, 62.3 ± 12.3 years; mean FEV1, 48.3 ± 21.6%) and 102 controls. The likelihood ratios (95% CIs) for the diagnosis of COPD were as follows: 4.75 (2.29-9.82; p < 0.0001) for accessory muscle recruitment; 5.05 (2.72-9.39; p < 0.0001) for pursed-lip breathing; 2.58 (1.45‑4.57; p < 0.001) for barrel chest; 3.65 (2.01-6.62; p < 0.0001) for decreased chest expansion; 7.17 (3.75-13.73; p < 0.0001) for reduced breath sounds; 2.17 (1.01-4.67; p < 0.05) for a thoracic index ≥ 0.9; 2.36 (1.22-4.58; p < 0.05) for laryngeal height ≤ 5.5 cm; 3.44 (1.92-6.16; p < 0.0001) for forced expiratory time ≥ 4 s; and 4.78 (2.13-10.70; p < 0.0001) for lower liver edge ≥ 4 cm from lower costal edge. Inter-rater reliability for those same variables was, respectively, 0.57, 0.45, 0.62, 0.32, 0.53, 0.32, 0.59, 0.52 and 0.44 (p < 0.0001 for all). Conclusions: Various clinical examination findings could be used as diagnostic tests for COPD.


Keywords: Physical examination; Diagnosis; Pulmonary disease, chronic obstructive.


4 - Association between nutritional status measurements and pulmonary function in children and adolescents with cystic fibrosis

Associação entre medidas do estado nutricional e a função pulmonar de crianças e adolescentes com fibrose cística

Célia Regina Moutinho de Miranda Chaves, José Augusto Alves de Britto, Cristiano Queiroz de Oliveira, Miriam Martins Gomes, Ana Lúcia Pereira da Cunha

J Bras Pneumol.2009;35(5):409-414

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the association between nutritional status measurements and pulmonary function in children and adolescents with cystic fibrosis. Methods: We evaluated the nutritional status of 48 children and adolescents (aged 6-18 years) with cystic fibrosis based on body mass index (BMI) and body composition measurements-mid-arm muscle circumference (MAMC) and triceps skinfold thickness (TST)-at a referral center in the city of Rio de Janeiro, Brazil. Pulmonary function was assessed by means of spirometry, using FEV1 to classify the severity of airway obstruction. We used Student's t-tests for comparisons between proportions and linear regression analysis for associations between continuous variables. The level of significance was set at p < 0.05. Results: The evaluation of nutritional status based on BMI identified a smaller number of malnourished patients than did that based on MAMC (14 vs. 25 patients, respectively). Most of the patients presented mild pulmonary disease. Mean FEV1 was 82.5% of predicted. Pulmonary function was found to correlate significantly with BMI, MAMC and TST (p = 0.001, p = 0.001 and p = 0.03, respectively). All subjects with moderate or severe pulmonary involvement were considered malnourished based on BMI and body composition parameters. Of the 25 patients considered malnourished based on body composition (MAMC), 19 were considered well-nourished based on their BMI. Conclusions: In the present study, all nutritional status measurements correlated directly with the pulmonary function of children and adolescents with cystic fibrosis. However, body composition measurements allowed earlier detection of nutritional deficiencies.


Keywords: Cystic fibrosis; Body composition; Spirometry; Nutrition assessment.


5 - Comparison of three sets of reference equations for spirometry in children and adolescents with distinct body mass indices

Comparação entre três equações de referência para a espirometria em crianças e adolescentes com diferentes índices de massa corpórea

Sarah Costa Drumond, Maria Jussara Fernandes Fontes, Irmgard de Assis, Marco Antônio Duarte, Joel Alves Lamounier, Luciana de Carvalho Lopes Orlandi, Maria da Glória Rodrigues Machado

J Bras Pneumol.2009;35(5):415-422

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Objective: To compare FEV1 and FVC, calculated using three sets of reference equations (devised by Polgar & Promadhat, Hsu et al. and Mallozi in 1971, 1979 and 1995, respectively), and to determine whether the three are similar in predicting lung function in children and adolescents with distinct body mass indices (BMIs). Methods: The individuals were separated into four groups in accordance with the reference standards of the National Center for Health Statistics: underweight (UW), normal weight (NW), overweight (OW), and obese (OB). All were then submitted to spirometry. Results: We evaluated 122 healthy children and adolescents, aged 7-14 years. The FVC values predicted for NW females and UW males through the use of the Hsu et al. equation were significantly higher than the measured values, as were the FEV1 values for UW females and males predicted via the Polgar & Promadhat and Hsu et al. equations. In NW females, the FEV1 values predicted via the Polgar & Promadhat equation were significantly higher than were the measured values. Conclusions: In individuals with distinct BMIs, the measured FVC and FEV1 values were not equivalent to those predicted via the Polgar & Promadhat and Hsu et al. equations. The same was not true for the Mallozi equations. The BMI was not a relevant factor for the predictive index of these equations; therefore, the Mallozi equations can be used without alteration for children and adolescents with distinct BMIs.


Keywords: Spirometry; Reference values; Body mass index; Child; Adolescent.


6 - Validation of a treadmill six-minute walk test protocol for the evaluation of patients with pulmonary arterial hypertension

Validação de um protocolo para o teste de caminhada de seis minutos em esteira para avaliação de pacientes com hipertensão arterial pulmonar

Viviane Moreira de Camargo, Barbara do Carmo dos Santos Martins, Carlos Jardim, Caio Julio Cesar Fernandes, Andre Hovnanian, Rogério Souza

J Bras Pneumol.2009;35(5):423-430

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Objective: To develop and validate a protocol for the treadmill six-minute walk test (tread6MWT) to evaluate patients with pulmonary arterial hypertension (PAH). Methods: The study population comprised 73 patients with PAH, diagnosed by means of right heart catheterization, with or without NO inhalation. All patients performed a hallway 6MWT and three tread6MWTs based on a pre-determined incremental speed protocol and interposed by a rest period. The patients who had been submitted to hemodynamic testing using NO performed the third tread6MWT while inhaling the same dose of NO that had been used during the catheterization. Results: We found that the treadmill six-minute walk distance (tread6MWD) correlated with hemodynamic data, functional class and the hallway six-minute walk distance (6MWD). In addition, the tread6MWD correlated significantly with survival, thereby confirming the correlation with disease severity. Inhalation of NO during the tread6MWT led to variations that were consistent with the hemodynamic changes induced by the same dose of inhaled NO, suggesting that the protocol developed can reflect the effect of therapeutic interventions. Conclusions: We conclude that the tread6MWD is a useful prognostic and functional marker for the routine evaluation of PAH patients.


Keywords: Hypertension, pulmonary; Exercise test; Hemodynamics.


7 - Bacterial pneumonia following bone marrow transplantation: HRCT findings

Achados de TCAR nas pneumonias bacterianas após transplante de medula óssea

Luiz Otávio de Mattos Coelho, Taísa Davaus Gasparetto, Dante Luiz Escuissato, Edson Marchiori

J Bras Pneumol.2009;35(5):431-435

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Objective: To describe HRCT findings in patients with bacterial pneumonia following bone marrow transplantation (BMT). Methods: This was a retrospective study involving 30 patients diagnosed with bacterial pneumonia in whom HRCT of the chest was performed within 24 h after the onset of symptoms and the diagnosis was confirmed, based on a positive culture of sputum or bronchial aspirate, together with a positive pleural fluid or blood culture, within one week after symptom onset. There were 20 male patients and 10 female patients. The median age was 21 years (range, 1-41 years). The BMT had been performed for the treatment of the following: chronic myeloid leukemia, in 14 cases; severe aplastic anemia, in 6; acute myeloid leukemia, in 4; Fanconi's anemia, in 3; and acute lymphocytic leukemia, in 3. Two radiologists analyzed the HRCT scans and reached their final decisions by consensus. Results: The most common HRCT findings were air-space consolidation (in 60%), small centrilobular nodules (in 50%), ground-glass opacities (in 40%), bronchial wall thickening (in 20%), large nodules (in 20%), pleural lesions (in 16.7%) and tree-in-bud opacities (in 10%). The pulmonary lesions were distributed in the central and peripheral areas in 15 patients, whereas they were exclusively peripheral in 11. Lesions were located in the lower and middle lobes of the lung in 22 and 20 patients, respectively. Conclusions: The most common HRCT findings in our patient sample were air-space consolidation, small centrilobular nodules and ground-glass opacities, most often in the central and peripheral regions of the middle and lower lung zones.


Keywords: Bone marrow transplantation; Pneumonia, bacterial; Tomography, X-Ray Computed.


8 - The impact of smoking cessation on patient quality of life

Impacto da cessação tabágica na qualidade de vida dos pacientes

Maria Penha Uchoa Sales, Maria Irenilza Oliveira, Isabela Melo Mattos, Cyntia Maria Sampaio Viana, Eanes Delgado Barros Pereira

J Bras Pneumol.2009;35(5):436-441

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Objective: To evaluate changes in health-related quality of life (HRQoL) after twelve months of smoking cessation. Methods: This was a prospective study to evaluate the effectiveness of a smoking cessation program on the quality of life of 60 self-referred subjects, at a public hospital, during the period of August 2006 to December 2007. The program consisted of 2-h group sessions once a week during the first month and then every 15 days over six months, followed by monthly phone contacts for another six months. The treatment was based on behavior modification and the use of bupropion in combination with nicotinic replacement therapy. Abstinence was verified by exhaled CO measurements. Patient HRQoL was quantified using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. Differences in quality of life scores between quitters and non-quitters at twelve months after the initial intervention were evaluated using analysis of covariance with baseline characteristics as covariates. Results: Self-reported quality of life scores were significantly higher among the 40 quitters than among the 20 non-quitters. The following SF-36 domains were most affected: role-emotional (p = 0.008); general health (p = 0.006); vitality (p < 0.001); and mental health (p = 0.002). At twelve months after the smoking cessation intervention, the SF-36 mental component and physical component summary scores were higher among quitters than among non-quitters (p = 0.004 and p = 0.001, respectively). Conclusions: Our findings illustrate that smoking abstinence is related to better HRQoL, especially in aspects of mental health.


Keywords: Quality of life; Smoking cessation; Questionnaires.


9 - Prevalence of and variables related to smoking among medical students at a university in the city of Passo Fundo, Brazil

Prevalência e fatores associados ao tabagismo em estudantes de medicina de uma universidade em Passo Fundo (RS)

Leandro Mazzoleni Stramari, Munique Kurtz, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2009;35(5):442-448

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Objective: To determine the prevalence of and factors associated with smoking among medical students, as well as to evaluate the profile of this group. Methods: A total of 316 medical students (98.7% of the total) at the University of Passo Fundo, in the city of Passo Fundo, Brazil, completed a self-report questionnaire with questions on tobacco intake and on attitudes related to smoking. In accordance with the World Health Organization guidelines, the students were classified as daily smokers, occasional smokers, former smokers or nonsmokers, those in the two first categories being considered active smokers. Results: We found that 16.5% of the students were active smokers (daily smokers, 5.4%; occasional smokers, 11.1%) and that 3.5% were former smokers. The mean age was 22.2 ± 2.4 years. Factors significantly associated with the smoking habit (p < 0.05) were male gender, paternal smoking, regular alcohol consumption and use of antidepressants or anxiolytics. For the majority (69.2%) of the smokers, the age at smoking onset was 15-19 years of age, and the main motivations to start smoking were self-initiative and influence of friends. The conceptualization of smoking as an illness was significantly higher among the nonsmokers. In 70.6% of the smokers, tobacco intake was 1-10 cigarettes a day. Among the smokers, 92.3% agreed that smoking is harmful to health, 67.3% had tried to quit smoking, 96.0% believed themselves able to do so, and 87.2% intended to quit smoking. Conclusions: The prevalence of smoking remains significant among medical students. Therefore, it is fundamental that we develop more effective strategies for smoking prevention and cessation in order to reduce the number of smokers among future doctors.


Keywords: Smoking; Prevalence; Students, medical; Behavior.


10 - Health team training and active community surveillance: strategies for the detection of TB cases

Treinamento da equipe de saúde e busca ativa na comunidade: estratégias para a detecção de casos de TB

Mônica Cardoso Façanha, Marina Alves Melo, Francisca de Fátima Vasconcelos, José Roberto Pereira de Sousa, Adivania de Souza Pinheiro, Ivna Aguiar Porto, Julianne Martins Parente

J Bras Pneumol.2009;35(5):449-454

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Objective: To evaluate the impact that Family Health Program (FHP) team training and active surveillance have on the detection of TB cases in a low-income community in the city of Fortaleza, Brazil. Methods: The study was performed in an area with approximately 25,000 inhabitants, served by a health care center with five FHP teams, in the city of Fortaleza, Brazil. Although all of the teams were trained, active surveillance was carried out only in one of the areas (area 5). We compared the number of TB cases detected in each of the five areas prior to and after the intervention. We also compared the number of TB cases detected in area 5 to the number of those detected in the other areas, as well as to the citywide number of reported TB cases in Fortaleza, within the same period. Results: The number of TB cases detected in the area studied increased from 1 in 2002 to 22 in 2004 (p < 0.05). There was no significant difference between the number of TB cases in area 5 and that observed for each of the other four areas (p > 0.05). There was a significant increase in the number of TB cases detected in the area studied when compared to the city as a whole (p < 0.05). Conclusions: Training and sensitization of FHP professionals were effective in promoting an increase in the number of TB cases detected in a low-income community.


Keywords: Tuberculosis; Communicable disease control; Family health program; Epidemiologic surveillance.


Brief Communication

11 - Physical therapy in the immediate postoperative period after abdominal surgery

Atendimento fisioterapêutico no pós-operatório imediato de pacientes submetidos à cirurgia abdominal

Luiz Alberto Forgiarini Junior, Alexandra Torres de Carvalho, Tatiane de Souza Ferreira, Mariane Borba Monteiro, Adriane Dal Bosco, Marisa Pereira Gonçalves, Alexandre Simões Dias

J Bras Pneumol.2009;35(5):455-459

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A series of pulmonary complications can occur after abdominal surgery. Therefore, it is necessary to introduce appropriate treatment early in order to minimize postoperative complications. The objective of the present study was to evaluate patients submitted to abdominal surgery in terms of the effect of physical therapy in the immediate postoperative period. This was a randomized clinical trial, in which one group of patients was submitted to physical therapy in the postoperative recovery room and, subsequently, in the infirmary, whereas another group was submitted to physical therapy in the infirmary exclusively. We conclude that physical therapy performed in the immediate postoperative period minimizes losses in lung function and respiratory muscle strength, as well as shortening recovery room stays.


Keywords: Physical therapy (specialty); Postoperative period; Surgery/abdomen.


12 - Guided sputum sample collection and culture contamination rates in the diagnosis of pulmonary TB

Associação entre coleta de escarro guiada e taxas de contaminação de culturas para o diagnóstico de TB pulmonar

Ethel Leonor Noia Maciel, Thiago Nascimento do Prado, Renata Lyrio Peres, Moises Palaci, John L. Johnson, Reynaldo Dietze

J Bras Pneumol.2009;35(5):460-463

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A comparative study to evaluate contamination in cultures of morning sputum samples, comparing those collected at home under currently recommended conditions and those collected under supervision after patient orientation and education. The home and supervised collection groups produced 43 and 76 sputum samples, respectively. The contamination rate was nearly 3-times higher among samples collected at home than among those collected under supervision (37% vs. 13%, p < 0.05; OR = 0.25). The simple educational and hygiene measures described can decrease the contamination rate among sputum samples collected for diagnostic culture.


Keywords: Tuberculosis/diagnosis; Sputum/microbiology; Culture techniques.


Special Article

13 - How to prevent, recognize and diagnose infection with the swine-origin Influenza A (H1N1) virus in humans

Infecção pelo vírus Influenza A (H1N1) de origem suína: como reconhecer, diagnosticar e prevenir

Alcyone Artioli Machado

J Bras Pneumol.2009;35(5):464-469

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In March of 2009, a flu epidemic began in Mexico. Shortly thereafter, similar cases appeared in other countries, alerting authorities to the risk of a pandemic. This article details the principal signs and symptoms of infection with the swine-origin Influenza A (H1N1) virus. In addition, the measures to be taken in suspected or confirmed cases are addressed, as are the procedures to follow in relation to contacts. Furthermore, the drugs used in the prophylaxis against and the treatment of infection with the H1N1 virus are described.


Keywords: Influenza A virus, H1N1 subtype; Influenza A virus; Disease outbreaks.


Review Article

14 - Avian influenza: the threat of the 21st century

Gripe aviária: a ameaça do século XXI

Cláudia Ribeiro de Andrade, Cássio da Cunha Ibiapina, Natália Silva Champs, Antonio Carlos Castro de Toledo Junior, Isabela Furtado de Mendonça Picinin

J Bras Pneumol.2009;35(5):470-479

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This study aimed to review the literature on infection with the H5N1 subtype of avian influenza A virus, taking into consideration the fact that, in the event of a pandemic, children might become a major risk group. Searches were limited to the past ten years and were carried out using the following electronic databases: Medline, MD Consult, HighWire and Medscape. Children and young adults account for a significant proportion of the susceptible population. We found that more than half of the individuals infected were under 20 years of age and that one quarter were under the age of 10. The incubation period ranged from 2 to 5 days. Initial clinical manifestations are nonspecific, which hinders the diagnosis. Most of the infected individuals presented severe pneumonia, which evolved to respiratory insufficiency within an average of 4 days. Chest X-rays can reveal diffuse multifocal/interstitial infiltrates or segmental/lobar consolidation with air bronchogram. The pathogenic potential is high, with mortality rates up to 63%, indicating that the pandemic virus might present high pathogenicity and high mortality. Knowledge of the risk of a pandemic and of the measures to be taken in suspect cases constitutes an important step toward controlling a potential pandemic.


Keywords: Influenza A virus; Disease vectors; Disease outbreaks; Influenza A virus, H5N1 subtype.


Case Report

15 - Aspergilloma formation in cavitary sarcoidosis

Formação de uma aspergilloma em sarcoidose com cavitação

Chandramani Panjabi, Sandeep Sahay, Ashok Shah

J Bras Pneumol.2009;35(5):480-483

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Pulmonary cavitation is rather uncommon in patients with sarcoidosis, and aspergilloma is even more uncommon in such cases. Here, we present the case of a 63-year-old female patient with cavitary lung disease who had been under treatment for TB for 9 months. A diagnosis of pulmonary sarcoidosis was established based on the fiberoptic bronchoscopy finding of noncaseating granuloma. Treatment with corticosteroids led to a dramatic improvement in symptoms. While under treatment for sarcoidosis, the patient developed an aspergilloma. She presented immediate skin test reactivity to Aspergillus fumigatus, as well as positivity for A. fumigatus serum precipitins. This is the first reported case of aspergilloma formation in a patient with cavitary sarcoidosis in India.


Keywords: Sarcoidosis, pulmonary; Aspergillosis; Medical records.


16 - Pseudotumoral presentation of chronic pulmonary schistosomiasis without pulmonary hypertension

Forma pseudoneoplásica de esquistossomose pulmonar crônica sem hipertensão pulmonar

Gisane Cavalcanti Rodrigues, Domício Carvalho Lacerda, Edson da Silva Gusmão, Fernando Antônio Colares, Vinícius Turano Mota

J Bras Pneumol.2009;35(5):484-488

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Schistosomiasis is a disease that, in Brazil, is caused by Schistosoma mansoni and is transmitted by snails of the genus Biomphalaria. This species occurs in Africa, the Antilles and South America. The parasite, developing to the adult stage in the vascular system of the host, migrates to the mesenteric veins. Each female lays approximately 400 eggs per day, and these travel from the submucosa to the intestinal lumen. There have been reported cases in which S. mansoni eggs were identified in the lungs of patients with no evidence of liver fibrosis. We report a case with this atypical presentation of the disease. The patient presented nonpleuritic chest pain, significant weight loss and dry cough. A CT scan revealed an irregular tumor in the left lower lobe. However, a lung biopsy revealed non-viable S. mansoni eggs. The patient presented no clinical signs of pulmonary or portal hypertension; nor was either identified through diagnostic tests.


Keywords: Schistosomiasis; Schistosoma mansoni; Lung diseases, parasitic.


17 - Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia accompanied by airflow obstruction

Hiperplasia de células neuroendócrinas pulmonares difusas com obstrução ao fluxo aéreo

Ester Nei Aparecida Martins Coletta, Larissa Rêgo Voss, Mariana Silva Lima, Jaquelina Sonoe Ota Arakaki, Juvêncio Câmara, Carlos D'Andretta Neto, Carlos Alberto de Castro Pereira

J Bras Pneumol.2009;35(5):489-494

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Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia with airflow obstruction is a rare form of lung injury. All of the reported cases have been diagnosed by surgical lung biopsy. Only three of the reported cases presented with diffuse interstitial lung opacities on HRCT scans. We report three additional cases of this entity. All of the patients were female and presented with mild-to-moderate airflow obstruction. In the first case, transbronchial biopsy and imaging data were sufficient to make the diagnosis. Although the HRCT scans of all three cases revealed a mosaic pattern, that of the third patient also revealed diffuse interstitial infiltrate. In extremely rare cases, HRCT findings can simulate those seen in other interstitial lung diseases.


Keywords: Neuroendocrine cells; Carcinoid tumor; Bronchiolitis obliterans.


Letters to the Editor

18 - Environmental control and prevention of respiratory allergy: evidence and obstacles

Controle ambiental e prevenção de alergia respiratória: evidências e obstáculos

Nelson Rosário

J Bras Pneumol.2009;35(5):495-496

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Year 2009 - Volume 35  - Number 6  (/June)


1 - Intermittent treatment for TB and resistance

Tratamento intermitente para TB e resistência

Marcus Barreto Conde

J Bras Pneumol.2009;35(6):497-499

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Original Article

2 - Obstructive sleep apnea syndrome in truck drivers

Síndrome da apneia obstrutiva do sono em motoristas de caminhão

Lucia Castro Lemos, Elaine Cristina Marqueze, Fernanda Sachi, Geraldo Lorenzi-Filho, Claudia Roberta de Castro Moreno

J Bras Pneumol.2009;35(6):500-506

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Objective: To determine the prevalence of obstructive sleep apnea syndrome (OSAS), as well as to identify factors associated with a greater risk of developing OSAS, among truck drivers. Methods: The study population comprised 209 truck drivers (mean age, 38.8 years; 98.5% males) at two branches of a transportation company. The mean body mass index was 26.5 ± 4.4 kg/m2. The participants completed questionnaires regarding sociodemographic data, physical activity and OSAS. The prevalence of OSAS was estimated using the Berlin Questionnaire, associations between OSAS and the factors studied being assessed through univariate and multivariate regression analysis. Results: The prevalence of OSAS in the population was 11.5%. Of the 209 truck drivers, 72 (34.5%) reported having fallen asleep while driving and 81 (38.7%) reported snoring. The following variables were found to present statistically significant associations with OSAS: informal employment (OR = 0.27; p = 0.01); body mass index ≥ 25 kg/m2 (OR = 13.64; p = 0.01); and poor sleep quality (OR = 3.00; p = 0.02). Conclusions: The prevalence of OSAS in this study was lower than that reported in other studies of truck drivers and yet higher that that observed for the general population. In addition, our results suggest that work characteristics, such as employment status, are associated with OSAS. These data show the relevance of considering work activity in studies of factors associated with OSAS.


