Brazilian Journal of Pulmonology

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


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Year 2014 - Volume 40  - Number 4  (July/August)



1 - New steps for the international consolidation of the Brazilian Journal of Pulmonology

Novos passos para a consolidação internacional do Jornal Brasileiro de Pneumologia

Carlos Roberto Ribeiro Carvalho, Bruno Guedes Baldi, Carlos Viana Poyares Jardim, Pedro Caruso, Rogério Souza

J Bras Pneumol.2014;40(4):325-326

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Special Article

2 - Brazilian recommendations of mechanical ventilation 2013. Part I

Recomendações brasileiras de ventilação mecânica 2013. Parte I


J Bras Pneumol.2014;40(4):327-363

Abstract PDF PT PDF EN Portuguese Text Appendix

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Keywords: Recommendations; Mechanical Ventilation; Respiratory Insufficiency.


Original Article

3 - Risk factors for death in patients with severe asthma

Fatores de risco de morte em pacientes portadores de asma grave

Andréia Guedes Oliva Fernandes, Carolina Souza-Machado, Renata Conceição Pereira Coelho, Priscila Abreu Franco, Renata Miranda Esquivel, Adelmir Souza-Machado, Álvaro Augusto Cruz

J Bras Pneumol.2014;40(4):364-372

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify risk factors for death among patients with severe asthma. Methods: This was a nested case-control study. Among the patients with severe asthma treated between December of 2002 and December of 2010 at the Central Referral Outpatient Clinic of the Bahia State Asthma Control Program, in the city of Salvador, Brazil, we selected all those who died, as well as selecting other patients with severe asthma to be used as controls (at a ratio of 1:4). Data were collected from the medical charts of the patients, home visit reports, and death certificates. Results: We selected 58 cases of deaths and 232 control cases. Most of the deaths were attributed to respiratory causes and occurred within a health care facility. Advanced age, unemployment, rhinitis, symptoms of gastroesophageal reflux disease, long-standing asthma, and persistent airflow obstruction were common features in both groups. Multivariate analysis showed that male gender, FEV1 pre-bronchodilator < 60% of predicted, and the lack of control of asthma symptoms were significantly and independently associated with mortality in this sample of patients with severe asthma. Conclusions: In this cohort of outpatients with severe asthma, the deaths occurred predominantly due to respiratory causes and within a health care facility. Lack of asthma control and male gender were risk factors for mortality.


Keywords: Asthma/mortality; Asthma/therapy; Risk factors.


4 - Evaluation of von Willebrand factor in COPD patients

Avaliação do fator de von Willebrand em pacientes com DPOC

Thiago Prudente Bártholo, Cláudia Henrique da Costa, Rogério Rufino

J Bras Pneumol.2014;40(4):373-379

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the absolute serum von Willebrand factor (vWF) levels and relative serum vWF activity in patients with clinically stable COPD, smokers without airway obstruction, and healthy never-smokers. Methods: The study included 57 subjects, in three groups: COPD (n = 36); smoker (n = 12); and control (n = 9). During the selection phase, all participants underwent chest X-rays, spirometry, and blood testing. Absolute serum vWF levels and relative serum vWF activity were obtained by turbidimetry and ELISA, respectively. The modified Medical Research Council scale (cut-off score = 2) was used in order to classify COPD patients as symptomatic or mildly symptomatic/asymptomatic. Results: Absolute vWF levels were significantly lower in the control group than in the smoker and COPD groups: 989 ± 436 pg/mL vs. 2,220 ± 746 pg/mL (p < 0.001) and 1,865 ± 592 pg/mL (p < 0.01). Relative serum vWF activity was significantly higher in the COPD group than in the smoker group (136.7 ± 46.0% vs. 92.8 ± 34.0%; p < 0.05), as well as being significantly higher in the symptomatic COPD subgroup than in the mildly symptomatic/asymptomatic COPD subgroup (154 ± 48% vs. 119 ± 8%; p < 0.05). In all three groups, there was a negative correlation between FEV1 (% of predicted) and relative serum vWF activity (r2 = −0.13; p = 0.009). Conclusions: Our results suggest that increases in vWF levels and activity contribute to the persistence of systemic inflammation, as well as increasing cardiovascular risk, in COPD patients.


