Brazilian Journal of Pulmonology

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

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Year 2015 - Volume 41  - Number 4  (July/August)

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Original Article

3 - Functional improvement in patients with idiopathic pulmonary fibrosis undergoing single lung transplantation

Melhora funcional em portadores de fibrose pulmonar idiopática submetidos a transplante pulmonar unilateral

Adalberto Sperb Rubin1,2, Douglas Zaione Nascimento1, Letícia Sanchez1, Guilherme Watte2, Arthur Rodrigo Ronconi Holand1, Derrick Alexandre Fassbind1, José Jesus Camargo1,2

J Bras Pneumol.2015;41(4):299-304

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the changes in lung function in the first year after single lung transplantation in patients with idiopathic pulmonary fibrosis (IPF). Methods: We retrospectively evaluated patients with IPF who underwent single lung transplantation between January of 2006 and December of 2012, reviewing the changes in the lung function occurring during the first year after the procedure. Results: Of the 218 patients undergoing lung transplantation during the study period, 79 (36.2%) had IPF. Of those 79 patients, 24 (30%) died, and 11 (14%) did not undergo spirometry at the end of the first year. Of the 44 patients included in the study, 29 (66%) were men. The mean age of the patients was 57 years. Before transplantation, mean FVC, FEV1, and FEV1/FVC ratio were 1.78 L (50% of predicted), 1.48 L (52% of predicted), and 83%, respectively. In the first month after transplantation, there was a mean increase of 12% in FVC (400 mL) and FEV1 (350 mL). In the third month after transplantation, there were additional increases, of 5% (170 mL) in FVC and 1% (50 mL) in FEV1. At the end of the first year, the functional improvement persisted, with a mean gain of 19% (620 mL) in FVC and 16% (430 mL) in FEV1. Conclusions: Single lung transplantation in IPF patients who survive for at least one year provides significant and progressive benefits in lung function during the first year. This procedure is an important therapeutic alternative in the management of IPF.

 


Keywords: Pulmonary fibrosis; Respiratory function tests; Lung transplantation.

 

4 - Analysis of three different equations for predicting quadriceps femoris muscle strength in patients with COPD

Análise de três diferentes fórmulas de predição de força muscular do quadríceps femoral em pacientes com DPOC

Aline Gonçalves Nellessen¹, Leila Donária¹, Nidia Aparecida Hernandes¹, Fabio Pitta¹

J Bras Pneumol.2015;41(4):305-312

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare equations for predicting peak quadriceps femoris (QF) muscle force; to determine the agreement among the equations in identifying QF muscle weakness in COPD patients; and to assess the differences in characteristics among the groups of patients classified as having or not having QF muscle weakness by each equation. Methods: Fifty-six COPD patients underwent assessment of peak QF muscle force by dynamometry (maximal voluntary isometric contraction of knee extension). Predicted values were calculated with three equations: an age-height-weight-gender equation (Eq-AHWG); an age-weight-gender equation (Eq-AWG); and an age-fat-free mass-gender equation (Eq-AFFMG). Results: Comparison of the percentage of predicted values obtained with the three equations showed that the Eq-AHWG gave higher values than did the Eq-AWG and Eq-AFFMG, with no difference between the last two. The Eq-AHWG showed moderate agreement with the Eq-AWG and Eq-AFFMG, whereas the last two also showed moderate, albeit lower, agreement with each other. In the sample as a whole, QF muscle weakness (< 80% of predicted) was identified by the Eq-AHWG, Eq-AWG, and Eq-AFFMG in 59%, 68%, and 70% of the patients, respectively (p > 0.05). Age, fat-free mass, and body mass index are characteristics that differentiate between patients with and without QF muscle weakness. Conclusions: The three equations were statistically equivalent in classifying COPD patients as having or not having QF muscle weakness. However, the Eq-AHWG gave higher peak force values than did the Eq-AWG and the Eq-AFFMG, as well as showing greater agreement with the other equations.