Keywords: Sleep apnea, obstructive; Sleep disorders; Questionnaires.


3 - Dimensions of sleepiness and their correlations with sleep-disordered breathing in mild sleep apnea

Dimensões da sonolência e suas correlações com os transtornos respiratórios do sono na apneia do sono leve

Denis Martinez, Magali Santos Lumertz, Maria do Carmo Sfreddo Lenz

J Bras Pneumol.2009;35(6):507-514

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Objective: There are many ways of assessing sleepiness, which has many dimensions. In patients presenting a borderline apnea-hypopnea index (AHI, expressed as events/hour of sleep), the mechanisms of excessive daytime sleepiness (EDS) remain only partially understood. In the initial stages of sleep-disordered breathing, the AHI might be related to as-yet-unexplored EDS dimensions. Methods: We reviewed the polysomnography results of 331 patients (52% males). The mean age was 40 ± 13 years, and the mean AHI was 4 ± 2 (range, 0-9). We assessed ten potential dimensions of sleepiness based on polysomnography results and medical histories. Results: The AHI in non-rapid eye movement (NREM) stage 1 sleep (AHI-N1), in NREM stage 2 sleep (AHI-N2), and in REM sleep (AHI-REM) were, respectively, 6 ± 7, 3 ± 3 and 10 ± 4. The AHI-N2 correlated significantly with the greatest number of EDS dimensions (5/10), including the Epworth sleepiness scale score (r = 0.216, p < 0.001). Factor analysis, using Cronbach's alpha, reduced the variables to three relevant factors: QUESTIONNAIRE (α = 0.7); POLYSOMNOGRAPHY (α = 0.68); and COMPLAINTS (α = 0.55). We used these factors as dependent variables in a stepwise multiple regression analysis, adjusting for age, gender, and body mass index. The AHI-N1 correlated significantly with POLYSOMNOGRAPHY (β = −0.173, p = 0.003), and the AHI-N2 correlated significantly with COMPLAINTS (β = −0.152, p = 0.017). The AHI-REM did not correlate with any factor. Conclusions: Our results underscore the multidimensionality of EDS in mild sleep apnea.


Keywords: Disorders of excessive somnolence; Sleep apnea syndromes; Sleep, REM; Polysomnography.


4 - Surgical treatment of congenital tracheal stenoses

Tratamento cirúrgico das estenoses traqueais congênitas

Ricardo Mingarini Terra, Helio Minamoto, Lívia Caroline Barbosa Mariano, Angelo Fernandez, José Pinhata Otoch, Fabio Biscegli Jatene

J Bras Pneumol.2009;35(6):515-520

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Objective: To analyze the outcomes of patients undergoing repair of congenital tracheal stenosis. Methods: This was a retrospective review of congenital tracheal stenosis patients treated between 2001 and 2007 at the University of São Paulo School of Medicine Hospital das Clínicas in São Paulo, Brazil. Results: Six boys and one girl (age at diagnosis ranging from 28 days to 3 years) were included. Five of the patients also had cardiac or major vessel malformations. The stenosis length was short in three patients, medium in one and long in three. The techniques used were pericardial patch tracheoplasty in three patients, resection and anastomosis in two, slide tracheoplasty in one and vascular ring correction in one. One patient died during surgery due to hypoxia and hemodynamic instability, and one died from septic shock on postoperative day 11. Other complications included pneumonia, arrhythmia, stenosis at the anastomosis level, residual stenosis, granuloma formation and malacia. The mean follow-up period was 31 months; four patients were cured, and one required the use of a T-tube to maintain airway patency. Conclusions: Congenital tracheal stenosis is a curable disease. However, its repair is complex and is associated with high rates of morbidity and mortality.


Keywords: Tracheal stenosis/congenital; Tracheal diseases; Surgical procedures, operative.


5 - Assessment of pulmonary function and quality of life in patients submitted to pulmonary resection for cancer

Avaliação da função pulmonar e da qualidade de vida em pacientes submetidos à ressecção pulmonar por neoplasia

Luciana Nunes Titton Lima, Rodrigo Afonso da Silva, Jefferson Luiz Gross, Daniel Deheinzelin, Elnara Márcia Negri

J Bras Pneumol.2009;35(6):521-528

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Objective: To evaluate the effects that pulmonary resection has on pulmonary function and quality of life (QoL) in patients with primary or metastatic lung cancer. Methods: This was a prospective cohort study involving all patients submitted to pulmonary resection for cancer between September of 2006 and March of 2007 at the A. C. Camargo Hospital in São Paulo, Brazil. Patients underwent spirometry in the preoperative period and at six months after the surgical procedure. After a postoperative period of six months, the patients completed an overall QoL questionnaire (the Medical Outcomes Study 36-item Short-form Health Survey) and another one, specific for respiratory symptoms (the Saint George's Respiratory Questionnaire). The scores obtained in our study were compared with those previously obtained for a general population and for a population of patients with COPD. Results: We included 33 patients (14 males and 19 females), ranging in age from 39 to 79 years. All of the patients, smokers and nonsmokers alike, presented significant worsening of pulmonary function. The mean scores on the overall QoL questionnaire were approximately 5% lower than those obtained for the general population. The scores of various domains of the symptom-specific QoL questionnaire were 50-60% lower than those obtained for the general population and approximately 20% higher than those obtained for the population with COPD. Conclusions: Pulmonary resection has a direct negative impact on pulmonary function and QoL, especially on the QoL related to aspects directly linked to pulmonary function. We highlight the importance of preoperative assessment of pulmonary function in patients undergoing pulmonary resection, in order to predict their postoperative evolution.


Keywords: Thoracic surgery; Lung neoplasms/surgery; Spirometry; Quality of life; Questionnaires.


6 - Esclerose sistêmica e pneumonia intersticial idiopática: diferenças histomorfométricas em biópsias pulmonares

Esclerose sistêmica e pneumonia intersticial idiopática: diferenças histomorfométricas em biópsias pulmonares

Edwin Roger Parra, Leandro Hideki Otani, Erika Franco de Carvalho, Alexandre Ab'Saber, Vera Luiza Capelozzi

J Bras Pneumol.2009;35(6):529-540

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Objective: The aim of this study was to examine the parenchymal and extracellular matrix remodeling process in two histologic patterns-nonspecific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP)-in cases of idiopathic and sclerosis/systemic sclerosis (SSc)-associated interstitial pneumonia. Methods: We examined 15 cases of idiopathic NSIP, 10 cases of idiopathic UIP, 5 cases of SSc-UIP and 9 cases of SSc-NSIP. In the lung parenchyma, epithelial cells, endothelial cells and myofibroblasts were evaluated by immunohistochemical staining, whereas histochemical staining was used in order to evaluate collagen/elastic fibers in the extracellular matrix. Results: The percentage of surfactant protein A-positive epithelial cells was significantly greater in idiopathic NSIP than in SSc-NSIP, as well as being greater in idiopathic UIP than in SSc-UIP. Idiopathic NSIP and idiopathic UIP presented significantly higher immunoexpression of alpha smooth muscle actin in myofibroblasts than did SSc-NSIP and SSc-UIP. The percentage of CD34 endothelial cells in the pulmonary microvasculature was significant lower in idiopathic UIP than in SSc-UIP. The density of collagen fibers was significantly greater in idiopathic NSIP and idiopathic UIP than in SSc-NSIP and UIP. In contrast, the elastic fiber density was significantly lower in idiopathic UIP than in SSc-UIP. Conclusions: Increased collagen synthesis, destruction of elastic fibers, high myofibroblast proliferation and poor microvascularization might represent a remodeling process found in idiopathic interstitial pneumonia, whereas the reverse might represent a repair process in SSc-associated interstitial pneumonia.


Keywords: Epithelial cells; Neovascularization, pathologic; Collagen; Elastin; Idiopathic interstitial pneumonias; Scleroderma, systemic.


7 - Evaluation of the diagnostic performance and cut-off value for the rapid shallow breathing index in predicting extubation failure

Avaliação do desempenho diagnóstico e do valor de corte para o índice de respiração rápida e superficial na predição do insucesso da extubação

Aline Roberta Danaga, Ana Lúcia Gut, Letícia Cláudia de Oliveira Antunes, Ana Lúcia dos Anjos Ferreira, Fábio Akio Yamaguti, José Carlos Christovan, Ubirajara Teixeira, Cristina Aparecida Veloso Guedes, Ana Beatriz Sasseron, Luis Cuadrado Martin

J Bras Pneumol.2009;35(6):541-547

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the diagnostic performance of the rapid shallow breathing index (RSBI) in predicting extubation failure among adult patients in the intensive care unit and to determine the appropriateness of the classical RSBI cut-off value. Methods: This was a prospective study conducted in the adult intensive care unit of the Botucatu School of Medicine Hospital das Clínicas. The RSBI was evaluated in 73 consecutive patients considered clinically ready for extubation. Results: The classical RSBI cut-off value (105 breaths/min/L) presented a sensitivity of 20% and a specificity of 95% (sum = 115%). Analysis of the receiver operator characteristic (ROC) curve revealed a better cut-off value (76.5 breaths/min/L), which presented a sensitivity of 66% and a specificity of 74% (sum = 140%). The area under the ROC curve for the RSBI was 0.78. Conclusions: The classical RSBI cut-off value proved inappropriate, predicting only 20% of the cases of extubation failure in our sample. The new cut-off value provided substantial improvement in sensitivity, with an acceptable loss of specificity. The area under the ROC curve indicated that the discriminative power of the RSBI is satisfactory, which justifies the validation of this index for use.


Keywords: Adult; Intensive care; ROC curve; Ventilator weaning; Diagnosis; Respiration, artificial.


8 - Epidemiological aspects of pleural tuberculosis in the state of São Paulo, Brazil (1998-2005)

Aspectos epidemiológicos da tuberculose pleural no estado de São Paulo (1998-2005)

Márcia Seiscento, Francisco Suso Vargas, Maria Josefa Penon Rujula, Sidney Bombarda, David Everson Uip, Vera Maria Nedes Galesi

J Bras Pneumol.2009;35(6):548-554

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the epidemiological characteristics of and trends regarding the incidence of pleural TB. Methods: This was a retrospective descriptive study of TB cases reported between 1998 and 2005 and compiled from the Epidemiological Surveillance Tuberculosis System (Epi-TB database). Results: A total of 144,347 new cases of TB were reported during the period studied. Pulmonary TB was the predominant form (118,575 cases; 82.2%). Among the extrapulmonary forms (25,773 cases; 17.8%), pleural TB was the form most often reported (12,545 cases; 48.7%). For all forms, the incidence (per 100,000 population) decreased (from 49.7 in 1998 to 44.6 in 2005; R2 = 0.898; p < 0.001), whereas the incidence of pleural TB remained stable (4.1 in 1998 and 3.8 in 2005; R2 = 0.433; p = 0.076). The highest incidence of pleural TB was found among males (2:1) aged from 30 to 59 years. Of the 12,545 patients with pleural TB, 4,018 (32.0%) presented comorbidities: alcoholism (9.5%); HIV (8.0%); diabetes (3.3%); and mental illness (1.2%). The diagnosis was based on bacteriological (14.2%) and histological (30.2%) methods, as well as on unspecified methods (55.6%). Conclusions: Pleural TB was the predominant extrapulmonary form of TB in the state of São Paulo, with a stable incidence between 1998 and 2005, although there was a trend toward a decrease in the incidence of the pulmonary forms. The diagnosis of pleural TB was confirmed through histology and bacteriology in 44.4% of the cases.


Keywords: Pleural effusion; Tuberculosis, pleural; HIV.


9 - Prevalence of drug-resistant Mycobacterium tuberculosis in patients under intermittent or daily treatment

Prevalência de Mycobacterium tuberculosis resistente em pacientes sob tratamento parcialmente intermitente ou sob tratamento diário

Tomás Aiza Alvarez, Marcelo Palmeira Rodrigues, Carlos Alberto de Assis Viegas

J Bras Pneumol.2009;35(6):555-560

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the prevalence rates of drug-resistant Mycobacterium tuberculosis in patients under intermittent treatment with those observed in patients under daily treatment. Methods: We used World Health Organization data regarding 5,138 patients with active pulmonary TB in Brazil, separated into two groups: patients in the Federal District of Brasília, treated with a one-month daily regimen followed by an intermittent thrice-weekly regimen; and patients in other parts of Brazil, treated with a daily regimen only. The resistance pattern was categorized as primary or acquired, based on the history of previous treatment. Multidrug resistance was defined as resistance to at least isoniazid and rifampin, whereas monoresistance was defined as resistance to only one drug. Results: The prevalence of primary resistance in the Federal District of Brasília and in the other parts of Brazil, respectively, was as follows: overall, 9.2% and 9.3% (p = 0.94); monoresistance, 6.6% and 6.9% (p = 0.89); and multidrug resistance, 1.0% and 1.2% (p = 0.85). The prevalence of acquired resistance in the Federal District of Brasília and in the other parts of Brazil, respectively, was as follows: overall, 15.8% and 26.8% (p = 0.39); monoresistance, 5.3% and 13.7% (p = 0.33); and multidrug resistance, 0.0% and 10.2% (p = 0.16). Conclusions: No significant differences were found between patients treated with an intermittent regimen and those treated with a daily regimen in term of resistance rates.


Keywords: Tuberculosis, pulmonary; Drug resistance; Drug administration schedule; Tuberculosis, multidrug-resistant.


Review Article

10 - Pulmonary eosinophilia

Eosinofilia pulmonar

Luiz Eduardo Mendes Campos, Luiz Fernando Ferreira Pereira

J Bras Pneumol.2009;35(6):561-573

Abstract PDF PT PDF EN Portuguese Text

Pulmonary eosinophilia comprises a heterogeneous group of diseases defined by eosinophilia in pulmonary infiltrates (bronchoalveolar lavage fluid) or in tissue (lung biopsy specimens). Although the inflammatory infiltrate is composed of macrophages, lymphocytes, neutrophils and eosinophils, eosinophilia is an important marker for the diagnosis and treatment. Clinical and radiological presentations can include simple pulmonary eosinophilia, chronic eosinophilic pneumonia, acute eosinophilic pneumonia, allergic bronchopulmonary aspergillosis and pulmonary eosinophilia associated with a systemic disease, such as in Churg-Strauss syndrome and hypereosinophilic syndrome. Asthma is frequently concomitant and can be a prerequisite, as in allergic bronchopulmonary aspergillosis and Churg-Strauss syndrome. In diseases with systemic involvement, the skin, the heart and the nervous system are the most affected organs. The radiological presentation can be typical, or at least suggestive, of one of three types of pulmonary eosinophilia: chronic eosinophilic pneumonia, acute eosinophilic pneumonia and allergic bronchopulmonary aspergillosis. The etiology of pulmonary eosinophilia can be either primary (idiopathic) or secondary, due to known causes, such as drugs, parasites, fungal infection, mycobacterial infection, irradiation and toxins. Pulmonary eosinophilia can be also associated with diffuse lung diseases, connective tissue diseases and neoplasia.


Keywords: Pulmonary eosinophilia; Hypereosinophilic syndrome; Aspergillosis, allergic bronchopulmonary; Churg-Strauss syndrome.


Guidelines SBPT

11 - Brazilian guidelines for community-acquired pneumonia in immunocompetent adults - 2009

Diretrizes brasileiras para pneumonia adquirida na comunidade em adultos imunocompetentes - 2009

Ricardo de Amorim Corrêa, Fernando Luiz Cavalcanti Lundgren, Jorge Luiz Pereira-Silva, Rodney Luiz Frare e Silva (editores); Grupo de Trabalho da Diretriz

J Bras Pneumol.2009;35(6):574-601

Abstract PDF PT PDF EN Portuguese Text

Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.


Keywords: Pneumonia; Diagnosis; Epidemiology; Practice guideline; Primary prevention.


Case Report

12 - Synchronous pulmonary and hepatic nodules in a patient with previous bronchogenic carcinoma: the relevance of histopathological confirmation

Nódulo sincrônico pulmonar e hepático em paciente com antecedente de carcinoma broncogênico: a importância da confirmação histopatológica

José de Jesus Peixoto Camargo, Tiago Noguchi Machuca, Spencer Marcantonio Camargo, Sadi Marcelo Schio, Rodrigo Moreira Bello

J Bras Pneumol.2009;35(6):602-605

Abstract PDF PT PDF EN Portuguese Text

The synchronous presentation of pulmonary and hepatic nodules in a patient with previously resected bronchogenic carcinoma raises suspicion of recurrence and mandates restaging. We present the case of a 71-year-old male with a history of lobectomy with pericardial resection and mediastinal lymphadenectomy (T3N0M0). At five years after the operation, he presented with a new pulmonary lesion. Restaging detected a synchronous nodule in the liver. Despite the strong suspicion of tumor recurrence, further investigation with a percutaneous liver biopsy revealed hepatocellular carcinoma. In order to investigate the etiology of the pulmonary lesion (hypotheses of recurrent bronchial cancer and of metastatic hepatocellular carcinoma), an open lung biopsy was performed, which revealed chronic inflammatory tissue with foci of anthracosis and dystrophic calcification. The patient was submitted to a non-anatomic resection of the liver lesion. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. This report highlights the relevance of the histopathological diagnosis in patients with a history of bronchogenic carcinoma and suspicion of tumor recurrence. Differential diagnoses and the treatment administered are discussed.


Keywords: Carcinoma, bronchogenic; Neoplasm metastasis; Carcinoma, hepatocellular.


13 - Uncommon pleural effusion: pleuropulmonary metastasis from primitive neuroectodermal tumor

Derrame pleural incomum: metástase pleuropulmonar de tumor neuroectodérmico primitivo

Leila Antonangelo, Adriana Gonçalves Rosa, Aline Pivetta Corá, Milena Marques Pagliarelli Acencio, Luís César Moreira, Francisco Vargas Suso

J Bras Pneumol.2009;35(6):606-609

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Primitive neuroectodermal tumor is an invasive neoplasm with neuronal differentiation, which frequently results in metastasis in various organs. We report the case of a patient with primitive neuroectodermal tumor whose primary site was the axilla. The patient presented with metastases in the lung, pleura, bone, iliac muscle and bone marrow. We highlight the uncommon finding in the pleural fluid cytology.


Keywords: Neuroectodermal tumors, primitive; Neoplasm metastasis; Cytology; Pleural effusion.


Special Article

14 - Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil

Questionário para avaliação de desempenho de serviços de atenção básica no controle da TB no Brasil

Tereza Cristina Scatena Villa, Antônio Ruffino-Netto

J Bras Pneumol.2009;35(6):610-612

Abstract PDF PT PDF EN Portuguese Text Appendix

The objective of this study was to provide access to and disseminate a questionnaire used as an instrument to assess the organizational elements and the performance of primary health care clinics regarding TB control in Brazil, comparing selected organizational dimensions by health care clinic, by municipality and by actor (patients, health care workers and managers). The results show that municipalities where the coverage of supervised treatment was more extensive presented more favorable indicators regarding access to TB treatment. The organizational format of the health care clinics involved in TB treatment-family health programs and referral centers with specialized teams in TB control programs (TCPs)-was not a factor that expanded access to diagnosis. The TCPs involving a smaller number of patients presented better performance regarding the health care professional-patient relationship. The majority of the patients faced economic and social difficulties, and most managers were unaware of the amount of resources allocated to TB control activities. The instrument proved to be viable and to have the potential to adequately assess the performance of health care clinics in the urban areas studied.


Keywords: Questionnaires; Patient satisfaction; Primary health care; Family health program; Tuberculosis.


Letters to the Editor

15 - Respiratory findings in sudden unexpected death in epilepsy: a point of convergence for clinical pulmonologists and neurologists

Alterações respiratórias e morte súbita em epilepsia: um ponto de convergência para pneumologistas clínicos e neurologistas

Fulvio Alexandre Scorza, Vera Cristina Terra, Marly de Albuquerque, Esper Abrão Cavalheiro

J Bras Pneumol.2009;35(6):613-614

PDF PT PDF EN Portuguese Text

Year 2009 - Volume 35  - Number 7  (/July)


1 - Medications to the north, patients to the south

Medicamentos ao Norte, doentes ao Sul

Paulo Augusto Moreira Camargos, Álvaro Augusto Cruz, Jean Bousquet

J Bras Pneumol.2009;35(7):615-617

PDF PT PDF EN Portuguese Text

Original Article

2 - Two-year evaluation of an educational program for adult outpatients with asthma

Avaliação de dois anos de um programa educacional para pacientes ambulatoriais adultos com asma

Luciene Angelini, Priscila Games Robles-Ribeiro, Regina Maria de Carvalho-Pinto, Marcos Ribeiro, Alberto Cukier, Rafael Stelmach

J Bras Pneumol.2009;35(7):618-627

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the understanding of asthma and the clinical improvement in patients with moderate or severe persistent asthma prior to and after their participation in an educational program presented during the routine outpatient visits. Methods: This was a prospective pilot study involving 164 patients over a two-year period. The educational program, presented to small groups on outpatient visit days, consisted of lectures divided into three parts: pathophysiology; environmental control; and treatment, including training in the inhalation technique. The program was evaluated using standardized questionnaires on clinical improvement and understanding of the disease. Results: By the end of the first year, 120 patients had completed three visits, and 51 of those patients were revaluated at the end of the second year. The mean age of the patients was 44 years, 70% were female, and 43% had up to eight years of schooling. The educational intervention significantly increased the understanding of the disease (p < 0.001), and allowed greater clinical improvement (p < 0.05) with a decrease in the use of oral corticosteroids, fewer visits to the emergency room and fewer days missed from work or school. Conclusions: The educational program offered during the routine outpatient visits of adult patients with asthma at our clinic resulted in a progressive long-term increase in knowledge, as well as in clinical improvement.


Keywords: Asthma; Adult; Patient education as topic.