Keywords: von Willebrand factor; Pulmonary disease, chronic obstructive; Endothelial cells.


5 - Clinical application of CT and CT-guided percutaneous transthoracic needle biopsy in patients with indeterminate pulmonary nodules

Aplicação clínica da TC e biópsia transtorácica percutânea guiada por TC em pacientes com nódulos pulmonares indeterminados

Luciana Vargas Cardoso, Arthur Soares Souza Júnior

J Bras Pneumol.2014;40(4):380-388

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the clinical application of CT and CT-guided percutaneous transthoracic needle biopsy (CT-PTNB) in patients with indeterminate pulmonary nodules (IPNs). Methods: We retrospectively studied 113 patients with PNs undergoing CT and CT-PTNB. Variables such as gender, age at diagnosis, smoking status, CT findings, and CT-PTNB techniques were analyzed. Data analysis was performed with the Student's t-test for independent samples the chi-square test, and normal approximation test for comparison of two proportions. Results: Of the 113 patients studied, 68 (60.2%) were male and 78 (69%) were smokers. The diameter of malignant lesions ranged from 2.6 cm to 10.0 cm. Most of the IPNs (85%) were located in the peripheral region. The biopsied IPNs were found to be malignant in 88 patients (77.8%) and benign in 25 (22.2%). Adenocarcinoma was the most common malignant tumor, affecting older patients. The IPN diameter was significantly greater in patients with malignant PNs than in those with benign IPNs (p < 0.001). Having regular contour correlated significantly with an IPN being benign (p = 0.022), whereas spiculated IPNs and bosselated IPNs were more often malignant (in 50.7% and 28.7%, respectively). Homogeneous attenuation and necrosis were more common in patients with malignant lesions (51.9% and 26.9%, respectively) Conclusions: In our sample, CT and CT-PTNB were useful in distinguishing between malignant and benign IPNs. Advanced age and smoking were significantly associated with malignancy. Certain CT findings related to IPNs (larger diameter, spiculated borders, homogeneous attenuation, and necrosis) were associated with malignancy.


Keywords: Solitary pulmonary nodule; Tomography; Image-guided biopsy.


6 - Comparison between two thoracotomy closure techniques: postoperative pain and pulmonary function

Comparação entre duas técnicas de fechamento de toracotomia: dor pós-operatória e função pulmonar

Juliana Duarte Leandro, Olavo Ribeiro Rodrigues, Annie France Frere Slaets, Aurelino F. Schmidt Jr, Milton L. Yaekashi

J Bras Pneumol.2014;40(4):389-396

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare two thoracotomy closure techniques (pericostal and transcostal suture) in terms of postoperative pain and pulmonary function. Methods: This was a prospective, randomized, double-blind study carried out in the Department of Thoracic Surgery of the Luzia de Pinho Melo Hospital das Clínicas and at the University of Mogi das Cruzes, both located in the city of Mogi das Cruzes, Brazil. We included 30 patients (18-75 years of age) undergoing posterolateral or anterolateral thoracotomy. The patients were randomized into two groups by the type of thoracotomy closure: pericostal suture (PS; n = 16) and transcostal suture (TS; n = 14). Pain intensity during the immediate and late postoperative periods was assessed by a visual analogic scale and the McGill Pain Questionnaire. Spirometry variables (FEV1, FVC, FEV1/FVC ratio, and PEF) were determined in the preoperative period and on postoperative days 21 and 60. Results: Pain intensity was significantly greater in the PS group than in the TS group. Between the preoperative and postoperative periods, there were decreases in the spirometry variables studied. Those decreases were significant in the PS group but not in the TS group. Conclusions: The patients in the TS group experienced less immediate and late post-thoracotomy pain than did those in the PS group, as well as showing smaller reductions in the spirometry parameters. Therefore, transcostal suture is recommended over pericostal suture as the thoracotomy closure technique of choice.


