Brazilian Journal of Pulmonology

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


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Year 2018 - Volume 44  - Number 1  (January/February)



1 - Respiratory muscles in COPD: be aware of the diaphragm

Músculos respiratórios na DPOC: atenção para o diafragma

Pauliane Vieira Santana1,a, Andre Luis Pereira de Albuquerque1,b

J Bras Pneumol.2018;44(1):1-2

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Continuing Education: Imaging

2 - Anterior mediastinal mass

Massa do mediastino anterior

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(1):3

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Continuing Education : Scientific Methodology

3 - Understanding diagnostic tests. Part 3.

Entendendo os testes diagnósticos. Parte 3.

Juliana Carvalho Ferreira1,2,a, Cecilia Maria Patino1,3,b

J Bras Pneumol.2018;44(1):4

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Original Article

4 - Comparison of diaphragmatic mobility between COPD patients with and without thoracic hyperkyphosis: a cross-sectional study

Comparação da mobilidade diafragmática em pacientes com DPOC com e sem hipercifose torácica: um estudo transversal

Márcia Aparecida Gonçalves1, Bruna Estima Leal1, Liseane Gonçalves Lisboa2, Michelle Gonçalves de Souza Tavares3, Wellington Pereira Yamaguti4, Elaine Paulin1

J Bras Pneumol.2018;44(1):5-11

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Objective: To compare diaphragmatic mobility, lung function, and respiratory muscle strength between COPD patients with and without thoracic hyperkyphosis; to determine the relationship of thoracic kyphosis angle with diaphragmatic mobility, lung function, and respiratory muscle strength in COPD patients; and to compare diaphragmatic mobility and thoracic kyphosis between male and female patients with COPD. Methods: Participants underwent anthropometry, spirometry, thoracic kyphosis measurement, and evaluation of diaphragmatic mobility. Results: A total of 34 patients with COPD participated in the study. Diaphragmatic mobility was significantly lower in the group of COPD patients with thoracic hyperkyphosis than in that of those without it (p = 0.002). There were no statistically significant differences between the two groups of COPD patients regarding lung function or respiratory muscle strength variables. There was a significant negative correlation between thoracic kyphosis angle and diaphragmatic mobility (r = −0.47; p = 0.005). In the sample as a whole, there were statistically significant differences between males and females regarding body weight (p = 0.011), height (p < 0.001), and thoracic kyphosis angle (p = 0.036); however, there were no significant differences in diaphragmatic mobility between males and females (p = 0.210). Conclusions: Diaphragmatic mobility is lower in COPD patients with thoracic hyperkyphosis than in those without it. There is a negative correlation between thoracic kyphosis angle and diaphragmatic mobility. In comparison with male patients with COPD, female patients with COPD have a significantly increased thoracic kyphosis angle.


Keywords: Pulmonary disease, chronic obstructive; Kyphosis; Diaphragm.


5 - Factors associated with asthma expression in adolescents

Fatores associados à expressão da asma em adolescentes

Silvia de Souza Campos Fernandes1,a, Dirceu Solé2,d, Paulo Camargos1,c, Cláudia Ribeiro de Andrade1,e, Cássio da Cunha Ibiapina1,b

J Bras Pneumol.2018;44(1):12-17

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Objective: To evaluate risk factors associated with asthma symptoms in adolescents in the 13- to 14-year age bracket. Methods: This was a cross-sectional study involving adolescents enrolled in randomly selected public schools in the city of Belo Horizonte, Brazil, and conducted with the use of the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire and its supplementary module for risk factor assessment. The ISAAC questionnaire was completed by the students themselves, whereas the supplementary questionnaire was completed by their parents or legal guardians. Variables showing p ≤ 0.25 in the univariate analysis were included in the multivariate analysis. Stepwise regression with backward elimination was used for variable selection. Results: We evaluated 375 adolescents, 124 (33.1%) of whom had asthma symptoms. The final multivariate analysis model revealed that asthma symptoms were associated with birth weight < 2,500 g (p < 0.001), day care center or nursery attendance (p < 0.002), maternal history of asthma (p < 0.001), contact with animals during the first year of life (p < 0.027), current contact with animals outside the home (dogs, cats, or farm animals; p < 0.005), and more than 20 cigarettes per day smoked by parents or other household members (p < 0.02). Conclusions: Exposure to animals in and outside the home is associated with asthma symptoms, as is environmental tobacco smoke exposure. Families, health professionals, and administrators of health care facilities should take that into account in order to prevent asthma and reduce asthma morbidity.


Keywords: Asthma; Risk factors; Adolescent.


6 - Diagnostic value of α-enolase expression and serum α-enolase autoantibody levels in lung cancer

Valor diagnóstico da expressão de α-enolase e dos níveis séricos de autoanticorpos contra α-enolase no câncer de pulmão

Lihong Zhang1,a, Hongbin Wang1,b, Xuejun Dong1,c

J Bras Pneumol.2018;44(1):18-23

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Objective: To investigate the diagnostic value of α-enolase (ENO1) and serum ENO1 autoantibody levels in lung cancer. Methods: Immunohistochemistry staining and ELISA were performed to detect ENO1 expression in lung tissue and serum ENO1 autoantibody levels, respectively. Results: The expression of ENO1 was higher in lung cancer tissues than in benign lung disease tissues (p < 0.001). The proportion of lung cancer samples expressing ENO1 was not significantly different among the various pathological classification groups. The proportion of samples expressing ENO1 was higher in lung cancer patients in stages I/II than in those in stages III/IV (χ2 = 5.445; p = 0.018). The expression of ENO1 in lung cancer tissues was not associated with age, gender, or smoking history. Serum ENO1 antibody levels were significantly higher in the lung cancer group than in the benign lung disease and control groups (p < 0.001). The differences among the pathological classification groups were not statistically significant. Serum ENO1 antibody levels were also in lung cancer patients in stages I/II than in those in stages III/IV (p < 0.01). Serum ENO1 antibody levels were not associated with age, gender, or smoking history in lung cancer patients. The ROC curve representing the diagnosis of lung cancer based on ENO1 antibody levels had an area under the curve of 0.806. Conclusions: Our results suggest that high levels of ENO1 are associated with the clinical stage of lung cancer and that ENO1 expression and its serum autoantibody levels show diagnostic value in lung cancer.


Keywords: Phosphopyruvate hydratase/analysis; Enzyme-linked immunosorbent assay; Immunohistochemistry; Lung neoplasms.


7 - Complexity of autonomic nervous system function in individuals with COPD

Complexidade do sistema nervoso autônomo em indivíduos com DPOC

Laís Manata Vanzella1,f, Aline Fernanda Barbosa Bernardo1,d, Tatiana Dias de Carvalho3,e, Franciele Marques Vanderlei2,a, Anne Kastelianne França da Silva1,c, Luiz Carlos Marques Vanderlei2,b

J Bras Pneumol.2018;44(1):24-30

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Objective: To evaluate autonomic modulation in individuals with COPD, compared with healthy controls, via recurrence plots (RPs) and linear heart rate variability (HRV) indices. Methods: We analyzed data on 74 volunteers, who were divided into two groups: COPD (n = 43) and control (n = 31). For calculation of HRV indices, heart rate was measured beat-by-beat during 30 min of supine rest using a heart-rate meter. We analyzed linear indices in the time and frequency domains, as well as indices derived from the RPs. Results: In comparison with the control group, the COPD group showed significant increases in the indices derived from the RPs, as well as significant reductions in the linear indices in the time and frequency domains. No significant differences were observed in the linear indices in the frequency domains expressed in normalized units or in the low frequency/high frequency ratio. Conclusions: Individuals with COPD show a reduction in both sympathetic and parasympathetic activity, associated with decreased complexity of autonomic nervous system function, as identified by RPs, which provide important complementary information in the detection of autonomic changes in this population.


Keywords: Pulmonary disease, chronic obstructive; Autonomic nervous system; Nonlinear dynamics; Recurrence; Heart rate; Sympathetic nervous system.


8 - Is suicidal ideation associated with allergic asthma and allergic rhinitis?

Ideação suicida apresenta associação com asma e rinite alérgicas?

Martín Bedolla-Barajas1,a, Norma Angélica Pulido-Guillén2,b, Bolívar Vivar-Aburto3,c, Jaime Morales-Romero4,d, José Raúl Ortiz-Peregrina5,e, Martín Robles-Figueroa3,f

J Bras Pneumol.2018;44(1):31-35

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Objective: To investigate whether there is an association between suicidal ideation (SI) and allergic diseases in adults. Methods: This was a comparative cross-sectional study involving individuals ranging from 20 to 50 years of age recruited from a university hospital in the city of Guadalajara, Mexico. We included patients with a confirmed diagnosis of allergic asthma, those with a confirmed diagnosis of allergic rhinitis, and healthy controls. All subjects completed the Beck Depression Inventory-II (BDI-II), which includes an item that evaluates the presence of suicidal thoughts or desires within the last two weeks, in order to identify SI. Results: The sample comprised 115 patients with allergic asthma, 111 patients with allergic rhinitis, and 96 healthy controls. The number of individuals identified with SI in the three groups were, respectively, 17 (14.8%), 13 (11.7%), and 8 (8.3%). Regarding the presence of SI, no statistically significant association was found in the allergic asthma group (OR = 1.98; 95% CI: 0.78-4.64; p = 0.154) or in the allergic rhinitis group (OR = 1.46; 95% CI: 0.58-3.68; p = 0.424) when they were compared with the control group. However, the presence of depression was associated with SI in the three groups: allergic asthma (OR = 12.36; 95% CI: 2.67-57.15; p = 0.001); allergic rhinitis (OR = 6.20; 95% CI: 1.66-23.14; p = 0.006); and control (OR = 21.0; 95% CI: 3.75-117.36; p < 0,001). Conclusions: In comparison with the control group, no association was found between SI and the groups with allergic diseases. In contrast, there was association between SI and depression in the three groups.


Keywords: Suicidal ideation; Asthma; Rhinitis, allergic; Adult.


9 - Soluble urokinase-type plasminogen activator receptor as a measure of treatment response in acute exacerbation of COPD

Receptor do ativador de plasminogênio tipo uroquinase solúvel como medida da resposta ao tratamento da exacerbação aguda da DPOC

Gehan Hassan AboEl-Magd1,a, Maaly Mohamed Mabrouk2,b

J Bras Pneumol.2018;44(1):36-41

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Objective: To evaluate the value of soluble urokinase-type plasminogen activator receptor (suPAR) in the diagnosis of acute exacerbation of COPD (AECOPD) and in monitoring treatment response, analyzing the relationship between suPAR and fibrinogen in AECOPD. AECOPD leads to increased airway inflammation, contributing to an exaggerated release of inflammatory mediators. Methods: We recruited 45 patients with AECOPD and 20 healthy control subjects. Medical histories were taken, and all subjects underwent clinical examination, chest X-ray, pulmonary function tests, and blood gas analysis. On day 1 (treatment initiation for the AECOPD patients) and day 14 (end of treatment), blood samples were collected for the determination of serum suPAR and plasma fibrinogen. Results: Serum levels of suPAR were significantly higher in the AECOPD group than in the control group. In the AECOPD patients, there was a significant post-treatment decrease in the mean serum suPAR level. The sensitivity, specificity, and accuracy of suPAR were 95.6%, 80.0%, and 93.0%, respectively. The Global Initiative for Chronic Obstructive Lung Disease stage (i.e., COPD severity) correlated positively and significantly with serum levels of suPAR and plasma levels of fibrinogen. Conclusions: Monitoring the serum suPAR level can be helpful in the evaluation of the COPD treatment response and might be a valuable biomarker for determining the prognosis of AECOPD. Because serum suPAR correlated with plasma fibrinogen, both markers could be predictive of AECOPD.


Keywords: Pulmonary disease, chronic obstructive/complications; Pulmonary disease, chronic obstructive/diagnosis; Receptors, urokinase plasminogen activator; Fibrinogen.


10 - Evaluation of smoking cessation treatment initiated during hospitalization in patients with heart disease or respiratory disease

Avaliação de um tratamento para cessação do tabagismo iniciado durante a hospitalização em pacientes com doença cardíaca ou doença respiratória

Thaís Garcia1,a, Sílvia Aline dos Santos Andrade2, Angélica Teresa Biral1, André Luiz Bertani1,b, Laura Miranda de Oliveira Caram1,c, Talita Jacon Cezare3, Irma Godoy4,d, Suzana Erico Tanni3,e

J Bras Pneumol.2018;44(1):42-48

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Objective: To evaluate the effectiveness of a smoking cessation program, delivered by trained health care professionals, in patients hospitalized for acute respiratory disease (RD) or heart disease (HD). Methods: Of a total of 393 patients evaluated, we included 227 (146 and 81 active smokers hospitalized for HD and RD, respectively). All participants received smoking cessation treatment during hospitalization and were followed in a cognitive-behavioral smoking cessation program for six months after hospital discharge. Results: There were significant differences between the HD group and the RD group regarding participation in the cognitive-behavioral program after hospital discharge (13.0% vs. 35.8%; p = 0.003); smoking cessation at the end of follow-up (29% vs. 31%; p < 0.001); and the use of nicotine replacement therapy (3.4% vs. 33.3%; p < 0.001). No differences were found between the HD group and the RD group regarding the use of bupropion (11.0% vs. 12.3%; p = 0.92). Varenicline was used by only 0.7% of the patients in the HD group. Conclusions: In our sample, smoking cessation rates at six months after hospital discharge were higher among the patients with RD than among those with HD, as were treatment adherence rates. The implementation of smoking cessation programs for hospitalized patients with different diseases, delivered by the health care teams that treat these patients, is necessary for greater effectiveness in smoking cessation.


Keywords: Smoking; Smoking cessation; Hospitalization; Respiratory tract diseases; Heart diseases.


Brief Communication

11 - Association between the display of cigarette packs at the point of sale and smoking susceptibility among adolescents in Brazil

Associação entre a exposição a maços de cigarros em pontos de venda e susceptibilidade ao tabagismo entre adolescentes brasileiros

Ana Luiza Curi Hallal1, Andreza Madeira Macario1, Roberto Hess de Souza2, Antônio Fernando Boing1, Lúcio Botelho1, Joanna Cohen3

J Bras Pneumol.2018;44(1):49-51

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This was a cross-sectional study aimed at determining the association between exposure to tobacco displays at the point of sale and susceptibility to smoking in schoolchildren in the 14- to 17-year age bracket. Of the participating students, 69.0%, 21.3%, and 9.7% were classified as never smokers, experimenters, and smokers, respectively. Of the participants who were classified as being exposed to smoking, 18.9% were susceptible to smoking. Of the participants who were classified as being unexposed to smoking, 12.9% were susceptible to smoking (OR = 1.56; 95% CI: 1.04 -2.35; p = 0.029). Exposure to point-of-sale tobacco displays is associated with smoking susceptibility in Brazilian adolescents.


12 - Between-occasion repeatability of fractional exhaled nitric oxide measurements in children

Repetibilidade de medidas da fração de óxido nítrico exalado em crianças em duas ocasiões

Kamil Barański1,a, Jan E. Zejda1,b

J Bras Pneumol.2018;44(1):52-54

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The aim of the study was to assess short-term repeatability of measurements of fractional exhaled nitric oxide (FENO) and its correlates in children in the 6- to 9-year age bracket participating in a respiratory epidemiological survey. FENO was measured in two sessions one week apart in 101 children. Participants were divided into three groups: asymptomatic (n = 76); symptomatic (n = 14); and asthma (n = 11). Absolute and relative differences between the measurements, as well as concordance correlation coefficients, were used in order to assess repeatability. The two FENO measurements were strongly correlated (0.98). Although intragroup comparisons of the two measurements were not significantly different (p = 0.2), intergroup comparisons were. FENO measurements are reproducible in children in epidemiological settings.


Keywords: Nitric oxide; Exhalation; Asthma.