3 - Evaluation of the treatment provided to patients with asthma by the Brazilian Unified Health Care System

Avaliação da assistência ao paciente asmático no Sistema Único de Saúde

Carla Discacciati Silveira, Flávia de Barros Araújo, Luiz Fernando Ferreira Pereira, Ricardo de Amorim Corrêa

J Bras Pneumol.2009;35(7):628-634

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine, based on international guidelines for asthma management, the appropriateness of the treatment that the Unified Health Care System provides to patients with asthma. Methods: This was a cross-sectional study involving patients suspected of having asthma and referred to the Pulmonology Clinic of the Federal University of Minas Gerais Hospital das Clínicas, Brazil, between November of 2006 and October of 2007. Results: A total of 102 patients were included, and 70 were diagnosed with asthma. The previous treatment was consistent with the guidelines in 18.6% of the patients; 50.0% of the patients had previously been submitted to spirometry, and 34.3% had previously been submitted to PEF. The most frequently prescribed medication was short-acting β2 agonists (90.3%). Conclusions: The results show that the majority of non-specialized physicians working within the public health care system do not manage the treatment of patients with asthma in accordance with the guidelines. This situation calls for continuing medical education programs that prioritize primary care.


Keywords: Asthma; Guideline adherence; Therapeutics; Public health.


4 - The study of severe asthma in Latin America and Spain (1994-2004): characteristics of patients hospitalized with acute severe asthma

Estudo sobre Asma Grave na América Latina e Espanha (1994-2004): características dos pacientes hospitalizados com asma aguda grave

Gustavo Javier Rodrigo, Vicente Plaza, Jesús Bellido-Casado, Hugo Neffen, María Teresa Bazús, Gur Levy, Joseph Armengol

J Bras Pneumol.2009;35(7):635-644

Abstract PDF PT PDF EN Portuguese Text

Objective: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities. Methods: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004. Results: Over time, the use of inhaled corticosteroids and long-acting β2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America. Conclusions: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.


Keywords: Status asthmaticus; Asthma/therapy; Hospitalization.


5 - Effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of patients with asthma

Efeito da obstrução de vias aéreas nas variações das propriedades resistivas e elásticas do sistema respiratório de asmáticos, mediadas pelo uso de salbutamol

Juliana Veiga, Agnaldo José Lopes, José Manoel Jansen, Pedro Lopes de Melo

J Bras Pneumol.2009;35(7):645-652

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of adult patients with asthma. Methods: This study comprised 24 healthy controls and 69 patients with asthma, all of whom were nonsmokers. The patients were divided into three groups according to the severity of airway obstruction (mild, moderate or severe). Each of the three groups was divided into two subgroups according to the bronchodilator response (BR): positive (BR+) or negative (BR−). These measurements were conducted before and after albuterol use (300 µg). Airway obstruction was determined by means of spirometry, and the resistive and elastic properties were determined by means of the forced oscillation technique. Results: The resistance at the intercept (R0) presented greater reductions in the groups with higher obstruction. This reduction was more evident in the BR+ subgroups than in the BR− subgroups (p < 0.02 and p < 0.03, respectively). There was a significant difference between the control group and the BR+ subgroup with severe obstruction (p < 0.002). The reductions in dynamic elastance (Edyn) were significantly greater in proportion to the degree of obstruction, in the BR− subgroups (p < 0.03), and in the BR+ subgroups (p < 0.003). The reductions in Edyn were significantly greater in the BR− subgroup with moderate obstruction (p < 0.008) and in the BR+ subgroup with severe obstruction (p < 0.0005) than in the control group. Conclusions: In patients with asthma, increased airway obstruction results in greater reductions in R0 and Edyn after albuterol use. These reductions are greater among BR+ patients than among BR− patients.


Keywords: Asthma; Bronchodilator agents; Respiratory mechanics; Spirometry; Albuterol.


6 - Foreign body aspiration in children and adolescents: experience of a Brazilian referral center

Aspiração de corpo estranho por menores de 15 anos: experiência de um centro de referência do Brasil

Sílvia Teresa Evangelista Vidotto de Sousa, Valdinar Sousa Ribeiro, José Mário de Menezes Filho, Alcione Miranda dos Santos, Marco Antonio Barbieri, José Albuquerque de Figueiredo Neto

J Bras Pneumol.2009;35(7):653-659

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the clinical, radiological and endoscopic characteristics of foreign body aspiration among individuals under the age of 15 treated at a referral center in the city of São Luís, Brazil. Methods: This was a descriptive study using data from the medical charts of patients treated for foreign body aspiration at the Hospital Universitário Materno Infantil between 1995 and 2005. We investigated 72 confirmed cases of foreign body aspiration, evaluating the place of residence, as well as biological, clinical, radiological and endoscopic variables. We used the chi-square test to identify statistically significant differences in frequency among the variables studied. Results: The majority of the patients were from outlying areas (55.6%). The following variables presented the highest frequencies: 0-3 year age bracket (81.9%); male gender (63.9%); evolution > 24 h (66.7%); hypotransparency on chest X-ray (57.7%); foreign body in the right lung (41.2%) or in the larynx (20.5%); organic nature of the foreign body (83.3%); complication in the form of localized inflammation (59.4%); glottal edema as an endoscopic complication (47.6%); and seeds (46.6%), fish bone (28.3%) or plastics (25.5%) as the type of foreign body. There were no deaths. Conclusions: Preventive care should be a priority for male children under the age of 3 living in outlying areas. Such children should not be given access to substances that can be aspirated, including certain foodstuffs. Simple and easily accessible radiological tests have been underused, which jeopardizes the quality of the initial treatment.


Keywords: Foreign bodies; Inhalation; Bronchoscopy.


7 - Thoracoscopy in children with complicated parapneumonic pleural effusion at the fibrinopurulent stage: a multi-institutional study

Toracoscopia em crianças com derrame pleural parapneumônico complicado na fase fibrinopurulenta: estudo multi-institucional

Sérgio Freitas, José Carlos Fraga, Fernanda Canani

J Bras Pneumol.2009;35(7):660-668

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the efficacy of thoracoscopy in the management of children with complicated parapneumonic pleural effusion at the fibrinopurulent stage. Methods: Retrospective study of 99 children submitted to thoracoscopy for the treatment of complicated parapneumonic pleural effusion at the fibrinopurulent stage between November of 1995 and July of 2005. The mean age was 2.6 years (range, 0.4-12 years), and 60% were males. Thoracoscopy was performed at three different hospitals following the same treatment algorithm. Results: Thoracoscopy was effective for 87 children (88%). In 12 (12%), a second surgical procedure was required: another thoracoscopy (n = 6) or thoracotomy/thoracostomy (n = 6). Mean duration of chest tube drainage following successful thoracoscopy was 3 days vs. 10 days in patients submitted to a second procedure (p < 0.001). In all of the children, the pleural infection resolved after treatment. Thoracoscopy-related complications included air leak (30%), chest tube bleeding (12%), subcutaneous emphysema associated with trocar insertion (2%) and surgical wound infection (2%). None of the children required additional surgical procedures due to the complications. Conclusions: The effectiveness of thoracoscopy in children with parapneumonic pleural effusion at the fibrinopurulent stage was 88%. The procedure was safe, with a low rate of severe complications. Thoracoscopy should be the first-choice treatment for children with parapneumonic pleural effusion at the fibrinopurulent stage.


Keywords: Thoracoscopy; Pleural effusion; Empyema, pleural.


8 - Proteinuria in cystic fibrosis: a possible correlation between genotype and renal phenotype

Proteinúria na fibrose cística: possível correlação entre genótipo e fenótipo renal

Jessica Cemlyn-Jones, Fernanda Gamboa

J Bras Pneumol.2009;35(7):669-675

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess proteinuria in patients with cystic fibrosis (CF), and to correlate proteinuria with genotype, CF-related diabetes and disease severity. Methods: A prospective study was carried out over a six-month period and involving 22 CF patients. After the collection and analysis of 24-h urine samples, the patients were divided into two subgroups: protein excretion < 150 mg/day (low-proteinuria); and protein excretion ≥ 150 mg/day (high-proteinuria). Patient charts were reviewed to obtain data on genotype and CF-related diabetes. Disease severity was assessed based on acute exacerbations in the last six months and FEV1 measured during the study period. To assess the correlation between genotype and proteinuria, the two main mutations (ΔF508 and R334W) were evaluated. Due to the existence of genotype ΔF508/R334W, two categories were created to enable statistical analysis, ΔF508 being evaluated in category 1 and R334W being evaluated in category 2. Results: The ΔF508 mutation tended to be associated with normal protein excretion: 100% of the low-proteinuria subgroup patients were considered ΔF508 in category 1, compared with 86.7% in category 2. Protein excretion tended to be higher in patients with the R334W mutation: 60.0% of the high-proteinuria subgroup patients were considered R334W in category 1, compared with 80.0% in category 2 (p = 0.009 and p = 0.014, respectively). No significant association was found for any of the other variables. Conclusions: The results suggest that genotype is associated with renal phenotype, depending on the mechanism by which the genotype alters the function of the cystic fibrosis transmembrane conductance regulator gene.


Keywords: Proteinuria; Cystic fibrosis; Genotype.


9 - Semiquantitative analysis of surgical biopsies of distinct lung lobes of patients with usual interstitial pneumonia/idiopathic pulmonary fibrosis

Análise semiquantitativa de biópsias cirúrgicas de diferentes lobos pulmonares de pacientes com pneumonia intersticial usual/fibrose pulmonar idiopática

José Júlio Saraiva Gonçalves, Luiz Eduardo Villaça Leão, Rimarcs Gomes Ferreira, Renato Oliveira, Luiz Hirotoshi Ota, Ricardo Sales dos Santos

J Bras Pneumol.2009;35(7):676-682

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Objective: To evaluate the differences between surgical biopsies of distinct lung lobes in terms of the histopathological features of usual interstitial pneumonia, using a semiquantitative score. Methods: We selected all of the patients diagnosed with idiopathic pulmonary fibrosis and submitted to surgical biopsy in two distinct lobes between 1995 and 2005 at the Hospital São Paulo and other hospitals operated by the Federal University of São Paulo. In the histological evaluation of the specimens, we used a semiquantitative method based on previous studies, assigning a score to each of the biopsied sites. Results: In this sample of patients, we found no statistically significant differences that would alter the stage of the disease, based on the score used. This finding was independent of the biopsy site (middle lobe or lingular segment). Conclusions: No significant histological differences were found between the lung lobes studied. The definitive histological diagnosis of usual interstitial pneumonia did not alter the stage of the disease.


Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Thoracic surgery; Pathology; Thoracic surgery, ­video-assisted.


10 - Modified Reasons for Smoking Scale: translation to Portuguese, cross‑cultural adaptation for use in Brazil and evaluation of test-retest reliability

Escala Razões Para Fumar Modificada: tradução e adaptação cultural para o português para uso no Brasil e avaliação da confiabilidade teste-reteste

Elisa Sebba Tosta de Souza, José Alexandre de Souza Crippa, Sonia Regina Pasian, José Antonio Baddini Martinez

J Bras Pneumol.2009;35(7):683-689

Abstract PDF PT PDF EN Portuguese Text

Objective: To translate the Modified Reasons for Smoking Scale (MRSS) to Portuguese, to submit it to cross-cultural adaptation for use in Brazil and to evaluate the test-retest reliability of the translated version. Methods: An English-language version of the MRSS was translated to Portuguese by Brazilian doctors who have thorough knowledge of the English language. A consensus version was produced by a multidisciplinary group including two pulmonologists, a psychiatrist and a psychologist. This version was back-translated to English by an American translator. Cross-cultural adaptation of the final version was evaluated in a sample of 20 healthy smokers. Test-retest reliability was evaluated by applying the translated version of the scale in 54 healthy smokers on two distinct occasions, 15 days apart. Results: This translated version of the MRSS was well understood by 95% of the smokers, indicating excellent cross-cultural equivalence. The degree of reliability of the answers in two different occasions was almost perfect for two questions, substantial for ten questions, moderate for eight questions, and low for one question. The intraclass correlation coefficients of the motivational factors obtained on the two different occasions, calculated according to previously published theoretical models, were higher than 0.7 for six of the seven subscales. Conclusions: The Portuguese-language version of the MRSS shows satisfactory cross-cultural equivalence and test-retest reliability. It can be a useful tool in the evaluation and treatment of smokers in Brazil.


Keywords: Smoking cessation; Scales; Translations; Validation studies.


11 - Performance of nested PCR in the specific detection of Mycobacterium tuberculosis complex in blood samples of pediatric patients

Desempenho da técnica nested PCR na detecção específica do complexo Mycobacterium tuberculosis em amostras sanguíneas de pacientes pediátricos

Juliana Figueirêdo da Costa Lima, Lílian Maria Lapa Montenegro, Rosana de Albuquerque Montenegro, Marta Maciel Lyra Cabral, Andrea Santos Lima, Frederico Guilherme Coutinho Abath (in memoriam), Haiana Charifker Schindler

J Bras Pneumol.2009;35(7):690-697

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the performance of nested PCR (nPCR) in detecting the Mycobacterium tuberculosis complex in blood samples of patients suspected of having TB, in order to determine its potential for use as an auxiliary tool in the laboratory diagnosis of TB in children. Methods: Detection of the M. tuberculosis complex in blood samples using as a target the insertion sequence IS6110 of the genomic DNA of the bacillus. Blood samples of 120 patients were evaluated. All of the patients were under 15 years of age at the time of their treatment at public hospitals in the city of Recife, Brazil (between January of 2003 and August of 2005). Attending physicians at the hospitals diagnosed TB based on the criteria recommended by the American Thoracic Society. The nPCR amplified a 123-bp fragment with outer oligonucleotides (IS1/IS2) and, in the subsequent reaction, using inner oligonucleotides (IS3/IS4), generating an 81-bp amplicon. Results: Active or latent TB was found in 65 patients, TB was ruled out in 28 suspected cases, and 27 patients were TB-free (controls). The sensitivity of nPCR was 26.15% and was significantly higher for the extrapulmonary form of the disease (55.56%) than for the pulmonary form (18.18%). The specificity was 92.73%. Conclusions: Despite the difficulties in diagnosing TB in children and the low number of cases evaluated in the present study, nPCR in blood samples proved to be a rapid and specific technique, albeit one with low sensitivity. In order to establish its true usefulness in the diagnosis of paucibacillary forms, especially extrapulmonary TB, further studies need to be carried out with a larger sample of children and analyzing biological specimens other than blood.


Keywords: Tuberculosis; Diagnosis; Blood; Polymerase chain reaction.


Review Article

12 - Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications

Manifestações respiratórias do transtorno de pânico: causas, consequências e implicações terapêuticas

Aline Sardinha, Rafael Christophe da Rocha Freire, Walter Araújo Zin, Antonio Egidio Nardi

J Bras Pneumol.2009;35(7):698-708

Abstract PDF PT PDF EN Portuguese Text

Multiple respiratory abnormalities can be found in anxiety disorders, especially in panic disorder (PD). Individuals with PD experience unexpected panic attacks, characterized by anxiety and fear, resulting in a number of autonomic and respiratory symptoms. Respiratory stimulation is a common event during panic attacks. The respiratory abnormality most often reported in PD patients is increased CO2 sensitivity, which has given rise to the hypothesis of fundamental abnormalities in the physiological mechanisms that control breathing in PD. There is evidence that PD patients with dominant respiratory symptoms are more sensitive to respiratory tests than are those who do not manifest such symptoms, and that the former group constitutes a distinct subtype. Patients with PD tend to hyperventilate and to panic in response to respiratory stimulants such as CO2, triggering the activation of a hypersensitive fear network. Although respiratory physiology seems to remain normal in these subjects, recent evidence supports the idea that they present subclinical abnormalities in respiration and in other functions related to body homeostasis. The fear network, composed of the hippocampus, the medial prefrontal cortex, the amygdala and its brain stem projections, might be oversensitive in PD patients. This theory might explain why medication and cognitive-behavioral therapy are both clearly effective. Our aim was to review the relationship between respiration and PD, addressing the respiratory subtype of PD and the hyperventilation syndrome, with a focus on respiratory challenge tests, as well as on the current mechanistic concepts and the pharmacological implications of this relationship.


Keywords: Panic disorder; Anxiety; Respiration; Hyperventilation; Carbon dioxide.


Case Report

13 - Sternal osteomyelitis caused by infection with Mycobacterium tuberculosis

Osteomielite esternal por Mycobacterium tuberculosis

Diego Michelon De Carli, Mateus Dornelles Severo, Carlos Jesus Pereira Haygert, Marcelo Guollo, Alex Omairi, Vinícius Dallagasperina Pedro, Eduardo Pedrolo Silva, Arnaldo Teixeira Rodrigues

J Bras Pneumol.2009;35(7):709-712

Abstract PDF PT PDF EN Portuguese Text

We report the case of a 74-year-old male patient with a one-year history of chest pain in the suprasternal notch associated with erythema, edema and drainage of purulent material from a fistulous lesion. The patient was HIV-negative with no history of TB. A CT scan of the chest showed an osteolytic lesion in the sternum, and a biopsy revealed caseous granuloma, which, in the microbiological evaluation, was negative for fungi and acid-fast bacilli. The diagnosis of sternal osteomyelitis caused by Mycobacterium tuberculosis was confirmed using PCR.


Keywords: Thorax; Mycobacterium infections; Tuberculosis, osteoarticular; Sternum; Diagnosis.


14 - Bronchial casts attributed to the use of pegylated interferon and ribavirin

Molde brônquico devido ao uso de interferon peguilado e ribavirina

Eduardo Garcia, Ângelo Ferreira da Silva Junior, Fabíola Schorr, Milene Hota, Ricardo Gondim Brizzi, André Barreto da Silva

J Bras Pneumol.2009;35(7):713-716

Abstract PDF PT PDF EN Portuguese Text

We report the case of a 53-year-old male patient with a rare profile: bronchial casts associated with the use of pegylated interferon and ribavirin. The patient sought treatment in a pulmonology clinic with a history of progressive dyspnea for four months that had evolved to progressive cough followed by frequent and abundant elimination of bronchial casts. The patient was initially treated with bronchodilators, as well as with oral and inhaled corticosteroids. Fiberoptic bronchoscopy, bronchoalveolar lavage and sputum analysis were carried out but did not contribute to the elucidation of the diagnosis. The symptoms developed while the patient was receiving pegylated interferon and ribavirin for the treatment of hepatitis C. The symptoms resolved 30 days after the discontinuation of the treatment. To our knowledge, this is the first report of bronchial casts caused by the use of pegylated interferon and ribavirin.


Keywords: Bronchitis; Interferons/adverse effects; Ribavirin/adverse effects.


15 - inflamSoft tissue Rosai-Dorfman disease of the posterior mediastinum

Doença de Rosai-Dorfman de partes moles no mediastino posterior

Antônio Luiz Penna Costa, Natália Oliveira e Silva, Marina Pamponet Motta, Rodrigo Abensur Athanazio, Daniel Abensur Athanazio, Paulo Roberto Fontes Athanazi

J Bras Pneumol.2009;35(7):717-720

Abstract PDF PT PDF EN Portuguese Text

Rosai-Dorfman disease (RDD) consists of sinus histiocytosis with massive lymphadenopathy. Extranodal involvement occurs in up to 43% of cases. However, isolated soft tissue RDD is rare. Isolated mediastinal RDD is exceedingly rare, and there have been only three previous reports. Involvement of the posterior mediastinum in RDD has been reported only in the context of disseminated RDD. Here, we report the case of a 49-year-old female patient with a two-year history of cervical pain and lymphadenomegaly, which resolved spontaneously. A CT scan revealed a left paravertebral mass with a diameter of 6 cm. The patient was submitted to surgical excision of the mass. Microscopic examination and immunophenotyping of the surgical specimen led to a diagnosis of RDD. During a 12-month follow-up period, the patient complained of mild cough and chest pain. Periodic imaging tests showed no sign of recurrence, and no postoperative cervical lymphadenomegaly was detected.


Keywords: Histiocytosis, sinus; Soft tissue neoplasms; Mediastinal neoplasms; Mediastinum.


Year 2009 - Volume 35  - Number 8  (/August)


1 - The importance of genetic studies of lung cancer

A importância dos estudos genéticos sobre câncer de pulmão

Wilson Araújo da Silva Jr

J Bras Pneumol.2009;35(8):721-722

PDF PT PDF EN Portuguese Text

Original Article

2 - Hospitalizations for asthma: impact of a program for the control of asthma and allergic rhinitis in Feira de Santana, Brazil

Hospitalizações por asma: impacto de um programa de controle de asma e rinite alérgica em Feira de Santana (BA)

Heli Vieira Brandão, Constança Margarida Sampaio Cruz, Ivan da Silva Santos Junior, Eduardo Vieira Ponte, Armênio Guimarães, Álvaro Augusto Cruz

J Bras Pneumol.2009;35(8):723-729

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of the Programa de Controle da Asma e Rinite Alérgica em Feira de Santana (ProAR-FS, Program for the Control of Asthma and Allergic Rhinitis in Feira de Santana) on the frequency of hospitalizations for asthma in patients monitored at a referral center for one year. Methods: This was a historical control study involving 253 consecutive patients with asthma, ages ranging from 4 to 76 years. We compared the frequency of hospital admissions and visits to the emergency room (ER) in the 12 months prior to and after their admission to the ProAR-FS. During the program, patients received free treatment, including inhaled medications and education on asthma. Demographic and socioeconomic aspects were also assessed. Results: There was a significant reduction in the number of hospitalizations (465 vs. 21) and of visits to the ER (2,473 vs. 184) after their admission to ProAR-FS (p < 0.001 for both). Of the 253 patients who had been hospitalized and had had ER visits within the year prior to the admission to ProAR-FS, only 16 were hospitalized and 92 visited the ER during the follow-up year, representing a reduction of 94% and 64%, respectively. Conclusions: Implementing a referral center for the treatment of asthma and rhinitis in the Unified Health Care System, with the free distribution of inhaled corticosteroids and the support of an education program, is a highly effective strategy for the control of asthma.


Keywords: Hospitalization; Asthma; Rhinitis; Health services; Public health.


3 - Influence of respiratory function parameters on the quality of life of COPD patients

Influência dos parâmetros funcionais respiratórios na qualidade de vida de pacientes com DPOC

Eanes Delgado Barros Pereira, Renata Pinto, Marcelo Alcantara, Marta Medeiros, Rosa Maria Salani Mota

J Bras Pneumol.2009;35(8):730-736

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the quality of life of COPD patients by using the Medical Outcomes 36-item Short-Form Survey (SF-36) and the Saint George's Respiratory Questionnaire (SGRQ), correlating the scores with respiratory function parameters. Methods: This was a cross-sectional study involving 42 COPD patients. We used the SGRQ (a specific questionnaire) and the SF-36 (a general questionnaire), together with their component summaries, in order to determine the quality of life of these patients. The functional profile was assessed by means of spirometry, arterial blood gas analysis and the six-minute walk test. Results: Of the 42 patients, 30 (71.4%) were male and 12 (28.6%) were female. The mean age of the patients was 65.4 ± 8.0 years. The mean physical component summary and mean mental component summary scores were 37.05 ± 11.19 and 45.61 ± 15.65, respectively. The physical component summary correlated significantly with FEV1 in L/s (r = 0.38; p = 0.012). There was a correlation between the SGRQ total score and FEV1 (r = −0.50; p < 0.01). The SGRQ activity domain showed negative correlations with all respiratory function parameters. The multiple regression analysis showed that only FEV1 correlated significantly with the SGRQ total score, as well as with the activity domain score (r= −0.32; p = 0.04 and r = −0.34; p = 0.03, respectively). Conclusions: In COPD patients, a decline in FEV1 is associated with poorer quality of life, as evaluated using the SGRQ.


