Brazilian Journal of Pulmonology

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


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

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

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

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

Abstract PDF PT PDF EN Portuguese Text

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


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


The electronic cigarette: the new cigarette of the 21st century?

Cigarro eletrônico: o novo cigarro do século 21?

Marli Maria Knorst, Igor Gorski Benedetto, Mariana Costa Hoffmeister, Marcelo Basso Gazzana

J Bras Pneumol.2014;40(5):564-573

Abstract PDF PT PDF EN Portuguese Text

The electronic nicotine delivery system, also known as the electronic cigarette, is generating considerable controversy, not only in the general population but also among health professionals. Smokers the world over have been increasingly using electronic cigarettes as an aid to smoking cessation and as a substitute for conventional cigarettes. There are few available data regarding the safety of electronic cigarettes. There is as yet no evidence that electronic cigarettes are effective in treating nicotine addiction. Some smokers have reported using electronic cigarettes for over a year, often combined with conventional cigarettes, thus prolonging nicotine addiction. In addition, the increasing use of electronic cigarettes by adolescents is a cause for concern. The objective of this study was to describe electronic cigarettes and their components, as well as to review the literature regarding their safety; their impact on smoking initiation and smoking cessation; and regulatory issues related to their use.


Keywords: Smoking; Tobacco Products; Nicotine.


Classification of journals in the Qualis system: time to broaden the discussion

Classificação dos periódicos no sistema Qualis: é o momento de ampliar a discussão

Marli Maria Knorst

J Bras Pneumol.2010;36(2):274-

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Alternative diagnoses based on CT angiography of the chest in patients with suspected pulmonary thromboembolism

Diagnósticos alternativos corroborados por angiotomografia computadorizada de tórax em pacientes com suspeita de tromboembolia pulmonar

Eleci Vaz Ferreira1,2, Marcelo Basso Gazzana2,3, Muriel Bossle Sarmento4, Pedro Arends Guazzelli4, Mariana Costa Hoffmeister4, Vinicius André Guerra2, Renato Seligman4,5, Marli Maria Knorst2,3,4

J Bras Pneumol.2016;42(1):35-41

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of alternative diagnoses based on chest CT angiography (CTA) in patients with suspected pulmonary thromboembolism (PTE) who tested negative for PTE, as well as whether those alternative diagnoses had been considered prior to the CTA. Methods: This was a cross-sectional, retrospective study involving 191 adult patients undergoing CTA for suspected PTE between September of 2009 and May of 2012. Chest X-rays and CTAs were reviewed to determine whether the findings suggested an alternative diagnosis in the cases not diagnosed as PTE. Data on symptoms, risk factors, comorbidities, length of hospital stay, and mortality were collected. Results: On the basis of the CTA findings, PTE was diagnosed in 47 cases (24.6%). Among the 144 patients not diagnosed with PTE via CTA, the findings were abnormal in 120 (83.3%). Such findings were consistent with an alternative diagnosis that explained the symptoms in 75 patients (39.3%). Among those 75 cases, there were only 39 (20.4%) in which the same alterations had not been previously detected on chest X-rays. The most common alternative diagnosis, made solely on the basis of the CTA findings, was pneumonia (identified in 20 cases). Symptoms, risk factors, comorbidities, and the in-hospital mortality rate did not differ significantly between the patients with and without PTE. However, the median hospital stay was significantly longer in the patients with PTE than in those without (18.0 and 9.5 days, respectively; p = 0.001). Conclusions: Our results indicate that chest CTA is useful in cases of suspected PTE, because it can confirm the diagnosis and reveal findings consistent with an alternative diagnosis in a significant number of patients.


Keywords: Pulmonary embolism/diagnosis; Pulmonary embolism/epidemiology; Angiography.


Predictors of physical and mental health-related quality of life in patients with interstitial lung disease: a multifactorial analysis

Fatores preditores da qualidade de vida relacionada à saúde física e mental em pacientes com doença pulmonar intersticial: uma análise multifatorial

Ana Cláudia Coelho, Marli Maria Knorst, Marcelo Basso Gazzana, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2010;36(5):562-570

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine predictors of health-related quality of life (HRQoL) in patients with interstitial lung disease (ILD). Methods: A cross-sectional study comprising 63 patients, all of whom underwent lung function testing and the six-minute walk test. The following instruments were used: the Medical Outcomes Study 36-item Short-form Survey (SF-36), the Saint George's Respiratory Questionnaire (SGRQ), the Beck Anxiety Inventory, the Beck Depression Inventory, and the Modified Medical Research Council Dyspnea Scale. Principal component analysis was used in order to reduce the dimensionality of the data, thereby identifying the predictor variables, and multiple linear regression analysis was used in order to identify the explanatory variables. Results: Of the 63 patients, 34 were female. The mean age was 60.1 ± 13.3 years, the mean FVC was 64.17 ± 15.54% of predicted, and the mean DLCO was 44.21 ± 14.47% of predicted. All of the patients evaluated had impaired HRQoL, scoring worst for the SF-36 physical functioning and SGRQ activity domains. Of the patients evaluated, 60.3% and 57.1% showed symptoms of anxiety and depression, respectively. The principal component analysis identified one predictor of physical HRQoL and one predictor of mental HRQoL. Depression had a strong influence on the predictor of mental HRQoL, and the degree of dyspnea had a strong influence on both predictors of HRQoL in the patients evaluated. Variables related to lung function, exercise capacity, and anxiety had no impact on these predictors. Conclusions: In our sample of patients with ILD, the degree of dyspnea had a major impact on the physical and mental HRQoL, and depression had an impact on mental HRQoL.