Review Article

13 - Lung cancer in Brazil

Câncer de pulmão no Brasil

Luiz Henrique Araujo1,2,a, Clarissa Baldotto1,2,b, Gilberto de Castro Jr3,4,c, Artur Katz4,d, Carlos Gil Ferreira5,6,e, Clarissa Mathias7,f, Eldsamira Mascarenhas7,g, Gilberto de Lima Lopes8,9,h, Heloisa Carvalho4,10,i, Jaques Tabacof8, Jeovany Martínez-Mesa11,j, Luciano de Souza Viana12,k, Marcelo de Souza Cruz13,l, Mauro Zukin1,2,m, Pedro De Marchi12,n, Ricardo Mingarini Terra3,o, Ronaldo Albuquerque Ribeiro14, Vladmir Cláudio Cordeiro de Lima15,p, Gustavo Werutsky16,q, Carlos Henrique Barrios17,r; Grupo Brasileiro de Oncologia Torácica

J Bras Pneumol.2018;44(1):55-64

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Lung cancer is one of the most incident types of cancer and a leading cause of cancer mortality in Brazil. We reviewed the current status of lung cancer by searching relevant data on prevention, diagnosis, and treatment in the country. This review highlights several issues that need to be addressed, including smoking control, patient lack of awareness, late diagnosis, and disparities in the access to cancer health care facilities in Brazil. We propose strategies to help overcome these limitations and challenge health care providers, as well as the society and governmental representatives, to work together and to take a step forward in fighting lung cancer.


Keywords: Lung neoplasms/epidemiology; Lung neoplasms/therapy; Lung neoplasms/diagnosis; Biomarkers; Brazil.


Case Report

14 - Sleep characteristics in an adult with sleep complaints in three cities at different altitudes

Características do sono em um adulto com queixas de sono em três cidades a diferentes altitudes

Julio Cesar Castellanos-Ramírez1,a, Alvaro J Ruíz2,3,b, Patricia Hidalgo-Martínez1,2,c, Liliana Otero-Mendoza4,d

J Bras Pneumol.2018;44(1):65-68

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Sleep studies conducted at an altitude that is different from the home altitude can yield misleading results regarding the severity of obstructive sleep apnea (OSA). The objective of the present study was to determine the sleep characteristics of a patient undergoing polysomnography (PSG) in three Colombian cities at different altitudes (Bogotá, at 2,640 m above sea level [ASL]; Bucaramanga, at 959 m ASL; and Santa Marta, at 15 m ASL). The patient was an obese man with diabetes and suspected OSA. All PSG recordings were scored and interpreted in accordance with American Academy of Sleep Medicine criteria. In Bogotá, PSG revealed moderate OSA (an apnea-hypopnea index [AHI] of 21 events/h); in Bucaramanga, PSG revealed increased upper airway resistance (an AHI of 2 events/h); in Santa Marta, PSG revealed mild OSA (an AHI of 7 events/h). The reduction in the AHI was predominantly a reduction in hypopneas and obstructive apneas. The respiratory events were shorter in duration in the city at an intermediate altitude. Given that the AHI varied widely across cities, we can assume that the patient is normal or has moderate OSA depending on the city where he is. Central apneas were found to have no influence on the AHI.


Keywords: Sleep apnea, obstructive; Polysomnography; Altitude.


Letters to the Editor

15 - Extracorporeal membrane oxygenation in an awake patient as a bridge to lung transplantation

Oxigenação por membrana extracorpórea em paciente acordado como ponte para o transplante pulmonar

Spencer Marcantonio Camargo1,a, Stephan Adamour Soder1,b, Fabiola Adelia Perin1,c, Douglas Zaione Nascimento1,d, Sadi Marcelo Schio1,e

J Bras Pneumol.2018;44(1):69-70

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Year 2018 - Volume 44  - Number 2  (March/April)



1 - Tuberculosis series

Série tuberculose

Denise Rossato Silva1,a, Fernanda Carvalho de Queiroz Mello2,b, Afrânio Kritski3,c, Margareth Dalcolmo4,d, Alimuddin Zumla5,e, Giovanni Battista Migliori6

J Bras Pneumol.2018;44(2):71-72

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2 - Eliminating tuberculosis in Latin America: making it the point

Eliminação da tuberculose na América Latina: considerações

Raquel Duarte1,2,3,a, Denise Rossato Silva4,b, Adrian Rendon5,c, Tatiana Galvẫo Alves6,d, Marcelo Fouad Rabahi7,e, Rosella Centis8,f, Afrânio Kritski9,g, Giovanni Battista Migliori8,h

J Bras Pneumol.2018;44(2):73-76

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3 - The role of the Brazilian Tuberculosis Research Network in national and international efforts to eliminate tuberculosis

O papel da Rede Brasileira de Pesquisas em Tuberculose nos esforços nacionais e internacionais para a eliminação da tuberculose

Afranio Kritski1,a, Margareth Pretti Dalcolmo2,b, Fernanda Carvalho Queiroz Mello3,c, Anna Cristina Calçada Carvalho4,d, Denise Rossato Silva5,e, Martha Maria de Oliveira6,f, Julio Croda7,8,g

J Bras Pneumol.2018;44(2):77-81

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4 - Tuberculosis: where are we?

Tuberculose: onde estamos?

Fernanda Carvalho de Queiroz Mello1,a, Denise Rossato Silva2,b, Margareth Pretti Dalcolmo3,c

J Bras Pneumol.2018;44(2):82

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Continuing Education: Imaging

5 - Lymph node calcifications

Calcificações linfonodais

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(2):83

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Continuing Education : Scientific Methodology

6 - Inclusion and exclusion criteria in research studies: definitions and why they matter

Critérios de inclusão e exclusão em estudos de pesquisa: definições e por que eles importam

Cecilia Maria Patino1,2,a, Juliana Carvalho Ferreira1,3,b

J Bras Pneumol.2018;44(2):84

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Original Article

7 - Sequential analysis as a tool for detection of amikacin ototoxicity in the treatment of multidrug-resistant tuberculosis

Análise sequencial como ferramenta na detecção da ototoxicidade da amicacina no tratamento da tuberculose multirresistente

Karla Anacleto de Vasconcelos1, Silvana Maria Monte Coelho Frota2, Antonio Ruffino-Netto3, Afrânio Lineu Kritski4

J Bras Pneumol.2018;44(2):85-92

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Objetivo: Verificar a detecção precoce de ototoxicidade causada pelo uso de amicacina numa população tratada para tuberculose multirresistente (TBMR) por meio da realização de três testes distintos: audiometria tonal liminar (ATL), audiometria de altas frequências (AAF) e pesquisa de emissões otoacústicas por produto de distorção (EOAPD). Métodos: Estudo longitudinal de coorte prospectiva incluindo pacientes de ambos os sexos, com idade entre 18 e 69 anos, com diagnóstico de TBMR pulmonar e que necessitaram utilizar amicacina por seis meses em seu esquema medicamentoso antituberculose pela primeira vez. A avaliação auditiva foi realizada antes do início do tratamento e depois de dois e seis meses do início do tratamento. A análise dos resultados foi realizada por meio de análise estatística sequencial. Resultados: Foram incluídos 61 pacientes, mas a população final foi constituída de 10 pacientes (7 homens e 3 mulheres), em razão da análise sequencial. Ao se comparar os valores das respostas dos testes com aqueles encontrados na avaliação basal, foram verificadas mudanças nos limiares auditivos compatíveis com ototoxicidade após dois meses de tratamento através da AAF e após seis meses de tratamento através da ATL. Entretanto, essas mudanças não foram verificadas através da pesquisa de EOAPD. Conclusões: Ao se considerar o método estatístico utilizado nessa população, é possível concluir que mudanças nos limiares auditivos foram associadas ao uso da amicacina no período de seis meses por meio de AAF e ATL e que a pesquisa de EOAPD não se mostrou eficiente na identificação dessas mudanças.


Keywords: Tuberculosis; Hearing loss; Aminoglycosides/toxicity.


8 - Clinical aspects in patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex, in the Brazilian Amazon

Aspectos clínicos em pacientes com infecção pulmonar por micobactérias do complexo Mycobacterium abscessus na Amazônia brasileira

José Tadeu Colares Monteiro1, Karla Valéria Batista Lima2, Adriana Rodrigues Barretto3, Ismari Perini Furlaneto1,2, Glenda Moraes Gonçalves3, Ana Roberta Fusco da Costa2, Maria Luiza Lopes2, Margareth Pretti Dalcolmo4,5

J Bras Pneumol.2018;44(2):93-98

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Objective: To describe the clinical manifestations of patients with pulmonary infection caused by mycobacteria of the Mycobacterium abscessus complex (MABSC), and to compare these manifestations with those of patients infected with other nontuberculous mycobacteria (NTM). Methods: This was a retrospective cohort study involving 43 patients divided into two groups: the MABSC group, consisting of patients with pulmonary infection caused by MABSC (n = 17); and the NTM group, consisting of patients with pulmonary infection caused by NTM other than MABSC (n = 26). Patients were previously treated with a regimen of rifampin, isoniazid, pyrazinamide, and ethambutol before the diagnosis of NTM was confirmed by two culture-positive sputum samples. The nucleotide sequences of the hsp65, 16S rRNA, and/or rpoB genes were analyzed to identify the mycobacteria. Data were collected on demographic, clinical, and radiological characteristics, as well as on treatment responses and outcomes. Results: Loss of appetite was the only clinical manifestation that was significantly more common in the MABSC group than in the NTM group (p = 0.0306). The chance of having to use a second treatment regimen was almost 12 times higher in the MABSC group than in the NTM group. Treatment success was significantly higher in the NTM group than in the MABSC group (83.2% vs. 17.6%; p < 0.0001). The chance of recurrence was approximately 37 times higher in the MABSC group than in the NTM group. Conclusions: In the study sample, treatment response of pulmonary disease caused by MABSC was less favorable than that of pulmonary disease caused by other NTM.


Keywords: Nontuberculous mycobacteria/classification; Nontuberculous mycobacteria/drug effects; Lung diseases.


9 - Impact of smoking on sputum culture conversion and pulmonary tuberculosis treatment outcomes in Brazil: a retrospective cohort study

Impacto do tabagismo na conversão de cultura e no desfecho do tratamento da tuberculose pulmonar no Brasil: estudo de coorte retrospectivo

Michelle Cailleaux-Cezar1,a, Carla Loredo1,b, José Roberto Lapa e Silva1,c, Marcus Barreto Conde1,2,d

J Bras Pneumol.2018;44(2):99-105

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Objective: To evaluate the impact of smoking on pulmonary tuberculosis (PTB) treatment outcomes and the two-month conversion rates for Mycobacterium tuberculosis sputum cultures among patients with culture-confirmed PTB in an area with a moderate incidence of tuberculosis in Brazil. Methods: This was a retrospective cohort study of PTB patients diagnosed and treated at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro between 2004 and 2012. Results: Of the 298 patients diagnosed with PTB during the study period, 174 were included in the outcome analysis: 97 (55.7%) were never-smokers, 31 (17.8%) were former smokers, and 46 (26.5%) were current smokers. Smoking was associated with a delay in sputum culture conversion at the end of the second month of TB treatment (relative risk = 3.58 [95% CI: 1.3-9.86]; p = 0.01), as well as with poor treatment outcomes (relative risk = 6.29 [95% CI: 1.57-25.21]; p = 0.009). The association between smoking and a positive culture in the second month of treatment was statistically significant among the current smokers (p = 0.027). Conclusions: In our sample, the probability of a delay in sputum culture conversion was higher in current smokers than in never-smokers, as was the probability of a poor treatment outcome.


Keywords: Tuberculosis; Treatment outcome; Smoking.


10 - Nontuberculous mycobacterial lung disease in a high tuberculosis incidence setting in Brazil

Doença pulmonar por micobactérias não tuberculosas em uma região de alta incidência de tuberculose no Brasil

Maiara dos Santos Carneiro1,2, Luciana de Souza Nunes2,3, Simone Maria Martini De David4, Claudia Fontoura Dias5, Afonso Luís Barth1,2, Gisela Unis5

J Bras Pneumol.2018;44(2):106-111

Abstract PDF PT PDF EN Portuguese Text

Objective: The incidence of lung disease caused by nontuberculous mycobacteria (NTM) has been increasing worldwide. In Brazil, there are few studies about nontuberculous mycobacterial lung disease (NTMLD), and its prevalence is yet to be known. Our objective was to determine the specific etiology of the disease in the state of Rio Grande do Sul, Brazil, as well as the frequency and diversity of NTM species in our sample of patients. Methods: This is a retrospective analysis of the medical records of patients diagnosed with NTMLD treated in a referral center located in the city of Porto Alegre, Brazil, between 2003 and 2013. Results: Our sample comprised 100 patients. The most prevalent NTM species were Mycobacterium avium complex (MAC), in 35% of the cases; M. kansasii, in 17%; and M. abscessus, in 12%. A total of 85 patients had received previous treatment for tuberculosis. Associated conditions included structural abnormalities in the lungs, such as bronchiectasis, in 23% of the cases; COPD, in 17%; and immunosuppressive conditions, such as AIDS, in 24%. Conclusions: MAC and M. kansasii were the most prevalent species involved in NTMLD in the state, similarly to what occurs in other regions of Brazil. Data on regional epidemiology of NTMLD, its specific etiology, and associated conditions are essential to establish appropriate treatment, since each species requires specific regimens. Most patients with NTMLD had received previous tuberculosis treatment, which might lead to development of resistance and late diagnosis.


Keywords: Nontuberculous mycobacteria; Mycobacterium infections, nontuberculous; Lung diseases.


11 - Rapid molecular test for tuberculosis: impact of its routine use at a referral hospital

Teste rápido molecular para tuberculose: avaliação do impacto de seu uso na rotina em um hospital de referência

Marilda Casela1,a, Silvânia Maria Andrade Cerqueira1,b, Thais de Oliveira Casela2,c, Mariana Araújo Pereira3,d, Samanta Queiroz dos Santos3,e, Franco Andres Del Pozo4,f, Songeli Menezes Freire3,g, Eliana Dias Matos5,h

J Bras Pneumol.2018;44(2):112-117

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of the use of the molecular test for Mycobacterium tuberculosis and its resistance to rifampin (Xpert MTB/RIF), under routine conditions, at a referral hospital in the Brazilian state of Bahia. Methods: This was a descriptive study using the database of the Mycobacteriology Laboratory of the Octávio Mangabeira Specialized Hospital, in the city of Salvador, and georeferencing software. We evaluated 3,877 sputum samples collected from symptomatic respiratory patients, under routine conditions, between June of 2014 and March of 2015. All of the samples were submitted to sputum smear microscopy and the Xpert MTB/RIF test. Patients were stratified by gender, age, and geolocation. Results: Among the 3,877 sputum samples evaluated, the Xpert MTB/RIF test detected M. tuberculosis in 678 (17.5%), of which 60 (8.8%) showed resistance to rifampin. The Xpert MTB/RIF test detected M. tuberculosis in 254 patients who tested negative for sputum smear microscopy, thus increasing the diagnostic power by 59.9%. Conclusions: The use of the Xpert MTB/RIF test, under routine conditions, significantly increased the detection of cases of tuberculosis among sputum smear-negative patients.


Keywords: Tuberculosis/diagnosis; Molecular diagnostic techniques; Sputum.


12 - Predictors of mortality among intensive care unit patients coinfected with tuberculosis and HIV

Preditores de mortalidade em pacientes da unidade de terapia intensiva coinfectados por tuberculose e HIV

Marcia Danielle Ferreira1,2,a, Cynthia Pessoa das Neves1,3,b, Alexandra Brito de Souza3,c, Francisco Beraldi-Magalhães1,3,d, Giovanni Battista Migliori4,e, Afrânio Lineu Kritski5,f, Marcelo Cordeiro-Santos1,3,g

J Bras Pneumol.2018;44(2):118-124

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify factors predictive of mortality in patients admitted to the ICU with tuberculosis (TB)/HIV coinfection in the Manaus, Amazon Region. Methods: This was a retrospective cohort study of TB/HIV coinfected patients over 18 years of age who were admitted to an ICU in the city of Manaus, Brazil, between January of 2011 and December of 2014. Sociodemographic, clinical, and laboratory variables were assessed. To identify factors predictive of mortality, we employed a Cox proportional hazards model. Results: During the study period, 120 patients with TB/HIV coinfection were admitted to the ICU. The mean age was 37.0 ± 11.7 years. Of the 120 patients evaluated, 94 (78.3%) died and 62 (66.0%) of those deaths having occurred within the first week after admission. Data on invasive mechanical ventilation (IMV) and ARDS were available for 86 and 67 patients, respectively Of those 86, 75 (87.2%) underwent IMV, and, of those 67, 48 (71.6%) presented with ARDS. The factors found to be independently associated with mortality were IMV (p = 0.002), hypoalbuminemia (p = 0.013), and CD4 count < 200 cells/mm3 (p = 0.002). Conclusions: A high early mortality rate was observed among TB/HIV coinfected ICU patients. The factors predictive of mortality in this population were IMV, hypoalbuminemia, and severe immunosuppression.