Keywords: Thoracic surgery; Suture techniques; Acute pain.


7 - Comparison between reference values for FVC, FEV1, and FEV1/FVC ratio in White adults in Brazil and those suggested by the Global Lung Function Initiative 2012

Comparação entre os valores de referência para CVF, VEF1 e relação VEF1/CVF em brasileiros caucasianos adultos e aqueles sugeridos pela Global Lung Function Initiative 2012

Carlos Alberto de Castro Pereira, Andrezza Araujo Oliveira Duarte, Andrea Gimenez, Maria Raquel Soares

J Bras Pneumol.2014;40(4):397-402

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the spirometry values predicted by the 2012 Global Lung Function Initia-tive (GLI) equations, which are recommended for international use, in comparison with those obtained for a sample of White adults used for the establishment of reference equations for spirometry in Brazil. Methods: The sample comprised 270 and 373 healthy males and females, respectively. The mean differences between the values found in this sample and the predicted values calculated from the GLI equations for FVC, FEV1, and VEF1/FVC, as well as their lower lim-its, were compared by paired t-test. The predicted values by each pair of equations were com-pared in various combinations of age and height. Results: For the males in our study sample, the values obtained for all of the variables studied were significantly higher than those predicted by the GLI equations (p < 0.01 for all). These differences become more evident in subjects who were shorter in stature and older. For the females in our study sample, only the lower limit of the FEV1/FVC ratio was significantly higher than that predicted by the GLI equation. Conclusions: The predicted values suggested by the GLI equations for White adults were significantly lower than those used as reference values for males in Brazil. For both genders, the lower limit of the FEV1/FVC ratio is significantly lower than that predicted by the GLI equations.


Keywords: Respiratory function tests/statistics and numerical data; Respiratory function tests/diagnosis; Reference values.


8 - Anemia in hospitalized patients with pulmonary tuberculosis

Anemia em pacientes internados com tuberculose pulmonar

Marina Gribel Oliveira, Karina Neves Delogo, Hedi Marinho de Melo Gomes de Oliveira, Antonio Ruffino-Netto, Afranio Lineu Kritski, Martha Maria Oliveira

J Bras Pneumol.2014;40(4):403-410

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the prevalence of anemia and of its types in hospitalized patients with pulmonary tuberculosis. Methods: This was a descriptive, longitudinal study involving pulmonary tuberculosis inpatients at one of two tuberculosis referral hospitals in the city of Rio de Janeiro, Brazil. We evaluated body mass index (BMI), triceps skinfold thickness (TST), arm muscle area (AMA), ESR, mean corpuscular volume, and red blood cell distribution width (RDW), as well as the levels of C-reactive protein, hemoglobin, transferrin, and ferritin. Results: We included 166 patients, 126 (75.9%) of whom were male. The mean age was 39.0  10.7 years. Not all data were available for all patients: 18.7% were HIV positive; 64.7% were alcoholic; the prevalences of anemia of chronic disease and iron deficiency anemia were, respectively, 75.9% and 2.4%; and 68.7% had low body weight (mean BMI = 18.21 kg/m2). On the basis of TST and AMA, 126 (78.7%) of 160 patients and 138 (87.9%) of 157 patients, respectively, were considered malnourished. Anemia was found to be associated with the following: male gender (p = 0.03); low weight (p = 0.0004); low mean corpuscular volume (p = 0.03);high RDW (p = 0; 0003); high ferritin (p = 0.0005); and high ESR (p = 0.004). We also found significant differences between anemic and non-anemic patients in terms of BMI (p = 0.04), DCT (p = 0.003), and ESR (p < 0.001). Conclusions: In this sample, high proportions of pulmonary tuberculosis patients were classified as underweight and malnourished, and there was a high prevalence of anemia of chronic disease. In addition, anemia was associated with high ESR and malnutrition.


Keywords: Tuberculosis, pulmonary; Anemia; Malnutrition; Iron.


