Brazilian Journal of Pulmonology

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


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Year 2015 - Volume 41  - Number 1  (January/February)


Special Article

2 - A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts

Programas e centros de atenção a asmáticos no Brasil; uma oficina de trabalho: revisitando e explicitando conceitos

Rafael Stelmach, Alcindo Cerci Neto, Ana Cristina de Carvalho Fernandez Fonseca, Eduardo Vieira Ponte, Gerardo Alves, Ildely Niedia Araujo-Costa, et al.

J Bras Pneumol.2015;41(1):3-15

Abstract PDF PT PDF EN Portuguese Text

Objective: To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs. Methods: The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs. Results: The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system. Conclusions: Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero.


Keywords: Asthma; Academic medical centers; Area health education centers; Health planning organiza-tions; Regional medical programs; Managed care programs.


Original Article

3 - Negative impact of asthma on patients in different age groups

Impacto negativo da asma em diferentes faixas etárias

Marcela Batan Alith, Mariana Rodrigues Gazzotti, Federico Montealegre, James Fish, Oliver Augusto Nascimento, José Roberto Jardim

J Bras Pneumol.2015;41(1):16-22

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of asthma on patients in Brazil, by age group (12-17 years, 18-40 years, and ≥ 41 years). Methods: From a survey conducted in Latin America in 2011, we obtained data on 400 patients diagnosed with asthma and residing in one of four Brazilian state capitals (São Paulo, Rio de Janeiro, Curitiba, and Salvador). The data had been collected using a standardized questionnaire in face-to-face interviews. For the patients who were minors, the parents/guardians had completed the questionnaire. The questions addressed asthma control, number of hospitalizations, number of emergency room visits, and school/work absenteeism, as well as the impact of asthma on the quality of life, sleep, and leisure. We stratified the data by the selected age groups. Results: The proportions of patients who responded in the affirmative to the following questions were significantly higher in the 12- to 17-year age group than in the other two groups: "Have you had at least one episode of severe asthma that prevented you from playing/exercising in the last 12 months?" (p = 0.012); "Have you been absent from school/work in the last 12 months?" (p < 0.001); "Have you discontinued your asthma relief or control medication in the last 12 months?" (p = 0.008). In addition, 30.2% of the patients in the 12- to 17-year age group reported that normal physical exertion was very limiting (p = 0.010 vs. the other groups), whereas 14% of the patients in the ≥ 41-year age group described social activities as very limiting (p = 0.011 vs. the other groups). Conclusions: In this sample, asthma had a greater impact on the patients between 12 and 17 years of age, which might be attributable to poor treatment compliance.


Keywords: Asthma; Age groups; Quality of life.


4 - Endobronchial ultrasound-guided transbronchial needle aspiration for lung cancer staging: early experience in Brazil

Punção aspirativa por agulha guiada por ultrassom endobrônquico no estadiamento do câncer de pulmão: experiência inicial no Brasil

Viviane Rossi Figueiredo, Paulo Francisco Guerreiro Cardoso, Márcia Jacomelli, Sérgio Eduardo Demarzo, Addy Lidvina Mejia Palomino, Ascédio José Rodrigues, Ricardo Mingarini Terra, Paulo Manoel Pego-Fernandes, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2015;41(1):23-30

Abstract PDF PT PDF EN Portuguese Text

Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive, safe and accurate method for collecting samples from mediastinal and hilar lymph nodes. This study focused on the initial results obtained with EBUS-TBNA for lung cancer and lymph node staging at three teaching hospitals in Brazil. Methods: This was a retrospective analysis of patients diagnosed with lung cancer and submitted to EBUS-TBNA for mediastinal lymph node staging. The EBUS-TBNA procedures, which involved the use of an EBUS scope, an ultrasound processor, and a compatible, disposable 22 G needle, were performed while the patients were under general anesthesia. Results: Between January of 2011 and January of 2014, 149 patients underwent EBUS-TBNA for lymph node staging. The mean age was 66 ± 12 years, and 58% were male. A total of 407 lymph nodes were sampled by EBUS-TBNA. The most common types of lung neoplasm were adenocarcinoma (in 67%) and squamous cell carcinoma (in 24%). For lung cancer staging, EBUS-TBNA was found to have a sensitivity of 96%, a specificity of 100%, and a negative predictive value of 85%. Conclusions: We found EBUS-TBNA to be a safe and accurate method for lymph node staging in lung cancer patients.