Keywords: Mycobacterium tuberculosis; Critical care; Respiration, artificial; Acquired immunodeficiency syndrome.


13 - Who are the patients with tuberculosis who are diagnosed in emergency facilities? An analysis of treatment outcomes in the state of São Paulo, Brazil

Quem são os pacientes com tuberculose diagnosticados no pronto-socorro? Uma análise dos desfechos do tratamento no Estado de São Paulo, Brasil

Otavio Tavares Ranzani1,2,a, Laura Cunha Rodrigues2,b, Eliseu Alves Waldman3,c, Elena Prina1,d, Carlos Roberto Ribeiro Carvalho1,e

J Bras Pneumol.2018;44(2):125-133

Abstract PDF PT PDF EN Portuguese Text

Objective: Early tuberculosis diagnosis and treatment are determinants of better outcomes and effective disease control. Although tuberculosis should ideally be managed in a primary care setting, a proportion of patients are diagnosed in emergency facilities (EFs). We sought to describe patient characteristics by place of tuberculosis diagnosis and determine whether the place of diagnosis is associated with treatment outcomes. A secondary objective was to determine whether municipal indicators are associated with the probability of tuberculosis diagnosis in EFs. Methods: We analyzed data from the São Paulo State Tuberculosis Control Program database for the period between January of 2010 and December of 2013. Newly diagnosed patients over 15 years of age with pulmonary, extrapulmonary, or disseminated tuberculosis were included in the study. Multiple logistic regression models adjusted for potential confounders were used in order to evaluate the association between place of diagnosis and treatment outcomes. Results: Of a total of 50,295 patients, 12,696 (25%) were found to have been diagnosed in EFs. In comparison with the patients who had been diagnosed in an outpatient setting, those who had been diagnosed in EFs were younger and more socially vulnerable. Patients diagnosed in EFs were more likely to have unsuccessful treatment outcomes (adjusted OR: 1.54; 95% CI: 1.42-1.66), including loss to follow-up and death. At the municipal level, the probability of tuberculosis diagnosis in EFs was associated with low primary care coverage, inequality, and social vulnerability. In some municipalities, more than 50% of the tuberculosis cases were diagnosed in EFs. Conclusions: In the state of São Paulo, one in every four tuberculosis patients is diagnosed in EFs, a diagnosis of tuberculosis in EFs being associated with poor treatment outcomes. At the municipal level, an EF diagnosis of tuberculosis is associated with structural and socioeconomic indicators, indicating areas for improvement.


Keywords: Tuberculosis/diagnosis; Emergency treatment; Treatment outcome; Delivery of health care.


Review Article

14 - Epidemiological aspects, clinical manifestations, and prevention of pediatric tuberculosis from the perspective of the End TB Strategy

Aspectos epidemiológicos, manifestações clínicas e prevenção da tuberculose pediátrica sob a perspectiva da Estratégia End TB

Anna Cristina Calçada Carvalho1,a, Claudete Aparecida Araújo Cardoso2,b, Terezinha Miceli Martire3,c, Giovanni Battista Migliori4,d, Clemax Couto Sant'Anna5,e

J Bras Pneumol.2018;44(2):134-144

Abstract PDF PT PDF EN Portuguese Text

Tuberculosis continues to be a public health priority in many countries. In 2015, tuberculosis killed 1.4 million people, including 210,000 children. Despite the recent progress made in the control of tuberculosis in Brazil, it is still one of the countries with the highest tuberculosis burdens. In 2015, there were 69,000 reported cases of tuberculosis in Brazil and tuberculosis was the cause of 4,500 deaths in the country. In 2014, the World Health Organization approved the End TB Strategy, which set a target date of 2035 for meeting its goals of reducing the tuberculosis incidence by 90% and reducing the number of tuberculosis deaths by 95%. However, to achieve those goals in Brazil, there is a need for collaboration among the various sectors involved in tuberculosis control and for the prioritization of activities, including control measures targeting the most vulnerable populations. Children are highly vulnerable to tuberculosis, and there are particularities specific to pediatric patients regarding tuberculosis development (rapid progression from infection to active disease), prevention (low effectiveness of vaccination against the pulmonary forms and limited availability of preventive treatment of latent tuberculosis infection), diagnosis (a low rate of bacteriologically confirmed diagnosis), and treatment (poor availability of child-friendly anti-tuberculosis drugs). In this review, we discuss the epidemiology, clinical manifestations, and prevention of tuberculosis in childhood and adolescence, highlighting the peculiarities of active and latent tuberculosis in those age groups, in order to prompt reflection on new approaches to the management of pediatric tuberculosis within the framework of the End TB Strategy.


Keywords: Tuberculosis, pulmonary/prevention & control; Mycobacterium tuberculosis; Lung diseases/etiology; Child; Adolescent.


15 - Risk factors for tuberculosis: diabetes, smoking, alcohol use, and the use of other drugs

Fatores de risco para tuberculose: diabetes, tabagismo, álcool e uso de outras drogas

Denise Rossato Silva1,a, Marcela Muñoz-Torrico2,b, Raquel Duarte3,4,c, Tatiana Galvão5,d, Eduardo Henrique Bonini6,7,e, Flávio Ferlin Arbex6,f, Marcos Abdo Arbex6,g, Valéria Maria Augusto8,h, Marcelo Fouad Rabahi9,i, Fernanda Carvalho de Queiroz Mello10,j

J Bras Pneumol.2018;44(2):145-152

Abstract PDF PT PDF EN Portuguese Text

Tuberculosis continues to be a major public health problem. Although efforts to control the epidemic have reduced mortality and incidence, there are several predisposing factors that should be modified in order to reduce the burden of the disease. This review article will address some of the risk factors associated with tuberculosis infection and active tuberculosis, including diabetes, smoking, alcohol use, and the use of other drugs, all of which can also contribute to poor tuberculosis treatment results. Tuberculosis can also lead to complications in the course and management of other diseases, such as diabetes. It is therefore important to identify these comorbidities in tuberculosis patients in order to ensure adequate management of both conditions.


Keywords: Tuberculosis/epidemiology; Tuberculosis/prevention & control; Diabetes mellitus/prevention & control; Smoking/adverse effects; Alcohol drinking/adverse effects; Street drugs/adverse effects.


16 - New and repurposed drugs to treat multidrug- and extensively drug-resistant tuberculosis

Novos fármacos e fármacos repropostos para o tratamento da tuberculose multirresistente e extensivamente resistente

Denise Rossato Silva1,a, Margareth Dalcolmo2,b, Simon Tiberi3,c, Marcos Abdo Arbex4,5,d, Marcela Munoz-Torrico6,e, Raquel Duarte7,8,9,f, Lia D'Ambrosio10,11,g, Dina Visca12,h, Adrian Rendon13,i, Mina Gaga14,j, Alimuddin Zumla15,k, Giovanni Battista Migliori10,l

J Bras Pneumol.2018;44(2):153-460

Abstract PDF PT PDF EN Portuguese Text

Multidrug-resistant and extensively drug-resistant tuberculosis (MDR-TB and XDR-TB, respectively) continue to represent a challenge for clinicians and public health authorities. Unfortunately, although there have been encouraging reports of higher success rates, the overall rate of favorable outcomes of M/XDR-TB treatment is only 54%, or much lower when the spectrum of drug resistance is beyond that of XDR-TB. Treating M/XDR-TB continues to be a difficult task, because of the high incidence of adverse events, the long duration of treatment, the high cost of the regimens used, and the drain on health care resources. Various trials and studies have recently been undertaken (some already published and others ongoing), all aimed at improving outcomes of M/XDR-TB treatment by changing the overall approach, shortening treatment duration, and developing a universal regimen. The objective of this review was to summarize what has been achieved to date, as far as new and repurposed drugs are concerned, with a special focus on delamanid, bedaquiline, pretomanid, clofazimine, carbapenems, and linezolid. After more than 40 years of neglect, greater attention has recently been paid to the need for new drugs to fight the "white plague", and promising results are being reported.


Keywords: Tuberculosis/therapy; Tuberculosis, multidrug-resistant; Extensively drug-resistant tuberculosis; Antitubercular agents.


17 - Chest X-ray and chest CT findings in patients diagnosed with pulmonary tuberculosis following solid organ transplantation: a systematic review

Achados de radiografia e de TC de tórax em pacientes transplantados de órgãos sólidos e diagnosticados com tuberculose pulmonar: uma revisão sistemática

Irai Luis Giacomelli1,a, Roberto Schuhmacher Neto1,b, Edson Marchiori2,c, Marisa Pereira1, Bruno Hochhegger1,d

J Bras Pneumol.2018;44(2):161-166

Abstract PDF PT PDF EN Portuguese Text

The objective of this systematic review was to select articles including chest X-ray or chest CT findings in patients who developed pulmonary tuberculosis following solid organ transplantation (lung, kidney, or liver). The following search terms were used: "tuberculosis"; "transplants"; "transplantation"; "mycobacterium"; and "lung". The databases used in this review were PubMed and the Brazilian Biblioteca Virtual em Saúde (Virtual Health Library). We selected articles in English, Portuguese, or Spanish, regardless of the year of publication, that met the selection criteria in their title, abstract, or body of text. Articles with no data on chest CT or chest X-ray findings were excluded, as were those not related to solid organ transplantation or pulmonary tuberculosis. We selected 29 articles involving a collective total of 219 patients. The largest samples were in studies conducted in Brazil and South Korea (78 and 35 patients, respectively). The imaging findings were subdivided into five common patterns. The imaging findings varied depending on the transplanted organ in these patients. In liver and lung transplant recipients, the most common pattern was the classic one for pulmonary tuberculosis (cavitation and "tree-in-bud" nodules), which is similar to the findings for pulmonary tuberculosis in the general population. The proportion of cases showing a miliary pattern and lymph node enlargement, which is most similar to the pattern seen in patients coinfected with tuberculosis and HIV, was highest among the kidney transplant recipients. Further studies evaluating clinical data, such as immunosuppression regimens, are needed in order to improve understanding of the distribution of these imaging patterns in this population.


Keywords: Tomography, X-ray computed; Radiography; Tuberculosis, pulmonary; Lung/transplantation; Kidney/transplantation; Liver/transplantation.


Images in Pulmonary Medicine

18 - Giant pulmonary artery aneurysm in a patient with schistosomiasis-associated pulmonary arterial hypertension

Aneurisma gigante da artéria pulmonar em paciente com hipertensão arterial pulmonar associada à esquistossomose

Francisca Gavilanes1,a, Bruna Piloto1,b, Caio Julio Cesar Fernandes1,c

J Bras Pneumol.2018;44(2):167

PDF PT PDF EN Portuguese Text

Letters to the Editor

19 - Knowledge and perceptions of tuberculosis transmission and prevention among physicians and nurses in three Brazilian capitals with high incidence of tuberculosis

Conhecimento e percepção de médicos e enfermeiros em três capitais brasileiras com alta incidência de tuberculose a respeito da transmissão e prevenção da doença

Jonas Ramos1,a, Maria F Wakoff-Pereira1,b, Marcelo Cordeiro-Santos2,3,c, Maria de Fátima Militão de Albuquerque4,d, Philip C Hill5,e, Dick Menzies6,f, Anete Trajman,6,7,g

J Bras Pneumol.2018;44(2):168-170

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20 - Rapidly growing pulmonary ground-glass nodule caused by metastatic melanoma lacking uptake on 18F-FDG PET-CT.

Nódulo em vidro fosco de crescimento rápido, causado por melanoma metastático e sem captação de 18F fluordesoxiglicose na tomografia por emissão de pósitrons com 18F fluordesoxiglicose/tomografia computadorizada

Giorgia Dalpiaz1,a, Sofia Asioli2,b, Stefano Fanti3,c, Gaetano Rea4,d, Edson Marchiori5,e

J Bras Pneumol.2018;44(2):171-172

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Year 2018 - Volume 44  - Number 3  (May/June)



1 - The importance of the World Symposium on Pulmonary Hypertension

A importância do Simpósio Mundial de Hipertensão Pulmonar

Carlos Jardim1,a, Daniel Waetge2

J Bras Pneumol.2018;44(3):173-174

PDF PT PDF EN Portuguese Text

2 - Cost analysis in the ICU from the standpoint of physical therapy

Análise de custos em UTI sob a perspectiva da fisioterapia

Liria Yuri Yamauchi1,a

J Bras Pneumol.2018;44(3):175

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3 - Reference values for assessing the arms: are we seeing a light at the end of the tunnel?

Valores de referência para a avaliação de membros superiores: estamos diante de uma luz no fim do túnel?

Luciana Dias Chiavegato1,2,a

J Bras Pneumol.2018;44(3):176-177

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4 - Opening windows of opportunity for smoking cessation treatment

Abrindo as janelas de oportunidade para tratar o tabagismo

Maria Vera Cruz de Oliveira Castellano1,a

J Bras Pneumol.2018;44(3):178-179

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5 - Vascular reperfusion in pulmonary thromboembolism: certainties and uncertainties

Reperfusão vascular no tromboembolismo pulmonar: dúvidas e certezas

Veronica Moreira Amado1,a

J Bras Pneumol.2018;44(3):180-181

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Continuing Education: Imaging

6 - Unilateral hyperlucent lung

Pulmão hipertransparente unilateral

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(3):182

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Continuing Education : Scientific Methodology

7 - Internal and external validity: can you apply research study results to your patients?

Validade interna e externa: você pode aplicar resultados de pesquisa para seus pacientes?

Cecilia Maria Patino1,2,a, Juliana Carvalho Ferreira1,3,b

J Bras Pneumol.2018;44(3):183

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Original Article

8 - Relationship between availability of physiotherapy services and ICU costs

Relação entre a disponibilidade de serviços de fisioterapia e custos de UTI

Bruna Peruzzo Rotta1,2,a, Janete Maria da Silva2,3,b, Carolina Fu2,4,c, Juliana Barbosa Goulardins4,5,d, Ruy de Camargo Pires-Neto2,4,e, Clarice Tanaka2,4,f

J Bras Pneumol.2018;44(3):184-189

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether 24-h availability of physiotherapy services decreases ICU costs in comparison with the standard 12 h/day availability among patients admitted to the ICU for the first time. Methods: This was an observational prevalence study involving 815 patients ≥ 18 years of age who had been on invasive mechanical ventilation (IMV) for ≥ 24 h and were discharged from an ICU to a ward at a tertiary teaching hospital in Brazil. The patients were divided into two groups according to h/day availability of physiotherapy services in the ICU: 24 h (PT-24; n = 332); and 12 h (PT-12; n = 483). The data collected included the reasons for hospital and ICU admissions; Acute Physiology and Chronic Health Evaluation II (APACHE II) score; IMV duration, ICU length of stay (ICU-LOS); and Omega score. Results: The severity of illness was similar in both groups. Round-the-clock availability of physiotherapy services was associated with shorter IMV durations and ICU-LOS, as well as with lower total, medical, and staff costs, in comparison with the standard 12 h/day availability. Conclusions: In the population studied, total costs and staff costs were lower in the PT-24 group than in the PT-12 group. The h/day availability of physiotherapy services was found to be a significant predictor of ICU costs.


Keywords: Intensive care units; Respiration, artificial; Respiratory therapy; Hospital costs.


