Brazilian Journal of Pulmonology

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


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Year 2014 - Volume 40  - Number 1  (January/February)


Original Article

2 - Can ultrasound guidance reduce the risk of pneumothorax following thoracentesis?

A ultrassonografia pode reduzir o risco de pneumotórax após toracocentese?

Alessandro Perazzo, Piergiorgio Gatto, Cornelius Barlascini, Maura Ferrari-Bravo, Antonello Nicolini

J Bras Pneumol.2014;40(1):6-12

Abstract PDF PT PDF EN Portuguese Text

Objective: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. Methods: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. Results: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960  500 mL vs. 770  480 mL), the difference being statistically significant (p = 0.03). Conclusions: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [])


Keywords: Pneumothorax; Ultrasonography; Thoracic surgical procedures.


3 - Factors related to the incorrect use of inhalers by asthma patients

Fatores relacionados ao uso incorreto dos dispositivos inalatórios em pacientes asmáticos

Paulo de Tarso Roth Dalcin, Denis Maltz Grutcki, Paola Paganella Laporte, Paula Borges de Lima, Samuel Millán Menegotto, Rosemary Petrik Pereira

J Bras Pneumol.2014;40(1):13-20

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate inhaler technique in outpatients with asthma and to determine associations between the correctness of that technique and the level of asthma control. Methods: This was a cross-sectional study involving patients ≥ 14 years of age with physician-diagnosed asthma. The patients were recruited from the Asthma Outpatient Clinic of the Hospital de Clínicas de Porto Alegre, in the city of Porto Alegre, Brazil. The patients completed two questionnaires (a general questionnaire and an asthma control questionnaire based on the 2011 Global Initiative for Asthma guidelines), demonstrated their inhaler technique, and performed pulmonary function tests. Incorrect inhaler technique was defined as the incorrect execution of at least two of the predefined steps. Results: We included 268 patients. Of those, 81 (30.2%) showed incorrect inhaler technique, which was associated with poor asthma control (p = 0.002). Logistic regression analysis identified the following factors associated with incorrect inhaler technique: being widowed (OR = 5.01; 95% CI, 1.74-14.41; p = 0.003); using metered dose inhalers (OR = 1.58; 95% CI, 1.35-1.85; p < 0.001); having a monthly family income < 3 times the minimum wage (OR = 2.67; 95% CI, 1.35-1.85; p = 0.008), and having ≥ 2 comorbidities (OR = 3.80; 95% CI, 1.03-14.02; p = 0.045). Conclusions: In the sample studied, incorrect inhaler technique was associated with poor asthma control. Widowhood, use of metered dose inhalers, low socioeconomic level, and the presence of ≥ 2 comorbidities were associated with incorrect inhaler technique.


Keywords: Inaladores dosimetrados; Inaladores de pó seco; Asma/terapia.


4 - Morbidity, mortality, and categorization of the risk of perioperative complications in lung cancer patients

Mortalidade, morbidade e categorização de risco para complicações perioperatórias em pacientes com câncer de pulmão

Fabiana Stanzani, Denise de Moraes Paisani, Anderson de Oliveira, Rodrigo Caetano de Souza, João Aléssio Juliano Perfeito, Sonia Maria Faresin

J Bras Pneumol.2014;40(1):21-29

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs). Methods: This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010. Results: Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs. Conclusions: Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies.


Keywords: Algorithms; Lung neoplasms; Postoperative complications.


5 - PLATINO, a nine-year follow-up study of COPD in the city of São Paulo, Brazil: the problem of underdiagnosis

PLATINO, estudo de seguimento de nove anos sobre DPOC na cidade de São Paulo: o problema do subdiagnóstico