Keywords: Lung neoplasms; Neoplasm staging; Bronchoscopy; Endoscopic ultrasound-guided fine needle aspiration; Lymph nodes.


5 - Preoperative predictive factors for intensive care unit admission after pulmonary resection

Fatores preditivos pré-operatórios de internação em unidade de terapia intensiva após ressecção pulmonar

Liana Pinheiro, Ilka Lopes Santoro, João Aléssio Juliano Perfeito, Meyer Izbicki, Roberta Pulcheri Ramos, Sonia Maria Faresin

J Bras Pneumol.2015;41(1):31-38

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. Methods: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. Results: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. Conclusions: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring.


Keywords: Thoracic surgery; Risk factors; Intensive care units.


6 - Chronic intermittent hypoxia increases encoding pigment epithelium-derived factor gene expression, although not that of the protein itself, in the temporal cortex of rats

Hipóxia intermitente crônica aumenta a expressão gênica, mas não proteica, de pigment epithelium-derived factor no córtex temporal de ratos

Guilherme Silva Julian, Renato Watanabe de Oliveira, Vanessa Manchim Favaro, Maria Gabriela Menezes de Oliveira, Juliana Cini Perry, Sergio Tufik, Jair Ribeiro Chagas

J Bras Pneumol.2015;41(1):39-47

Abstract PDF PT PDF EN Portuguese Text

Objective: Obstructive sleep apnea syndrome is mainly characterized by intermittent hypoxia (IH) during sleep, being associated with several complications. Exposure to IH is the most widely used animal model of sleep apnea, short-term IH exposure resulting in cognitive and neuronal impairment. Pigment epithelium-derived factor (PEDF) is a hypoxia-sensitive factor acting as a neurotrophic, neuroprotective, and antiangiogenic agent. Our study analyzed performance on learning and cognitive tasks, as well as PEDF gene expression and PEDF protein expression in specific brain structures, in rats exposed to long-term IH. Methods: Male Wistar rats were exposed to IH (oxygen concentrations of 21-5%) for 6 weeks-the chronic IH (CIH) group-or normoxia for 6 weeks-the control group. After CIH exposure, a group of rats were allowed to recover under normoxic conditions for 2 weeks (the CIH+N group). All rats underwent the Morris water maze test for learning and memory, PEDF gene expression and PEDF protein expression in the hippocampus, frontal cortex, and temporal cortex being subsequently assessed. Results: The CIH and CIH+N groups showed increased PEDF gene expression in the temporal cortex, PEDF protein expression remaining unaltered. PEDF gene expression and PEDF protein expression remained unaltered in the frontal cortex and hippocampus. Long-term exposure to IH did not affect cognitive function. Conclusions: Long-term exposure to IH selectively increases PEDF gene expression at the transcriptional level, although only in the temporal cortex. This increase is probably a protective mechanism against IH-induced injury.


Keywords: Sleep apnea, central; Disease models, animal; Cognition; Sleep; Sleep apnea, obstructive.


7 - Community-acquired pneumonia: economics of inpatient medical care vis-à-vis clinical severity

Pneumonia adquirida na comunidade: economia de cuidados médicos, em relação à gravidade clínica

Vojislav Cupurdija, Zorica Lazic, Marina Petrovic, Slavica Mojsilovic, Ivan Cekerevac, Nemanja Rancic, Mihajlo Jakovljevic