9 - Reference values for the six-minute pegboard and ring test in healthy adults in Brazil

Valores de referência para o teste de argolas de seis minutos em adultos saudáveis no Brasil

Vanessa Pereira Lima1,2,a, Fabiana Damasceno Almeida3,4,b, Tania Janaudis-Ferreira5,6,c, Bianca Carmona3,4,d, Giane Amorim Ribeiro-Samora3,4,e, Marcelo Velloso3,4,f

J Bras Pneumol.2018;44(3):190-194

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine reference values for the six-minute pegboard and ring test (6PBRT) in healthy adults in Brazil, correlating the results with arm length, circumference of the upper arm/forearm of the dominant arm, and the level of physical activity. Methods: The participants (all volunteers) performed two 6PBRTs, 30 min apart. They were instructed to move as many rings as possible in six minutes. The best test result was selected for data analysis. Results: The sample comprised 104 individuals, all over 30 years of age. Reference values were reported by age bracket. We found that age correlated with 6PBRT results. The number of rings moved was higher in the 30- to 39-year age group than in the > 80-year age group (430.25 ± 77.00 vs. 265.00 ± 65.75), and the difference was significant (p < 0.05). The 6PBRT results showed a weak, positive correlation with the level of physical activity (r = 0.358; p < 0.05) but did not correlate significantly with any other variable studied. Conclusions: In this study, we were able to determine reference values for the 6PBRT in healthy adults in Brazil. There was a correlation between 6PBRT results and age.


Keywords: Upper extremity; Physical endurance; Exercise tolerance; Exercise test.


10 - Comparison of two smoking cessation interventions for inpatients

Comparação de duas intervenções de cessação do tabagismo em pacientes internados

Antonio Carlos Ferreira Campos1,a, Angela Santos Ferreira Nani2,b, Vilma Aparecida da Silva Fonseca3,c, Eduardo Nani Silva1,2,d, Marcos César Santos de Castro2,4,e, Wolney de Andrade Martins1,2,f

J Bras Pneumol.2018;44(3):195-201

Abstract PDF PT PDF EN Portuguese Text

Objective: This study aimed to compare the effectiveness of two cognitive behavioral therapy-based smoking cessation interventions initiated during hospitalization and to evaluate the factors related to relapse after discharge. Methods: This was a prospective randomized study involving 90 smokers hospitalized in a university hospital. We collected data related to sociodemographic characteristics, reasons for admission, smoking-related diseases, smoking history, the degree of nicotine dependence (ND), and the level of craving. Patients were divided into two treatment groups: brief intervention (BrInter, n = 45); and intensive intervention with presentation of an educational video (InInterV, n=45). To assess relapse, all patients were assessed by telephone interview in the first, third, and sixth months after discharge. Abstinence was confirmed by measurement of exhaled carbon monoxide (eCO). Results: Of the 90 patients evaluated, 55 (61.1%) were male. The mean age was 51.1 ± 12.2 years. The degree of ND was elevated in 39 (43.4%), and withdrawal symptoms were present in 53 (58.9%). The mean eCO at baseline was 4.8 ± 4.5 ppm. The eCO correlated positively with the degree of ND (r = 0.244; p = 0.02) and negatively with the number of smoke-free days (r = −0.284; p = 0.006). There were no differences between the groups in terms of the variables related to socioeconomic status, smoking history, or hospitalization. Of the 81 patients evaluated at 6 months, 33 (40.7%) remained abstinent (9 and 24 BrInter and InInterV group patients, respectively; p = 0.001), and 48 (59.3%) had relapsed (31 and 17 BrInter and InInterV group patients, respectively; p= 0.001). Moderate or intense craving was a significant independent risk factor for relapse, with a relative risk of 4.0 (95% CI: 1.5-10.7; p < 0.00001). Conclusions: The inclusion of an educational video proved effective in reducing relapse rates. Craving is a significant risk factor for relapse.


Keywords: Smoking cessation; Tobacco use disorder; Inpatients; Hospitalization.


11 - The triad of obstructive sleep apnea syndrome, COPD, and obesity: sensitivity of sleep scales and respiratory questionnaires

Tríade síndrome da apneia obstrutiva do sono, DPOC e obesidade: sensibilidade de escalas de sono e de questionários respiratórios

Flávio Danilo Mungo Pissulin1,a, Francis Lopes Pacagnelli1,b, Maiara Almeida Aldá1,c, Ricardo Beneti1,d, Jefferson Luis de Barros2,e, Suzana Tanni Minamoto2,f, Silke Anna Thereza Weber2,g

J Bras Pneumol.2018;44(3):202-206

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate whether the presence of obstructive sleep apnea syndrome (OSAS) alters the perception of respiratory symptoms and quality of life in COPD patients, by using specific questionnaires, as well as to determine whether scales for assessing daytime sleepiness and for screening for OSAS can be used in the triad of OSAS, COPD, and obesity. Methods: We included 66 patients diagnosed with mild-to-moderate or severe COPD and presenting with a body mass index > 27 kg/m2. After polysomnography, patients completed the Epworth sleepiness scale (ESS), the Berlin questionnaire (BQ), the modified Medical Research Council (mMRC) scale, the Baseline Dyspnea Index (BDI), and the Saint George's Respiratory Questionnaire (SGRQ). Results: Patients were first divided into two groups: COPD + OSAS (n = 46); and COPD-only (n = 20). The COPD + OSAS group was subdivided into a COPD + mild-to-moderate OSAS group (n = 32) and a COPD + severe OSAS group (n = 14), all of which were compared with the COPD-only group. There was a significant difference in mean FEV1 (L) between the COPD + OSAS groups and the COPD-only group (p = 0.073). The presence of the triad did not lead to significantly higher ESS scores, and scores > 10 had a specificity of 0.58. The BQ did not identify high risk for OSAS in the presence of the triad (specificity of 0.31). There were no significant differences in domain or total scores of the SGRQ between the COPD + OSAS groups and the COPD-only group. Conclusions: The confounding factors present in the triad of OSAS, COPD, and obesity prevented the perception of increased daytime sleepiness and high risk for OSAS. We observed no worsening of dyspnea perception or quality of life.


Keywords: Sleep apnea, obstructive; Pulmonary disease, chronic obstructive; Obesity; Surveys and questionnaires.


12 - Obesity and asthma: clinical and laboratory characterization of a common combination

Obesidade e asma: caracterização clínica e laboratorial de uma associação frequente

Juliana Pires Viana de Jesus1,2,a, Aline Silva Lima-Matos2,3,b, Paula Cristina Andrade Almeida2,c, Valmar Bião Lima2,d, Luane Marques de Mello4,e, Adelmir Souza-Machado2,5,f, Eduardo Vieira Ponte5,6,g, Álvaro Augusto Cruz2,7,h

J Bras Pneumol.2018;44(3):207-212

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the relationship between obesity and asthma. Methods: This was a preliminary cross-sectional analysis involving 925 subjects with mild-to-moderate or severe asthma evaluated between 2013 and 2015. Obesity was defined on the basis of body mass index (BMI) and abdominal circumference. We collected clinical, laboratory, and anthropometric parameters, as well as pulmonary function test results and data regarding comorbidities. The subjects also completed asthma control and quality of life questionnaires. Results: Obese individuals had a significantly higher number of neutrophils in peripheral blood than did nonobese individuals (p = 0.01). Among the obese individuals, 163 (61%) had positive skin-prick test results, as did 69% and 71% of the individuals classified as being overweight or normal weight, respectively. Obese individuals showed lower spirometric values than did nonobese individuals, and 32% of the obese individuals had uncontrolled asthma, a significantly higher proportion than that found in the other groups (p = 0.02). Conclusions: Obese individuals with asthma seem to present with poorer asthma control and lower pulmonary function values than do nonobese individuals. The proportion of subjects with nonatopic asthma was higher in the obese group. Our results suggest that obese individuals with asthma show a distinct inflammatory pattern and are more likely to present with difficult-to-control asthma than are nonobese individuals.


Keywords: Asthma; Obesity; Overweight; Eosinophilia.


13 - Is the COPD Assessment Test sensitive for differentiating COPD patients from active smokers and nonsmokers without lung function impairment? A population-based study

O COPD Assessment Test é sensível para diferenciar pacientes com DPOC de indivíduos tabagistas e não tabagistas sem a doença? Um estudo de base populacional

Manuela Karloh1,2,a, Simone Aparecida Vieira Rocha1,b, Marcia Margaret Menezes Pizzichini1,3,c, Francine Cavalli1,d, Darlan Laurício Matte1,2,4,e, Emilio Pizzichini1,3,f; The Respira Floripa Group

J Bras Pneumol.2018;44(3):213-219

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess COPD Assessment Test (CAT) scores in adults with and without COPD, as well as to compare the CAT scores for nonsmokers, former smokers, and smokers without COPD with those for patients with COPD. Methods: This was a cross-sectional population-based study (the Respira Floripa study). The study included adults ≥ 40 years of age residing in the city of Florianópolis, Brazil. A total of 846 households were surveyed. In addition to completing the Respira Floripa questionnaire and the CAT, participants underwent pulmonary function testing. Results: We analyzed data on 1,057 participants (88.1% of the predicted sample size). A functional diagnosis of COPD was made in 92 participants (8.7%). Of those, 72% were unaware that they had COPD. The mean CAT score was higher in the group of COPD patients than in that of individuals without COPD (10.6 [95% CI: 8.8-12.4] vs. 6.6 [95% CI: 6.1-7.0]; p < 0.01). Individual item scores were significantly higher in the patients with COPD than in the individuals without COPD (p < 0.001), the exception being the scores for the items related to sleep (p = 0.13) and energy (p = 0.08). The mean CAT score was higher in the group of COPD patients than in nonsmokers (5.8 [95% CI: 5.3-6.4]) and former smokers (6.4 [95% CI: 5.6-7.2]; p < 0.05). However, there were no significant differences in the mean CAT score between the group of COPD patients and smokers without COPD (9.5 [95% CI: 8.2-10.8]; p > 0.05), the exception being the mean scores for confidence leaving home (p = 0.02). Conclusions: CAT scores were higher in the group of patients with COPD than in nonsmokers and former smokers without COPD. However, there were no significant differences in CAT scores between COPD patients and smokers without COPD. Smokers with an FEV1/FVC ratio > 0.70 have impaired health status and respiratory symptoms similar to those observed in COPD patients.


Keywords: Respiratory function tests; Pulmonary disease, chronic obstructive; Smoking.


14 - Validity and reliability of assessing diaphragmatic mobility by area on X-rays of healthy subjects

Validade e confiabilidade da avaliação da mobilidade diafragmática pelo método da área radiográfica em sujeitos saudáveis

Aline Pedrini1,a, Márcia Aparecida Gonçalves1,b, Bruna Estima Leal1,c, Michelle Gonçalves de Souza Tavares2,d, Wellington Pereira Yamaguti3,e, David Luiz Góes4,f, Elaine Paulin1,g

J Bras Pneumol.2018;44(3):220-226

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the concurrent validity, as well as the intra- and inter-rater reliability, of assessing diaphragmatic mobility by area (DMarea) on chest X-rays of healthy adults. Methods: We evaluated anthropometric parameters, pulmonary function, and diaphragmatic mobility in 43 participants. Two observers (rater A and rater B) determined diaphragmatic mobility at two time points. We used Pearson's correlation coefficient to evaluate the correlation between DMarea and the assessment of diaphragmatic mobility by distance (DMdist). To evaluate intra- and inter-rater reliability, we used the intraclass correlation coefficient (ICC [2,1]), 95% CI, and Bland-Altman analysis. Results: A significant correlation was found between the DMarea and DMdist methods (r = 0.743; p < 0.0001). For DMarea, the intra-rater reliability was found to be quite high for the right hemidiaphragm (RHD)-ICC (2,1) = 0.92 (95% CI: 0.86-0.95) for rater A and ICC (2,1) = 0.90 (95% CI: 0.84-0.94) for rater B-and the left hemidiaphragm (LHD)-ICC (2,1) = 0.96 (95% CI: 0.93-0.97) for rater A and ICC (2,1) = 0.91 (95% CI: 0.81-0.95) for rater B-(p < 0.0001 for all). Also for DMarea, the inter-rater reliability was found to be quite high for the first and second evaluations of the RHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.95 (95% CI: 0.86-0.97), respectively-and the LHD-ICC (2,1) = 0.99 (95% CI: 0.98-0.99) and ICC (2,1) = 0.94 (95% CI: 0.87-0.97)-(p < 0.0001 for both). The Bland-Altman analysis showed good agreement between the mobility of the RHD and that of the LHD. Conclusions: The DMarea method proved to be a valid, reliable measure of diaphragmatic mobility.


Keywords: Diaphragm/physiology; Validation studies; Reproducibility of results; Radiography.


Brief Communication

15 - Mini-thoracostomy with vacuum-assisted closure: a minimally invasive alternative to open-window thoracostomy

Minipleurostomia com curativo a vácuo: uma opção minimamente invasiva a pleurostomia

Alessandro Wasum Mariani1,a, João Bruno Ribeiro Machado Lisboa1,b, Guilherme de Abreu Rodrigues1,c, Ester Moraes Avila2,d, Ricardo Mingarini Terra1,e, Paulo Manuel Pêgo-Fernandes1,f

J Bras Pneumol.2018;44(3):227-230

Abstract PDF PT PDF EN Portuguese Text

Thoracostomy is a common treatment option for patients with stage III pleural empyema who do not tolerate pulmonary decortication. However, thoracostomy is considered mutilating because it involves a thoracic stoma, the closure of which can take years or require further surgery. A new, minimally invasive technique that uses the vacuum-assisted closure has been proposed as an alternative to thoracostomy. This study aims to analyze the safety and effectiveness of mini-thoracostomy with vacuum-assisted closure in an initial sample of patients.


Keywords: Infection; Empyema, pleural; Negative-pressure wound therapy; Thoracostomy.


Case Series

16 - Characterization and outcomes of pulmonary alveolar proteinosis in Brazil: a case series

Proteinose alveolar pulmonar: caracterização e desfechos em uma série de casos no Brasil

Rodolfo Augusto Bacelar de Athayde1,a, Fábio Eiji Arimura1,b, Ronaldo Adib Kairalla1,c, Carlos Roberto Ribeiro Carvalho1,d, Bruno Guedes Baldi1,e

J Bras Pneumol.2018;44(3):231-236

Abstract PDF PT PDF EN Portuguese Text

Objective: Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by the alveolar accumulation of surfactant, which is composed of proteins and lipids. PAP is caused by a deficit of macrophage activity, for which the main treatment is whole-lung lavage (WLL). We report the experience at a referral center for PAP in Brazil. Methods: This was a retrospective study involving patients with PAP followed between 2002 and 2016. We analyzed information regarding clinical history, diagnostic methods, treatments, and outcomes, as well as data on lung function, survival, and complications. Results: We evaluated 12 patients (8 of whom were women). The mean age was 41 ± 15 years. Most of the patients were diagnosed by means of BAL and transbronchial biopsy. The mean number of WLLs performed per patient was 2.8 ± 2.5. One third of the patients never underwent WLL. Four patients (33.3%) had associated infections (cryptococcosis, in 2; nocardiosis, in 1; and tuberculosis, in 1), and 2 (16.6%) died: 1 due to lepidic adenocarcinoma and 1 due to complications during anesthesia prior to WLL. When we compared baseline data with those obtained at the end of the follow-up period, there were no significant differences in the functional data, although there was a trend toward an increase in SpO2. The median follow-up period was 45 months (range, 1-184 months). The 5-year survival rate was 82%. Conclusions: To our knowledge, this is the largest case series of patients with PAP ever conducted in Brazil. The survival rate was similar to that found at other centers. For symptomatic, hypoxemic patients, the treatment of choice is still WLL. Precautions should be taken in order to avoid complications, especially opportunistic infections.


Review Article

17 - Reperfusion in acute pulmonary thromboembolism

Reperfusão no tromboembolismo pulmonar agudo

Caio Julio Cesar dos Santos Fernandes1,2,a, Carlos Vianna Poyares Jardim1,b, José Leonidas Alves Jr1,2,c, Francisca Alexandra Gavilanes Oleas1,d, Luciana Tamie Kato Morinaga1,e, Rogério de Souza1,f

J Bras Pneumol.2018;44(3):237-243

Abstract PDF PT PDF EN Portuguese Text

Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.


Keywords: Embolism; Shock; Hypotension; Thrombolytic therapy; Reperfusion; Hemorrhage.