Keywords: Pulmonary disease, chronic obstructive; Quality of life; Respiratory function tests.


4 - Portuguese-language version of the Chronic Respiratory Questionnaire: a validity and reproducibility study

Versão em português do Chronic Respiratory Questionnaire: estudo da validade e reprodutibilidade

Graciane Laender Moreira, Fábio Pitta, Dionei Ramos, Cinthia Sousa Carvalho Nascimento, Danielle Barzon, Demétria Kovelis, Ana Lúcia Colange, Antonio Fernando Brunetto, Ercy Mara Cipulo Ramos

J Bras Pneumol.2009;35(8):737-744

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the validity and reproducibility of a Portuguese-language version of the Chronic Respiratory Questionnaire (CRQ) in patients with COPD. Methods: A Portuguese-language version of the CRQ (provided by McMaster University, the holder of the questionnaire copyright) was applied to 50 patients with COPD (70 ± 8 years of age; 32 males; FEV1 = 47 ± 18% of predicted) on two occasions, one week apart. The CRQ has four domains (dyspnea, fatigue, emotional function, and mastery) and was applied as an interviewer-administered instrument. The Saint George's Respiratory Questionnaire (SGRQ), already validated for use in Brazil, was used as the criterion for validation. Spirometry and the six-minute walk test (6MWT) were performed to analyze the correlations with the CRQ scores. Results: There were no significant CRQ test-retest differences (p > 0.05 for all domains). The test-retest intraclass correlation coefficient was 0.98, 0.97, 0.98 and 0.95 for the dyspnea, fatigue, emotional function and mastery domains, respectively. The Cronbach's alpha coefficient was 0.91. The CRQ domains correlated significantly with the SGRQ domains (−0.30 < r < −0.67; p < 0.05). There were no significant correlations between spirometric variables and the CRQ domains or between the CRQ domains and the 6MWT, with the exception of the fatigue domain (r = 0.30; p = 0.04). Conclusions: The Portuguese-language version of the CRQ proved to be reproducible and valid for use in Brazilian patients with COPD.


Keywords: Quality of life; Pulmonary disease, chronic obstructive; Questionnaires.


5 - Respiratory diseases morbidity and mortality among adults attending a tertiary hospital in Nigeria

Morbidade e mortalidade relacionadas a doenças respiratórias em adultos atendidos em um hospital terciário na Nigéria

Desalu O. Olufemi, Joshua Afolayan Oluwafemi, Ololade Ojo

J Bras Pneumol.2009;35(8):745-752

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the morbidity and mortality related to respiratory diseases among adults attending a tertiary-care hospital in Nigeria. Methods: We carried out a retrospective study of 183 adult patients (> 15 years of age), diagnosed with respiratory diseases between November of 2006 and October of 2008 at the Federal Medical Centre in Ido-Ekiti, Nigeria. Results: Of the 183 patients enrolled in the study, 78 (42.6%) were male and 105 (57.4%) were female, the male:female ratio being 1:1.4. Respiratory diseases were predominant in the 25-44 year age bracket (37.2%) and lower socioeconomic class (81.4%). Pulmonary TB was the leading cause of morbidity (in 42.1%), followed by asthma (in 17.5%) and pneumonia (in 15.3%). Lung cancer was uncommon (in only 0.6%). Pulmonary TB was the leading cause of hospitalization for respiratory disease (in 32%). Pulmonary TB, asthma, pneumonia and pleural pathologies were more common in women, whereas COPD was more common in men. The most common comorbidity was HIV infection (in 11.5%). The overall mean length of hospital stay was 14 days. Overall mortality was 8.7%; 50% of the deaths were attributed to pulmonary TB, 25% were attributed to pleural disease, 12.5% were attributed to pneumonia, and 6.25% were attributed to acute exacerbation of COPD. Mortality was higher in women and in the 25-44 year age bracket. Conclusions: Pulmonary TB, asthma and pneumonia were the leading causes of respiratory disease-related morbidity. Pulmonary TB was the leading cause of respiratory disease-related mortality among the adult Nigerians evaluated. Therefore, these conditions should be given higher priority in patient care. In addition, antiretroviral therapy should be readily accessible and affordable to HIV-infected individuals.


Keywords: Morbidity; Mortality; Respiratory tract diseases; Africa.


6 - Spatial analysis of hospitalizations for pneumonia in the Vale do Paraíba region of Brazil

Análise espacial das internações por pneumonia na região do Vale do Paraíba (SP)

Adriana de Oliveira Mukai, Kátia de Souza Costa Alves, Luiz Fernando Costa Nascimento

J Bras Pneumol.2009;35(8):753-758

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify spatial patterns in hospitalizations for pneumonia in infants under one year of age in the Vale do Paraíba region of Brazil. Methods: This was an ecological exploratory study using a georeferencing technique based on data from the Information Technology Department of the Brazilian Unified Health Care System on the number of hospitalizations for pneumonia among infants under one year of age in the Vale do Paraíba region between 2004 and 2005. Based on the distribution of the rates of hospitalizations for pneumonia per 1,000 live births, thematic maps were created. Moran's spatial autocorrelation coefficient was estimated, and the cities with the highest rates were identified using box maps. Results: During the study period, 2,227 infants under one year of age were hospitalized for pneumonia. Moran's coefficient was 0.37 (p = 0.02), demonstrating a spatial autocorrelation for these hospitalizations. Eight cities deserving special attention for future interventions were identified. Conclusions: The spatial analysis was successful in determining the spatial autocorrelation, as well as in identifying the cities in which an intervention is necessary regarding the number of hospitalizations for pneumonia in infants under one year of age.


Keywords: Pneumonia; Geographic information systems; Child health (Public health); Infant.


7 - Stability of the animal model of oleic acid-induced acute lung injury

Estabilidade do modelo animal de lesão pulmonar aguda induzida por ácido oleico

Eduardo Gaio, César Augusto de Melo e Silva, Flávio Brito, Marco Aurélio Pereira Firmino, Rodrigo Storck, Eduardo Freitas

J Bras Pneumol.2009;35(8):759-766

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the stability of hemodynamic, respiratory and gas exchange variables in an animal model of oleic acid-induced acute lung injury. Methods: This was an experimental study involving 10 mongrel dogs. The variables were measured at baseline, as well as at 30, 60, 90 and 120 min after the administration of oleic acid. In order to analyze repeated measurements, linear and quadratic effects were tested. Mixed linear models with diversified variance and covariance structures were used, depending on the variable studied. Results: We found that mean arterial blood pressure stabilized at 30 min, as did heart rate, pulmonary arterial pressure and pulmonary capillary pressure at 60 min. Respiratory rate, tidal volume, minute volume and respiratory work stabilized at 30 min. Regarding gas exchange variables, PaO2, PaO2/FiO2 ratio and pulmonary shunt fraction stabilized at 30 min. The remaining variables maintained a continuous rise or fall. Conclusions: This oleic acid-induced acute lung injury model is stable for some of the variables tested, although stabilization occurs at different times. The respiratory and gas exchange variables stabilized at 30 min, whereas the hemodynamic variables stabilized at 60 min.


Keywords: Respiratory distress syndrome, adult; Models, animal; Statistical analysis.


8 - Polymorphism of the CYP1A1*2A gene and susceptibility to lung cancer in a Brazilian population

O polimorfismo do gene CYP1A1*2A e a suscetibilidade ao câncer de pulmão na população brasileira

Helen Naemi Honma, Eduardo Mello De Capitani, Aristóteles de Souza Barbeiro, Daniel Botelho Costa, André Morcillo, Lair Zambon

J Bras Pneumol.2009;35(8):767-772

Abstract PDF PT PDF EN Portuguese Text

Objective: To estimate and compare the frequency of CYP1A1*2A gene polymorphisms in a Brazilian population and determine the possible contribution of these genetic variations to lung cancer risk. Methods: The study population included 200 patients with lung cancer, and the control group consisted of 264 blood donors. Genomic DNA was obtained from peripheral blood samples. The PCR-RFLP method was used for analysis of the CYP1A1*2A gene. Results: There was no statistically significant difference between the lung cancer patients and the controls in terms of the distribution of CYP1A1*2A polymorphisms (p = 0.49). A multivariate logistic regression model analysis by ethnic group revealed that, within the lung cancer group, the CYP1A1*2A genotype CC plus TC was more common among the African-Brazilian patients than among the White patients (adjusted OR = 3.19; 95% CI: 1.53‑6.65). Conclusions: The CYP1A1*2A gene cannot be linked with lung cancer risk in Brazilian patients at this time. Larger epidemiologic studies are needed in order to establish whether the CC plus TC polymorphism increases the risk of lung cancer in African-Brazilians.


Keywords: Lung neoplasms; Polymorphism, genetic; Metabolism.


9 - Isoniazid-resistant Mycobacterium tuberculosis strains arising from mutations in two different regions of the katG gene

Resistência do Mycobacterium tuberculosis à isoniazida por mutações em duas regiões diferentes do gene katG

Helio Ribeiro de Siqueira, Flávia Alvim Dutra de Freitas, Denise Neves de Oliveira, Angela Maria Werneck Barreto, Margareth Pretti Dalcolmo, Rodolpho Mattos Albano

J Bras Pneumol.2009;35(8):773-779

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze and compare the mutations in two different regions of the katG gene, which is responsible for isoniazid (INH) resistance. Methods: We analyzed 97 multidrug-resistant Mycobacterium tuberculosis strains isolated in cultures of sputum samples obtained from the Professor Hélio Fraga Referral Center, in Brasília, Brazil. Another 6 INH-sensitive strains did not present mutations and were included as controls. We used PCR to amplify two regions of the katG gene (GenBank accession no. U06258)-region 1, (from codon 1 to codon 119) and region 2 (from codon 267 to codon 504)-which were then sequenced in order to identify mutations. Results: Seven strains were resistant to INH and did not contain mutations in either region. Thirty strains carried mutations in region 1, which was characterized by a high number of deletions, especially at codon 4 (24 strains). Region 2 carried 83 point mutations, especially at codon 315, and there was a serine-to-threonine (AGC-to-ACC) substitution in 73 of those cases. The analysis of region 2 allowed INH resistance to be diagnosed in 81.4% of the strains. Nine strains had mutations exclusively in region 1, which allowed the proportion of INH-resistant strains identified to be increased to 90.6%. Conclusions: The number of mutations at codon 315 was high, which is consistent with cases described in Brazil and in other countries, and the analysis of region 1 resulted in a 9.2% increase in the rate at which mutations were identified.


Keywords: Isoniazid; Mutation; Tuberculosis; Drug resistance, multiple.


10 - Epidemiological profile of hospitalized patients with TB at a referral hospital in the city of Rio de Janeiro, Brazil

Perfil epidemiológico de pacientes portadores de TB internados em um hospital de referência na cidade do Rio de Janeiro

Hedi Marinho de Melo Guedes de Oliveira, Rossana Coimbra Brito, Afranio Lineu Kritski, Antonio Ruffino-Netto

J Bras Pneumol.2009;35(8):780-787

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the epidemiological profile of inpatients at a TB referral hospital. Methods: This was a descriptive, retrospective study of the medical charts of patients with TB hospitalized at the Hospital Estadual Santa Maria (HESM), in the city of Rio de Janeiro, Brazil, between January of 2002 and December of 2003. Data were collected using a standardized form. Results: Of the 451 patients included in the study, 313 (69.4%) had been referred to the HESM from health care clinics, and 302 (67.0%) were male. Most of the patients were in the 30-59  year age bracket, 443 (98.2%) lived in the greater metropolitan region of Rio de Janeiro, and 298 (66.1%) lived in the city of Rio de Janeiro itself. The most common reason for hospitalization was poor health status (in 237, 52.5%). The most common comorbidity was AIDS (in 137, 30.4%). The most common signs and symptoms at admission were weight loss, fever and productive cough. Sputum smear microscopy was positive in 122 (71.0%) of the patients presenting with productive cough at admission. Of the 212 patients being retreated, 156 (73.6%) reported noncompliance with previous treatment. Regarding the outcome, 273 (65.8%) of the patients were referred to municipal health care centers, 83 (18.4%) died, 44 (9.8%) were cured, and 27 (6%) were discharged against medical advice. Conclusions: Providing hospitals specializing in TB is relevant for TB control, especially in metropolitan regions. In addition to taking biosafety measures, these hospitals must be prepared to treat patients with TB-related comorbidities and social problems. This study has resulted in improvements at the HESM.


Keywords: Tuberculosis; Epidemiology; Hospitalization.


Brief Communication

11 - Experimental diabetes mellitus: oxidative stress and changes in lung structure

Estresse oxidativo e alterações estruturais pulmonares no diabetes mellitus experimental

Luiz Alberto Forgiarini Junior, Nélson Alexandre Kretzmann, Marilene Porawski, Alexandre Simões Dias, Norma Anair Possa Marroni

J Bras Pneumol.2009;35(8):788-791

Abstract PDF PT PDF EN Portuguese Text

Diabetes mellitus is an endocrine/metabolic disorder characterized by hyperglycemia. Its impact on the respiratory system is characterized by functional changes and alterations in gas exchange. The objective of this study was to evaluate the increase in oxidative stress and the potential damages to the lung structure in an experimental model of streptozotocin-induced diabetes. We conducted histological, biochemical and blood gas analyses in the lungs of diabetic rats. We concluded that the effects of experimental diabetes mellitus include oxidative stress, structural changes in the lung tissue and altered gas exchange.


Keywords: Lung; Diabetes mellitus; Oxidative stress; Diabetes mellitus, experimental; Free radicals.


Review Article

12 - Chronic interstitial lung diseases in children

Doenças pulmonares intersticiais crônicas na criança

Maria Aparecida Soares de Souza Paiva, Sandra Mara Moreira Amaral

J Bras Pneumol.2009;35(8):792-803

Abstract PDF PT PDF EN Portuguese Text

Interstitial lung diseases (ILDs) in children constitute a heterogeneous group of rare diseases that have been described and classified according to experiences and research in adults. However, pediatric pulmonologists have observed that the clinical spectrum is broader in children than in adults, and that many of these disorders have different courses and treatment responses. In addition, probably due to the various stages of lung development and maturation, new clinical forms have been described, particularly in infants. This has broadened the classification of ILDs in this age bracket. The understanding that neither the usual definition nor the standard classification of these disorders entirely apply to children has prompted multicenter studies designed to increase knowledge of these disorders, as well as to standardize diagnostic and therapeutic strategies. We have reviewed the conceptualization of ILDs in children, taking into consideration the particularities of this group of patients when using the criteria for the classification of these diseases in adults. We have also made a historical review of several multicenter studies in order to further understanding of the problem. We have emphasized the differences in the clinical presentation, in an attempt to highlight knowledge of newly described entities in young children. We underscore the need to standardize management of laboratory and radiological routines, as well as of lung biopsy processing, taking such knowledge into account. It is important to bear in mind that, among the recently described disorders, genetic surfactant dysfunction, which is often classified as an idiopathic disease in adults, should be included in the differential diagnosis of ILDs.


Keywords: Lung diseases, interstitial; Lung diseases, interstitial/diagnosis; Lung diseases, interstitial/therapy; Child.


Case Report

13 - Systemic corticosteroids as first-line treatment in pulmonary hypertension associated with POEMS syndrome

Corticoide sistêmico como tratamento de primeira linha da hipertensão pulmonar secundária a síndrome POEMS

Samia Rached, Rodrigo Abensur Athanazio, Sérvulo Azevedo Dias Júnior, Carlos Jardim, Rogério Souza

J Bras Pneumol.2009;35(8):804-808

Abstract PDF PT PDF EN Portuguese Text


A síndrome POEMS é uma rara doença de plasmócitos. A ocorrência de hipertensão pulmonar como complicação respiratória da síndrome é pouco frequente e pode estar ligada ao aumento de várias citocinas, quimiocinas e fatores de crescimento como parte dos fenômenos inflamatórios que cercam a fisiopatologia da síndrome POEMS. Descrevemos o caso de uma mulher de 54 anos com síndrome POEMS e hipertensão pulmonar, que foi tratada com corticoide como terapia de primeira linha. Tratava-se de uma paciente com clássicos sintomas dessa síndrome: polineuropatia (confirmada por eletroneuromiografia), organomegalia, hipotireoidismo subclínico, gamopatia monoclonal em dosagem urinária e alterações cutâneas. A cateterização cardíaca direita revelou pressão arterial pulmonar média de 48 mmHg, débito cardíaco de 4,1 L/min e resistência vascular pulmonar de 8,05 Woods. O nível sérico de brain natriuretic peptide (BNP) foi de 150 pg/mL. Nenhuma outra doença foi encontrada durante investigação. Prednisona (1 mg/kg por três meses) foi iniciada, com dramática melhora clínica e funcional, além de normalização dos níveis dos hormônios tireoidianos e de proteína em urina por eletroforese. A pressão arterial pulmonar média caiu para 26 mmHg, o débito cardíaco para 3,8 L/min e a resistência vascular pulmonar para 2,89 Woods. O nível sérico de BNP caiu para 8pg/mL. Nossos achados indicam o potencial papel da corticoterapia como primeira linha de tratamento na hipertensão pulmonar associada à síndrome POEMS. Diante da raridade dessa apresentação, um registro multicêntrico deveria ser desenvolvido para permitir a aquisição de mais dados que suportem essa conduta.


Palavras-chave: Síndrome POEMS; Hipertensão pulmonar; Glucocorticoides.


14 - Post-intubation tracheal injury: report of three cases and literature review

Laceração traqueal pós-intubação: análise de três casos e revisão de literatura

Carlos Remolina Medina, José de Jesus Camargo, José Carlos Felicetti, Tiago Noguchi Machuca, Bruno de Moraes Gomes, Iury Andrade Melo

J Bras Pneumol.2009;35(8):809-813

Abstract PDF PT PDF EN Portuguese Text

Post-intubation tracheal injury is a rare and potentially fatal complication. Among the most common causes, cuff overinflation and repetitive attempts of orotracheal intubation in emergency situations are paramount. Diagnosis is based on clinical and radiological suspicion, confirmed by fiberoptic bronchoscopy. Both conservative and surgical management apply, and the decision-making process depends on the patient profile (comorbidities, respiratory stability), characteristics of the lesion (size and location) and the time elapsed between the occurrence of the injury and the diagnosis. We report the cases of three patients presenting tracheal laceration due to traumatic orotracheal intubation, two submitted to surgical treatment and one submitted to conservative treatment.


Keywords: Tracheal diseases; Rupture; Intubation.


15 - Intimal sarcoma of the pulmonary artery: a differential diagnosis of chronic pulmonary thromboembolism

Sarcoma intimal de artéria pulmonar: um diagnóstico diferencial do tromboembolismo pulmonar crônico

Ana Paula Alves Valle Dornas, Frederico Thadeu Assis Figueiredo Campos, Cláudia Juliana Rezende, Carlos Alberto Ribeiro, Nilson Figueiredo Amaral, Ricardo de Amorim Corrêa

J Bras Pneumol.2009;35(8):814-818

Abstract PDF PT PDF EN Portuguese Text

Intimal sarcoma of the pulmonary artery is a rare and potentially lethal tumor, the diagnosis of which is difficult and therefore frequently delayed. The clinical signs and symptoms are nonspecific, often mimicking chronic pulmonary thromboembolism (CPTE). We report the case of a 45-year-old male under treatment for CPTE associated with pulmonary arterial hypertension and chronic cor pulmonale. There was no response to treatment with anticoagulants and sildenafil. We emphasize the difficulties in diagnosing intimal sarcoma of the pulmonary artery, the need to investigate this neoplasm in the differential diagnosis of CPTE and the systematic use of criteria for the appropriate prescription of new medications for pulmonary artery hypertension.


Keywords: Pulmonary embolism; Hypertension, pulmonary; Hemangiosarcoma; Diagnosis, differential.


Letters to the Editor

16 - Narghile smoking keeps researchers in Wonderland

O uso de narguilé mantém pesquisadores no País das Maravilhas

Kamal Chaouachi

J Bras Pneumol.2009;35(8):819-820

PDF PT PDF EN Portuguese Text



J Bras Pneumol.2009;35(8):

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Year 2009 - Volume 35  - Number 9  (/September)


1 - Tomographic diagnosis of pulmonary emphysema

Diagnóstico tomográfico de enfisema pulmonar

Klaus Loureiro Irion, Edson Marchiori, Bruno Hochhegger

J Bras Pneumol.2009;35(9):

PDF PT PDF EN Portuguese Text

Original Article

2 - Knowledge of and technique for using inhalation devices among asthma patients and COPD patients

Técnica e compreensão do uso dos dispositivos inalatórios em pacientes com asma ou DPOC

Maria Luiza de Moraes Souza, Andrea Cristina Meneghini, Érica Ferraz, Elcio Oliveira Vianna, Marcos Carvalho Borges

J Bras Pneumol.2009;35(9):824-831

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To evaluate knowledge of and techniques for using prescribed inhalation devices among patients with asthma or COPD treated at a tertiary teaching hospital. Methods: Patients were assessed after medical visits, and their physicians were blinded to this fact. Patients were asked to demonstrate their inhaler technique and were then interviewed regarding their knowledge of inhalation devices, control of the disease and instructions received during medical visits. Results: We included 120 volunteers: 60 with asthma and 60 with COPD. All of the asthma patients and 98.3% of the COPD patients claimed to know how to use inhaled medications. In the sample as a whole, 113 patients (94.2%) committed at least one error when using the inhalation device. Patients committed more errors when using metered-dose inhalers than when using the dry-powder inhalers Aerolizer® (p < 0.001) or Pulvinal® (p < 0.001), as well as committing more errors when using the Aerolizer® inhaler than when using the Pulvinal® inhaler (p < 0.05). Using the metered-dose, Pulvinal® and Aerolizer® inhalers, the COPD group patients committed more errors than did the asthma group patients (p = 0.0023, p = 0.0065 and p = 0.012, respectively). Conclusions: Although the majority of the patients claimed to know how to use inhalation devices, the fact that 94.2% committed at least one error shows that their technique was inappropriate and reveals a discrepancy between understanding and practice. Therefore, it is not sufficient to ask patients whether they know how to use inhalation devices. Practical measures should be taken in order to minimize errors and optimize treatment.