 


Keywords: Pulmonary disease, chronic obstructive; Muscle strength; Quadriceps muscle; Reference values.

 

5 - Validation of scores of use of inhalation devices: valoration of errors

Validação de escores de uso de dispositivos para inalação: valoração dos erros cometidos

Letícia Zambelli-Simões1, Maria Cleusa Martins2, Juliana Carneiro da Cunha Possari3, Greice Borges Carvalho4, Ana Carla Carvalho Coelho5, Sonia Lucena Cipriano6, Regina Maria de Carvalho-Pinto7, Alberto Cukier7, Rafael Stelmach7

J Bras Pneumol.2015;41(4):313-322

Abstract PDF PT PDF EN Portuguese Text

Objective: To validate two scores quantifying the ability of patients to use metered dose inhalers (MDIs) or dry powder inhalers (DPIs); to identify the most common errors made during their use; and to identify the patients in need of an educational program for the use of these devices. Methods: This study was conducted in three phases: validation of the reliability of the inhaler technique scores; validation of the contents of the two scores using a convenience sample; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria. Results: The convenience sample comprised 16 patients. Interobserver disagreement was found in 19% and 25% of the DPI and MDI scores, respectively. After expert analysis on the subject, the scores were modified and were applied in 72 patients. The most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation. The degree of correlation of the scores by observer was 0.97 (p < 0.0001). There was good interobserver agreement in the classification of patients as able/not able to use a DPI (50%/50% and 52%/58%; p < 0.01) and an MDI (49%/51% and 54%/46%; p < 0.05). Conclusions: The validated scores allow the identification and correction of inhaler technique errors during consultations and, as a result, improvement in the management of inhalation devices.

 


Keywords: Asthma; Dry powder inhalers; Metered dose inhalers; Validation studies.

 

6 - Cocaine-induced pulmonary changes: HRCT findings

Alterações pulmonares induzidas pelo uso de cocaína: avaliação por TCAR de tórax

Renata Rocha de Almeida1, Gláucia Zanetti1,2, Arthur Soares Souza Jr.3, Luciana Soares de Souza4, Jorge Luiz Pereira e Silva5, Dante Luiz Escuissato6, Klaus Loureiro Irion7, Alexandre Dias Mançano8, Luiz Felipe Nobre9, Bruno Hochhegger10, Edson Marchiori1,11

J Bras Pneumol.2015;41(4):323-330

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate HRCT scans of the chest in 22 patients with cocaine-induced pulmonary disease. Methods: We included patients between 19 and 52 years of age. The HRCT scans were evaluated by two radiologists independently, discordant results being resolved by consensus. The inclusion criterion was an HRCT scan showing abnormalities that were temporally related to cocaine use, with no other apparent causal factors. Results: In 8 patients (36.4%), the clinical and tomographic findings were consistent with "crack lung", those cases being studied separately. The major HRCT findings in that subgroup of patients included ground-glass opacities, in 100% of the cases; consolidations, in 50%; and the halo sign, in 25%. In 12.5% of the cases, smooth septal thickening, paraseptal emphysema, centrilobular nodules, and the tree-in-bud pattern were identified. Among the remaining 14 patients (63.6%), barotrauma was identified in 3 cases, presenting as pneumomediastinum, pneumothorax, and hemopneumothorax, respectively. Talcosis, characterized as perihilar conglomerate masses, architectural distortion, and emphysema, was diagnosed in 3 patients. Other patterns were found less frequently: organizing pneumonia and bullous emphysema, in 2 patients each; and pulmonary infarction, septic embolism, eosinophilic pneumonia, and cardiogenic pulmonary edema, in 1 patient each. Conclusions: Pulmonary changes induced by cocaine use are varied and nonspecific. The diagnostic suspicion of cocaine-induced pulmonary disease depends, in most of the cases, on a careful drawing of correlations between clinical and radiological findings.