Images in Pulmonary Medicine

18 - Fat embolism syndrome: chest CT findings

Síndrome da embolia gordurosa: achados de TC de tórax

Alessandro Graziani1,a, Chiara Carli Moretti2,b, Federica Mirici Cappa3,c

J Bras Pneumol.2018;44(3):244

PDF PT PDF EN Portuguese Text

Letters to the Editor

19 - Response to cytotoxic chemotherapy and overall survival in non-small cell lung cancer patients with positive or negative ERCC1 expression

Resposta à quimioterapia citotóxica e sobrevida global em pacientes com câncer de pulmão não pequenas células com expressão positiva ou negativa para ERCC1

Helen Naemi Honma1,a, Maurício Wesley Perroud Jr1,b, André Moreno Morcillo2,c, José Vassallo3,d, Lair Zambon1,e

J Bras Pneumol.2018;44(3):245-246

PDF PT PDF EN Portuguese Text

20 - Hemoptysis in recurrent respiratory papillomatosis: also think about aspergillosis

Hemoptise na papilomatose respiratória recorrente: pense também em aspergilose

Giorgia Dalpiaz1,a, Sofia Asioli2,b, Stefania Damiani2,c, Gaetano Rea3,d, Edson Marchiori4,e

J Bras Pneumol.2018;44(3):247-248

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21 - Reflections upon the article "Evaluation of the impact that the changes in tuberculosis treatment implemented in Brazil in 2009 have had on disease control in the country"

Reflexões sobre o artigo "Avaliação do impacto das mudanças do tratamento da tuberculose implantadas em 2009 no controle da tuberculose pulmonar no Brasil"

Ethel Leonor Maciel1,a, José Ueleres Braga2,3,b, Adelmo Inácio Bertolde4,c, Eliana Zandonade4,d

J Bras Pneumol.2018;44(3):249-252

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Author's reply

22 - Authors' reply

Resposta dos autores

Marcelo Fouad Rabahi1,a, José Laerte Rodrigues da Silva Júnior2,3,b, Marcus Barreto Conde4,5,c

J Bras Pneumol.2018;44(3):251-252

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Year 2018 - Volume 44  - Number 4  (July/August)



1 - A teacher to remember and to emulate

Um Mestre para lembrar e copiar

Ana Luisa Godoy Fernandes1,a, Sonia Maria Faresin1,b

J Bras Pneumol.2018;44(4):253

PDF PT PDF EN Portuguese Text

2 - Community-acquired pneumonia: challenges of the situation in Brazil

Pneumonia adquirida na comunidade: os desafios da realidade brasileira

Mauro Gomes1,2,a

J Bras Pneumol.2018;44(4):254-256

PDF PT PDF EN Portuguese Text

3 -  Six-minute walk test in patients with idiopathic pulmonary fibrosis

Teste da caminhada de seis minutos em pacientes com fibrose pulmonar idiopática

José Antônio Baddini-Martinez1,a

J Bras Pneumol.2018;44(4):257-258

PDF PT PDF EN Portuguese Text

Continuing Education: Imaging

4 - Nodular fissure

Cissura nodular

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(4):259

PDF PT PDF EN Portuguese Text

Continuing Education : Scientific Methodology

5 - Twelve tips to write an abstract for a conference: advice for young and experienced investigators

Doze dicas para escrever um resumo para uma conferência: conselhos para investigadores iniciantes e experientes

Juliana Carvalho Ferreira1,2,a, Cecilia Maria Patino1,3,b

J Bras Pneumol.2018;44(4):260

PDF PT PDF EN Portuguese Text

Original Article

6 - Clinical, epidemiological, and etiological profile of inpatients with community-acquired pneumonia in a public hospital in the interior of Brazil

Perfil clínico, epidemiológico e etiológico de pacientes internados com pneumonia adquirida na comunidade em um hospital público do interior do Brasil

Laura Fuchs Bahlis1,2,3,a, Luciano Passamani Diogo3,b, Ricardo de Souza Kuchenbecker4,c, Sandra Costa Fuchs4,d

J Bras Pneumol.2018;44(4):261-266

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the patient profile, mortality rates, the accuracy of prognostic scores, and mortality-associated factors in patients with community-acquired pneumonia (CAP) in a general hospital in Brazil. Methods: This was a cohort study involving patients with a clinical and laboratory diagnosis of CAP and requiring admission to a public hospital in the interior of Brazil between March 2014 and April 2015. We performed multivariate analysis using a Poisson regression model with robust variance to identify factors associated with in-hospital mortality. Results: We included 304 patients. Approximately 70% of the patients were classified as severely ill on the basis of the severity criteria used. The mortality rate was 15.5%, and the ICU admission rate was 29.3%. After multivariate analysis, the factors associated with in-hospital mortality were need for mechanical ventilation (OR: 3.60; 95% CI: 1.85-7.47); a Charlson Comorbidity Index score > 3 (OR: 1.30; 95% CI: 1.18-1.43); and a mental Confusion, Urea, Respiratory rate, Blood pressure, and age > 65 years (CURB-65) score > 2 (OR: 1.46; 95% CI: 1.09-1.98). The mean time from patient arrival at the emergency room to initiation of antibiotic therapy was 10 h. Conclusions: The in-hospital mortality rate of 15.5% and the need for ICU admission in almost one third of the patients reflect the major impact of CAP on patients and the health care system. Individuals with a high burden of comorbidities, a high CURB-65 score, and a need for mechanical ventilation had a worse prognosis. Measures to reduce the time to initiation of antibiotic therapy may result in better outcomes in this group of patients.


Keywords: Community-acquired infections; Pneumonia; Hospital mortality; Risk factors.


7 - Six-minute walk distance and survival time in patients with idiopathic pulmonary fibrosis in Brazil

Distância no teste de caminhada de seis minutos e sobrevida na fibrose pulmonar idiopática no Brasil

Eliane Viana Mancuzo1,2,a, Maria Raquel Soares3,b, Carlos Alberto de Castro Pereira4,c

J Bras Pneumol.2018;44(4):267-272

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the cut-off point for the six-minute walk distance (6MWD) that indicates lower survival time in patients with idiopathic pulmonary fibrosis (IPF) in Brazil. Methods: This was retrospective study carried out in two referral centers for IPF. The 6MWT was performed twice, considering the highest value of the 6MWD. Various cut-off points were estimated, in absolute values and in percentage of predicted values, using ROC curves, the Kaplan-Meier method, and data from other studies. Results: The sample comprised 70 patients with IPF. The mean age was 71.9 ± 6.4 years, and 50 patients (71.4%) were male. The mean FVC was 76.6 ± 18.2% of predicted value. The mean SpO2 at rest before and after 6MWT were 93.8 ± 2.5% and 85.3 ± 6.5%, respectively. The median survival time was 44 months (95% CI: 37-51 months). The mean 6MWD was 381 ± 115 m (79.2 ± 24.0% of predicted). After the analyses, the best cut-off points for estimating survival were 6MWD < 330 m and < 70% of predicted. The median survival time of patients with a 6MWD < 330 m was 24 months (95% CI: 3-45 months), whereas that of those with a 6MWD ≥ 330 m was 59 months (95% CI: 41-77 months; p = 0.009). Similarly, the median survival times of those with a 6MWD < 70% and ≥ 70% of predicted, respectively, were 24 months (95% CI: 13-35 months) and 59 months (95% CI: 38-80 months; p = 0.013). Cox multivariate regression models including age, sex, smoking status, SpO2 at the end of the 6MWT, and FVC% showed that 6MWD remained significantly associated with survival (p = 0.003). Conclusions: Values of 6MWD < 330 m and < 70% of predicted value were associated with lower survival time in IPF patients in Brazil.


Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Exercise tolerance.


8 - Asthma control, lung function, nutritional status, and health-related quality of life: differences between adult males and females with asthma

Controle da asma, função pulmonar, estado nutricional e qualidade de vida relacionada à saúde: diferenças entre homens e mulheres adultos com asma

Gabriele Carra Forte1,a, Maria Luiza Hennemann2,b, Paulo de Tarso Roth Dalcin1,3,c

J Bras Pneumol.2018;44(4):273-278

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate health-related quality of life in asthma patients treated at a referral center in southern Brazil, identifying differences between male and female patients, as well as to evaluate differences between the males and females in terms of asthma control, lung function, and nutritional status. Methods: This was a cross-sectional study involving patients ≥ 18 years of age treated at an asthma outpatient clinic. We evaluated clinical parameters, lung function, nutritional status, and quality of life. Results: A total of 198 patients completed the study. The mean age was 56.2 ± 14.8 years, and 81.8% were female. The proportion of patients with uncontrolled asthma was higher among females than among males (63.0% vs. 44.4%; p = 0.041). The body mass index (BMI) and percentage of body fat were higher in females than in males (30.2 ± 5.8 kg/m2 vs. 26.9 ± 4.5 kg/m2 and 37.4 ± 6.4% vs. 26.5 ± 7.4%; p = 0.002 and p < 0.001, respectively). Quality of life was lower in females than in males in the following domains: symptoms (3.8 ± 1.5 vs. 4.6 ± 1.7; p = 0.006); activity limitation (3.6 ± 1.3 vs. 4.4 ± 1.5; p = 0.001); emotional function (3.6 ± 1.9 vs. 4.5 ± 1.7; p = 0.014); and environmental stimuli (3.2 ± 1.6 vs. 4.3 ± 1.9; p = 0.001). Conclusions: Male asthma patients appear to fare better than do female asthma patients in terms of health-related quality of life, asthma control, BMI, percentage of body fat, and comorbidities.


Keywords: Asthma; Nutritional status; Quality of life; Adult.


9 - Correlation of lung function and respiratory muscle strength with functional exercise capacity in obese individuals with obstructive sleep apnea syndrome

Associação entre função pulmonar, força muscular respiratória e capacidade funcional de exercício em indivíduos obesos com síndrome da apneia obstrutiva do sono

Thays Maria da Conceição Silva Carvalho1,a, Anísio Francisco Soares2,b, Danielle Cristina Silva Climaco3,c, Isaac Vieira Secundo3,d, Anna Myrna Jaguaribe de Lima2,e

J Bras Pneumol.2018;44(4):279-284

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate lung function and inspiratory muscle strength, correlating them with exercise tolerance, in obese individuals with obstructive sleep apnea syndrome (OSAS). Methods: The sample comprised 31 adult subjects with moderate-to-severe OSAS diagnosed by polysomnography. We used spirometry to measure FVC, FEV1, and FVC/FEV1 ratio, using pressure manometry to measure MIP and MEP. The incremental shuttle walk test (ISWT) and the six-minute walk test (6MWT) were used in order to determine functional exercise capacity. Results: In this sample, the mean values for FVC (% of predicted), FEV1 (% of predicted): MIP, and MEP were 76.4 ± 12.3%, 80.1 ± 6.3%, 60.0 ± 21.9 cmH2O, and 81.3 ± 22.2 cmH2O, respectively. The mean distances covered on the ISWT and 6MWT were 221 ± 97 m and 480.8 ± 67.3 m, respectively. The ISWT distance showed moderate positive correlations with FVC (r = 0.658; p = 0.001) and FEV1 (r = 0.522; p = 0.003). Conclusions: In this sample of obese subjects with untreated OSAS, lung function, inspiratory muscle strength, and exercise tolerance were all below normal. In addition, we found that a decline in lung function, but not in respiratory muscle strength, was associated with exercise tolerance in these patients.


Keywords: Sleep apnea syndromes; Exercise tolerance; Respiratory function tests; Respiratory muscles.


10 - Translation, cross-cultural adaptation, and reliability of the Understanding COPD questionnaire for use in Brazil

Tradução, adaptação transcultural e confiabilidade do questionário Understanding COPD para uso no Brasil

Anamaria Fleig Mayer1,2,a, Aline Almeida Gulart1,2,b, Karoliny dos Santos1,c, Katerine Cristhine Cani1,2,d, Manuela Karloh1,2,e, Brenda O'Neill3,f

J Bras Pneumol.2018;44(4):285-291

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To translate the Understanding COPD (UCOPD) questionnaire into Portuguese, adapt it for use in Brazil, and assess its reliability. Methods: The UCOPD questionnaire consists of two sections, designated section A and section B. Section A comprises 18 items divided into three domains: "About COPD", "Managing Symptoms of COPD", and "Accessing Help and Support". Section B includes five questions regarding patient satisfaction with the educational component of pulmonary rehabilitation programs. The UCOPD questionnaire was applied twice on the same day by two different raters (with a 10-min interval between applications) and once again 15-20 days later. The Wilcoxon test was used in order to compare the scores among applications. Reliability was assessed by the intraclass correlation coefficient and Bland-Altman plots. Results: The study sample consisted of 50 COPD patients (35 men; mean age, 65.3 ± 7.91 years; mean FEV1, 36.4 ± 16.2% of the predicted value). Inter-rater intraclass correlation coefficients for section A total scores and domain scores ranged from moderate to high. Section A scores and domain scores had no significant differences regarding test-retest reliability (p < 0.05). The test-retest and inter-rater Cronbach's alpha coefficients for section A total scores were 0.93 and 0.86, respectively (p < 0.001). There were no floor or ceiling effects. Conclusions: The Brazilian Portuguese version of the UCOPD questionnaire is reliable.


Keywords: Pulmonary disease, chronic obstructive; reproducibility of results; Health knowledge, attitudes, practice.


11 - Hyperhidrosis: prevalence and impact on quality of life

Hiperidrose: prevalência e impacto na qualidade de vida

Erica Nishida Hasimoto1,a, Daniele Cristina Cataneo2,b, Tarcísio Albertin dos Reis3,c, Antonio José Maria Cataneo2,d

J Bras Pneumol.2018;44(4):292-298

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of primary hyperhidrosis in the city of Botucatu, Brazil, and to evaluate how this disorder affects the quality of life in those suffering from it. Methods: A population survey was conducted in order to identify cases of hyperhidrosis among residents in the urban area of the city, selected by systematic cluster sampling. In accordance with the census maps of the city, the sample size should be at least 4,033 participants. Ten interviewers applied a questionnaire that evaluated the presence of excessive sweating and invited the subjects who reported hyperhidrosis to be evaluated by a physician in order to confirm the diagnosis. Results: A total of 4,133 residents, in 1,351 households, were surveyed. Excessive sweating was reported by 85 residents (prevalence = 2.07%), of whom 51 (60%) were female. Of those 85 respondents, 51 (60%) agreed to undergo medical evaluation to confirm the diagnosis and only 23 (45%) were diagnosed with primary hyperhidrosis (prevalence = 0.93%). Of the 23 subjects diagnosed with primary hyperhidrosis, 11 (48%) reported poor or very poor quality of life. Conclusions: Although the prevalence of self-reported excessive sweating was greater than 2%, the actual prevalence of primary hyperhidrosis in our sample was 0.93% and nearly 50% of the respondents with primary hyperhidrosis reported impaired quality of life.


Keywords: Hyperhidrosis/epidemiology; Hyperhidrosis/diagnosis; Quality of life.


12 - Spirometry in patients screened for coronary artery disease: is it useful?

Espirometria em pacientes submetidos a investigação para detecção de doença arterial coronariana: é útil?

Frederico Leon Arrabal Fernandes1,a, Regina Maria Carvalho-Pinto1,b, Rafael Stelmach1,c, João Marcos Salge1,d, Carlos Eduardo Rochitte2,e, Eliane Cardoso dos Santos Souza1,f, Janaina Danielle Pessi1,g, Alberto Cukier1,h

J Bras Pneumol.2018;44(4):299-306

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of spirometric abnormalities in patients screened for coronary artery disease (CAD) and the risk factors for lung function impairment. Methods: Patients referred for cardiac CT underwent spirometry and were subsequently divided into two groups, namely normal lung function and abnormal lung function. The prevalence of spirometric abnormalities was calculated for the following subgroups of patients: smokers, patients with metabolic syndrome, elderly patients, and patients with obstructive coronary lesions. All groups and subgroups were compared in terms of the coronary artery calcium score and the Duke CAD severity index. Results: A total of 205 patients completed the study. Of those, 147 (72%) had normal lung function and 58 (28%) had abnormal lung function. The median coronary artery calcium score was 1 for the patients with normal lung function and 36 for those with abnormal lung function (p = 0.01). The mean Duke CAD severity index was 15 for the former and 27 for the latter (p < 0.01). Being a smoker was associated with the highest OR for abnormal lung function, followed by being over 65 years of age and having obstructive coronary lesions. Conclusions: The prevalence of spirometric abnormalities appears to be high in patients undergoing cardiac CT for CAD screening. Smokers, elderly individuals, and patients with CAD are at an increased risk of lung function abnormalities and therefore should undergo spirometry. ( identifier: NCT01734629 [])


Keywords: Pulmonary disease, chronic obstructive; Spirometry; Coronary disease; Tomography, X-ray computed.