Keywords: Metered dose inhalers; Nebulizers and vaporizers; Asthma; Pulmonary disease, chronic obstructive.


3 - Characteristics associated with complete surgical resection of primary malignant mediastinal tumors

Características associadas à ressecção cirúrgica completa de tumores malignos primários do mediastino

Jefferson Luiz Gross, Ulisses Augusto Correia Rosalino, Riad Naim Younes, Fábio José Haddad, Rodrigo Afonso da Silva, Antonio Bomfim Marçal Avertano Rocha

J Bras Pneumol.2009;35(9):832-838

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify preoperative characteristics associated with complete surgical resection of primary malignant mediastinal tumors. Methods: Between 1996 and 2006, 42 patients with primary malignant mediastinal tumors were submitted to surgery with curative intent at a single facility. Patient charts were reviewed in order to collect data related to demographics, clinical manifestation, characteristics of mediastinal tumors and imaging aspects of invasiveness. Results: The surgical resection was considered complete in 69.1% of the patients. Cases of incomplete resection were attributed to invasion of the following structures: large blood vessels (4 cases); the superior vena cava (3 cases); the heart (2 cases); the lung and chest wall (3cases); and the trachea (1 case). Overall survival was significantly better among the patients submitted to complete surgical resection than among those submitted to incomplete resection. The frequency of incomplete resection was significantly higher in cases in which the tumor had invaded organs other than the lung (as identified through imaging studies) than in those in which it was restricted to the lung (47.6% vs. 14.3%; p = 0.04). None of the other preoperative characteristics analyzed were found to be associated with complete resection. Conclusions: Preoperative radiological evidence of invasion of organs other than the lung is associated with the incomplete surgical resection of primary malignant mediastinal tumors.


Keywords: Thoracic surgery; Survival rate; Mediastinal neoplasms; Diagnostic imaging.


4 - Evolution of exogenous lipoid pneumonia in children: clinical aspects, radiological aspects and the role of bronchoalveolar lavage

Evolução da pneumonia lipoide exógena em crianças: aspectos clínicos e radiológicos e o papel da lavagem broncoalveolar

Selma Maria de Azevedo Sias, Angela Santos Ferreira, Pedro Augusto Daltro, Regina Lúcia Caetano, José da Silva Moreira, Thereza Quirico-Santos

J Bras Pneumol.2009;35(9):838-845

Abstract PDF PT PDF EN Portuguese Text

Objective: To present aspects of the evolution of lipoid pneumonia in children, based on clinical, radiological and bronchoalveolar lavage fluid findings, emphasizing the importance of bronchoalveolar lavage for the diagnosis and treatment. Methods: We included 28 children, with a mean age of 20 months (range, 1-108 months), diagnosed with chronic pneumonia refractory to antimicrobial therapy, with TB or with a combination of the two. Most of the children had at least one risk factor for aspiration, and all of them had a history of mineral oil ingestion for intestinal constipation (23/28) or complicated ascaridiasis (5/28). Clinical evaluations, tomographic evaluations and analyses of bronchoalveolar lavage fluid were carried out at the beginning of treatment and throughout a follow-up period of 24 months. Results: Tachypnea and cough were the most common symptoms. The most common radiological alterations were areas of consolidation (23/28), perihilar infiltrates (13/28) and hyperinflation (11/28). Chest CT scans showed areas of consolidation with air bronchogram (24/28), decreased attenuation in the areas of consolidation (16/28), ground-glass opacities (3/28) and crazy-paving pattern (1/28). In the analysis of the bronchoalveolar lavage fluid, Sudan staining revealed foamy macrophages, confirming the diagnosis of lipoid pneumonia. After treatment with multiple bronchoalveolar lavages (mean = 9.6), 20 children became asymptomatic, 18 of those presenting normal tomographic images. Conclusions: A diagnosis of lipoid pneumonia should be considered in patients with chronic refractory pneumonia or TB, especially if there is a history of mineral oil ingestion. Bronchoscopy with multiple bronchoalveolar lavages was an efficient treatment for the clearance of mineral oil from the lung parenchyma and the prevention of fibrosis. This strategy contributed to reducing the morbidity of lipoid pneumonia, which remains a rare diagnosis.


Keywords: Pneumonia, lipid; Bronchoalveolar lavage; Treatment outcome.


5 - Factors associated with the minimal clinically important difference for health-related quality of life after physical conditioning in patients with COPD

Fatores associados à diferença clinicamente significativa da qualidade de vida relacionada à saúde após condicionamento físico em pacientes com DPOC

Victor Zuniga Dourado, Letícia Cláudia de Oliveira Antunes, Suzana Erico Tanni, Irma Godoy

J Bras Pneumol.2009;35(9):846-853

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify factors associated with the minimal clinically important difference (MCID) for health-related quality of life (HRQoL) after physical conditioning in patients with COPD. Methods: Thirty-five patients were submitted to a 12-week program of physical conditioning (strength training plus low-intensity aerobic exercise). Body composition, incremental treadmill test results, endurance treadmill test results, six-minute walk test results, peripheral muscle strength, MIP, baseline dyspnea index (BDI) and Saint George's Respiratory Questionnaire (SGRQ) scores were assessed at baseline and after the program, thus allowing the variations (Δ) to be calculated. The MCID for HRQoL was defined as a reduction of ≥ 4% in the SGRQ total score. Subjects who responded to the program, achieving the MCID for HRQoL, were allocated to the responders (R) group (n = 24), and the remainder were allocated to the non-responders (NR) group (n = 11). Results: The values obtained for the following variables were significantly higher in group R than in group NR (p < 0.05): FEV1 (1.48 ± 0.54 L vs. 1.04 ± 0.34 L); VEF1/FVC (47.9 ± 11.7% vs. 35.5 ± 10.7%); PaO2 (74.1 ± 9.7 mmHg vs. 65.0 ± 8.9 mmHg); and ΔBDI, expressed as median and interquartile range (2.0 [0.0-3.5] vs. 0.0 [0.0-1.0]). The ΔBDI correlated significantly with the ΔSGRQ symptoms domain score, activity domain score and total score (r = 0.44, 0.60 and 0.62, respectively, p < 0.01 for all). After logistic regression, only ΔBDI remained as a predictor of MCID for HRQoL. Conclusions: Achieving the MCID for HRQoL after physical conditioning is associated with dyspnea reduction in COPD patients. Therefore, there is a need to develop treatment strategies designed to interrupt the dyspnea-inactivity-dyspnea cycle in such patients.


Keywords: Pulmonary disease, chronic obstructive; Quality of life; Dyspnea; Exercise; Rehabilitation.


6 - Respiratory patterns in spirometric tests of adolescents and adults with cystic fibrosis

Padrões ventilatórios na espirometria em pacientes adolescentes e adultos com fibrose cística

Bruna Ziegler, Paula Maria Eidt Rovedder, Paulo de Tarso Roth Dalcin, Sérgio Saldanha Menna-Barreto

J Bras Pneumol.2009;35(9):854-859

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate spirometric patterns of respiratory disorders and their relationship with functional severity and maximal expiratory flows at low lung volumes in patients with cystic fibrosis (CF). Methods: A retrospective cross-sectional study including adolescents and adults with CF. All of the patients were submitted to spirometry. Patients were classified as having preserved respiratory function, obstructive lung disease (OLD), OLD with reduced FVC, presumptive restrictive lung disease (RLD) or mixed obstructive and restrictive lung disease (MORLD). Maximal expiratory flows at low lung volumes were assessed using FEF25-75%, FEF75% and FEF75%/FVC. We included 65 normal subjects, also submitted to spirometry, as a control group. Results: The study group included 65 patients: 8 (12.3%) with preserved lung function; 18 (27.7%) with OLD; 24 (36.9%) with OLD and reduced FVC; 5 (7.7%) with presumptive RLD; and 10 (15.4%) with MORLD. The FEV1 was significantly lower in the OLD with reduced FVC group and the MORLD group than in the other groups (p < 0.001). In the patients with preserved respiratory function, FEF25-75% and FEF75% were significantly reduced in 1 patient, as was FEF75%/FVC in 2 patients. Conclusions: The respiratory pattern was impaired in 88% of the patients with CF. The most common pattern was OLD with reduced FVC. The degree of functional impairment was greater in the OLD with reduced FVC group and in the MORLD group than in the other groups. Maximal expiratory flows at low lung volumes were impaired in a low percentage of patients with preserved respiratory function.


Keywords: Cystic fibrosis; Respiratory function tests; Spirometry; Maximal expiratory flow-volume curves.


7 - Comparison of the effects that two different respiratory physical therapy techniques have on cardiorespiratory parameters in infants with acute viral bronchiolitis

Comparação dos efeitos de duas técnicas fisioterapêuticas respiratórias em parâmetros cardiorrespiratórios de lactentes com bronquiolite viral aguda

Melissa Karina Pupin, Adriana Gut Lopes Riccetto, José Dirceu Ribeiro, Emílio Carlos Elias Baracat

J Bras Pneumol.2009;35(9):860-867

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the expiratory flow increase technique (EFIT) and vibration accompanied by postural drainage (PD) in terms of their effects on the heart rate (HR), respiratory rate (RR) and SpO2 of infants with acute viral bronchiolitis (AVB). Methods: Infants with clinical and radiological diagnosis of AVB were analyzed. The HR, RR and SpO2 were registered at four time points: prior to the procedure; and at 10, 30 and 60 min after the procedure. The patients were divided into three groups: submitted to the EFIT; submitted to vibration/PD; and control. Results: We included 81 infants, 27 per group, with a mean age of 4.52 years and a mean weight of 6.56 kg. Using ANOVA, we found that the EFIT and vibration/PD groups presented no significant differences in relation to the control group in terms of the mean values for HR, RR or SpO2 (p > 0.05). Considering only the four time points evaluated, the mean RR was significantly lower in the EFIT and vibration/PD groups than in the control group (p < 0.05). Conclusions: In terms of overall improvement of cardiorespiratory parameters, neither the EFIT nor vibration/PD provided any benefit to infants with BVA. However, over time, respiratory physical therapy seems to contribute to decreasing the RR in these patients.


Keywords: Bronchiolitis, viral; Physical therapy modalities; Infant.


8 - Computer-assisted evaluation of pulmonary emphysema in CT scans: comparison between a locally developed system and a freeware system

Avaliação computacional de enfisema pulmonar em TC: comparação entre um sistema desenvolvido localmente e um sistema de uso livre

John Hebert da Silva Felix, Paulo César Cortez, Rodrigo Carvalho Sousa Costa, Simone Castelo Branco Fortaleza, Eanes Delgado Barros Pereira, Marcelo Alcantara Holanda

J Bras Pneumol.2009;35(9):868-876

Abstract PDF PT PDF EN Portuguese Text

Objective: To present a locally developed system of computer vision for use with HRCT images, designated SIStema para a Detecção e a quantificação de Enfisema Pulmonar (SISDEP, System to Detect and Quantify Pulmonary Emphysema), and to compare this system with a freeware system tool. Methods: Thirty-three HRCT images scanned at the apex, hilum and base of the lungs of 11 patients with COPD were analyzed. The SISDEP was compared with the Osiris Medical Imaging Software Program regarding lung parenchyma segmentation, precision of the measurement of the cross-sectional area of the lungs in mm2, mean lung density (MLD), relative area (RA) of the lung occupied by voxels with attenuation values < −950 Hounsfield units (RA −950), 15th percentile point (Perc15) and visualization of hyperinflated areas using a color mask. Results: Although both computational systems were efficient in segmenting the lungs, the SISDEP performed this task automatically and more rapidly. There were significant correlations between the two systems in terms of the results obtained for lung cross-sectional area, MLD, RA −950 and Perc15 (r2 = 0.99, 0.99, 0.99 and 1.00, respectively). The color mask tool of the SISDEP allowed excellent visualization of hyperinflated areas, discriminating them from normal areas. Conclusions: The SISDEP was efficient in segmenting the lungs and quantifying lung hyperinflation, presenting an excellent correlation with the Osiris system. The SISDEP constitutes a promising computational tool for diagnosing and assessing the progression of emphysema in HRCT images of COPD patients.


Keywords: Pulmonary disease, chronic obstructive; Emphysema; Tomography, X-ray computed; Decision making, computer-assisted.


9 - Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil

Validação da escala de sonolência de Epworth em português para uso no Brasil

Alessandra Naimaier Bertolazi, Simone Chaves Fagondes, Leonardo Santos Hoff, Vinícius Dallagasperina Pedro, Sérgio Saldanha Menna Barreto, Murray W. Johns

J Bras Pneumol.2009;35(9):877-883

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of this study was to develop a Portuguese-language version of the Epworth sleepiness scale (ESS) for use in Brazil. Methods: The steps involved in creating the ESS in Brazilian Portuguese (ESS-BR) were as follows: translation; back-translation; comparison (by a committee) between the translation and the back-translation; and testing in bilingual individuals. The ESS-BR was applied to a group of patients who were submitted to overnight polysomnography in order to identify obstructive sleep apnea-hypopnea syndrome (OSAHS), insomnia and primary snoring. A control group was composed of subjects with a history of normal sleep habits, without reported snoring. Results: A total of 114 patients and 21 controls were included. The 8-item scores of the ESS-BR had an overall reliability coefficient of 0.83. The study group was composed of 59 patients with OSAHS, 34 patients with primary snoring and 21 patients with insomnia. One-way ANOVA demonstrated significant differences in ESS-BR scores among the four diagnostic groups (p < 0.001). Post-hoc tests between groups showed that the ESS-BR scores of the patients with insomnia did not differ from those of the controls (p > 0.05). The ESS-BR scores were significantly higher for OSAHS patients and for primary snorers than for controls (p < 0.05). In addition, the scores for OSAHS patients were significantly higher than were those for primary snorers (p < 0.05). Conclusions: The results of the present study demonstrate that the ESS-BR is a valid and reliable instrument for the assessment of daytime sleepiness, equivalent to its original version when applied to individuals who speak Brazilian Portuguese.


Keywords: Validation studies; Sleep disorders; Cross-cultural comparison; Disorders of excessive somnolence.


10 - Factors associated with nonadherence to TB chemoprophylaxis in Vitória, Brazil: a historical cohort study

Fatores associados ao abandono da quimioprofilaxia de TB no município de Vitória (ES): um estudo de coorte histórica

Ethel Leonor Noia Maciel, Ana Paula Brioschi, Letícia Molino Guidoni, Anne Caroline Barbosa Cerqueira, Thiago Nascimento do Prado, Geisa Fregona, Reynaldo Dietze

J Bras Pneumol.2009;35(9):884-891

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the factors associated with nonadherence to TB chemoprophylaxis in patients older than 15 years of age treated via referral TB control programs. Methods: A historical cohort study was carried out based on medical charts related to cases treated via referral TB control programs in the city of Vitória, Brazil, between 2002 and 2007. Cases of infection with Mycobacterium tuberculosis were stratified into two groups: health care workers (HCW group); and individuals who were not health care workers (NHCW group). Results: A total of 395 patients were included in the study: 35 in the HCW group and 360 in the NHCW group. The mean age in the HCW and NHCW groups was 34.8 and 32.4 years, respectively (p = 0.36). Of the 35 patients in the HCW group, 29 (82.9%) were female, compared with 180 (50.0%) of the 360 patients in the NHCW group. In the HCW and NHCW groups, respectively, 15 (42.9%) and 169 (46.9%) of the patients were contacts of TB cases. In addition, 9 (25.7%) and 157 (78.5%) the HCW and NHCW group patients, respectively, were HIV-infected. Nonadherence to chemoprophylaxis was 37.1% and 21.9% in the HCW and NHCW groups, respectively (p = 0.045). In the multivariate analysis, the factors associated with nonadherence were being a health care worker (OR = 8.60; 95% CI: 2.09-35.41), being HIV-infected (OR = 4.57; 95% CI: 1.2-17.5) and having had contact with a TB patient (OR = 2.65; 95% CI: 1.15-6.12). Conclusions: In order to improve adherence to TB chemoprophylaxis, new TB control program strategies are needed, especially for health care workers and HIV-infected patients.


Keywords: Tuberculosis; Chemoprevention; Isoniazid.


11 - Active tuberculosis in surgical patients with negative preoperative sputum smear results

Tuberculose ativa em pacientes cirúrgicos com baciloscopia negativa no pré‑operatório

Daniele Cristina Cataneo, Raul Lopes Ruiz Jr, Antonio José Maria Cataneo

J Bras Pneumol.2009;35(9):892-898

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Objective: To determine the proportion of negative preoperative sputum smear results among patients presenting active TB, as identified through the evaluation of surgical samples. Methods: A retrospective study of patients undergoing surgery between 2003 and 2006 at a university hospital and receiving a histopathological diagnosis of active or latent TB. We reviewed patient histories, TB-related clinical aspects, acid-fast bacilli (AFB) test results, type of surgery performed and histopathological findings in surgical samples. Results: We included 43 patients, 27 of whom were male. The mean age was 44 ± 19 years. Twenty-eight patients had a history of TB (treated appropriately), and 15 reported no history of the disease. The main reason for seeking treatment was recurrent infection, followed by alterations seen in imaging studies. Of the 43 patients, 35 underwent preoperative AFB testing: 32 tested negative, and 3 tested positive. Among those 35 patients, the histopathological diagnosis was active TB in 26 and latent TB in 9. The 8 patients not submitted to preoperative AFB testing were also diagnosed with latent TB. The proportion of active TB in patients with negative sputum smear results was 72% (23/32), whereas that of negative sputum smear results in patients with active TB was 88% (23/26). Only 11.5% (3/26) of the patients had tested positive for AFB. Conclusions: Direct sputum smear microscopy has a very low yield. Many previously treated patients can present negative sputum smear results and yet have active TB. Active TB can be mistaken for secondary infections or for cancer.


Keywords: Tuberculosis; Diagnosis, differential; Sputum; Thoracic surgery; Thoracic surgery, video-assisted.


Review Article

12 - Viral pneumonia: epidemiological, clinical, pathophysiological and therapeutic aspects

Pneumonias virais: aspectos epidemiológicos, clínicos, fisiopatológicos e tratamento

Luiz Tadeu Moraes Figueiredo

J Bras Pneumol.2009;35(9):899-906

Abstract PDF PT PDF EN Portuguese Text

In humans, the most common types of infection are respiratory tract infections, among which viral infections predominate. Viruses can also infect the low respiratory tract, causing bronchiolitis, bronchitis and pneumonia. The objective of this review article was to show epidemiological, pathophysiological, clinical and therapeutic aspects of viral community-acquired pneumonia. These types of pneumonia are commonly caused by influenza A and B; parainfluenza 1, 2 and 3; respiratory syncytial virus; or adenovirus. We also address the types of pneumonia caused by hantaviruses, metapneumoviruses and rhinoviruses.


Keywords: Pneumonia, viral; Influenza, human; Respiratory syncytial virus infections; Hantavirus.


Update Course - Mycoses

13 - Chapter 1 - Laboratory diagnosis of pulmonary mycoses

Capítulo 1 - Diagnóstico laboratorial das micoses pulmonares

Melissa Orzechowski Xavier, Flávio de Mattos Oliveira, Luiz Carlos Severo

J Bras Pneumol.2009;35(9):907-919

Abstract PDF PT PDF EN Portuguese Text

In this era of immunosuppression and transplantation, it is imperative that laboratory scientists remain in close communication with physicians. In patients receiving immunosuppressive therapy, the diagnosis of mycoses must be rapid, which is complicated, requiring the cooperation and collaboration of a number of professionals from various fields of expertise. In this paper, the laboratory diagnosis of pulmonary fungal infection is reviewed. The following topics are included: host factors such as immunological response and predisposing anatomical features; collection, transport and storage of specimens; laboratory processing of samples; direct microscopy; staining techniques, culture and identification of fungi; laboratory biosafety; tissue tropism and reactions; serology; and antigen detection.


Keywords: Mycology; Laboratories, hospital; Diagnostic techniques and procedures; Lung diseases, fungal.


14 - Chapter 2 - Coccidioidomycosis

Capítulo 2 - Coccidioidomicose

Antônio de Deus Filho

J Bras Pneumol.2009;35(9):920-930

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Coccidioidomycosis is a systemic mycosis caused by the dimorphic fungi Coccidioides immitis and Coccidioides posadasii. Infection is acquired by inhalation of infective arthroconidia that live in the soil. In 60% of cases, the infection is benign and resolves spontaneously. In the northern hemisphere, coccidioidomycosis is endemic to arid and semi-arid regions at latitudes between 40°N and 40°S, particularly in the southwestern United States and in northern Mexico. In the semi-arid northeastern region of Brazil, cases of coccidioidomycosis have recently been reported in four states: Piauí (100 cases); Ceará (20 cases); Maranhão (6 cases); and Bahia (2 cases). The illness manifests in one of three clinical forms: the primary pulmonary form; the progressive pulmonary form; or the disseminated form. On average, the symptoms of respiratory infection appear 10 days after exposure. The diagnosis is made by the isolation of Coccidioides sp. in culture or by positive results from smear microscopy (10% potassium hydroxide test), periodic acid-Schiff staining or silver staining of any suspect material (sputum, cerebrospinal fluid, skin exudate, lymph node aspirate, etc.) Agar gel immunodiffusion is the diagnostic test most widely used. The most common finding on X-rays and CT scans is diffuse distribution of multiple pulmonary nodules, most of which are cavitated. The recommended treatment is fluconazole or itraconazole, the mean dose ranging from 200 to 400 mg/day, although as much as 1,200 mg/day is used in certain cases. In severe cases, amphotericin B can be the drug of choice. In cases of neurological involvement, the recommended treatment is administration of fluconazole, at a minimum dose of 400 mg/day.


Keywords: Mycoses/immunology; Coccidioidomycosis; Lung diseases, fungal.