9 - Oxidative damage induced by cigarette smoke exposure in mice: impact on lung tissue and dia-phragm muscle

Dano oxidativo induzido por exposição a fumaça de cigarro em camundongos: impacto sobre o pulmão e o músculo diafragma

Samanta Portão de Carlos, Alexandre Simões Dias, Luiz Alberto Forgiarini Júnior, Patrícia Damiani Patricio, Thaise Graciano, Renata Tiscoski Nesi, Samuel Valença, Adriana Meira Guntzel Chiappa, Gerson Cipriano Jr, Claudio Teodoro de Souza, Gaspar Rogério da Silva Chiappa

J Bras Pneumol.2014;40(4):411-420

Abstract PDF PT PDF EN Portuguese Text

Objetivo: Avaliar o dano oxidativo (oxidação lipídica, oxidação proteica, thiobarbituric acid-reactive substances [TBARS, substâncias reativas ao ácido tiobarbitúrico], e carbonilação) e inflamação (expressão de phosphorylated AMP-activated protein kinase e de phosphorylated mammalian target of rapamycin (p-AMPK e p-mTOR, respectivamente) em tecido pulmonar e músculos do diafragma em camundongos C57BL/6 machos expostos à fumaça de cigarro (FC) por 7, 15, 30, 45 ou 60 dias. Métodos: Trinta e seis camundongos machos da espécie C57BL/6 foram divididos em seis grupos (n = 6/grupo): grupo controle e 5 grupos expostos a FC por 7, 15, 30, 45 e 60 dias, respectivamente. Resultados: Comparados aos camundongos controle, os camundongos expostos à FC apresentaram menor peso corporal em 30 dias. Nos camundongos expostos à FC (comparados aos controle) as maiores diferenças (aumentos) nos níveis de TBARS foram observados no dia 7 no músculo diafragma, comparado ao dia 45 em tecido pulmonar; as maiores diferenças (aumentos) nos níveis de carbonilas foram observados no dia 7 em ambos os tipos de tecido; e os níveis de sulfidrilas foram menores, nos dois tipos de tecidos, em todos os tempos. No tecido pulmonar e no músculo diafragma, a expressão de p-AMPK exibiu um comportamento semelhante ao dos níveis de TBARS. A expressão de p-mTOR foi maior que o valor controle nos dias 7 e 15 no tecido pulmonar, assim como no dia 45 no músculo diafragma. Conclusões: Nossos dados demonstram que a exposição à FC produz dano oxidativo tanto no tecido pulmonar quanto (primariamente) no tecido muscular, tendo um efeito adicional no músculo respiratório, como é frequentemente observado em fumantes com DPOC.


Keywords: Oxidative stress; Mice; Respiratory system; Smoking; Inflammation.


Brief Communication

10 - Lodenafil treatment in the monocrotaline model of pulmonary hypertension in rats

Tratamento com lodenafila no modelo de hipertensão pulmonar induzida por monocrotalina em ratos

Igor Bastos Polonio, Milena Marques Pagliareli Acencio, Rogério Pazetti, Francine Maria de Almeida, Bárbara Soares da Silva, Karina Aparecida Bonifácio Pereira, Rogério Souza

J Bras Pneumol.2014;40(4):421-424

Abstract PDF PT PDF EN Portuguese Text

We assessed the effects of lodenafil on hemodynamics and inflammation in the rat model of monocrotaline-induced pulmonary hypertension (PH). Thirty male Sprague-Dawley rats were randomly divided into three groups: control; monocrotaline (experimental model); and lodenafil (experimental model followed by lodenafil treatment, p.o., 5 mg/kg daily for 28 days) Mean pulmonary artery pressure (mPAP) was obtained by right heart catheterization. We investigated right ventricular hypertrophy (RVH) and IL-1 levels in lung fragments. The number of cases of RVH was significantly higher in the monocrotaline group than in the lodenafil and control groups, as were mPAP and IL-1 levels. We conclude that lodenafil can prevent monocrotaline-induced PH, RVH, and inflammation.