13 - CT-guided percutaneous core needle biopsy of pulmonary nodules smaller than 2 cm: technical aspects and factors influencing accuracy

Biópsia percutânea com agulha grossa, guiada por TC, de nódulos pulmonares menores que 2 cm: aspectos técnicos e fatores que influenciam a precisão

Juliano Ribeiro de Andrade1,a, Rafael Dahmer Rocha1,b, Priscila Mina Falsarella1,c, Antonio Rahal Junior1,d, Ricardo Sales dos Santos2,e, Juliana Pereira Franceschini3,f, Hiran Chrishantha Fernando4,g, Rodrigo Gobbo Garcia1,h

J Bras Pneumol.2018;44(4):307-314

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the diagnostic accuracy of CT-guided percutaneous core needle biopsy (CT-CNB) of pulmonary nodules ≤ 2 cm, as well as to identify factors influencing the accuracy of the procedure and its morbidity. Methods: This was a retrospective, single-center study of 170 consecutive patients undergoing CT-CNB of small pulmonary nodules (of ≤ 2 cm) between January of 2010 and August of 2015. Results: A total of 156 CT-CNBs yielded a definitive diagnosis, the overall diagnostic accuracy being 92.3%. Larger lesions were associated with a higher overall accuracy (OR = 1.30; p = 0.007). Parenchymal hemorrhage occurring during the procedure led to lower accuracy rates (OR = 0.13; p = 0.022). Pneumothorax was the most common complication. A pleura-to-lesion distance > 3 cm was identified as a risk factor for pneumothorax (OR = 16.94), whereas performing a blood patch after biopsy was a protective factor for pneumothorax (OR = 0.18). Conclusions: Small nodules (of < 2 cm) represent a technical challenge for diagnosis. CT-CNB is an excellent diagnostic tool, its accuracy being high.


Keywords: Image-guided biopsy; Neoplasms; Lung.


14 - Validation of a bioelectrical impedance analysis system for body composition assessment in patients with COPD

Validação de um sistema de análise de impedância bioelétrica para a avaliação da composição corporal de pacientes com DPOC

Fernanda Rodrigues Fonseca1,2,a, Manuela Karloh2,3,b, Cintia Laura Pereira de Araujo1,2,c, Cardine Martins dos Reis1,2,d, Anamaria Fleig Mayer1,2,3,e

J Bras Pneumol.2018;44(4):315-320

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the validity of an eight-contact electrode bioelectrical impedance analysis (BIA) system within a household scale for assessing whole body composition in COPD patients. Methods: Seventeen patients with COPD (mean age = 67 ± 8 years; mean FEV1 = 38.6 ± 16.1% of predicted; and mean body mass index = 24.7 ± 5.4 kg/m2) underwent dual-energy X-ray absorptiometry (DEXA) and an eight-contact electrode BIA system for body composition assessment. Results: There was a strong inter-method correlation for fat mass (r = 0.95), fat-free mass (r = 0.93), and lean mass (r = 0.93), but the correlation was moderate for bone mineral content (r = 0.73; p < 0.01 for all). In the agreement analysis, the values between DEXA and the BIA system differed by only 0.15 kg (−6.39 to 6.70 kg), 0.26 kg (−5.96 to 6.49 kg), −0.13 kg (−0.76 to 0.50 kg), and −0.55 kg (−6.71 to 5.61 kg) for fat-free mass, lean mass, bone mineral content, and fat mass, respectively. Conclusions: The eight-contact electrode BIA system showed to be a valid tool in the assessment of whole body composition in our sample of patients with COPD.


Keywords: Pulmonary disease, chronic obstructive; Body composition; Electric impedance.


Review Article

15 - Patient-ventilator asynchrony

Assincronia paciente-ventilador

Marcelo Alcantara Holanda1,2,a, Renata dos Santos Vasconcelos2,b, Juliana Carvalho Ferreira3,c, Bruno Valle Pinheiro4,d

J Bras Pneumol.2018;44(4):321-333

Abstract PDF PT PDF EN Portuguese Text

Patient-ventilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.


Keywords: Respiration, artificial; Respiratory insufficiency; Interactive ventilatory support.


Images in Pulmonary Medicine

16 - Presence of gas in an unusual place: spontaneous pneumomediastinum (Hamman's syndrome)

Presença de gás em um local incomum: pneumomediastino espontâneo (síndrome de Hamman)

Nicholas Oliveira Duarte1,a, Camila Hino Verdelho1,b, Rodolfo Mendes Queiroz2,3,c

J Bras Pneumol.2018;44(4):334

PDF PT PDF EN Portuguese Text

Letters to the Editor

17 - Hyperimmunoglobulin E syndrome (Job syndrome): chest CT findings

Síndrome de hiperimunoglobulina E (síndrome de Jó): achados da TC de tórax

Pablo Rydz Pinheiro Santana1,2,a, Augusto Kreling Medeiros1,b, Cinthia Callegari Barbisan1,c, Antônio Carlos Portugal Gomes1,d, Edson Marchiori3,e

J Bras Pneumol.2018;44(4):335-336

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18 - Left main coronary artery compression in a patient with portopulmonary hypertension

Compressão de tronco de artéria coronária esquerda em paciente com hipertensão portopulmonar

Iara Teixeira de Araújo1,a, Pammela Jacomeli Lembi1,b, Eduardo Belisario Falchetto2,c, Ricardo de Amorim Corrêa3,4,d

J Bras Pneumol.2018;44(4):337-338

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19 - Patient-ventilator asynchrony. Ahead of print

Assincronia paciente-ventilador. Versão ahead of print

Marcelo Alcantara Holanda1,2,a, Renata dos Santos Vasconcelos2,b, Juliana Carvalho Ferreira3,c, Bruno Valle Pinheiro4,d

J Bras Pneumol.2018;44(4):339

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20 - Tuberculosis treatment

Tratamento da tuberculose

Marcelo Fouad Rabahi1,2, José Laerte Rodrigues da Silva Júnior2, Anna Carolina Galvão Ferreira1,3, Daniela Graner Schuwartz Tannus-Silva1, Marcus Barreto Conde4,5

J Bras Pneumol.2018;44(4):340

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Year 2018 - Volume 44  - Number 5  (September/October)



1 - Epidemiology of asthma: it is necessary to expand our concepts

Epidemiologia da asma: é necessário ampliar nossos conceitos

Maria Alenita de Oliveira1,2,a

J Bras Pneumol.2018;44(5):341-342

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2 - Getting to know our pneumococcus

Conhecimento do nosso pneumococo

Fernando Luiz Cavalcanti Lundgren1,2,a

J Bras Pneumol.2018;44(5):343-344

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3 - Electronic cigarettes-the new playbook and revamping of the tobacco industry

Cigarro eletrônico-repaginação e renovação da indústria do tabagismo

Ubiratan Paula Santos1,a

J Bras Pneumol.2018;44(5):345-346

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4 - Global TB Network: working together to eliminate tuberculosis

Global TB Network: trabalhando juntos para eliminar a tuberculose

Denise Rossato Silva1,a, Adrian Rendon2,b, Jan-Willem Alffenaar3,c, Jeremiah Muhwa Chakaya4,5,d, Giovanni Sotgiu6,e, Susanna Esposito7,f, Giovanni Battista Migliori8,g

J Bras Pneumol.2018;44(5):347-349

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5 - The importance of strong fundamentals in scientific methodology

A importância de fundamentos robustos em metodologia científica

Rogério Souza1,2

J Bras Pneumol.2018;44(5):350-351

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Continuing Education: Imaging

6 - Paravertebral mass

Massa paravertebral

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(5):352


Continuing Education : Scientific Methodology

7 - Meeting the assumptions of statistical tests: an important and often forgotten step to reporting valid results

Atender as premissas dos testes estatísticos: um passo importante e muitas vezes negligenciado na comunicação de resultados válidos

Cecilia Maria Patino1,2,a Juliana Carvalho Ferreira1,3,b

J Bras Pneumol.2018;44(5):353

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Original Article

8 - Asthma mortality in Brazil, 1980-2012: a regional perspective

Mortalidade por asma no Brasil, 1980-2012: uma perspectiva regional

Thaís de Sá Brito1,a, Ronir Raggio Luiz2,b, José Roberto Lapa e Silva3,c, Hisbello da Silva Campos4,5,d

J Bras Pneumol.2018;44(5):354-360

Abstract PDF PT PDF EN Portuguese Text

Objective: To estimate asthma mortality rates in Brazil for the period 1980-2012. Methods: On the basis of data from the Brazilian National Ministry of Health Mortality Database, we estimated mortality rates by calculating moving averages from a municipal perspective that would allow an evaluation differentiating between urban, rural, and intermediate (rurban) Brazil during the period 2002-2012. Trends were assessed using simple linear regression. Results: On average, 2,339 asthma-related deaths were reported per year during the study period. Asthma ranged from the 53rd to 95th leading cause of death. There was a decrease in asthma mortality rates in the country, from 1.92/100,000 population in 1980 to 1.21/100,000 population in 2012. From the municipal perspective, rates fell in urban and rurban Brazil, but increased in rural Brazil, except in the 5-34-year age group. Asthma mortality rates fell in the population under 25 years of age and increased among those over 74 years of age. Rates were always higher in females. Conclusions: Asthma mortality rates in Brazil have been decreasing slightly, with the decrease being more marked in the decade 2002-2012. Only the northeastern region of Brazil showed the opposite trend. Asthma mortality rates in urban and rurban Brazil showed a downward trend similar to that of the national scenario, whereas rural Brazil showed the opposite behavior. Analysis by age group showed that rates decreased among younger individuals and increased among the elderly aged ≥ 75 years.


Keywords: Asthma/mortality; Brazil; urban population; rural population.


9 - Theoretical pneumococcal vaccine coverage: analysis of serotypes isolated from inpatients at a tertiary care hospital

Cobertura vacinal pneumocócica teórica: análise de sorotipos isolados de pacientes internados em hospital terciário

Cynthia Rocha Dullius1,a, Luciana Zani2,b, José Miguel Chatkin2,c

J Bras Pneumol.2018;44(5):361-366

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate Streptococcus pneumoniae serotypes isolated from an inpatient population at a tertiary care hospital, in order to determine the theoretical coverage of the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPV23). Methods: This was a cross-sectional study involving 118 inpatients at the Hospital São Lucas, in the city of Porto Alegre, Brazil, whose cultures of blood, cerebrospinal fluid, or other sterile body fluid specimens, collected between January 2005 and December 2016, yielded pneumococcal isolates. The theoretical vaccine coverage was studied in relation to the serotypes identified in the sample and their relationship with those contained in the pneumococcal vaccines available in Brazil. Results: The majority of the population was male (n = 66; 55.9%), with a median age of 57 years (interquartile range: 33-72 years). The most common manifestation was pneumonia, and the pneumococcus was most commonly isolated from blood cultures. More than one fourth of the study population had some degree of immunosuppression (n = 34; 28.8%). Of the total sample, 39 patients (33.1%) died. There were no significant associations between mortality and comorbidity type, ICU admission, or need for mechanical ventilation. The theoretical vaccine coverage of PPV23 alone and PCV13 plus PPV23 was 31.4% and 50.8%, respectively. Conclusions: If the patients in this sample had been previously vaccinated with PCV13 plus PPV23, theoretically, 50.8% of the cases of invasive pneumococcal disease that required hospital admission could potentially have been prevented. Invasive pneumococcal disease should be prevented by vaccination not only of children and the elderly but also of adults in their economically productive years, so as to reduce the socioeconomic costs, morbidity, and mortality still associated with the disease, especially in underdeveloped countries.


Keywords: Keywords: Pneumococcal infections; Serotyping; Tertiary care centers.


10 - Electronic cigarette awareness and use among students at the Federal University of Mato Grosso, Brazil

Conhecimento e uso do cigarro eletrônico entre estudantes da Universidade Federal de Mato Grosso

Wemerson José Corrêa de Oliveira1,a, Alexandre Figueiredo Zobiole1,b, Claudia Bonadiman de Lima1,c, Rebeca Melo Zurita1,d, Pedro Eduarto Muniz Flores1,e, Luís Guilherme Val Rodrigues1,f, Raissa Carolina de Assis Pinheiro1,g, Victor Francisco Figueiredo Rocha Soares e Silva1,h

J Bras Pneumol.2018;44(5):367-369

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the prevalence of electronic cigarette (e-cigarette) awareness and experimentation among university students, as well as the characteristics associated with that awareness. Methods: This was a cross-sectional study, conducted in 2015, in which 489 university students at the Federal University of Mato Grosso (Cuiabá campus), Brazil, were interviewed with the use of a specific questionnaire. We estimated the prevalence of e-cigarette awareness and use, as well as analyzing the major characteristics associated with that awareness and use. Results: The prevalence of e-cigarette awareness was 37%, and the rate of e-cigarette experimentation was 2.7%. Awareness of e-cigarettes was found to be associated with marital status, work status, the level of parental education, and the presence or absence of smokers in the family. Conclusions: A high proportion of university students were aware of e-cigarettes. Although the prevalence of those who had experimented with e-cigarettes was low, there is concern that there could be an increase in the use of these types of device. There is a need for measures targeting university students, in order to build awareness of and prevent e-cigarette use.


Keywords: Electronic Nicotine Delivery Systems; Young adult; Smoking.


11 - Functional capacity measurement: reference equations for the Glittre Activities of Daily Living test

Avaliação da capacidade funcional: equações de referência para o teste Glittre Activities of Daily Living

Cardine Martins dos Reis1,2,a, Manuela Karloh1,3,b, Fernanda Rodrigues Fonseca1,2,c, Roberta Rodolfo Mazzali Biscaro1,2,d, Giovana Zarpellon Mazo4,5,e, Anamaria Fleig Mayer1,2,3,5,f

J Bras Pneumol.2018;44(5):370-377

Abstract PDF PT PDF EN Portuguese Text

Objective: To develop reference equations for the Glittre Activities of Daily Living test (Glittre ADL-test) on the basis of anthropometric and demographic variables in apparently healthy individuals. A secondary objective was to determine the reliability of the equations in a sample of COPD patients. Methods: This was a cross-sectional study including 190 apparently healthy individuals (95 males; median age, 54.5 years [range, 42-65]; median FEV1 = 97% [range, 91-105.2]; and median FVC = 96% [range, 88.5-102]) recruited from the general community and 74 COPD patients (55 males; mean age, 65 ± 8 years; body mass index [BMI] = 25.9 ± 4.7 kg/m2; FEV1 = 36.1 ± 14.1%; and FVC = 62.7 ± 16.1%) recruited from a pulmonary rehabilitation center. Results: The mean time to complete the Glittre ADL-test was 2.84 ± 0.45 min. In the stepwise multiple linear regression analysis, age and height were selected as Glittre ADL-test performance predictors, explaining 32.1% (p < 0.01) of the total variance. Equation 1 was as follows: Glittre ADL-testpredicted = 3.049 + (0.015 × ageyears) + (−0.006 × heightcm). Equation 2 included age and BMI and explained 32.3% of the variance in the test, the equation being as follows: Glittre ADL-testpredicted = 1.558 + (0.018 × BMI) + (0.016 × ageyears). Conclusions: The reference equations for the time to complete the Glittre ADL-test were based on age, BMI, and height as independent variables and can be useful for predicting the performance of adult individuals. The predicted values appear to be reliable when applied to COPD patients.


Keywords: Activities of daily living; Exercise test; Reference values.


12 - Does methylene blue attenuate inflammation in nonischemic lungs after lung transplantation?