Case Series

15 - Outbreak of invasive pulmonary aspergillosis among patients hospitalized in a bone marrow transplant ward: tomographic findings

Surto de aspergilose pulmonar invasiva em enfermaria de transplante de medula óssea: achados tomográficos

Daniela Batista de Almeida Freitas, Ana Cláudia Piovesan, Gilberto Szarf, Dany Jasinowodolinski, Gustavo de Souza Portes Meirelles

J Bras Pneumol.2009;35(9):931-936

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the main aspects on CT scans of six patients hospitalized in a bone marrow transplant ward, diagnosed with invasive pulmonary aspergillosis (IPA), during an in-hospital outbreak of the disease. Methods: We reviewed 10 chest CT scans of six neutropenic or immunocompromised patients hospitalized in the hematology and bone marrow transplant ward of the Hospital São Paulo, in the city of São Paulo, Brazil, who were diagnosed with IPA between April of 2007 and October of 2007. The diagnosis of IPA was confirmed by anatomopathological findings (in 2 cases), culture (in 3 cases) or appropriate treatment response (in 1 case). Results: We evaluated the CT scans of three male and three female patients, ranging from 22 to 58 years of age. The most common tomographic findings were nodules (5/6 cases) and areas of consolidation (2/6 cases). The nodules were more often multiple (3/5 cases), with irregular contours (4/5 cases) and accompanied by the halo sign (3/5 cases). One case presented multiple, centrally distributed areas of consolidation, and another presented an isolated, peripheral area of consolidation. Areas of ground-glass attenuation and septal thickening were found in three and two patients, respectively. Bilateral pleural effusion occurred in three cases. Conclusions: Consolidation, nodules, septal thickening, pleural effusion and ground-glass opacities were the principal tomographic findings in the six patients hospitalized in the abovementioned ward during the IPA outbreak. The nodules were often (in 67% of the cases) accompanied by the halo sign, a classically described finding in patients with IPA.


Keywords: Aspergillosis; Lung diseases, fungal; Neutropenia; Bone marrow transplantation; Tomography, X-Ray computed.


Case Report

16 - Use of virtual bronchoscopy in children with suspected foreign body aspiration

Uso da broncoscopia virtual em pacientes pediátricos com suspeita de aspiração de corpo estranho

Tiago Neves Veras, Gilberto Hornburg, Adrian Maurício Stockler Schner, Leonardo Araújo Pinto

J Bras Pneumol.2009;35(9):937-941

Abstract PDF PT PDF EN Portuguese Text

Foreign body aspiration (FBA) into the tracheobronchial tree is a common problem in children, especially in those under three years of age. Preliminary radiological evaluation reveals normal chest X-rays in nearly 30% of such patients. Tomography-generated virtual bronchoscopy (VB) can facilitate the early diagnosis and rapid management of these cases. The definitive treatment is the removal of the foreign body by means of rigid bronchoscopy under general anesthesia. The objective of this study was to describe the use of VB in two patients with suspicion of FBA, as well as to review the literature regarding this topic. The two patients presented with sudden onset of respiratory symptoms and history of cough or choking with foods before these symptoms. Both patients were submitted to VB. In both cases, we detected an endobronchial foreign body, which was then removed by conventional rigid bronchoscopy in one of the cases. Only recently developed, VB is a noninvasive imaging method that has potential for use in detecting foreign bodies in the airways of children. In select cases, VB can indicate the exact location of the foreign body and even preclude the need to submit patients to rigid bronchoscopy in the absence of a foreign body.


Keywords: Bronchoscopy; Pediatrics; Respiratory aspiration.


17 - Rheumatoid pneumoconiosis (Caplan's syndrome) with a classical presentation

Pneumoconiose reumatoide (síndrome de Caplan) com apresentação clássica

Eduardo Mello De Capitani, Marcelo Schweller, Cristiane Mendes da Silva, Konradin Metze, Elza Maria Figueiras Pedreira de Cerqueira, Manoel Barros Bértol

J Bras Pneumol.2009;35(9):942-946

Abstract PDF PT PDF EN Portuguese Text

Although rare, rheumatoid pneumoconiosis, also known as Caplan's syndrome, can occur in workers exposed to silica, as well as in patients with silicosis, coal workers' pneumoconiosis or asbestosis. Prevalence is higher among patients with silicosis, despite the fact that it was originally described in coal workers with pneumoconiosis. The classical finding that defines this syndrome is that of rheumatoid nodules in the lungs, regardless of whether there are small rounded opacities suggestive of pneumoconiosis or large opacities consistent with massive pulmonary fibrosis, with or without clinical rheumatoid arthritis. We describe the case of a female patient with rheumatoid arthritis, diagnosed 34 years after 7 years of occupational exposure to silica at a porcelain plant. A chest X-ray showed circular opacities of 1-5 cm in diameter, bilaterally distributed at the periphery of the lungs. A CT-guided thoracic punch biopsy of one of those nodules revealed that it was rheumatoid nodule surrounded by a palisade of macrophages, which is typical of Caplan's syndrome. Aspects of diagnosis, classification and occurrence of this syndrome are discussed, emphasizing the importance of the occupational anamnesis of patients with rheumatoid arthritis and lung opacities on chest X-rays.


Keywords: Pneumoconiosis; Arthritis, rheumatoid; Caplan's syndrome; Silicosis.


Year 2009 - Volume 35  - Number 10  (/October)


1 - More than good lungs!

Mais do que bons pulmões!

Ilma Aparecida Paschoal

J Bras Pneumol.2009;35(10):947-948

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Original Article

2 - Profile of the level of physical activity in the daily lives of patients with COPD in Brazil

Perfil do nível de atividade física na vida diária de pacientes portadores de DPOC no Brasil

Nidia Aparecida Hernandes, Denilson de Castro Teixeira, Vanessa Suziane Probst, Antonio Fernando Brunetto, Ercy Mara Cipulo Ramos, Fábio Pitta

J Bras Pneumol.2009;35(10):949-956

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate characteristics of physical activities in daily life in COPD patients in Brazil, correlating those characteristics with physiological variables. Methods: Physical activities in daily life were evaluated in 40 COPD patients (18 males; 66 ± 8 years of age; FEV1 = 46 ± 16 % of predicted; body mass index = 27 ± 6 kg/m2) and 30 healthy age- and gender-matched subjects, using a multiaxial accelerometer-based sensor for 12 h/day on two consecutive days. We also assessed maximal and functional exercise capacity, using the incremental exercise test and the six-minute walk test (6MWT), respectively; MIP and MEP; peripheral muscle force, using the one-repetition maximum test and the handgrip test; quality of life, using the Saint George's Respiratory Questionnaire (SGRQ); functional status, using the London Chest Activity of Daily Living questionnaire; and dyspnea sensation, using the Medical Research Council (MRC) scale. Results: Mean walking time/day was shorter for COPD patients than for the controls (55 ± 33 vs. 80 ± 28 min/day; p = 0.001), as movement intensity was lower (1.9 ± 0.4 vs. 2.3 ± 0.6 m/s2; p = 0.004). The COPD patients also tended to spend more time seated (294 ± 114 vs. 246 ± 122 min/day, p = 0.08). Walking time/day correlated with the 6MWT (r = 0.42; p = 0.007) and maximal workload (r = 0.41; p = 0.009), as well as with age, MRC scale score and SGRQ activity domain score (−0.31 ≤ r ≤ −0.43; p ≤ 0.05 for all). Conclusions: This sample of Brazilian patients with COPD, although more active than those evaluated in studies conducted in Europe, were less active than were the controls. Walking time/day correlated only moderately with maximal and functional exercise capacity.


Keywords: Pulmonary disease, chronic obstructive; Motor activity; Exercise tolerance.


3 - Predictors of oxygen desaturation during the six-minute walk test in patients with cystic fibrosis

Preditores da dessaturação do oxigênio no teste da caminhada de seis minutos em pacientes com fibrose cística

Bruna Ziegler, Paula Maria Eidt Rovedder, Claudine Lacerda Oliveira, Sandra Jungblut Schuh, Fernando Abreu e Silva, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2009;35(10):957-965

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify the predictive factors of oxygen desaturation during the six-minute walk test (6MWT) in patients with cystic fibrosis (CF). Methods: Prospective cross-sectional study involving clinically stable patients with CF aged ≥ 10 years. The patients were submitted to nutritional evaluations, oral glucose tolerance tests, pulmonary function tests, chest X-rays and 6MWTs. Results: The study included 88 patients (43 females and 45 males; mean age, 19.9 ± 7.2 years; mean FEV1, 65.4 ± 28.4%). We observed oxygen desaturation in 13 patients (OD+ group) and no oxygen desaturation in 75 (OD− group). In comparison with OD− group patients, OD+ group patients presented higher mean age (p = 0.004), worse clinical score (p < 0.001), worse radiological score (p < 0.001), higher incidence of glucose intolerance (p = 0.004), lower incidence of methicillin-sensitive Staphylococcus aureus infection (p < 0.001), higher incidence of methicillin-resistant S. aureus infection (p = 0.016), higher incidence of Pseudomonas aeruginosa infection (p = 0.008), lower mean resting SpO2 (p < 0.001) and lower mean FEV1 (p < 0.001). In the logistic regression analysis, oxygen desaturation during the 6MWT correlated with resting SpO2 (OR = 0.305, p < 0.001) and FEV1 (OR = 0.882, p = 0.025). The parameters maximizing the predictive value for oxygen desaturation were resting SpO2 < 96% and FEV1 < 40%. In this sample, 15% of the patients with CF aged ≥ 10 years presented oxygen desaturation during the 6MWT. Conclusions: Resting SpO2 < 96% and FEV1 < 40% can predict oxygen desaturation during the 6MWT.


Keywords: Cystic fibrosis; Respiratory function tests; Exercise tolerance.


4 - Association between nutritional status and dietary intake in patients with cystic fibrosis

Associação entre o estado nutricional e a ingestão dietética em pacientes com fibrose cística

Míriam Isabel Souza dos Santos Simon, Michele Drehmer, Sérgio Saldanha Menna-Barreto

J Bras Pneumol.2009;35(10):966-972

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the relationship between nutritional status and dietary intake in patients with cystic fibrosis. Methods: Cross-sectional study involving 85 cystic fibrosis patients between 6 and 18 years of age. Dietary intake was evaluated by the 3-day diet record (weighing the food consumed). The outcome measures were the following nutritional status indicators: weight/height (W/H%) percentage, body mass index (BMI) percentiles, Z score for weight/age (W/A), Z score for height/age (H/A) and percentage of dietary intake compared with the Recommended Dietary Allowance (RDA). Results: The prevalence of well-nourished patients was 77.7%, using BMI above the 25th percentile as the cut-off value, and the W/H% was above 90% in 83.5%. The mean dietary intake, evaluated in 82 patients, was 124.5% of the RDA. In the univariate logistic regression analyses, we found a significant association between the independent variable calorie intake and the Z score for W/A. The multivariate analysis, based on the Z score for H/A and adjusted for FEV1, methicillin-resistant Staphylococcus aureus colonization and number of hospitalizations, demonstrated that a 1% increase in the calorie intake decreases the chance of having short stature by 2% (OR: 0.98; 95% CI: 0.96-1.00). Maternal level of education showed a borderline association (p = 0.054). Conclusions: The prevalence of malnutrition was low in this sample of patients. The study model demonstrated an association between dietary intake and nutritional status. Dietary intake was a predictive factor of statural growth in patients with cystic fibrosis.


Keywords: Cystic fibrosis; Nutritional status; Diet records; Child; Adolescent.


5 - Air stacking and chest compression increase peak cough flow in patients with Duchenne muscular dystrophy

Empilhamento de ar e compressão torácica aumentam o pico de fluxo da tosse em pacientes com distrofia muscular de Duchenne

Magneide Fernandes Brito, Gustavo Antonio Moreira, Márcia Pradella-Hallinan, Sergio Tufik

J Bras Pneumol.2009;35(10):973-979

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate cough efficiency using two manually-assisted cough techniques. Methods: We selected 28 patients with Duchenne muscular dystrophy. The patients were receiving noninvasive nocturnal ventilatory support and presented FVC values < 60% of predicted. Peak cough flow (PCF) was measured, with the patient seated, at four time points: at baseline, during a spontaneous maximal expiratory effort (MEE); during an MEE while receiving chest compression; during an MEE after air stacking with a manual resuscitation bag; and during an MEE with air stacking and compression (combined technique). The last three measurements were conducted in random order. The results were compared using Pearson's correlation test and ANOVA with repeated measures, followed by Tukey's post-hoc test (p < 0.05). Results: The mean age of the patients was 20 ± 4 years, and the mean FVC was 29 ± 12%. Mean PCF at baseline, with chest compression, after air stacking and with the use of the combined technique was 171 ± 67, 231 ± 81, 225 ± 80, and 292 ± 86 L/min, respectively. The results obtained with the use of the combined technique were significantly better than were those obtained with the use of either technique alone (F[3.69] = 67.07; p < 0.001). Conclusions: Both chest compression and air stacking techniques were efficient in increasing PCF. However, the combination of these two techniques had a significant additional effect (p < 0.0001).


Keywords: Muscular dystrophy, Duchenne; Intermittent positive-pressure ventilation; Cough; Insufflation;Peak expiratory flow rate.


6 - Characteristics of smokers enrolled in a public smoking cessation program

Perfil de fumantes atendidos em serviço público para tratamento do tabagismo

Laura Miranda de Oliveira Caram, Renata Ferrari, Suzana Erico Tanni, Liana Sousa Coelho, Ilda de Godoy, Rosana dos Santos e Silva Martin, Irma de Godoy

J Bras Pneumol.2009;35(10):980-985

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the characteristics of smokers seeking treatment in a public smoking cessation program. Methods: This was a retrospective evaluation of data collected during the interview for enrollment in the smoking cessation program of the Smoking Outpatient Clinic of the Paulista State University School of Medicine in the city of Botucatu, Brazil, between April of 2003 and April of 2007. Demographic variables; previous use of the behavioral approach, medications or alternative treatments for smoking cessation; degree of nicotine dependence; and history of comorbidities were evaluated in 387 smokers. Results: In our sample, 63% of the smokers were female. The mean age of the subjects was 50 ± 25 years. More than half of the subjects (61%) had up to eight years of schooling, and 66% had a monthly income of less than twice the national minimum wage. The degree of nicotine dependence was high/very high in 59%, medium in 17% and low/very low in 24% of the subjects. Although 95% of the patients presented comorbidities, only 35% had been referred to the program by a physician. More than half of the subjects (68%) had made at least one smoking-cessation attempt, 83% of whom did so without the help of a structured program. Conclusions: Smokers seeking assistance for smoking cessation were socially disadvantaged, presented a high degree of nicotine dependence and had previously made smoking-cessation attempts without the benefit of a structured program. Therefore, in order to be effective, smoking control interventions should take into consideration the general characteristics of the smokers treated via the public health care system.


Keywords: Smoking; Tobacco use disorder; Smoking cessation.


7 - Prevalence of smoking and its association with the use of other drugs among students in the Federal District of Brasília, Brazil

Prevalência do tabagismo e associação com o uso de outras drogas entre escolares do Distrito Federal

Márcia Cardoso Rodrigues, Carlos Alberto de Assis Viegas, Emannuel Lucas Gomes, João Paulo Majella de Godoy Morais, Juliano Coelho de Oliveira Zakir

J Bras Pneumol.2009;35(10):986-991

Abstract PDF PT PDF EN Portuguese Text

Objective: To estimate the prevalence of smoking, as well as to determine the association between smoking and the use of other drugs, among middle and high school students in the Federal District of Brasília, Brazil. Methods: Epidemiological study involving a reference population of students in the District. Our sample comprised 2,661 students from 9 to 19 years of age, in all middle and high school grades. All participating students completed a standard questionnaire. Results were analyzed by gender and type of school (public or private). Results: The prevalence of smoking among students in the District was 10.5%. Smoking was found to be associated with the use of alcohol and other drugs. Conclusions: Smoking is a gateway to the use of other drugs.


Keywords: Smoking; Tobacco; Adolescent; Students; Alcohol drinking; Dependency (Psychology).


8 - Food baskets given to tuberculosis patients at a primary health care clinic in the city of Duque de Caxias, Brazil: effect on treatment outcomes

Efeito do incentivo alimentício sobre o desfecho do tratamento de pacientes com tuberculose em uma unidade primária de saúde no município de Duque de Caxias, Rio de Janeiro

João Paulo Cantalice Filho

J Bras Pneumol.2009;35(10):992-997

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effect that the distribution of food baskets to tuberculosis (TB) patients has on treatment outcomes at a primary health care clinic. Methods: Retrospective comparative study of the medical and social aspects of 142 patients at a primary health care clinic in the city of Duque de Caxias, Brazil. The patients were divided into two groups: the first group included 68 patients treated with standard regimens (between September of 2001 and December of 2003); and the second group included 74 patients treated with the same regimens but also receiving food baskets on a monthly basis (between January of 2004 and July of 2006). Results: The statistical comparison between the two groups revealed that the cure rate was higher in the group receiving the food baskets (87.1% vs. 69.7%), whereas the rate of noncompliance was markedly lower (12.9% vs. 30.3%). Conclusions: The results indicate that the distribution of food baskets can be a useful strategy to improve compliance with TB treatment at primary health care clinics.


Keywords: Tuberculosis; Nutritional support; Treatment outcome; Ambulatory health services.


9 - Characteristics of pulmonary tuberculosis in a hyperendemic area-the city of Santos, Brazil

Características da tuberculose pulmonar em área hiperendêmica - município de Santos (SP)

Andrea Gobetti Vieira Coelho, Liliana Aparecida Zamarioli, Carmen Argüello Perandones, Ivonete Cuntiere, Eliseu Alves Waldman

J Bras Pneumol.2009;35(10):998-1007

Abstract PDF PT PDF EN Portuguese Text

Objective: To characterize the profile of patients with pulmonary tuberculosis (PTB) in the city of Santos, Brazil, according to biological, environmental and institutional factors. Methods: Descriptive study, using the TB surveillance database, including patients with PTB, aged 15 years or older, residing in the city of Santos and whose treatment was initiated between 2000 and 2004. Results: We identified 2,176 cases, of which 481 presented a history of TB. Of those 481 patients, 29.3% were cured, and 70.7% abandoned treatment. In 61.6% of the cases, the diagnosis was confirmed by sputum smear microscopy, whereas it was confirmed based on clinical and radiological criteria in 33.8%; 69.0% were male; and 69.5% were between 20 and 49 years of age. There were 732 hospitalizations, and the mean length of hospital stay was 32 days (first hospitalization). The prevalence of alcoholism, diabetes and TB/HIV coinfection was, respectively, 11.7%, 8.2% and 16.2%. The prevalence of TB/HIV coinfection decreased from 20.7% to 12.9% during the study period. The treatment outcome was cure, abandonment, death from TB and death attributed to TB/HIV coinfection in 71.0%, 12.1%, 3.9% and 2.5%, respectively. The directly observed treatment, short-course (DOTS) was adopted in 63.4% of cases, and there were no significant differences between DOTS and the conventional treatment approach in terms of outcomes (p > 0.05). The mean annual incidence of PTB was 127.9/100,000 population (range: 72.8-272.92/100,000 population, varying by region). The mean annual mortality rate for PTB was 6.9/100,000 population. Conclusions: In areas hyperendemic for TB, DOTS should be prioritized for groups at greater risk of treatment abandonment or death, and the investigation of TB contacts should be intensified.


Keywords: Tuberculosis, pulmonary; Epidemiology, descriptive; Control.


Review Article

10 - Primary immunodeficiency diseases: relevant aspects for pulmonologists

Imunodeficiências primárias: aspectos relevantes para o pneumologista

Pérsio Roxo Júnior

J Bras Pneumol.2009;35(10):1008-1017

Abstract PDF PT PDF EN Portuguese Text

Primary immunodeficiency diseases comprise a genetically heterogeneous group of disorders that affect distinct components of the innate and adaptive immune system, such as neutrophils, macrophages, dendritic cells, complement proteins and natural killer cells, as well as T and B lymphocytes. The study of these diseases has provided essential insights into the functioning of the immune system. Primary immunodeficiency diseases have been linked to over 120 different genes, abnormalities in which account for approximately 180 different forms of these diseases. Patients with primary immunodeficiency diseases are most often recognized because of their increased susceptibility to infections. However, these patients can also present with a variety of other manifestations, such as autoimmune diseases, inflammatory diseases and cancer. The purpose of this article is to update the main aspects of primary immunodeficiency diseases, especially regarding the clinical manifestations related to the diagnosis, emphasizing the need for the early recognition of warning signs for these diseases.


Keywords: Respiratory tract infections; Complement activation; Immunologic deficiency syndromes; Phagocytes; Immunoglobulins.


Guidelines SBPT

11 - III Brazilian Thoracic Association Guidelines on TB

III Diretrizes para Tuberculose da Sociedade Brasileira de Pneumologia e Tisiologia

BTA Committee on Tuberculosis1, BTA Guidelines on Tuberculosis Work Group2

J Bras Pneumol.2009;35(10):1018-1048

Abstract PDF PT PDF EN Portuguese Text

New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations on TB have been evaluated, discussed by all of the members of the BTA Committee on TB and of the TB Work Group, and highlighted. The first version of the present Guidelines was posted on the BTA website and was available for public consultation for three weeks. Comments and critiques were evaluated. The level of scientific evidence of each reference was evaluated before its acceptance for use in the final text.


Keywords: Tuberculosis; Mycobacterium infections; Diagnosis; Tuberculosis, multidrug-resistant.


Case Report

12 - Asymptomatic giant mediastinal mass: a rare case of thymolipoma

Massa mediastinal gigante assintomática: um raro caso de timolipoma

Omar Moté Abou Mourad, Filipe Moreira de Andrade, Pedro Abrahão, Andréa Monnerat, Luiz Felippe Judice

J Bras Pneumol.2009;35(10):1049-1052

Abstract PDF PT PDF EN Portuguese Text

Thymolipoma is a very rare benign neoplasm of the thymus. We present the case of a 42-year-old male with a massive mediastinal tumor discovered on a chest X-ray after a motorcycle accident. The patient had no complaints, and his physical examination was unremarkable. Chest CT scans revealed a lipomatous mass containing areas of soft tissue density. The patient was submitted to median sternotomy expanded to left anterolateral thoracotomy, resulting in the complete excision of the tumor. The pathological diagnosis was thymolipoma. Thymolipoma usually attains enormous dimensions by the time of diagnosis, and the occasional symptoms are related to compression of adjacent structures. Surgical resection is the treatment of choice and offers the only possibility of cure. The airway deserves special care during anesthesia induction.


Keywords: Thymus neoplasms; Mediastinal neoplasms; Thymectomy; Lipoma.


13 - Madelung's disease as a rare cause of obstructive sleep apnea

Doença de Madelung como causa rara de apneia obstrutiva do sono

Vitor Alexandre Oliveira Fonseca, Carlos Alves, Helena Marques, Elvira Camacho, António Pinto Saraiva

J Bras Pneumol.2009;35(10):1053-1056

Abstract PDF PT PDF EN Portuguese Text

Madelung's disease, or multiple symmetric lipomatosis, is a rare disease, characterized by accumulation of unencapsulated fat, generally located symmetrically around the neck and shoulders. Here, we present the case of a patient with diffuse lipomatosis accompanied by obstructive sleep apnea due to cervical involvement and facial deformity, which made it necessary to use nasal pillows for ventilation. The patient was hospitalized with a diagnosis of pneumonia and required noninvasive ventilation due to severe hypercapnia. A brief review of the literature was made, and we describe and discuss the investigation of this rare clinical case.