J Bras Pneumol.2014;40(1):30-37

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the underdiagnosis rate in new COPD cases at the end of a nine-year follow-up period-in the study designated "Projeto Latino-Americano de Investigação em Obstrução Pulmonar" (PLATINO, Latin-American Pulmonary Obstruction Investigation Project)-and compare that with the underdiagnosis rate during the initial phase of the study, as well as to identify the clinical features exhibited by the subjects who were not diagnosed until the end of the follow-up phase. Methods: The study population comprised the 1,000 residents of the city of São Paulo, Brazil, who took part in the PLATINO study. Of those, 613 participated in the follow-up phase, during which the subjects were assessed with the same instruments and equipment employed in the initial phase of the study. We used the chi-square test or the independent sample t-test to analyze the underdiagnosis rate and to identify the characteristics of the subjects who were not diagnosed until the end of the follow-up phase. Results: The underdiagnosis rate for new COPD cases at the end of the nine-year follow-up period was 70.0%. The underdiagnosis rate during the follow-up phase was 17.5% lower than that reported for the initial phase of the study. The subjects who were not diagnosed until the end of the follow-up phase presented with fewer respiratory symptoms, better pulmonary function, and less severe disease than did those previously diagnosed with COPD. Conclusions: The underdiagnosis rate for new COPD cases was lower in the follow-up phase of the study than in the initial phase. The subjects who were not diagnosed until the end of the follow-up phase of the PLATINO study presented with the same clinical profile as did those who were not diagnosed in the initial phase. These findings underscore the need for spirometry in order to confirm the diagnosis of COPD and provide early intervention.


Keywords: Pulmonary disease, chronic obstructive/diagnosis; Pulmonary disease, chronic obstructive/epidemiology; Spirometry.


6 - Incidence of pulmonary embolism during COPD exacerbation

Incidência de embolia pulmonar durante exacerbação da DPOC

Eylem Akpinar, Derya Hoşgün, Serdar Akpinar, Gökçe Kaan Ataç, Beyza, Doğanay, Meral Gülhan

J Bras Pneumol.2014;40(1):38-45

Abstract PDF PT PDF EN Portuguese Text

Objective: Because pulmonary embolism (PE) and COPD exacerbation have similar presentations and symptoms, PE can be overlooked in COPD patients. Our objective was to determine the prevalence of PE during COPD exacerbation and to describe the clinical aspects in COPD patients diagnosed with PE. Methods: This was a prospective study conducted at a university hospital in the city of Ankara, Turkey. We included all COPD patients who were hospitalized due to acute exacerbation of COPD between May of 2011 and May of 2013. All patients underwent clinical risk assessment, arterial blood gas analysis, chest CT angiography, and Doppler ultrasonography of the lower extremities. In addition, we measured D-dimer levels and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels. Results: We included 172 patients with COPD. The prevalence of PE was 29.1%. The patients with pleuritic chest pain, lower limb asymmetry, and high NT-pro-BNP levels were more likely to develop PE, as were those who were obese or immobile. Obesity and lower limb asymmetry were independent predictors of PE during COPD exacerbation (OR = 4.97; 95% CI, 1.775-13.931 and OR = 2.329; 95% CI, 1.127-7.105, respectively). Conclusions: The prevalence of PE in patients with COPD exacerbation was higher than expected. The association between PE and COPD exacerbation should be considered, especially in patients who are immobile or obese.


Keywords: Pulmonary disease, chronic obstructive; Pulmonary embolism; Risk factors.


7 - A new experimental model of cigarette smoke-induced emphysema in Wistar rats

Um novo modelo experimental de enfisema induzido por fumaça de cigarro em ratos Wistar

Rodrigo de las Heras Kozma, Edson Marcelino Alves, Valter Abraão Barbosa-de-Oliveira, Fernanda Degobbi Tenorio Quirino dos Santos Lopes, Renan Cenize Guardia, Henrique Vivi Buzo, Carolina Arruda de Faria, Camila Yamashita, Manzelio Cavazzana Júnior, Fernando Frei, Maria José de Oliveira Ribeiro-Paes, João Tadeu Ribeiro-Paes

J Bras Pneumol.2014;40(1):46-54

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe a new murine model of cigarette smoke-induced emphysema. Methods: Twenty-four male Wistar rats were divided into two groups: the cigarette smoke group, comprising 12 rats exposed to smoke from 12 commercial filter cigarettes three times a day (a total of 36 cigarettes per day) every day for 30 weeks; and the control group, comprising 12 rats exposed to room air three times a day every day for 30 weeks. Lung function was assessed by mechanical ventilation, and emphysema was morphometrically assessed by measurement of the mean linear intercept (Lm). Results: The mean weight gain was significantly (approximately ten times) lower in the cigarette smoke group than in the control group. The Lm was 25.0% higher in the cigarette smoke group. There was a trend toward worsening of lung function parameters in the cigarette smoke group. Conclusions: The new murine model of cigarette smoke-induced emphysema and the methodology employed in the present study are effective and reproducible, representing a promising and economically viable option for use in studies investigating the pathophysiology of and therapeutic approaches to COPD.