O azul de metileno atenua a inflamação em pulmões não isquêmicos após transplante pulmonar?

Marcus da Matta Abreu1,a, Francine Maria de Almeida1,b, Kelli Borges dos Santos2,c, Emílio Augusto Campos Pereira de Assis3,d, Rafael Kenji Fonseca Hamada4,e, Fabio Biscegli Jatene1,f, Paulo Manuel Pêgo-Fernandes1,g, Rogerio Pazetti1,h

J Bras Pneumol.2018;44(5):378-382

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate whether methylene blue (MB) could minimize the effects of ischemia-reperfusion injury in the nonischemic lung on a lung transplantation rodent model. Methods: Forty female Sprague-Dawley rats were divided into 20 donors and 20 recipients. The 20 recipient rats were divided into two groups (n = 10) according to the treatment (0.9% saline vs. 1% MB solutions). All animals underwent unilateral lung transplantation. Recipients received 2 mL of saline or MB intraperitoneally prior to transplantation. After 2 h of reperfusion, the animals were euthanized and histopathological and immunohistochemical analyses were performed in the nonischemic lung. Results: There was a significant decrease in inflammation-neutrophil count and intercellular adhesion molecule-1 (ICAM-1) expression in lung parenchyma were higher in the saline group in comparison with the MB group-and in apoptosis-caspase-3 expression was higher in the saline group and Bcl-2 expression was higher in MB group. Conclusions: MB is an effective drug for the protection of nonischemic lungs against inflammation and apoptosis following unilateral lung transplantation in rats.


Keywords: Reperfusion injury; Methylene blue; Lung transplantation; Apoptosis; Inflammation.


13 - The patient profile of individuals with Alpha-1 antitrypsine gene mutations at a referral center in Brazil

Perfil dos pacientes com mutação no gene da alfa-1 antitripsina em um centro de referência no Brasil

Manuela Brisot Felisbino1,a, Frederico Leon Arrabal Fernandes2,b, Maria Cecília Nieves Maiorano de Nucci2,c, Regina Maria de Carvalho Pinto2,d, Emilio Pizzichini1,e, Alberto Cukier2,f

J Bras Pneumol.2018;44(5):383-389

Abstract PDF PT PDF EN Portuguese Text

Objective: The clinical, functional, radiological and genotypic descriptions of patients with an alpha-1 antitrypsin (A1AT) gene mutation in a referral center for COPD in Brazil. Methods: A cross-sectional study of patients with an A1AT gene mutation compatible with deficiency. We evaluated the A1AT dosage and genotypic, demographic, clinical, tomographic, and functional characteristics of these patients. Results: Among the 43 patients suspected of A1AT deficiency (A1ATD), the disease was confirmed by genotyping in 27 of them. The A1AT median dosage was 45 mg/dL, and 4 patients (15%) had a normal dosage. Median age was 54, 63% of the patients were male, and the respiratory symptoms started at the age of 40. The median FEV1 was 1.37L (43% predicted). Tomographic emphysema was found in 77.8% of the individuals. The emphysema was panlobular in 76% of them and 48% had lower lobe predominance. The frequency of bronchiectasis was 52% and the frequency of bronchial thickening was 81.5%. The most common genotype was Pi*ZZ in 40.7% of participants. The other genotypes found were: Pi*SZ (18.5%), PiM1Z (14.8%), Pi*M1S (7.4%), Pi*M2Z (3.7%), Pi*M1I (3.7%), Pi*ZMnichinan (3.7%), Pi*M3Plowell (3.7%), and Pi*SF (3.7%). We did not find any significant difference in age, smoking load, FEV1, or the presence of bronchiectasis between the groups with a normal and a reduced A1AT dosage, neither for 1 nor 2-allele mutation for A1ATD. Conclusions: Our patients presented a high frequency of emphysema, bronchiectasis and bronchial thickening, and early-beginning respiratory symptoms. The most frequent genotype was Pi*ZZ. Heterozygous genotypes and normal levels of A1AT also manifested significant lung disease.


Keywords: Alpha-1 antitrypsin; Emphysema; Alleles.


14 - Impact of adherence to long-term oxygen therapy on patients with COPD and exertional hypoxemia followed for one year

Impacto da adesão à oxigenoterapia de longa duração em pacientes com DPOC e hipoxemia decorrente do esforço acompanhados durante um ano

Carolina Bonfanti Mesquita1,a, Caroline Knaut1,b, Laura Miranda de Oliveira Caram1,c, Renata Ferrari1,d, Silmeia Garcia Zanati Bazan2,e, Irma Godoy1,f, Suzana Erico Tanni3,g

J Bras Pneumol.2018;44(5):390-397

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the impact of adherence to long-term oxygen therapy (LTOT) on quality of life, dyspnea, and exercise capacity in patients with COPD and exertional hypoxemia followed for one year. Methods: Patients experiencing severe hypoxemia during a six-minute walk test (6MWT) performed while breathing room air but not at rest were included in the study. At baseline and after one year of follow-up, all patients were assessed for comorbidities, body composition, SpO2, and dyspnea, as well as for anxiety and depression, having also undergone spirometry, arterial blood gas analysis, and the 6MWT with supplemental oxygen. The Saint George's Respiratory Questionnaire (SGRQ) was used in order to assess quality of life, and the Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity (BODE) index was calculated. The frequency of exacerbations and the mortality rate were noted. Treatment nonadherence was defined as LTOT use for < 12 h per day or no LTOT use during exercise. Results: A total of 60 patients with COPD and exertional hypoxemia were included in the study. Of those, 10 died and 11 experienced severe hypoxemia during follow-up, 39 patients therefore being included in the final analysis. Of those, only 18 (46.1%) were adherent to LTOT, showing better SGRQ scores, higher SpO2 values, and lower PaCO2 values than did nonadherent patients. In all patients, SaO2, the six-minute walk distance, and the BODE index worsened after one year. There were no differences between the proportions of adherence to LTOT at 3 and 12 months of follow-up. Conclusions: Quality of life appears to be lower in patients with COPD and exertional hypoxemia who do not adhere to LTOT than in those who do. In addition, LTOT appears to have a beneficial effect on COPD symptoms (as assessed by SGRQ scores). (Brazilian Registry of Clinical Trials - ReBEC; identification number RBR‑9b4v63 [])


Keywords: Respiratory insufficiency; Pulmonary disease, chronic obstructive; Patient compliance; Hypoxia; Oxygen inhalation therapy.


15 - Noncompliance with the law prohibiting the sale of cigarettes to minors in Brazil: an inconvenient truth

Descumprimento da lei que proíbe a venda de cigarros para menores de idade no Brasil: uma verdade inconveniente

André Salem Szklo1,a,Tânia Maria Cavalcante2,b

J Bras Pneumol.2018;44(5):398-404

Abstract PDF PT PDF EN Portuguese Text

Objective: To draw up an up-to-date scenario of compliance with the law prohibiting the sale of cigarettes to minors. Methods: We used data about youth access to cigarette purchase that were obtained through a nationwide survey conducted in 2015 among students aged 13-17 years. We estimated simple proportions of attempts to buy cigarettes, success of attempts, purchase of cigarettes on a regular basis, and purchase of cigarettes on a regular basis in a store or bar. All estimates were stratified by gender, age group, and Brazilian macro-region. Crude absolute difference and adjusted absolute difference in the proportion of smokers in each category by variable of interest were analyzed by a generalized linear model with binomial distribution and identity link function. Results: Approximately 7 in every 10 adolescent smokers attempted to buy cigarettes at least once in the 30 days prior to the survey. Of those, approximately 9 in every 10 were successful, and individuals aged 16-17 years (vs. those aged 13-15 years) were less often prevented from buying cigarettes (adjusted absolute difference, 8.1%; p ≤ 0.05). Approximately 45% of all smokers aged 13-17 years in Brazil reported buying their own cigarettes on a regular basis without being prevented from doing so, and, of those, 80% reported buying them in a store or bar (vs. from a street vendor). Conclusions: Our findings raise an important public health concern and may contribute to supporting educational and surveillance measures to enforce compliance with existing anti-tobacco laws in Brazil, which have been disregarded.


Keywords: Smoking/epidemiology; Smoking/legislation & jurisprudence; Adolescent behavior; Public health.


Special Article

16 - 2018 recommendations for the management of community acquired pneumonia

Recomendações para o manejo da pneumonia adquirida na comunidade 2018

Ricardo de Amorim Corrêa1,a, Andre Nathan Costa2,b, Fernando Lundgren3.c, Lessandra Michelim4,d, Mara Rúbia Figueiredo5,e, Marcelo Holanda6,f, Mauro Gomes7,g, Paulo José Zimermann Teixeira8,h, Ricardo Martins9,i, Rodney Silva10,j, Rodrigo Abensur Athanazio2,k, Rosemeri Maurici da Silva11,l, Mônica Corso Pereira12,m

J Bras Pneumol.2018;44(5):405-423

Abstract PDF PT PDF EN Portuguese Text

Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.


Keywords: Pneumonia/diagnosis; Pneumonia/prevention & control; Pneumonia/therapy; Pneumonia/drug therapy.


Review Article

17 - The pulmonary microbiome: challenges of a new paradigm

Microbioma pulmonar: desafios de um novo paradigma

André Nathan Costa1,a, Felipe Marques da Costa1,b, Silvia Vidal Campos1,c, Roberta Karla Salles1,d, Rodrigo Abensur Athanazio1,e

J Bras Pneumol.2018;44(5):424-432

Abstract PDF PT PDF EN Portuguese Text

The study of the human microbiome-and, more recently, that of the respiratory system-by means of sophisticated molecular biology techniques, has revealed the immense diversity of microbial colonization in humans, in human health, and in various diseases. Apparently, contrary to what has been believed, there can be nonpathogenic colonization of the lungs by microorganisms such as bacteria, fungi, and viruses. Although this physiological lung microbiome presents low colony density, it presents high diversity. However, some pathological conditions lead to a loss of that diversity, with increasing concentrations of some bacterial genera, to the detriment of others. Although we possess qualitative knowledge of the bacteria present in the lungs in different states of health or disease, that knowledge has advanced to an understanding of the interaction of this microbiota with the local and systemic immune systems, through which it modulates the immune response. Given this intrinsic relationship between the microbiota and the lungs, studies have put forth new concepts about the pathophysiological mechanisms of homeostasis in the respiratory system and the potential dysbiosis in some diseases, such as cystic fibrosis, COPD, asthma, and interstitial lung disease. This departure from the paradigm regarding knowledge of the lung microbiota has made it imperative to improve understanding of the role of the microbiome, in order to identify possible therapeutic targets and to develop innovative clinical approaches. Through this new leap of knowledge, the results of preliminary studies could translate to benefits for our patients.


Keywords: Microbiota; Microbiology; Immune system.


Images in Pulmonary Medicine

18 - Hamman's syndrome

Síndrome de Hamman

João Filipe Alves Mesquita Rosinhas1,a, Sara Maria Castelo Branco Soares1,b, Adelina Branca Madeira Pereira2,c

J Bras Pneumol.2018;44(5):433

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19 - Clinical aspects of the Mycobacterium abscessus complex

Aspectos clínicos do complexo Mycobacterium abscessus

Beuy Joob1,a, Viroj Wiwanitkit2,b

J Bras Pneumol.2018;44(5):434

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Author's reply

20 - Authors' reply

Resposta dos autores

José Tadeu Colares Monteiro1,a

J Bras Pneumol.2018;44(5):435

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Letters to the Editor

21 - Smoking cessation before initiation of chemotherapy in metastatic non-small cell lung cancer: influence on prognosis

Cessação tabágica antes do início da quimioterapia no câncer de pulmão de células não pequenas metastático: influência sobre o prognóstico

Ana Rita Diegues Linhas1,a, Margarida Carmo Pinho Dias1,2,b, Ana Maria Paixão Barroso1,2,c

J Bras Pneumol.2018;44(5):436-438

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22 - Omalizumab as add-on therapy in patients with asthma and allergic bronchopulmonary aspergillosis

Omalizumabe como terapia adicional no tratamento da aspergilose broncopulmonar alérgica em asmáticos

Fernanda Sales da Cunha1,a, Solange Oliveira Rodrigues Valle1,b, José Elabras Filho1,c, Sérgio Duarte Dortas Júnior1,2,d, Alfeu Tavares França1,e

J Bras Pneumol.2018;44(5):439-441

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23 - Lung transplantation with extracorporeal membrane oxygenation as intraoperative support

Transplante pulmonar com oxigenação extracorpórea por membrana como suporte intraoperatório

Mariana Schettini-Soares1,a, Pedro Henrique Cunha Leite1,b, Ludhmila Abrahão Hajjar2,c, André Nathan Costa3,d, Paulo Manuel Pêgo-Fernandes1,e, Marcos Naoyuki Samano1,f

J Bras Pneumol.2018;44(5):442-444

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Year 2018 - Volume 44  - Number 6  (November/December)



1 - The need for a balance between highly prevalent diseases and neglected diseases

A necessidade de equilíbrio entre doenças de alta prevalência e doenças negligenciadas

Rogério Souza1,2,a

J Bras Pneumol.2018;44(6):445-446

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Continuing Education: Imaging

2 - Pleural calcifications

Calcificações pleurais

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(6):

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Continuing Education : Scientific Methodology

3 - Critical appraisal of the literature. Why do we care?

Avaliação crítica da literatura. Por que nos importamos?

Juliana Carvalho Ferreira1,2,a, Cecilia Maria Patino1,3,b

J Bras Pneumol.2018;44(6):448

PDF PT PDF EN Portuguese Text

Original Article

4 - Spirometry reference values for Black adults in Brazil

Valores de referência para espirometria forçada em adultos negros no Brasil

Tarciane Aline Prata1,a, Eliane Mancuzo2,3,b, Carlos Alberto de Castro Pereira4,c,Silvana Spíndola de Miranda2,d, Larissa Voss Sadigursky5,e, Camila Hirotsu6,f, Sérgio Tufik6,g

J Bras Pneumol.2018;44(6):449-455

Abstract PDF PT PDF EN Portuguese Text

Objective: To derive reference equations for spirometry in healthy Black adult never smokers in Brazil, comparing them with those published in 2007 for White adults in the country. Methods: The examinations followed the standards recommended by the Brazilian Thoracic Association, and the spirometers employed met the technical requirements set forth in the guidelines of the American Thoracic Society/European Respiratory Society. The lower limits were defined as the 5th percentile of the residuals. Results: Reference equations and limits were derived from a sample of 120 men and 124 women, inhabitants of eight Brazilian cities, all of whom were evaluated with a flow spirometer. The predicted values for FVC, FEV1 , FEV1 /FVC ratio, and PEF were better described by linear equations, whereas the flows were better described by logarithmic equations. The FEV1 and FVC reference values derived for Black adults were significantly lower than were those previously derived for White adults, regardless of gender. Conclusions: The fact that the predicted spirometry values derived for the population of Black adults in Brazil were lower than those previously derived for White adults in the country justifies the use of an equation specific to the former population.


Keywords: Spirometry; Reference values; African continental ancestry group.


5 - Longitudinal follow-up of cardiac vagal activity in individuals undergoing endoscopic thoracic sympathectomy

Acompanhamento longitudinal da atividade vagal cardíaca de indivíduos submetidos à simpatectomia torácica endoscópica

Ana Paula Ferreira1,2,3,a, Plinio dos Santos Ramos1,2,3,b, Jorge Montessi2,3,4,c, Flávia Duarte Montessi2,3,d, Eveline Montessi Nicolini3,4,e, Edmilton Pereira de Almeida4,f, Djalma Rabelo Ricardo1,2,3,g

J Bras Pneumol.2018;44(6):456-460

Abstract PDF PT PDF EN Portuguese Text

Objective: To conduct a longitudinal investigation of cardiac vagal activity (CVA) by measuring resting HR and calculating the cardiac vagal index (CVI) in individuals undergoing sympathectomy for the treatment of primary hyperhidrosis. Methods: This was a descriptive longitudinal study involving 22 patients, 13 of whom were female. The mean age was 22.5 ± 8.8 years. The palms, soles, and axillae were the most commonly affected sites. Resting HR was measured by an electrocardiogram performed 20 min before the 4-second exercise test (4sET), which was used in order to evaluate CVA at three different time points: before surgery, one month after surgery, and four years after surgery. Results: Resting HR (expressed as mean ± SE) was found to have decreased significantly at 1 month after surgery (73.1 ± 1.6 bpm before surgery vs. 69.7 ± 1.2 bpm at one month after surgery; p = 0.01). However, the HR values obtained at four years after surgery tended to be similar to those obtained before surgery (p = 0.31). The CVI (expressed as mean ± SE) was found to have increased significantly at one month after surgery (1.44 ± 0.04 before surgery vs. 1.53 ± 0.03 at one month after surgery; p = 0.02). However, the CVI obtained at four years after surgery tended to be similar to that obtained before surgery (p = 0.10). Conclusions: At one month after sympathectomy for primary hyperhidrosis, patients present with changes in resting HR and CVA, both of which tend to return to baseline at four years after surgery.