Keywords: Hypertension, pulmonary; Monocrotaline; Interleukin-1.


11 - Cytokine levels in pleural fluid as markers of acute rejection after lung transplantation

Citocinas no líquido pleural após transplante pulmonar como marcadores de rejeição aguda

Priscila Cilene León Bueno de Camargo, José Eduardo Afonso Jr, Marcos Naoyuki Samano, Milena Marques Pagliarelli Acencio, Leila Antonangelo, Ricardo Henrique de Oliveira Braga Teixeira

J Bras Pneumol.2014;40(4):425-428

Abstract PDF PT PDF EN Portuguese Text

Our objective was to determine the levels of lactate dehydrogenase, IL-6, IL-8, and VEGF, as well as the total and differential cell counts, in the pleural fluid of lung transplant recipients, correlating those levels with the occurrence and severity of rejection. We analyzed pleural fluid samples collected from 18 patients at various time points (up to postoperative day 4). The levels of IL-6, IL-8, and VEGF tended to elevate in parallel with increases in the severity of rejection. Our results suggest that these levels are markers of acute graft rejection in lung transplant recipients.


Keywords: Lung transplantation; Pleural effusion; Cytokines; Graft rejection.


Review Article

12 - Overview of the biochemical and genetic processes in malignant mesothelioma

Panorama dos processos bioquímicos e genéticos presentes no mesotelioma maligno

Leonardo Vinícius Monteiro de Assis, Mauro César Isoldi

J Bras Pneumol.2014;40(4):429-442

Abstract PDF PT PDF EN Portuguese Text

Malignant mesothelioma (MM) is a highly aggressive form of cancer, has a long latency period, and is resistant to chemotherapy. It is extremely fatal, with a mean survival of less than one year. The development of MM is strongly correlated with exposure to asbestos and erionite, as well as to simian virus 40. Although various countries have banned the use of asbestos, MM has proven to be difficult to control and there appears to be a trend toward an increase in its incidence in the years to come. In Brazil, MM has not been widely studied from a genetic or biochemical standpoint. In addition, there have been few epidemiological studies of the disease, and the profile of its incidence has yet to be well established in the Brazilian population. The objective of this study was to review the literature regarding the processes of malignant transformation, as well as the respective mechanisms of tumorigenesis, in MM.


Keywords: Occupational diseases; Mesothelioma; Genes, tumor suppressor; Oncogenes; Signal transduction.


Case Report

13 - Use of volume-targeted non-invasive bilevel positive airway pressure ventilation in a patient with amyotrophic lateral sclerosis

Utilização de ventilação não invasiva com dois níveis de pressão positiva nas vias aéreas e volume alvo em paciente com esclerose lateral amiotrófica

Montserrat Diaz-Abad, John Edward Brown

J Bras Pneumol.2014;40(4):443-447

Abstract PDF PT PDF EN Portuguese Text

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease in which most patients die of respiratory failure. Although volume-targeted non-invasive bilevel positive airway pressure (BPAP) ventilation has been studied in patients with chronic respiratory failure of various etiologies, its use in ALS has not been reported. We present the case of a 66-year-old woman with ALS and respiratory failure treated with volume-targeted BPAP ventilation for 15 weeks. Weekly data downloads showed that disease progression was associated with increased respiratory muscle weakness, decreased spontaneous breathing, and increased use of non-invasive positive pressure ventilation, whereas tidal volume and minute ventilation remained relatively constant.


Keywords: Amyotrophic lateral sclerosis; Respiratory insufficiency; Hypoventilation; Intermittent positive-pressure ventilation; Sleep.


15 - Ground-glass nodules and CT-guided placement of platinum coils

Nódulos em vidro fosco e marcadores espirais de platina guiados por TC

Bruno Hochhegger, Fabíola Adélia Perin, Spencer Marcantonio Camargo, Edson Marchiori, Klaus Irion, Marcos Duarte Guimarães, Jose Carlos Felicetti, Jose Camargo

J Bras Pneumol.2014;40(4):450-452

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