Keywords: Tobacco smoke pollution; Emphysema; Disease models, animal; Equipment and supplies.


8 - Chest compression with a higher level of pressure support ventilation: effects on secretion removal, hemodynamics, and respiratory mechanics in patients on mechanical ventilation

Compressão torácica com incremento da pressão em ventilação com pressão de suporte: efeitos na remoção de secreções, hemodinâmica e mecânica pulmonar em pacientes em ventilação mecânica

Wagner da Silva Naue, Luiz Alberto Forgiarini Junior, Alexandre Simões Dias, Silvia Regina Rios Vieira

J Bras Pneumol.2014;40(1):55-60

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the efficacy of chest compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation, in comparison with that of aspiration alone, in removing secretions, normalizing hemodynamics, and improving respiratory mechanics in patients on mechanical ventilation. Methods: This was a randomized crossover clinical trial involving patients on mechanical ventilation for more than 48 h in the ICU of the Porto Alegre Hospital de Clínicas, in the city of Porto Alegre, Brazil. Patients were randomized to receive aspiration alone (control group) or compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation (intervention group). We measured hemodynamic parameters, respiratory mechanics parameters, and the amount of secretions collected. Results: We included 34 patients. The mean age was 64.2  14.6 years. In comparison with the control group, the intervention group showed a higher median amount of secretions collected (1.9 g vs. 2.3 g; p = 0.004), a greater increase in mean expiratory tidal volume (16  69 mL vs. 56  69 mL; p = 0.018), and a greater increase in mean dynamic compliance (0.1  4.9 cmH2O vs. 2.8  4.5 cmH2O; p = 0.005). Conclusions: In this sample, chest compression accompanied by an increase in pressure support significantly increased the amount of secretions removed, the expiratory tidal volume, and dynamic compliance. ( Identifier:NCT01155648 [])


Keywords: Physical therapy modalities; Respiration, Artificial; Intensive care units; Respiratory therapy.


9 - The burden of disease due to tuberculosis in the state of Santa Catarina, Brazil

A carga de doença por tuberculose no estado de Santa Catarina

J Bras Pneumol.2014;40(1):61-68

Abstract PDF PT PDF EN Portuguese Text

Objetivo: Estimar a carga de doença por tuberculose no estado de Santa Catarina em 2009. Métodos: Estudo epidemiológico de delineamento ecológico. Dados sobre a incidência e mortalidade de tuberculose foram coletados de bancos de dados específicos do Ministério da Saúde do Brasil. A carga de doença por tuberculose baseou-se no cálculo de disability-adjusted life years (DALYs, anos de vida perdidos ajustados por incapacidade). Os DALYs foram estimados pela soma de years of life lost (YLLs, anos de vida perdidos) e years lived with disability (YLDs, anos vividos com incapacidade). Os valores absolutos foram transformados em taxas por 100 mil habitantes. As taxas foram calculadas por sexo, faixa etária e macrorregião de saúde. Resultados: A carga de doença por tuberculose foi de 5.644,27 DALYs (92,25 DALYs/100 mil habitantes), dos quais 78,77% foram YLLs e 21,23% foram YLDs. As maiores taxas foram encontradas no sexo masculino nas faixas etárias de 30-44 e 45-59 anos, com distribuição desigual por macrorregião de saúde. A maior carga foi estimada na macrorregião do Planalto Norte (179,56 DALYs/100 mil habitantes), seguida pela do Nordeste (167,07 DALYs/100 mil habitantes). Conclusões: A carga de doença por tuberculose concentrou-se em homens adultos, com distribuição desigual nas macrorregiões de saúde de Santa Catarina.


Keywords: Tuberculosis/epidemiology; Life expectancy; Cost of illness.


Brief Communication

10 - Assessment of ICU readmission risk with the Stability and Workload Index for Transfer score

Avaliação de riscos de readmissão em UTI através do escore Stability and Workload Index for Transfer

Daiane Ferreira Oakes, Ingrid Nemitz Krás Borges, Luiz Alberto Forgiarini Junior, Marcelo de Mello Rieder

J Bras Pneumol.2014;40(1):69-72

Abstract PDF PT PDF EN Portuguese Text

We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.