Keywords: Lipomatosis, multiple symmetrical; Sleep apnea, obstructive; Continuous positive airway pressure; Masks.


Year 2009 - Volume 35  - Number 11  (/November)


1 - New perspectives in lung transplantation: from conventional preservation to ex vivo lung perfusion and lung reconditioning

As novas perspectivas do transplante de pulmão: da preservação convencional à perfusão pulmonar ex vivo com recondicionamento pulmonar

Paulo Francisco Guerreiro Cardoso

J Bras Pneumol.2009;35(11):1057-1059

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Original Article

2 - Prevalence of asthma among adolescents in the city of Fortaleza, Brazil

Prevalência de asma em adolescentes na cidade de Fortaleza, CE

Maria de Fátima Gomes de Luna, Paulo César de Almeida, Marcelo Gurgel Carlos da Silva

J Bras Pneumol.2009;35(11):1160-1167

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of asthma among adolescents (13-14 years of age) in the city of Fortaleza, Brazil. Methods: This was a cross-sectional study involving 3,015 adolescents at public and private schools between 2006 and 2007. The participants completed the International Study of Asthma and Allergies in Childhood questionnaire. Results: The prevalences of "wheezing ever", "wheezing within the last 12 months" (active asthma) and "asthma ever" (physician-diagnosed asthma) were 44.1%, 22.6% and 11.6%, respectively. The prevalences of "wheezing ever" (p = 0.001), "1-3 wheezing attacks within the last 12 months" (p = 0.001), active asthma (p = 0.002), "sleep disturbed due to wheezing less than one night per week" (p < 0.001) and "dry cough at night" (p < 0.001) were higher among girls. Private school students presented higher prevalences of "wheezing ever", active asthma, "1-3 wheezing attacks within the last 12 months", "4-12 wheezing attacks within the last 12 months" and physician-diagnosed asthma (p < 0.001 for all), as well as of "exercise-induced wheezing" (p = 0.032). Conclusions: The prevalence of asthma and asthma-related symptoms in students aged 13-14 years in the city of Fortaleza, Brazil, was high, predominantly among girls and private school students. The difference between the prevalence of physician-diagnosed asthma and that of active asthma suggests that asthma was underdiagnosed in the population studied.


Keywords: Asthma/diagnosis; Asthma/epidemiology; Asthma/prevalence.


3 - Joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the evaluation of mediastinal lymph nodes in patients with non-small cell lung cancer

Utilização conjunta de mediastinoscopia cervical e videotoracoscopia para a avaliação linfática mediastinal em pacientes com carcinoma de pulmão não-pequenas células

Darcy Ribeiro Pinto Filho, Alexandre José Gonçalves Avino, Suzan Lucia Brancher Brandão, Wilson Paloschi Spiandorello

J Bras Pneumol.2009;35(11):1068-1074

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the efficacy of the joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the sampling of mediastinal lymph nodes in patients with non-small cell lung cancer (NSCLC) and candidates for pulmonary resection. Methods: Sixty-two patients diagnosed with NSCLC were submitted to cervical mediastinoscopy and video-assisted thoracoscopy. The samples obtained (from paratracheal chains, anterior and posterior subcarinal chains, paraesophageal chains and pulmonary ligament) were submitted to frozen section analysis. The following variables were also evaluated: age; gender; weight loss; diagnostic method; tomographic findings; histological type; staging; and location and size of the primary tumor. Results: In 11 patients, mediastinoscopy showed no involvement of the subcarinal chain, whereas such involvement was identified when video-assisted thoracoscopy was used: positive predictive value = 88.89% (95% CI: 51.75-99.72); negative predictive value = 94.34% (95% CI: 84.34-98.82); prevalence = 17.74% (95% CI: 9.2-29.53); sensitivity = 72.73% (95% CI: 39.03-93.98); and specificity = 98.77% (95% CI: 93.31-99.97). In 60% of the patients with involvement of the posterior subcarinal chain, the primary tumor was in the right inferior lobe. (p = 0.029) Conclusions: The joint use of cervical mediastinoscopy and video-assisted thoracoscopy for the evaluation of posterior mediastinal lymph nodes proved to be an efficacious method. When there is no access to posterior chains by means of ultrasound with transbronchial or transesophageal biopsy, which dispenses with general anesthesia, this should be the method of choice for the correct evaluation of mediastinal lymph nodes in patients with NSCLC.


Keywords: Neoplasm staging; Mediastinoscopy; Biopsy; Lymphatic metastasis.


4 - Prevalence of obstructive sleep apnea in children and adolescents with sickle cell anemia

Prevalência da apneia obstrutiva do sono em crianças e adolescentes portadores da anemia falciforme

Cristina Salles, Regina Terse Trindade Ramos, Carla Daltro, Andréa Barral, Jamocyr Moura Marinho, Marcos Almeida Matos

J Bras Pneumol.2009;35(11):1075-1083

Abstract PDF PT PDF EN Portuguese Text

Objective: To estimate the prevalence of obstructive sleep apnea syndrome (OSAS) in children and adolescents with sickle cell anemia (SCA); to investigate the possible correlation between mean annual hemoglobin level and total sleep time with SpO2 < 90%, as well as between mean annual hemoglobin level and total sleep time with SpO2 < 80%; and to investigate the possible correlation between apnea-hypopnea index (AHI) and painful crisis. Methods: The study involved 85 patients with SCA. The patients completed a questionnaire, were submitted to polysomnography and underwent clinical evaluation (by a pediatrician and an otolaryngologist). An AHI > 1 was considered indicative of a diagnosis of OSAS. Results: The prevalence of OSAS was 10.6%. We found a negative correlation between mean annual hemoglobin level and total sleep time with SpO2 < 90% (r = −0.343; p = 0.002), as well as between mean annual hemoglobin level and total sleep time with SpO2 < 80% (r = −0.270; p = 0.016). There was no association between AHI and painful crisis. Conclusions: The prevalence of OSAS in this population was high (10.6%). Therefore, it is important to identify signs of OSAS as soon as possible and to determine the mean annual hemoglobin level because of the inverse correlation between that level and the total sleep time with SpO2 < 90% or < 80%.


Keywords: Prevalence; Sleep apnea, obstructive; Anemia, sickle cell; Polysomnography; Sleep apnea syndromes.


5 - Ventilator-associated pneumonia: epidemiology and impact on the clinical evolution of ICU patients

Pneumonia associada à ventilação mecânica: epidemiologia e impacto na evolução clínica de pacientes em uma unidade de terapia intensiva

Pedro Mendes de Azambuja Rodrigues, Edgard do Carmo Neto, Luiz Rodrigo de Carneiro Santos, Marcos Freitas Knibel

J Bras Pneumol.2009;35(11):1084-1091

Abstract PDF PT PDF EN Portuguese Text

Objective: Although ventilator-associated pneumonia (VAP) is a major cause of nosocomial infection, its role in the prognosis of patients remains undefined. The objective of this study was to evaluate the impact of VAP on the clinical evolution of patients. Methods: This was a prospective cohort study involving 233 patients on mechanical ventilation (VAP group, n = 64; control group, n = 169). Primary outcomes were time on mechanical ventilation (TMV), time in ICU (TICU), overall length of hospital stay (LHS) and in-ICU mortality. Secondary outcomes were in-hospital mortality, microbiological profile, prior use of antibiotics and risk factors for VAP acquisition. Results: Control and VAP group outcomes were, respectively, as follows: median TMV (days), 9 (interquartile range [IQR]: 5-15) and 23 (IQR: 15-37; p < 0.0001); median TICU (days), 12 (IQR: 8-21) and 27 (IQR: 17-42; p < 0.0001); median LHS (days), 33 (IQR: 18-64) and 46 (IQR: 25-90; p = 0.05); and in-ICU mortality, 38% (95% CI: 31-45) and 55% (95% CI: 42-67; p = 0.02). VAP was a predictor of in-ICU mortality (OR = 3.40; 95% CI: 1.54‑7.48). TMV (OR = 2.27; 95% CI: 1.05-4.87) and prior use of antibiotics (OR = 1.07; 95% CI: 1.04-1.10) were risk factors for VAP. VAP did not affect in-hospital mortality. Acinetobacter spp. was the most common isolate (28%). Inappropriate empirical antibiotic therapy was administered in 48% of cases. Conclusions: In this study, there was a high incidence of infection with resistant bacteria and inappropriate initial antibiotic therapy. Long TMV and prior use of antibiotics are risk factors for VAP.


Keywords: Pneumonia, ventilator-associated; Cross infection; Intensive care units; Hospital mortality; Risk factors.


6 - Bacteriological analysis of induced sputum for the diagnosis of pulmonary tuberculosis in the clinical practice of a general tertiary hospital

Análise bacteriológica do escarro induzido para o diagnóstico de tuberculose pulmonar na prática clínica de um hospital geral terciário

Sabrina Bollmann Garcia, Christiano Perin, Marcel Muller da Silveira, Gustavo Vergani, Sérgio Saldanha Menna-Barreto, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2009;35(11):1092-1099

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Objective: To determine the diagnostic sensitivity of bacteriological analyses in induced sputum (IS) for the diagnosis of pulmonary tuberculosis (TB) and to identify the clinical characteristics associated with the confirmed diagnosis, as well as to determine the diagnostic yield of bronchoscopy carried out when IS tests negative for AFB in smear microscopy. Methods: A retrospective, cross-sectional study of patients suspected of having active pulmonary TB and referred to our clinic for sputum induction. We consecutively reviewed the laboratory data of all patients submitted to sputum induction between June of 2003 and January of 2006, as well as their electronic medical records. In addition, the results of the bacteriological analysis of bronchoscopic specimens collected from the patients whose AFB tests were negative in IS were reviewed. Results: Of the 417 patients included in the study, 83 (19.9%) presented IS samples that tested positive for TB (smear microscopy or culture). In the logistic regression analysis, radiological findings of cavitation (OR = 3.8; 95% CI: 1.9-7.6) and of miliary infiltrate (OR = 3.7; 95% CI: 1.6-8.6) showed the strongest association with the diagnosis of pulmonary TB. In 134 patients, bronchoscopy was carried out after negative AFB results in IS and added 25 (64.1%) confirmed diagnoses of pulmonary TB. Conclusions: In our clinical practice, the frequency of confirmed diagnosis of pulmonary TB using IS (19.9%) was lower than that previously reported in controlled trials. Cavitation and miliary infiltrate increase the diagnostic probability of pulmonary TB using IS. The use of bronchoscopy when IS tests negative for AFB significantly increases sensitivity in the diagnosis of pulmonary TB.


Keywords: Tuberculosis, pulmonary; Diagnosis; Sputum.


7 - Tuberculosis treatment: integration between hospitals and public health care clinics in the city of São Paulo, Brazil

Tratamento de tuberculose: integração entre assistência hospitalar e rede básica na cidade de São Paulo

Mirtes Cristina Telles Perrechi, Sandra Aparecida Ribeiro

J Bras Pneumol.2009;35(11):1100-1106

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Objective: To evaluate the level of access to health care clinics of a population of patients hospitalized for tuberculosis (TB) at two hospitals in the city of São Paulo, Brazil, comparing them with a population of TB patients under outpatient treatment only. Methods: We compiled sociodemographic, clinical and epidemiological data related to patients hospitalized for TB at two hospitals in the city of São Paulo, Brazil, between January and December of 2007, using a structured questionnaire. We also identified the outpatient clinics to which the patients were referred at discharge. The same variables were evaluated for TB outpatients during the same period, using a database. Results: The study sample consisted of 474 patients (166 inpatients and 308 outpatients: mean age, 41.0 and 39.1 years, respectively). The univariate analysis showed positive associations between hospitalization due to TB and the following variables: 30-39 year age bracket (OR = 2.17); 50-59 year age bracket (OR = 2.17); combination of pulmonary and extrapulmonary forms of TB (OR = 5.31); TB re-treatment (OR = 2.66); seeking treatment at other health care facilities prior to the diagnosis of TB (OR = 2.05); symptom duration of more than 12 weeks (OR = 2.23); and TB diagnosed at hospitals or in emergency rooms (OR = 4.68). The proportion of inpatients who resided in the same regional health district area as that in which the respective hospital was located was 77.6% and 36.8%. The proportion of discharged patients who were referred to outpatient clinics in the same areas was 67.1% and 39.7%, respectively. Conclusions: Patients hospitalized for TB should be monitored from discharge until their admission to the outpatient clinic.


Keywords: Tuberculosis; Health services accessibility; Inpatients; Outpatients.


Brief Communication

8 - Ex vivo lung perfusion: initial Brazilian experience

Perfusão pulmonar ex vivo: experiência nacional inicial

Paulo Manuel Pêgo-Fernandes, Israel Lopes de Medeiros, Alessandro Wasum Mariani, Flávio Guimarães Fernandes, Fernando do Valle Unterpertinger, Marcos Naoyuki Samano, Eduardo de Campos Werebe, Fábio Biscegli Jatene

J Bras Pneumol.2009;35(11):1107-1111

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In the last 20 years, lung transplantation has become the standard treatment for patients with end-stage lung disease. However, less than 20% of the donor lungs available for transplant are actually usable. This disparity between the growing number of recipients and the small number of donors has resulted in increased mortality among lung transplant candidates on waiting lists. Strategies such as the utilization of organs from marginal donors have proven ineffective in increasing the number of transplants. In 2000, a new method for reconditioning human lungs that had been previously rejected for transplantation was developed in Sweden. We describe our initial experience with ex vivo lung perfusion.


Keywords: Lung transplantation; Organ preservation; Organ preservation solutions; Thoracic surgery.


9 - Pulmonary rehabilitation in COPD: from exercise training to "real life"

Reabilitação respiratória na DPOC: do treinamento de exercício para a "vida real"

Susana Alves Ferreira, Miguel Guimarães, Natália Taveira

J Bras Pneumol.2009;35(11):1112-1115

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The objective of this study was to assess the efficacy of exercise training by means of a rehabilitative walking protocol. Twenty patients with COPD staged as III/IV according to the Global Initiative for Chronic Obstructive Lung Disease were included. Patients were evaluated at baseline and at the end of the exercise program regarding oxygen desaturation, sensation of dyspnea/fatigue, quality of life and six-minute walk distance. The comparison between the six-minute walk distance prior to and after training proved the efficacy of the protocol, which also resulted in a decrease in oxygen desaturation and in the sensation of dyspnea. This protocol can be easily put into practice.


Keywords: Activities of daily living; Pulmonary disease, chronic obstructive; Rehabilitation; Exercise therapy; Exercise test.


Review Article

10 - Nosocomial pneumonia: importance of the oral environment

Pneumonia nosocomial: importância do microambiente oral

Simone Macedo Amaral, Antonieta de Queiróz Cortês, Fábio Ramôa Pires

J Bras Pneumol.2009;35(11):1116-1124

Abstract PDF PT PDF EN Portuguese Text

Nosocomial pneumonia, especially ventilator-associated pneumonia, is a common infection in ICUs. The main etiologic factors involve colonizing and opportunistic bacteria from the oral cavity. Oral hygiene measures, including the use of oral antiseptic agents, such as chlorhexidine, have proven useful in reducing its incidence. The objective of this article was to review the literature on the importance of the oral environment in the development of nosocomial pneumonia.


Keywords: Intensive care; Oral hygiene; Cross infection; Pneumonia.


11 - Methods for the assessment of peripheral muscle fatigue and its energy and metabolic determinants in COPD

Métodos de avaliação da fadigabilidade muscular periférica e seus determinantes energético-metabólicos na DPOC

Rafaella Rezende Rondelli, Simone Dal Corso, Alexandre Simões, Carla Malaguti

J Bras Pneumol.2009;35(11):1125-1135

Abstract PDF PT PDF EN Portuguese Text

It has been well established that, in addition to the pulmonary involvement, COPD has systemic consequences that can lead to peripheral muscle dysfunction, with greater muscle fatigue, lower exercise tolerance and lower survival in these patients. In view of the negative repercussions of early muscle fatigue in COPD, the objective of this review was to discuss the principal findings in the literature on the metabolic and bioenergy determinants of muscle fatigue, its functional repercussions, as well as the methods for its identification and quantification. The anatomical and functional substrate of higher muscle fatigue in COPD appears to include lower levels of high-energy phosphates, lower mitochondrial density, early lactacidemia, higher serum ammonia and reduced muscle perfusion. These alterations can be revealed by contraction failure, decreased firing rates of motor units and increased recruitment of motor units in a given activity, which can be functionally detected by a reduction in muscle strength, power and endurance. This review article also shows that various types of muscle contraction regimens and protocols have been used in order to detect muscle fatigue in this population. With this understanding, rehabilitation strategies can be developed in order to improve the resistance to muscle fatigue in this population.


Keywords: Pulmonary disease, chronic obstructive; Neuromuscular manifestations; Muscle fatigue; Exercise tolerance; Energy metabolism; Evaluation.


Update Course - Mycoses

12 - Chapter 3 - Pulmonary cryptococcosis

Capítulo 3 - Criptococose pulmonar

Cecília Bittencourt Severo, Alexandra Flávia Gazzoni, Luiz Carlos Severo

J Bras Pneumol.2009;35(11):1136-1144

Abstract PDF PT PDF EN Portuguese Text

Cryptococcosis is a systemic mycosis caused by two species of the encapsulated basidiomycetes, Cryptococcus neoformans and C. gattii, which, respectively, cause infection in immunocompromised individuals and in immunologically normal hosts. Patients with T-cell deficiencies are more susceptible to this infection. The spectrum of the disease ranges from asymptomatic pulmonary lesions to disseminated infection with meningoencephalitis. The medical relevance of cryptococcosis increased dramatically as a consequence of the AIDS epidemic and organ transplants.


Keywords: Cryptococcus neoformans; Pneumonia; Acquired immunodeficiency syndrome; Amphotericin B; Fluconazole.


13 - Chapter 4 - Histoplasmosis

Capítulo 4 - Histoplasmose

Miguel Abidon Aidé

J Bras Pneumol.2009;35(11):1145-1151

Abstract PDF PT PDF EN Portuguese Text

Histoplasmosis is systemic mycosis caused by a small fungus, Histoplasma capsulatum var. capsulatum, whose natural habitat is soil contaminated by bat or bird excrement. The incidence of histoplasmosis is worldwide. In Brazil, the disease is found in all regions; however, the state of Rio de Janeiro is responsible for most of the microepidemics described. Human infection occurs when airborne spores of H. capsulatum are inhaled. The most common clinical presentation is asymptomatic. The symptoms of acute or epidemic histoplasmosis are high fever, cough, asthenia and retrosternal pain, as well as enlargement of the cervical lymph nodes, liver and spleen. The most common radiological findings are diffuse reticulonodular infiltrates in both lungs, as well as hilar and mediastinal lymph node enlargement. In chronic pulmonary histoplasmosis, the clinical and radiological manifestations are identical to those of reinfection with pulmonary tuberculosis. Histoplasmosis is diagnosed by means of the identification or culture growth of the fungus in sputum or fiberoptic bronchoscopy specimens. Histopathological examination reveals the fungus itself within or surrounding macrophages, as well as granulomatous lesions with or without caseous necrosis. Double agar gel immunodiffusion is the most easily used and readily available serologic test for making the immunological diagnosis. Acute histoplasmosis with prolonged symptoms requires treatment, as do the disseminated or chronic pulmonary forms of the disease. The drug of choice is itraconazole.


Keywords: Mycosis; Histoplasmosis; Lung diseases, fungal.


Case Report

14 - A rare case of co-infection with pulmonary tuberculosis and oronasal actinomycosis

Caso raro de coinfecção tuberculose pulmonar e actinomicose oronasal

Vitor Alexandre Oliveira Fonseca, Gustavo Reis, Carlos Alves, Maria José Simões, Elvira Camacho, António Pinto Saraiva

J Bras Pneumol.2009;35(11):1152-1155

Abstract PDF PT PDF EN Portuguese Text

Oronasal actinomycosis is an infection seldom described in the literature, especially in the form of a co-infection with pulmonary tuberculosis. We report the case of a 48-year-old male admitted to the isolation ward due to active pulmonary tuberculosis, with a history of diabetes and alcohol abuse. While hospitalized, the patient complained of dysphagia and nasal regurgitation of food. The examination of the oral cavity revealed an oronasal fistula. The infecting agent was identified, and the treatment was successful. We also present a brief review of the literature, as well as a full description and discussion of the process of investigating this rare clinical case.


Keywords: Actinomycosis, cervicofacial; Tuberculosis, pulmonary; Oral fistula.


15 - Endoscopic treatment of tracheobronchial tree fistulas using atrial septal defect occluders: preliminary results

Tratamento endoscópico de fístulas da árvore traqueobrônquica com dispositivos para a correção de defeitos do septo interatrial: resultados preliminares

Paulo Rogério Scordamaglio, Miguel Lia Tedde, Hélio Minamoto, Carlos Augusto Cardoso Pedra, Fábio Biscegli Jatene

J Bras Pneumol.2009;35(11):1156-1160

Abstract PDF PT PDF EN Portuguese Text

Fistulas in the tracheobronchial tree (bronchopleural and tracheoesophageal fistulas) have a multifactorial etiology and present a variable incidence in the literature. In general, the related morbidity and mortality are high. Once such a fistula has been diagnosed, surgical closure is formally indicated. However, the clinical status of affected patients is usually unfavorable, which precludes the use of additional, extensive surgical interventions. In addition, attempts at endoscopic closure of these fistulas have seldom been successful, especially when the fistula is large in diameter. We report the cases of three patients submitted to endoscopic closure of fistulas, two of which were larger than 10 mm in diameter, by means of the insertion of atrial septal defect occluders. The procedure was minimally invasive, and the initial results were positive. The results indicate that this is a promising technique for the resolution of tracheobronchial tree fistulas.


Keywords: Bronchial fistula; Tracheoesophageal fistula; Bronchoscopy; Respiratory therapy.


16 - Chronic cavitary pulmonary histoplasmosis

Histoplasmose pulmonar cavitária crônica

José Wellington Alves dos Santos, Gustavo Trindade Michel, Mônica Lazzarotto, Juliana Kaczmareck Figaro, Daniel Spilmann, Gustavo Köhler Homrich

J Bras Pneumol.2009;35(11):1161-1164

Abstract PDF PT PDF EN Portuguese Text

Histoplasmosis is a systemic mycosis caused by the thermally dimorphic fungus Histoplasma capsulatum, which can be isolated from soil contaminated with droppings from birds or bats. Chronic cavitary pulmonary histoplasmosis is one of the rarest clinical presentations of this disease. The differential diagnosis with tuberculosis should be made in patients presenting with cavitated lesions in upper lung segments. We report the case of a female patient with chronic cavitary pulmonary histoplasmosis who had presented with progressive dyspnea and worsening of the radiological pattern over a four-year period.