Keywords: Anxiety; Depression; Dyspnea; Lung diseases, interstitial; Quality of life; Respiratory function tests.


Idiopathic pulmonary fibrosis and emphysema in smokers

Fibrose pulmonar idiopática simultânea a enfisema em pacientes tabagistas

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

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

Abstract PDF PT PDF EN Portuguese Text

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


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


Can the single-breath helium dilution method predict lung volumes as measured by whole-body plethysmography?

Pode o método de diluição do hélio em respiração única estimar os volumes pulmonares medidos pela pletismografia de corpo inteiro?

Patrícia Chaves Coertjens, Marli Maria Knorst, Anelise Dumke, Adriane Schmidt Pasqualoto, João Riboldi, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2013;39(6):675-685

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare TLC and RV values obtained by the single-breath helium dilution (SBHD) method with those obtained by whole-body plethysmography (WBP) in patients with normal lung function, patients with obstructive lung disease (OLD), and patients with restrictive lung disease (RLD), varying in severity, and to devise equations to estimate the SBHD results. Methods: This was a retrospective cross-sectional study involving 169 individuals, of whom 93 and 49 presented with OLD and RLD, respectively, the remaining 27 having normal lung function. All patients underwent spirometry and lung volume measurement by both methods. Results: TLC and RV were higher by WBP than by SBHD. The discrepancy between the methods was more pronounced in the OLD group, correlating with the severity of airflow obstruction. In the OLD group, the correlation coefficient of the comparison between the two methods was 0.57 and 0.56 for TLC and RV, respectively (p < 0.001 for both). We used regression equations, adjusted for the groups studied, in order to predict the WBP values of TLC and RV, using the corresponding SBHD values. It was possible to create regression equations to predict differences in TLC and RV between the two methods only for the OLD group. The TLC and RV equations were, respectively, ∆TLCWBP-SBHD in L = 5.264 − 0.060 × FEV1/FVC (r2 = 0.33; adjusted r2 = 0.32) and ∆RVWBP-SBHD in L = 4.862 − 0.055 × FEV1/FVC (r2 = 0.31; adjusted r2 = 0.30). Conclusions: The correction of TLC and RV results obtained by SBHD can improve the accuracy of this method for assessing lung volumes in patients with OLD. However, additional studies are needed in order to validate these equations.


Keywords: Plethysmography, whole body; Total lung capacity; Residual volume.


Delay in the diagnosis and surgical treatment of lung cancer

Retardo no diagnóstico e no tratamento cirúrgico do câncer de pulmão

Marli Maria Knorst, Rodrigo Dienstmann, Luciane Pankowski Fagundes

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

Abstract PDF PT

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


Keywords: Lung neoplasm/surgery. Disease progression.


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

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

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

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

Abstract PDF PT PDF EN Portuguese Text

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


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


Hepatopulmonary syndrome in a patient with AIDS and virus C cirrhosis (viral cirrhosis type C)

Síndrome hepatopulmonar em paciente com cirrose por vírus C e SIDA

Maria Angélica Pires Ferreira, Marcelo Basso Gazzana, Sérgio Saldanha Menna Barreto, Marli Maria Knorst

J Bras Pneumol.2001;27(1):52-55

Abstract PDF PT

Hepatopulmonary syndrome is characterized by a triad consisting of liver disorder, pulmonary vascular dilatation, and hypoxemia. No case of hepatopulmonary syndrome associated with AIDS has been reported so far. In this study, the authors report the case of a 43-year woman with AIDS and virus C cirrhosis taking prophylactic cotrimoxazole for pneumocystosis and retroviral therapy. Upon admission, the patient presented dyspnea, cyanosis, digital clubbing, vascular spiders, and normal chest examination. Chest X-ray revealed bilateral interstitial infiltration and evidenced increased alveolar-arterial gradient and liver function impairment. Intrapulmonary shunt was evidenced by contrast-enhanced echocardiography and radionuclide perfusion scanning, thus confirming hepatopulmonary syndrome.


Keywords: Hepatopulmonary syndrome. Acquired human immunodeficiency syndrome. Human viral hepatitis. Anoxemia. Liver cirrhosis.


Inhalation therapy in mechanical ventilation

Terapia inalatória em ventilação mecânica

Juçara Gasparetto Maccari, Cassiano Teixeira, Marcelo Basso Gazzana, Augusto Savi, Felippe Leopoldo Dexheimer-Neto, Marli Maria Knorst

J Bras Pneumol.2015;41(5):467-472

Abstract PDF PT PDF EN Portuguese Text

Patients with obstructive lung disease often require ventilatory support via invasive or noninvasive mechanical ventilation, depending on the severity of the exacerbation. The use of inhaled bronchodilators can significantly reduce airway resistance, contributing to the improvement of respiratory mechanics and patient-ventilator synchrony. Although various studies have been published on this topic, little is known about the effectiveness of the bronchodilators routinely prescribed for patients on mechanical ventilation or about the deposition of those drugs throughout the lungs. The inhaled bronchodilators most commonly used in ICUs are beta adrenergic agonists and anticholinergics. Various factors might influence the effect of bronchodilators, including ventilation mode, position of the spacer in the circuit, tube size, formulation, drug dose, severity of the disease, and patient-ventilator synchrony. Knowledge of the pharmacological properties of bronchodilators and the appropriate techniques for their administration is fundamental to optimizing the treatment of these patients.


Keywords: Bronchial hyperreactivity; Drug delivery systems; Respiration, artificial.




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