 


Keywords: Cocaine, Cocaine-related disorders; Tomography, X-ray computed; Lung diseases.

 

7 - Pulmonary involvement in rheumatoid arthritis: evaluation by radiography and spirometry

Doença pulmonar em pacientes com artrite reumatoide: avaliação radiográfica e espirométrica

Alexandre Melo Kawassaki1, Daniel Antunes Silva Pereira1, Fernando Uliana Kay2, Ieda Maria Magalhães Laurindo3, Carlos Roberto Ribeiro Carvalho4, Ronaldo Adib Kairalla1

J Bras Pneumol.2015;41(4):331-342

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA). Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry. Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure. Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

 


Keywords: Arthritis, rheumatoid; Lung diseases, interstitial; Spirometry; Radiography, thoracic; Airway ob-struction.

 

8 - Clinical characteristics of children and adolescents with severe therapy-resistant asthma in Brazil

Características clínicas de crianças e adolescentes brasileiros com asma grave resistente a terapia

Andrea Mendonça Rodrigues1, Cristian Roncada1, Giovana Santos2, João Paulo Heinzmann-Filho1, Rodrigo Godinho de Souza2, Mauro Henrique Moraes Vargas1, Leonardo Araújo Pinto3, Marcus Herbert Jones3, Renato Tetelbom Stein3, Paulo Márcio Pitrez3

J Bras Pneumol.2015;41(4):343-350

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether simple diagnostic methods can yield relevant disease information in patients with rheumatoid arthritis (RA). Methods: Patients with RA were randomly selected for inclusion in a cross-sectional study involving clinical evaluation of pulmonary function, including pulse oximetry (determination of SpO2, at rest), chest X-ray, and spirometry. Results: A total of 246 RA patients underwent complete assessments. Half of the patients in our sample reported a history of smoking. Spirometry was abnormal in 30% of the patients; the chest X-ray was abnormal in 45%; and the SpO2 was abnormal in 13%. Normal chest X-ray, spirometry, and SpO2 were observed simultaneously in only 41% of the RA patients. A history of smoking was associated with abnormal spirometry findings, including evidence of obstructive or restrictive lung disease, and with abnormal chest X-ray findings, as well as with an interstitial pattern on the chest X-ray. Comparing the patients in whom all test results were normal (n = 101) with those in whom abnormal test results were obtained (n = 145), we found a statistically significant difference between the two groups, in terms of age and smoking status. Notably, there were signs of airway disease in nearly half of the patients with minimal or no history of tobacco smoke exposure. Conclusions: Pulmonary involvement in RA can be identified through the use of a combination of diagnostic methods that are simple, safe, and inexpensive. Our results lead us to suggest that RA patients with signs of lung involvement should be screened for lung abnormalities, even if presenting with no respiratory symptoms.

 


Keywords: Arthritis, rheumatoid; Lung diseases, interstitial; Spirometry; Radiography, thoracic; Airway ob-struction.

 

9 - Sleep-disordered breathing in patients with cystic fibrosis

Distúrbios respiratórios do sono em pacientes com fibrose cística

Jefferson Veronezi1,2, Ana Paula Carvalho3, Claudio Ricachinewsky4, Anneliese Hoffmann4, Danielle Yuka Kobayashi5, Otavio Bejzman Piltcher6, Fernando Antonio Abreu e Silva7, Denis Martinez1,2,8