Keywords: Histoplasmosis; Cavitation; Pulmonary emphysema.


Year 2009 - Volume 35  - Number 12  (/December)


1 - A national scientific treasure

Um patrimônio científico nacional

José Antônio Baddini Martinez

J Bras Pneumol.2009;35(12):1165-1167

PDF PT PDF EN Portuguese Text

Original Article

2 - Risk factors for ER visits due to asthma exacerbations in patients enrolled in a program for the control of asthma and allergic rhinitis in Feira de Santana, Brazil

Fatores de risco para visitas à emergência por exacerbações de asma em pacientes de um programa de controle da asma e rinite alérgica em Feira de Santana, BA

Heli Vieira Brandão, Constança Sampaio Cruz, Murilo Cerqueira Pinheiro, Edgar Adolfo Costa, Armênio Guimarães, Adelmir Souza-Machado, Álvaro Augusto Cruz

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the risk factors for ER visits due to asthma exacerbations in patients monitored at a referral center. Methods: Prospective cohort study of 253 outpatients (children and adults) with asthma who were monitored for 12 months at the Referral Center of the Program for the Control of Asthma and Allergic Rhinitis in the city of Feira de Santana, Brazil. Results: Exacerbations were common, and 36.5% of the patients sought ER treatment within the twelve-month period. The risk factors for asthma exacerbations were being over 20 years of age (OR = 1.34: (95% CI: 1.06-1.70), residing in an urban area (OR = 1.19; 95% CI: 1.06-1.33); having a low level of education (OR = 1.53: 95% CI: 1.00-2.39); having severe asthma (OR = 1.65; 95% CI: 1.24-2.18); and having chronic rhinitis (OR = 2.20; 95% CI: 1.00-4.80). Conclusions: In this cohort, having chronic rhinitis, having asthma that is more severe and having a low level of education were the main risk factors for ER visits due to asthma exacerbations. These results are similar to those reported for asthma patients who are receiving no regular treatment.


Keywords: Asthma/etiology; Health services; Program evaluation.


3 - Diaphragmatic dysfunction and mortality in patients with COPD

Disfunção diafragmática e mortalidade em pacientes portadores de DPOC

Wellington Pereira dos Santos Yamaguti, Elaine Paulin, João Marcos Salge, Maria Cristina Chammas, Alberto Cukier, Celso Ricardo Fernandes de Carvalho

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether COPD patients with diaphragmatic dysfunction present higher risk of mortality than do those without such dysfunction. Methods: We evaluated pulmonary function, diaphragm mobility and quality of life, as well as determining the Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) index, in 42 COPD patients. The patients were allocated to two groups according to the degree to which diaphragm mobility was impaired: low mobility (LM; mobility ≤ 33.99 mm); and high mobility (HM; mobility ≥ 34.00 mm). The BODE index and the quality of life were quantified in both groups. All patients were followed up prospectively for up to 48 months in order to determine the number of deaths resulting from respiratory complications due to COPD. Results: Of the 42 patients evaluated, 20 were allocated to the LM group, and 22 were allocated to the HM group. There were no significant differences between the groups regarding age, lung hyperinflation or quality of life. However, BODE index values were higher in the LM group than in the HM group (p = 0.01). During the 48-month follow-up period, there were four deaths within the population studied, and all of those deaths occurred in the LM group (15.79%; p = 0.02). Conclusions: These findings suggest that COPD patients with diaphragmatic dysfunction, characterized by low diaphragm mobility, have a higher risk of death than do those without such dysfunction.


Keywords: Pulmonary disease, chronic obstructive/mortality; Diaphragm; Exercise tolerance; Quality of life.


4 - Prevalence of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis

Prevalência da doença do refluxo gastroesofágico em pacientes com fibrose pulmonar idiopática

Cristiane Dupont Bandeira, Adalberto Sperb Rubin, Paulo Francisco Guerreiro Cardoso, José da Silva Moreira, Mirna da Mota Machado

J Bras Pneumol.2009;35(12):1182-1189

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate its clinical presentation, as well as the esophageal function profile in patients with idiopathic pulmonary fibrosis (IPF). Methods: In this prospective study, 28 consecutive patients with IPF underwent stationary esophageal manometry, 24-h esophageal pH-metry and pulmonary function tests. All patients also completed a symptom and quality of life in GERD questionnaire. Results: In the study sample, the prevalence of GERD was 35.7%. The patients were then divided into two groups: GERD+ (abnormal pH-metry; n = 10) and GERD− (normal pH-metry; n = 18). In the GERD+ group, 77.7% of the patients presented at least one typical GERD symptom. The pH-metry results showed that 8 (80%) of the GERD+ group patients had abnormal supine reflux, and that the reflux was exclusively in the supine position in 5 (50%). In the GERD+ and GERD− groups, respectively, 5 (50.0%) and 7 (38.8%) of the patients presented a hypotensive lower esophageal sphincter, 7 (70.0%) and 10 (55.5%), respectively, presenting lower esophageal dysmotility. There were no significant differences between the groups regarding demographic characteristics, pulmonary function, clinical presentation or manometric findings. Conclusions: The prevalence of GERD in the patients with IPF was high. However, the clinical and functional characteristics did not differ between the patients with GERD and those without.


Keywords: Pulmonary fibrosis; Gastroesophageal reflux; Prevalence; Manometry; Esophageal pH monitoring.


5 - Influence that oscillating positive expiratory pressure using predetermined expiratory pressures has on the viscosity and transportability of sputum in patients with bronchiectasis

Influência da técnica de pressão expiratória positiva oscilante utilizando pressões expiratórias pré-determinadas na viscosidade e na transportabilidade do escarro em pacientes com bronquiectasia

Ercy Mara Cipulo Ramos, Dionei Ramos, Daniela Mizusaki Iyomasa, Graciane Laender Moreira, Kátia Cristina Teixeira Melegati, Luiz Carlos Marques Vanderlei, José Roberto Jardim, Adriana Siqueira de Oliveira

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the effectiveness of oscillating positive expiratory pressure (OPEP) using predetermined expiratory pressures on the viscosity and transportability of sputum in patients with bronchiectasis. Methods: The study involved 15 stable patients with bronchiectasis (7 males; mean age = 53 ± 16 years), submitted to two consecutive OPEP interventions, with a 24-h interval between the two, using positive expiratory pressures set at 15 cmH2O (P15) and 25 cmH2O (P25). The protocol consisted of a voluntary cough; another voluntary cough 20 min later, designated time zero (T0); a 10-min rest period; and two 10-min series (S1 and S2, using OPEP at P15 and P25 in both), with a 10-min interval between the two. The viscosity and transportability of sputum were evaluated by viscometry, relative transport velocity on frog palate, transport in a simulated cough machine and contact angle. Sputum samples were collected at T0, after S1 and after S2. Specific statistical tests were performed depending on the type of data distribution. Results: In comparison with the values obtained at T0, sputum viscosity decreased significantly after S1 at P15 and after S2 at P25. There were no significant differences among all of the samples in terms of transportability. Conclusions: The fact that sputum viscosity decreased whether OPEP was performed at P15 or at P25 suggests that there is no need to generate high expiratory pressure to achieve the desired result.


Keywords: Viscosity; Bronchiectasis; Physical therapy (specialty); Sputum.


6 - Knowledge of and practices related to smoking cessation among physicians in Nigeria

Conhecimento e práticas para a cessação do tabagismo entre médicos nigerianos

Olufemi Olumuyiwa Desalu, Adebowale Olayinka Adekoya, Adetokunbo Olujimi Elegbede, Adeolu Dosunmu, Tolutope Fasanmi Kolawole, Kelechukwu Chukwudi Nwogu

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the knowledge and practices of smoking cessation among physicians in Nigeria. Methods: We conducted a cross-sectional survey in Lagos and three geopolitical zones of Nigeria. A self-administered structured questionnaire was used to obtain information on tobacco use and its health effects, as well as on the knowledge and practices of smoking cessation, from 436 physicians. Results: Of the 436 physicians, 292 (67.0%) were aware of smoking cessation, but only 132 (30.3%) showed good knowledge on this topic. The prevalence of smoking among the physicians was 17.7%. In addition, 308 physicians (70.6%) reported that tobacco education in the medical school curriculum was inadequate. Of the 436 physicians, 372 (86.2%) asked their patients whether they smoked, and 172 (39.4%) asked their patients the reasons for using tobacco. As a means of smoking cessation intervention, 268 (61.5%) used brief advice/counseling (2-5 min), 12 (3.7%) prescribed antidepressants, 16 (2.8%) prescribed nicotine replacement therapy (NRT), and 76 (17.4%) arranged follow-up visits. When the physicians were questioned regarding the obstacles to smoking cessation interventions, 289 (66.3%) cited poor knowledge of the issue, 55 (12.6%) cited a lack of time, and 20 (4.6%) cited unavailability of NRT. Conclusions: The results of this study highlight the lack of knowledge among physicians in Nigeria in terms of smoking cessation, as well as their failure to apply appropriate practices. The results of this study can further the evaluation and formulation of guidelines on smoking cessation and smoking education programs for physicians. Our findings also underscore the need to offer smoking cessation programs in all treatment facilities.


Keywords: Smoking cessation; Tobacco; Physicians; Nigeria; Health knowledge, attitudes, practice.


7 - Random sample survey on the prevalence of smoking in the major cities of Brazil

Levantamento randomizado sobre a prevalência de tabagismo nos maiores municípios do Brasil

Fernando Sergio Leitão Filho, José Carlos Fernandes Galduróz, Ana Regina Noto, Solange Aparecida Nappo, Elisaldo Araújo Carlini, Oliver Augusto Nascimento, Sérgio Ricardo Santos, José Roberto Jardim

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To provide access to the results of a randomized cross-sectional study conducted by the Brazilian Center for Information on Psychotropic Drugs in 2001. Methods: This survey involved a random sample of individuals ranging from 12 to 65 years of age and residing in the 107 largest cities (over 200,000 inhabitants) in Brazil, which represented 27.7% of the Brazilian population, estimated to be 169,799,170 inhabitants at the time. A total of 8,589 interviews were conducted. The Substance Abuse and Mental Health Services Administration questionnaire, translated and adapted for use in Brazil, was used in the interviews. Results: Of the sample as a whole, 41.1% of the interviewees reported having experimented with tobacco products. The prevalence of daily smokers was 17.4% (20.3% among males and 14.8% among females). We found that 9% of the sample (10.1% of the men and 7.9% of the women) were nicotine-dependent, according to the criteria of the National Household Survey on Drug Abuse. Conclusions: The prevalence of current smoking in the 107 largest cities of Brazil is significantly lower in this decade than was the national prevalence at the end of last century.


Keywords: Smoking/epidemiology; Tobacco use disorder; Smoking cessation.


8 - Cord factor detection and macroscopic evaluation of mycobacterial colonies: an efficient combined screening test for the presumptive identification of Mycobacterium tuberculosis complex on solid media

Detecção do fator corda e avaliação do aspecto macroscópico das colônias de micobactérias: um eficiente teste de triagem combinado para a identificação presuntiva do complexo Mycobacterium tuberculosis em meios sólidos

Fernanda Cristina dos Santos Simeão, Erica Chimara, Rosângela Siqueira Oliveira, Jonas Umeoka Yamauchi, Fábio Oliveira Latrilha, Maria Alice da Silva Telles

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: The rapid differentiation between Mycobacterium tuberculosis and nontuberculous mycobacteria is fundamental for patients co-infected with tuberculosis and HIV. To that end, we use two methods in our laboratory: detection of cord factor and PCR-restriction enzyme analysis (PRA). The objective of this study was to evaluate the accuracy of a screening test on solid medium as a rapid method for the presumptive identification of M. tuberculosis complex, considering costs and turnover time. Methods: A total of 152 strains were submitted to a combined screening test, consisting of the detection of cord factor under microscopy (Ziehl-Neelsen staining) and evaluation of the macroscopic aspect of colonies, as well as to PRA, which was used as the gold standard. Costs were estimated by calculating the price of all of the materials needed for each test. Results: The overall accuracy of cord factor detection alone was 95.4% (95% CI: 90.7-98.1%), and that of the combined screening test was 99.3% (95% CI: 96.4-100%). Cord factor detection costs US$ 0.25, whereas the PRA costs US$ 7.00. Results from cord factor detection are ready in 2 days, whereas PRA requires 4 days to yield results. Conclusions: The presumptive identification of M. tuberculosis using the macroscopic evaluation of colonies combined with cord factor detection under microscopy is a simple, rapid and inexpensive test. We recommend the combined screening test to rapidly identify M. tuberculosis in resource-poor settings and in less well-equipped laboratories while awaiting a definite identification by molecular or biochemical methods.


Keywords: Tuberculosis; Mycobacterium/classification; Polymerase chain reaction; Diagnostic tests, routine.


Brief Communication

9 - Evolução do estado nutricional de pacientes desnutridos ou com excesso de peso candidatos a transplante pulmonar

Giuliana Bastos Esteves, Alessandra Macedo, Miyoko Nakasato, Maria Lúcia Mendes Bruno

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

A retrospective study using anthropometric data to assess the evolution of nutritional status in lung transplant candidates who are initially malnourished or overweight. We included patients with an initial body mass index (BMI) < 17 kg/m2 (malnourished, n = 10) or > 27 kg/m2 (overweight, n = 20). Each patient subsequently had three appointments with a nutritionist (nutritional interventions). In the malnourished group, there were no significant post-intervention changes in the anthropometric variables. In the overweight group, however, nutritional intervention had a positive impact on weight, BMI and waist circumference.


Keywords: Lung transplantation; Nutritional status; Body mass index; Anthropometry.


Review Article

10 - Genetic associations with asthma and virus-induced wheezing: a systematic review

Associação genética da asma e da sibilância induzida por vírus: uma revisão sistemática

Leonardo Araujo Pinto, Renato Tetelbom Stein, José Dirceu Ribeiro

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Various wheezing phenotypes can be identified based on differences in natural histories, risk factors and responses to treatment. In epidemiologic studies, atopic asthma or virus-induced wheezing can be discriminated by the presence or the absence of sensitization to allergens. Children with asthma have been shown to present lower levels of lung function. Patients with viral respiratory infections evolve from normal lung function to enhanced airway reactivity. The objective of this study was to identify genes and polymorphisms associated with different wheezing phenotypes. Using data obtained from the Genetic Association Database, we systematically reviewed studies on genes and polymorphisms that have been associated with virus-induced wheezing or atopic asthma. The research was carried out in February of 2009. Genes associated with the studied outcomes in more than three studies were included in the analysis. We found that different genes and loci have been associated with virus-induced wheezing or atopic asthma. Virus-induced wheezing has frequently been associated with IL-8 polymorphisms, whereas atopic asthma and atopy have frequently been associated with Th2 cytokine gene (CD14 and IL-13) polymorphisms on chromosome 5. This review provides evidence that different wheezing disorders in childhood can be differently affected by genetic variations, considering their role on airway inflammation and atopy. Future studies of genetic associations should consider the different wheezing phenotypes in infancy. In addition, stratified analyses for atopy can be useful for elucidating the mechanisms of the disease.


Keywords: Genetics; Polymorphism, genetic; Asthma; Interleukins; Respiratory syncytial viruses.


11 - The role of oxidative stress in COPD: current concepts and perspectives

O papel do estresse oxidativo na DPOC: conceitos atuais e perspectivas

Antonio George de Matos Cavalcante, Pedro Felipe Carvalhedo de Bruin

J Bras Pneumol.2009;35(12):1227-1237

Abstract PDF PT PDF EN Portuguese Text

Worldwide, COPD is a major cause of morbidity and mortality. The clinical and functional manifestations of COPD result from lung injury occurring through various mechanisms, including oxidative stress, inflammation, protease-antiprotease imbalance and apoptosis. Oxidative stress is central to the pathogenesis of COPD, since it can directly damage lung structures and exacerbate the other mechanisms involved. The cellular and molecular events involved in such lung injury are believed to occur long before the clinical and functional expression of COPD. Although the use of bronchodilators is currently the principal treatment for COPD, bronchodilators have little or no effect on disease progression. A better understanding of the pathogenesis of COPD, together with renewed efforts in basic and clinical research, will allow the diagnosis of COPD at a pre-clinical stage and provide more appropriate monitoring of disease activity, as well as leading to the development of novel therapeutic agents that will effectively prevent the progression of the disease.


Keywords: Pulmonary disease, chronic obstructive; Oxidative stress; Oxidants; Antioxidants; Inflammation.


Update Course - Mycoses

12 - Chapter 5 - Aspergillosis: from diagnosis to treatment

Capítulo 5 - Aspergilose: do diagnóstico ao tratamento

Maria da Penha Uchoa Sales

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Aspergillosis is a multifaceted disease whose clinical manifestations (allergic, saprophytic and invasive forms) are determined by the host immune response. Allergic bronchopulmonary aspergillosis is characterized by corticosteroid-dependent asthma, fever, hemoptysis and destruction of the airways, which can evolve to fibrosis with honeycombing. The treatment consists of the combined use of a corticosteroid and itraconazole. Invasive pulmonary aspergillosis, which has a worse prognosis, is diagnosed based on histopathological documentation and positive culture of a sterile specimen. The treatment response obtained with voriconazole is better, in terms of survival and safety, than that obtained with amphotericin B. In patients with chronic pulmonary disease who are mildly immunocompromised, chronic necrotizing pulmonary aspergillosis causes progressive destruction of the lung. Such patients are treated with oral itraconazole. Chronic cavitary pulmonary aspergillosis causes multiple cavities, with or without aspergilloma, accompanied by pulmonary and systemic symptoms. In patients with chronic pulmonary disease, the aspergilloma is characterized by chronic productive cough and hemoptysis, together with a cavity containing a rounded, sometimes mobile, mass separated from the cavity wall by airspace. Surgical resection is the definitive treatment for both types of aspergillosis. Triazole fungicides provide long-term treatment benefits with minimal risk.


Keywords: Aspergillosis; Pulmonary aspergillosis; Lung diseases, fungal.


13 - Chapter 6 - Paracoccidioidomycosis

Capítulo 6 - Paracoccidioidomicose

Bodo Wanke, Miguel Abidon Aidê

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Paracoccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis. The disease is restricted to Latin America. It is the principal systemic mycosis in Brazil, with higher incidences in the southern, southeastern and central regions. The disease is acquired by inhaling fungal propagules. In endemic areas, the primary infection occurs during childhood and involves the immune system. The most common chronic form of paracoccidioidomycosis in adults is the multifocal form, in which there is dissemination to the lungs, lymph nodes, skin and mucosae. This form of the disease has a chronic progression, and the diagnosis is typically delayed. Cough, dyspnea and weight loss due to cutaneous and mucosal lesions are evident and are the principal complaints reported by paracoccidioidomycosis patients. Chest X-rays reveal diffuse reticulonodular infiltrates, which are more evident in the upper lobes. The etiologic diagnosis is based on the identification of P. brasiliensis in clinical specimens, such as lymph node aspirates or BAL fluid, by direct microscopy and culture. Histopathological testing of tissue samples reveals the thick birefringent cell wall of the fungus and the typical pattern of multiple budding around the mother cell. Double agar gel immunodiffusion is useful for the diagnosis when the fungus cannot be detected through mycological tests. Although paracoccidioidomycosis is most often treated with the sulfamethoxazole-trimethoprim combination, itraconazole is preferable. Amphotericin B is used in severe cases.


Keywords: Paracoccidioidomycosis; Mycosis; Lung diseases, fungal.


Case Report

14 - Complex tracheal lesion: correction with an intercostal muscle pedicle flap

Lesão complexa da traqueia: correção com retalho pediculado de músculo intercostal

Hylas Paiva da Costa Ferreira, Carlos Alberto Almeida de Araújo, Jeancarlo Fernandes Cavalcante, Ronnie Peterson de Melo Lima

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Esophageal reconstruction is one of the most complex types of gastrointestinal surgery, principally when it is performed using minimally invasive techniques. The procedure is associated with various complications, such as anastomotic dehiscence, chylothorax, esophageal necrosis and fistulae. We report the case of a patient diagnosed with epidermoid carcinoma in the distal third of the esophagus. The patient was submitted to esophagectomy by video-assisted thoracoscopy and laparoscopy. During the operation, the left main bronchus was injured, and this required immediate surgical correction. In the postoperative period, the patient presented with acute respiratory failure and profuse air leak through the thoracic drains and through the cervical surgical wound. The patient underwent a second surgical procedure, during which a large lesion was discovered in the membranous wall of the trachea. The lesion was corrected with an intercostal muscle pedicle flap.


Keywords: Trachea; Esophageal fistula; Respiratory tract fistula; Intercostal muscles; Esophagectomy.


15 - Hard metal lung disease in an oil industry worker

Doença pulmonar por metal duro em trabalhador da indústria petrolífera

Patrícia Nunes Bezerra, Ana Giselle Alves Vasconcelos, Lílian Loureiro Albuquerque Cavalcante,Vanessa Beatriz de Vasconcelos Marques, Teresa Neuma Albuquerque Gomes Nogueira,Marcelo Alcantara Holanda

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Hard metal lung disease, which manifests as giant cell interstitial pneumonia, is caused by exposure to hard metal dust. We report the case of an oil industry worker diagnosed with hard metal lung disease. The diagnosis was based on the clinical, radiological and anatomopathological analysis, as well as on pulmonary function testing.


Keywords: Alloys/adverse effects; Cobalt; Tungsten; Occupational exposure; Lung diseases, interstitial.


16 - Primary complex of paracoccidioidomycosis and hypereosinophilia

Complexo primário da paracoccidioidomicose e hipereosinofilia

Roberto Martinez, Maria Janete Moya

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Primary infection with Paracoccidioides brasiliensis has rarely been observed. A 28-year-old male patient presented with a three-month history of fever, respiratory symptoms and malaise. Chest X-rays revealed bilateral apical infiltrates, right pleuritis and hilar lymphadenomegaly. The patient presented with leukocytosis, severe eosinophilia and increasing titers of anti-P. brasiliensis antibodies in serum. To our knowledge, this is the first report of the primary pulmonary lymph node complex of paracoccidioidomycosis accompanied by hypereosinophilia and affecting a previously healthy adult.


Keywords: Paracoccidioidomycosis; Eosinophilia; Lung diseases, fungal.


Index of Issues

17 - SUBJECT INDEX FOR V.35 (1-12)

Índice remissivo de assuntos do volume 35 (1-12), 2009

J Bras Pneumol.2009;35(12):

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Index of Authors

18 - AUTHOR INDEX FOR V.35 (1-12)

Índice remissivo de autores do volume 35 (1-12), 2009

J Bras Pneumol.2009;35(12):

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Relationship of Reviewers

19 - REVIEWERS FOR V. 35 (1-12)

Relação de revisores

J Bras Pneumol.2009;35(12):

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