J Bras Pneumol.2015;41(1):48-57

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the direct and indirect costs of diagnosing and treating community-acquired pneumonia (CAP), correlating those costs with CAP severity at diagnosis and identifying the major cost drivers. Methods: This was a prospective cost analysis study using bottom-up costing. Clinical severity and mortality risk were assessed with the pneumonia severity index (PSI) and the mental Confusion-Urea-Respiratory rate-Blood pressure-age ≥ 65 years (CURB-65) scale, respectively. The sample comprised 95 inpatients hospitalized for newly diagnosed CAP. The analysis was run from a societal perspective with a time horizon of one year. Results: Expressed as mean  standard deviation, in Euros, the direct and indirect medical costs per CAP patient were 696  531 and 410  283, respectively, the total per-patient cost therefore being 1,106  657. The combined budget impact of our patient cohort, in Euros, was 105,087 (66,109 and 38,979 in direct and indirect costs, respectively). The major cost drivers, in descending order, were the opportunity cost (lost productivity); diagnosis and treatment of comorbidities; and administration of medications, oxygen, and blood derivatives. The CURB-65 and PSI scores both correlated with the indirect costs of CAP treatment. The PSI score correlated positively with the overall frequency of use of health care services. Neither score showed any clear relationship with the direct costs of CAP treatment. Conclusions: Clinical severity at admission appears to be unrelated to the costs of CAP treatment. This is mostly attributable to unwarranted hospital admission (or unnecessarily long hospital stays) in cases of mild pneumonia, as well as to over-prescription of antibiotics. Authorities should strive to improve adherence to guidelines and promote cost-effective prescribing practices among physicians in southeastern Europe.


Keywords: Pneumonia; Cost of illness; Costs and cost analysis; Health care costs; Hospitalization; Severity of illness index.


8 - Diagnostic accuracy of the Bedside Lung Ultrasound in Emergency protocol for the diagnosis of acute respiratory failure in spontaneously breathing patients

Acurácia diagnóstica do protocolo de ultrassom pulmonar à beira do leito em situações de emergência para diagnóstico de insuficiência respiratória aguda em pacientes com ventilação espontânea

Felippe Leopoldo Dexheimer Neto, Juliana Mara Stormovski de Andrade, Ana Carolina Tabajara Raupp, Raquel da Silva Townsend, Fabiana Gabe Beltrami, Hélène Brisson, Qin Lu, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2015;41(1):58-64

Abstract PDF PT PDF EN Portuguese Text

Objective: Bedside lung ultrasound (LUS) is a noninvasive, readily available imaging modality that can complement clinical evaluation. The Bedside Lung Ultrasound in Emergency (BLUE) protocol has demonstrated a high diagnostic accuracy in patients with acute respiratory failure (ARF). Recently, bedside LUS has been added to the medical training program of our ICU. The aim of this study was to investigate the accuracy of LUS based on the BLUE protocol, when performed by physicians who are not ultrasound experts, to guide the diagnosis of ARF. Methods: Over a one-year period, all spontaneously breathing adult patients consecutively admitted to the ICU for ARF were prospectively included. After training, 4 non-ultrasound experts performed LUS within 20 minutes of patient admission. They were blinded to patient medical history. LUS diagnosis was compared with the final clinical diagnosis made by the ICU team before patients were discharged from the ICU (gold standard). Results: Thirty-seven patients were included in the analysis (mean age, 73.2  14.7 years; APACHE II, 19.2  7.3). LUS diagnosis had a good agreement with the final diagnosis in 84% of patients (overall kappa, 0.81). The most common etiologies for ARF were pneumonia (n = 17) and hemodynamic lung edema (n = 15). The sensitivity and specificity of LUS as measured against the final diagnosis were, respectively, 88% and 90% for pneumonia and 86% and 87% for hemodynamic lung edema. Conclusions: LUS based on the BLUE protocol was reproducible by physicians who are not ultrasound experts and accurate for the diagnosis of pneumonia and hemodynamic lung edema.


Keywords: Ultrasonography, interventional; Respiratory insufficiency; Intensive care units.


Review Article

9 - Chronic rhinosinusitis and nasal polyposis in cystic fibrosis: update on diagnosis and treatment

Rinossinusite crônica e polipose nasossinusal na fibrose cística: atualização sobre diagnóstico e tratamento

Suzie Hyeona Kang, Paulo de Tarso Roth Dalcin, Otavio Bejzman Piltcher, Raphaella de Oliveira Migliavacca