J Bras Pneumol.2015;41(4):351-357

Abstract PDF PT PDF EN Portuguese Text

Objective: To test the hypothesis that disease severity in patients with cystic fibrosis (CF) is correlated with an increased risk of sleep apnea. Methods: A total of 34 CF patients underwent clinical and functional evaluation, as well as portable polysomnography, spirometry, and determination of IL-1β levels. Results: Mean apnea-hypopnea index (AHI), SpO2 on room air, and Epworth Sleepiness Scale score were 4.8 ± 2.6, 95.9 ± 1.9%, and 7.6 ± 3.8 points, respectively. Of the 34 patients, 19 were well-nourished, 6 were at nutritional risk, and 9 were malnourished. In the multivariate model to predict the AHI, the following variables remained significant: nutritional status (β = −0.386; p = 0.014); SpO2 (β = −0.453; p = 0.005), and the Epworth Sleepiness Scale score (β = 0.429; p = 0.006). The model explained 51% of the variation in the AHI. Conclusions: The major determinants of sleep apnea were nutritional status, SpO2, and daytime sleepiness. This knowledge not only provides an opportunity to define the clinical risk of having sleep apnea but also creates an avenue for the treatment and prevention of the disease.

 


Keywords: Cystic fibrosis; Oxygenation; Sleep apnea, obstructive.

 

10 - Reflex cough PEF as a predictor of successful extubation in neurological patients

Pico de fluxo de tosse reflexa como preditor de sucesso na extubação em pacientes neurológicos

Fernanda Machado Kutchak1,2, Andressa Maciel Debesaitys2, Marcelo de Mello Rieder2,3, Carla Meneguzzi2, Amanda Soares Skueresky3, Luiz Alberto Forgiarini Junior3,4, Marino Muxfeldt Bianchin5

J Bras Pneumol.2015;41(4):358-364

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the use of reflex cough PEF as a predictor of successful extubation in neurological patients who were candidates for weaning from mechanical ventilation. Methods: This was a cross-sectional study of 135 patients receiving mechanical ventilation for more than 24 h in the ICU of Cristo Redentor Hospital, in the city of Porto Alegre, Brazil. Reflex cough PEF, the rapid shallow breathing index, MIP, and MEP were measured, as were ventilatory, hemodynamic, and clinical parameters. Results: The mean age of the patients was 47.8 ± 17 years. The extubation failure rate was 33.3%. A reflex cough PEF of < 80 L/min showed a relative risk of 3.6 (95% CI: 2.0-6.7), and the final Glasgow Coma Scale score showed a relative risk of 0.64 (95% CI: 0.51-0.83). For every 1-point increase in a Glasgow Coma Scale score of 8, there was a 36% reduction in the risk of extubation failure. Conclusions: Reflex cough PEF and the Glasgow Coma Scale score are independent predictors of extubation failure in neurological patients admitted to the ICU.

 


Keywords: Weaning; Intensive care units; Cough.

 

Review Article

11 - Identifying activating mutations in the EGFR gene: prognostic and therapeutic implications in non-small cell lung cancer

Identificação de mutações ativadoras no gene EGFR: implicações no prognóstico e no tratamento do carcinoma pulmonar de células não pequenas

Gabriel Lima Lopes1, Edoardo Filippo de Queiroz Vattimo2, Gilberto de Castro Junior2,3

J Bras Pneumol.2015;41(4):365-375

Abstract PDF PT PDF EN Portuguese Text

Lung cancer is the leading cause of cancer-related deaths worldwide. Promising new therapies have recently emerged from the development of molecular targeted drugs; particularly promising are those blocking the signal transduction machinery of cancer cells. One of the most widely studied cell signaling pathways is that of EGFR, which leads to uncontrolled cell proliferation, increased cell angiogenesis, and greater cell invasiveness. Activating mutations in the EGFR gene (deletions in exon 19 and mutation L858R in exon 21), first described in 2004, have been detected in approximately 10% of all non-squamous non-small cell lung cancer (NSCLC) patients in Western countries and are the most important predictors of a response to EGFR tyrosine-kinase inhibitors (EGFR-TKIs). Studies of the EGFR-TKIs gefitinib, erlotinib, and afatinib, in comparison with platinum-based regimens, as first-line treatments in chemotherapy-naïve patients have shown that the EGFR-TKIs produce gains in progression-free survival and overall response rates, although only in patients whose tumors harbor activating mutations in the EGFR gene. Clinical trials have also shown EGFR-TKIs to be effective as second- and third-line therapies in advanced NSCLC. Here, we review the main aspects of EGFR pathway activation in NSCLC, underscore the importance of correctly identifying activating mutations in the EGFR gene, and discuss the main outcomes of EGFR-TKI treatment in NSCLC.