Keywords: Empyema, pleural; Pneumonia, pneumococcal; Pneumococcal infections.


11 - Empyema and bacteremic pneumococcal pneumonia in children under five years of age

Empiema e pneumonia pneumocócica bacterêmica em menores de cinco anos de idade

Maria Regina Alves Cardoso, Cristiana Maria Costa Nascimento-Carvalho, Fernando Ferrero, Eitan Naaman Berezin, Raul Ruvinsky, Clemax Couto Sant'Anna, Maria Cristina de Cunto Brandileone, Maria de Fátima Bazhuni Pombo March, Ruben Maggi, Jesus Feris-Iglesias, Yehuda Benguigui, Paulo Augusto Moreira Camargos; the CARIBE group

J Bras Pneumol.2014;40(1):73-76

Abstract PDF PT PDF EN Portuguese Text

Patient discharge from the ICU is indicated on the basis of clinical evidence and the result of strategies aimed at improving health care. Nevertheless, some patients might be discharged too early. We attempted to identify risk factors for unplanned ICU readmission, using a score for risk assessment, designated the Stability and Workload Index for Transfer (SWIFT) score. We evaluated 100 patients discharged from an ICU and found that the SWIFT score can be used as a tool for improving the assessment of ICU patients and the appropriateness of ICU discharge, thus preventing readmission.


Keywords: Intensive care units; Risk factors; Patient readmission.


Case Report

12 - Adalimumab-induced acute interstitial lung disease in a patient with rheumatoid arthritis

Doença pulmonar intersticial aguda induzida por adalimumabe em paciente com artrite reumatoide

Olívia Meira Dias, Daniel Antunes Silva Pereira, Bruno Guedes Baldi, André Nathan Costa, Rodrigo Abensur Athanazio, Ronaldo Adib Kairalla, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2014;40(1):77-81

Abstract PDF PT PDF EN Portuguese Text

The use of immunobiological agents for the treatment of autoimmune diseases is increasing in medical practice. Anti-TNF therapies have been increasingly used in refractory autoimmune diseases, especially rheumatoid arthritis, with promising results. However, the use of such therapies has been associated with an increased risk of developing other autoimmune diseases. In addition, the use of anti-TNF agents can cause pulmonary complications, such as reactivation of mycobacterial and fungal infections, as well as sarcoidosis and other interstitial lung diseases (ILDs). There is evidence of an association between ILD and the use of anti-TNF agents, etanercept and infliximab in particular. Adalimumab is the newest drug in this class, and some authors have suggested that its use might induce or exacerbate preexisting ILDs. In this study, we report the first case of acute ILD secondary to the use of adalimumab in Brazil, in a patient with rheumatoid arthritis and without a history of ILD.


Keywords: Lung diseases, interstitial; Arthritis, rheumatoid; Antirheumatic agents; Antibodies, monoclonal, humanized/adverse effects.


13 - Add-on treatment with nebulized hypertonic saline in a child with plastic bronchitis after the Glenn procedure

Tratamento adjuvante com nebulização de salina hipertônica em uma criança com bronquite plástica após a operação de Glenn

Grzegorz Lis, Ewa Cichocka-Jarosz, Urszula Jedynak-Wasowicz, Edyta Glowacka

J Bras Pneumol.2014;40(1):82-85

Abstract PDF PT PDF EN Portuguese Text

Plastic bronchitis (PB), although a rare cause of airway obstruction, has mortality rates up to 50% in children after Fontan-type cardiac surgery. We present the case of an 18-month-old female patient with PB following pneumonia. At 6 months of age, the patient underwent the Glenn procedure due to functionally univentricular heart. Fiberoptic bronchoscopy revealed complete blockage of the left bronchus by mucoid casts. Pharmacotherapy consisted of glucocorticosteroids, azithromycin, and enalapril maleate. The child also received nebulized 3% NaCl solution, which proved to be beneficial. In children submitted to Fontan-type procedures, physicians must be alert for PB, which can be triggered by respiratory tract infection.


Keywords: Bronchitis; Heart defects, congenital; Saline solution, hypertonic.



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