J Bras Pneumol.2015;41(1):65-76

Abstract PDF PT PDF EN Portuguese Text

Although cystic fibrosis (CF) is an irreversible genetic disease, advances in treatment have increased the life expectancy of CF patients. Upper airway involvement, which is mainly due to pathological changes in the paranasal sinuses, is prevalent in CF patients, although many are only mildly symptomatic (with few symptoms). The objective of this literature review was to discuss the pathophysiology and current therapeutic management of chronic rhinosinusitis (CRS) in CF patients. The review was based on current evidence, which was classified in accordance with the Oxford Centre for Evidence-Based Medicine criteria. When symptomatic, CRS with nasal polyps can affect quality of life and can lead to pulmonary exacerbations, given that the paranasal sinuses can be colonized with pathogenic bacteria, especially Pseudomonas aeruginosa. Infection with P. aeruginosa plays a crucial role in morbidity and mortality after lung transplantation in CF patients. Although clinical treatment of the upper airways is recommended as initial management, this recommendation is often extrapolated from studies of CRS in the general population. When sinonasal disease is refractory to noninvasive therapy, surgery is indicated. Further studies are needed in order to gain a better understanding of upper airway involvement and improve the management of CRS in CF patients, with the objective of preserving lung function and avoiding unnecessary invasive procedures.


Keywords: Nose diseases; Cystic fibrosis; Nasal polyps; Paranasal sinuses; Sinusitis.


10 - Risk factors associated with adverse reactions to antituberculosis drugs

Fatores de risco associados às reações adversas a medicamentos antituberculose

Laíse Soares Oliveira Resende, Edson Theodoro dos Santos-Neto

J Bras Pneumol.2015;41(1):77-89

Abstract PDF PT PDF EN Portuguese Text

This review sought to identify the available scientific evidence on risk factors associated with adverse reactions to antituberculosis drugs. We performed a systematic review of studies published in the 1965-2012 period and indexed in the MEDLINE and LILACS databases. A total of 1,389 articles were initially selected. After reading their abstracts, we selected 85 studies. Of those 85 studies, 16 were included in the review. Risk factors for adverse reactions to antituberculosis drugs included age > 60 years, treatment regimens, alcoholism, anemia, and HIV co-infection, as well as sodium, iron, and albumin deficiency. Protective factors against hepatic adverse effects of antituberculosis drugs included being male (combined OR = 0.38; 95% CI: 0.20-0.72) and showing a rapid/intermediate N-acetyltransferase 2 acetylator phenotype (combined OR = 0.41; 95% CI: 0.18-0.90). There is evidence to support the need for management of adverse reactions to antituberculosis drugs at public health care facilities.


Keywords: Tuberculosis; Drug-related side effects and adverse reactions; Antitubercular agents; Review.


Case Report

11 - Video-assisted thoracoscopic implantation of a diaphragmatic pacemaker in a child with tetraplegia: indications, technique, and results

Implante de marca-passo diafragmático por videotoracoscopia em criança com tetraplegia: indi-cações, técnica e resultados

Darcy Ribeiro Pinto Filho, Miguel Lia Tedde, Alexandre José Gonçalves Avino, Suzan Lúcia Brancher Brandão, Iuri Zanatta, Rafael Hahn

J Bras Pneumol.2015;41(1):90-94

Abstract PDF PT PDF EN Portuguese Text

We report the case of a child with tetraplegia after cervical trauma, who subsequently underwent diaphragmatic pacemaker implantation. We reviewed the major indications for diaphragmatic pacing and the types of devices employed. We highlight the unequivocal benefit of diaphragmatic pacing in the social and educational reintegration of individuals with tetraplegia.


Keywords: Spinal cord injuries; Respiration, artificial; Pacemaker, artificial; Quadriplegia.


Letters to the Editor

12 - Nonadherence to treatment in lung transplant recipients: a matter of life and death

Falta de adesão ao tratamento em pacientes submetidos a transplante pulmonar: uma questão de vida ou morte

André Nathan Costa, Elaine Marques Hojaij, Liliane Saraiva de Mello, Felipe Xavier de Melo, Priscila Cilene Leon Bueno de Camargo, Silvia Vidal Campos, Jose Eduardo Afonso Junior, Rafael Medeiros Carraro, Ricardo Henrique de Oliveira Braga Teixeira

J Bras Pneumol.2015;41(1):95-97

PDF PT PDF EN Portuguese Text

15 - Hibernoma: an uncommon cause of a pleural mass

Hibernoma: uma causa incomum de massa pleural

Edson Marchiori, Gláucia Zanetti, Bruno Hochhegger

J Bras Pneumol.2015;41(1):103-104

PDF PT PDF EN Portuguese Text


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