Keywords: Hyperhidrosis; Sympathectomy; Autonomic nervous system; Exercise test;


6 - Prevalence of latent Mycobacterium tuberculosis infection in renal transplant recipients

Prevalência da infecção latente por Mycobacterium tuberculosis em transplantados renais

Mônica Maria Moreira Delgado Maciel1,2,a, Maria das Graças Ceccato3,b, Wânia da Silva Carvalho3,c, Pedro Daibert de Navarro1,d, Kátia de Paula Farah1,e, Silvana Spindola de Miranda1,f

J Bras Pneumol.2018;44(6):461-467

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Objective: To estimate the prevalence of latent Mycobacterium tuberculosis infection (LTBI) in renal transplant recipients and to assess sociodemographic, behavioral, and clinical associations with positive tuberculin skin test (TST) results. Methods: This was a cross-sectional study of patients aged ≥ 18 years who underwent renal transplantation at the Renal Transplant Center of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. We included renal transplant recipients who underwent the TST between January 2011 and July 2013. If the result of the first TST was negative, a second TST was administered. Bivariate and multivariate analyses using logistic regression were used to determine factors associated with positive TST results. Results: The sample included 216 patients. The prevalence of LTBI was 18.5%. In the multivariate analysis, history of contact with a tuberculosis case and preserved graft function (estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2) were associated with positive TST results. TST induration increased by 5.8% from the first to the second test, which was considered significant (p = 0.012). Conclusions: The prevalence of LTBI was low in this sample of renal transplant recipients. The TST should be administered if renal graft function is preserved. A second TST should be administered if the first TST is negative.


Keywords: Tuberculosis; Tuberculin test; Immunocompromised host.


7 - Impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer

Impacto da radioterapia torácica na função respiratória e capacidade de exercício em pacientes com câncer de mama

Milena Mako Suesada1,a, Heloisa de Andrade Carvalho2,b, André Luis Pereira de Albuquerque1,c, João Marcos Salge1,d, Silvia Radwanski Stuart2,e, Teresa Yae Takagaki1,f

J Bras Pneumol.2018;44(6):469-476

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Objective: To evaluate the impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer. Methods: Breast cancer patients in whom thoracic radiotherapy was indicated after surgical treatment and chemotherapy were submitted to HRCT, respiratory evaluation, and exercise capacity evaluation before radiotherapy and at three months after treatment completion. Respiratory muscle strength testing, measurement of chest wall mobility, and complete pulmonary function testing were performed for respiratory evaluation; cardiopulmonary exercise testing was performed to evaluate exercise capacity. The total radiotherapy dose was 50.4 Gy (1.8 Gy/fraction) to the breast or chest wall, including supraclavicular lymph nodes (SCLN) or not. Dose-volume histograms were calculated for each patient with special attention to the ipsilateral lung volume receiving 25 Gy (V25), in absolute and relative values, and mean lung dose. Results: The study comprised 37 patients. After radiotherapy, significant decreases were observed in respiratory muscle strength, chest wall mobility, exercise capacity, and pulmonary function test results (p < 0.05). DLCO was unchanged. HRCT showed changes related to radiotherapy in 87% of the patients, which was more evident in the patients submitted to SCLN irradiation. V25% significantly correlated with radiation pneumonitis. Conclusions: In our sample of patients with breast cancer, thoracic radiotherapy seemed to have caused significant losses in respiratory and exercise capacity, probably due to chest wall restriction; SCLN irradiation represented an additional risk factor for the development of radiation pneumonitis.


Keywords: Breast neoplasms; Radiotherapy; Radiation pneumonitis; Respiratory function tests; Exercise test.


8 - Self-reported smoking status and urinary cotinine levels in patients with asthma

Tabagismo entre asmáticos: avaliação por autorrelato e dosagem de cotinina urinária

Gabriela Pimentel Pinheiro1,2,a, Carolina de Souza-Machado1,3,b, Andréia Guedes Oliva Fernandes4,c, Raquel Cristina Lins Mota5,d, Liranei Limoeiro Lima2,e, Diego da Silva Vasconcellos6,f, Ives Pereira da Luz Júnior7,g, Yvonbergues Ramon dos Santos Silva7,h, Valmar Bião Lima1,4,i, Sérgio Telles de Oliva8,j, Luane Marques de Mello9,k, Ricardo David Couto10,l, José Miguel Chatkin11,m, Constança Margarida Sampaio Cruz12,13,n, Álvaro Augusto Cruz1,14,o

J Bras Pneumol.2018;44(6):477-485

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Objective: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. Methods: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. Results: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. Conclusions: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.


Keywords: Asthma; Smoking; Cotinine.


9 - Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study

Mitomicina C no tratamento endoscópico de estenose traqueal: estudo prospectivo de coorte

Daniele Cristina Cataneo1,a, Aglaia Moreira Garcia Ximenes2,b, Antônio José Maria Cataneo1,c

J Bras Pneumol.2018;44(6):486-490

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Objective: To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods: Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results: Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions: MMC appears to be effective in the endoscopic treatment of tracheal stenosis.


Keywords: Tracheal stenosis; Mitomycin; Endoscopy.


10 - Trend of self-reported asthma prevalence in Brazil from 2003 to 2013 in adults and factors associated with prevalence

Tendência da prevalência de asma autorreferida no Brasil de 2003 a 2013 em adultos e fatores associados à prevalência

Felipe Moraes dos Santos1,a, Karynna Pimentel Viana1,b, Luciana Tarbes Saturnino1,c, Evelyn Lazaridis1,d, Mariana Rodrigues Gazzotti1,e, Rafael Stelmach2,f, Claudia Soares1,g

J Bras Pneumol.2018;44(6):491-497

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Objectives: To determine the trend of self-reported asthma diagnosed prevalence and to describe the factors associated with asthma in Brazilian adults. Method: Epidemiological cross-sectional study based on databases analysis from three national household surveys: Pesquisa Nacional por Amostra de Domicílios (PNAD) 2003, PNAD 2008 and Pesquisa Nacional de Saúde (PNS) 2013. Participants between 18-45 years old were included. Trend analysis of asthma diagnosed prevalence was conducted using a logistic general linear model. A hierarchical logistic regression model was used to select factors significantly associated with asthma prevalence. Results: Asthma diagnosed prevalence was 3.6% (2003), 3.7% (2008) and 4.5% (2013), showing a statistically significant increased trend. Asthma diagnosed prevalence also increased when analysed by gender (annual change for men: 2.47%, p < 0.003; women: 2.16%, p < 0.001), urban area (annual change for urban: 2.15%, p < 0.001; rural: 2.69%, p = 0.072), healthcare insurance status (annual change without healthcare insurance: 2.18%, p < 0.001; with healthcare insurance: 1.84%, p = 0.014), and geographic regions (annual change North: 4.68%, p < 0.001; Northeast: 4.14%, p < 0.001; and Southeast: 1.84%, p = 0.025). Female gender, obesity, living in urban areas and depression were associated with asthma diagnosed prevalence. Discussion: PNAD and PNS surveys allow for a very large, representative community-based sample of the Brazilian adults to investigate the asthma prevalence. From 2003 to 2013, the prevalence of self-reported physician diagnosis of asthma increased, especially in the North and Northeast regions. Gender, region of residence, household location (urban/rural), obesity, and depression diagnosis seem to play significant roles in the epidemiology of asthma in Brazil.


Keywords: Adults; Asthma; Logistic models; Prevalence; Risk factors.


11 - Genetic and phenotypic traits of children and adolescents with cystic fibrosis in Southern Brazil

Características genéticas e fenotípicas de crianças e adolescentes com fibrose cística no Sul do Brasil

Katiana Murieli da Rosa1,a, Eliandra da Silveira de Lima2,b, Camila Correia Machado3,c, Thaiane Rispoli4,d, Victória d'Azevedo Silveira3,e, Renata Ongaratto2,f, Talitha Comaru2,g, Leonardo Araújo Pinto5,h

J Bras Pneumol.2018;44(6):498-504

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Objectives: To characterize the main identified mutations on cystic fibrosis transmembrane conductance regulator (CFTR) in a group of children and adolescents at a cystic fibrosis center and its association with the clinical and laboratorial characteristics. Method: Descriptive cross-sectional study including patients with cystic fibrosis who had two alleles identified with CFTR mutation. Clinical, anthropometrical, laboratorial and pulmonary function (spirometry) data were collected from patients' records in charts and described with the results of the sample genotyping. Results: 42 patients with cystic fibrosis were included in the study. The most frequent mutation was F508del, covering 60 alleles (71.4%). The second most common mutation was G542X (six alleles, 7.1%), followed by N1303K and R1162X mutations (both with four alleles each). Three patients (7.14%) presented type III and IV mutations, and 22 patients (52.38%) presented homozygous mutation for F508del. Thirty three patients (78.6%) suffered of pancreatic insufficiency, 26.2% presented meconium ileus, and 16.7%, nutritional deficit. Of the patients in the study, 59.52% would be potential candidates for the use of CFTR-modulating drugs. Conclusions: The mutations of CFTR identified more frequently were F508del and G542X. These are type II and I mutations, respectively. Along with type III, they present a more severe cystic fibrosis phenotype. More than half of the sample (52.38%) presented homozygous mutation for F508del, that is, patients who could be treated with Lumacaftor/Ivacaftor. Approximately 7% of the patients (7.14%) presented type III and IV mutations, therefore becoming candidates for the treatment with Ivacaftor.


Keywords: Cystic fibrosis; Mutations; Genetics; Phenotype; Child


12 - Proportional weight loss in six months as a risk factor for mortality in stage IV nonsmall cell lung cancer

Perda de peso proporcional em seis meses como fator de risco para mortalidade no câncer de pulmão de células não pequenas estádio IV

Guilherme Watte1,2,5,a, Claudia Helena de Abreu Nunes1,b, Luzielio Alves Sidney-Filho3,c, Matheus Zanon2,4,d, Stephan Philip Leonhardt Altmayer4,5,e, Gabriel Sartori Pacini4,f, Marcelo Barros5,g, Ana Luiza Schneider Moreira4,h, Rafael José Vargas Alves1,i, Alice de Medeiros Zelmanowicz4,j, Bashir Mnene Matata2,k, Jose da Silva Moreira1,l

J Bras Pneumol.2018;44(6):505-509

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Objective: To evaluate different weight loss (WL) cut-off points as prognostic markers of 3-month survival after diagnosis of stage IV non-small cell lung cancer (NSCLC). Methods: This was a prospective study involving 104 patients with metastatic (stage IV) NSCLC who were admitted to a cancer treatment center in southern Brazil between January of 2014 and November of 2016. We evaluated total WL and WL per month, as well as WL and WL per month in the 6 months preceding the diagnosis. The patients were followed for 3 months after diagnosis. A Cox proportional hazards regression model and Kaplan-Meier curves were used in order to evaluate 3-month survival. Results: The median WL in the 6 months preceding the diagnosis was 6% (interquartile range, 0.0- 12.9%). Patients with WL ≥ 5% had a median survival of 78 days, compared with 85 days for those with WL < 5% (p = 0.047). Survival at 3 months was 72% for the patients with WL ≥ 5% (p = 0.047), 61% for those with WL ≥ 10% (p < 0.001), and 45% for those with WL ≥ 15% (p < 0.001). In the multivariate analysis, the hazard ratio for risk of death was 4.51 (95% CI: 1.32-15.39) for the patients with WL ≥ 5%, 6.34 (95% CI: 2.31-17.40) for those with WL ≥ 10%, and 14.17 (95% CI: 5.06-39.65) for those with WL ≥ 15%. Conclusions: WL in the 6 months preceding the diagnosis of NSCLC is a relevant prognostic factor and appears to be directly proportional to the rate of survival at 3 months.


Keywords: Weight loss; Carcinoma, non-small-cell lung; Prognosis.


Review Article

13 - Obesity hypoventilation syndrome: a current review

Síndrome de obesidade-hipoventilação: uma revisão atual

Rodolfo Augusto Bacelar de Athayde1,2,a, José Ricardo Bandeira de Oliveira Filho1,b, Geraldo Lorenzi Filho2,c, Pedro Rodrigues Genta2,d

J Bras Pneumol.2018;44(6):510-518

Abstract Portuguese Text

Obesity hypoventilation syndrome (OHS) is defined as the presence of obesity (body mass index ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg) in the absence of other causes of hypoventilation. OHS is often overlooked and confused with other conditions associated with hypoventilation, particularly COPD. The recognition of OHS is important because of its high prevalence and the fact that, if left untreated, it is associated with high morbidity and mortality. In the present review, we address recent advances in the pathophysiology and management of OHS, the usefulness of determination of venous bicarbonate in screening for OHS, and diagnostic criteria for OHS that eliminate the need for polysomnography. In addition, we review advances in the treatment of OHS, including behavioral measures, and recent studies comparing the efficacy of continuous positive airway pressure with that of noninvasive ventilation.


Keywords: Obesity; Obesity hypoventilation syndrome; Noninvasive ventilation.


Letters to the Editor

16 - Pulmonary involvement in Crohn's disease

Comprometimento pulmonar na doença de Crohn

Rodolfo Augusto Bacelar de Athayde1,a, Felipe Marques da Costa1,b, Ellen Caroline Toledo do Nascimento2,c, Roberta Karla Barbosa de Sales1,d, Andre Nathan Costa1,e

J Bras Pneumol.2018;44(6):519-521

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17 - Eosinophilic pneumonia: remember topical drugs as a potential etiology

Pneumonia eosinofílica: lembre-se de medicamentos tópicos como possível etiologia

Olívia Meira Dias1,a, Ellen Caroline Toledo do Nascimento2,b, Rodrigo Caruso Chate3,c, Ronaldo Adib Kairalla1,d, Bruno Guedes Baldi1,e

J Bras Pneumol.2018;44(6):522-524

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18 - Near-fatal pulmonary embolism: capnographic perspective

Embolia pulmonar quase fatal: perspectiva capnográfica

Marcos Mello Moreira1,2,a, Luiz Claudio Martins3,b, Konradin Metze4,c, Marcus Vinicius Pereira2,d, Ilma Aparecida Paschoal1,e

J Bras Pneumol.2018;44(6):525-528

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19 - Empyema caused by infection with Clostridium septicum in a patient with lung cancer

Empiema causado por infecção por Clostridium septicum em um paciente com câncer de pulmão

Gabriel Afonso Dutra Kreling1,a, Marilia Ambiel Dagostin1,b, Marcelo Park2,c

J Bras Pneumol.2018;44(6):529-531

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20 -  2018 recommendations for the management of community acquired pneumonia

Recomendações para o manejo da pneumonia adquirida na comunidade 2018

J Bras Pneumol.2018;44(6):532

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Index of Issues

21 - Índice remissivo de assuntos do volume 44 (1-6) 2018

Índice remissivo de assuntos do volume 44 (1-6) 2018

J Bras Pneumol.2018;44(6):533-534

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Index of Authors

22 - Índice remissivo de autores do volume 44 (1-6) 2018

Índice remissivo de autores do volume 44 (1-6) 2018

J Bras Pneumol.2018;44(6):535-538

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Relationship of Reviewers

23 - Relação de revisores do volume 44 (1-6) 2018

Relação de revisores do volume 44 (1-6) 2018

J Bras Pneumol.2018;44(6):539-542

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