 


Keywords: Molecular targeted therapy; Receptor, epidermal growth factor; Lung neoplasms/drug therapy; Mutation; Oncogenes.

 

12 - Stereotactic body radiotherapy in lung cancer: an update

Radioterapia estereotáxica extracraniana em câncer de pulmão: atualização

Carlos Eduardo Cintra Vita Abreu1, Paula Pratti Rodrigues Ferreira1, Fabio Ynoe de Moraes1, Wellington Furtado Pimenta Neves Jr1, Rafael Gadia2, Heloisa de Andrade Carvalho1,3

J Bras Pneumol.2015;41(4):376-387

Abstract PDF PT PDF EN Portuguese Text

For early-stage lung cancer, the treatment of choice is surgery. In patients who are not surgical candidates or are unwilling to undergo surgery, radiotherapy is the principal treatment option. Here, we review stereotactic body radiotherapy, a technique that has produced quite promising results in such patients and should be the treatment of choice, if available. We also present the major indications, technical aspects, results, and special situations related to the technique.

 


Keywords: Radiation oncology; Lung neoplasms/radiotherapy; Lung neoplasms/surgery; Respiratory function tests.

 

Continuing Education: Imaging

13 - Dense consolidation

Consolidação densa

Edson Marchiori1,2, Gláucia Zanetti2,3, Bruno Hochhegger4,5

J Bras Pneumol.2015;41(4):388

PDF PT PDF EN Portuguese Text


Case Series

14 - Streptococcus pneumoniae-associated pneumonia complicated by purulent pericarditis: case series

Pneumonia por Streptococcus pneumoniae complicada por pericardite purulenta: uma série de casos

Catia Cillóniz1, Ernesto Rangel2, Cornelius Barlascini3, Ines Maria Grazia Piroddi4, Antoni Torres1, Antonello Nicolini4

J Bras Pneumol.2015;41(4):389-394

Abstract PDF PT PDF EN Portuguese Text

Objective: In the antibiotic era, purulent pericarditis is a rare entity. However, there are still reports of cases of the disease, which is associated with high mortality, and most such cases are attributed to delayed diagnosis. Approximately 40-50% of all cases of purulent pericarditis are caused by Gram-positive bacteria, Streptococcus pneumoniae in particular. Methods: We report four cases of pneumococcal pneumonia complicated by pericarditis, with different clinical features and levels of severity. Results: In three of the four cases, the main complication was cardiac tamponade. Microbiological screening (urinary antigen testing and pleural fluid culture) confirmed the diagnosis of severe pneumococcal pneumonia complicated by purulent pericarditis. Conclusions: In cases of pneumococcal pneumonia complicated by pericarditis, early diagnosis is of paramount importance to avoid severe hemodynamic compromise. The complications of acute pericarditis appear early in the clinical course of the infection. The most serious complications are cardiac tamponade and its consequences. Antibiotic therapy combined with pericardiocentesis drastically reduces the mortality associated with purulent pericarditis.

 


Keywords: Pneumonia, pneumococcal/complications; Pneumonia, pneumococcal/mortality; Pericarditis/therapy; Cardiac tamponade; Streptococcus pneumoniae/pathogenicity.

 

Images in Pulmonary Medicine

15 - Pulmonary cement embolism

Embolia pulmonar por cimento ósseo

Manuel Lessa Ribeiro Neto1, Marcel Lima Albuquerque1, Daniela Barboza Santos Cavalcante1, João Ricardo Maltez de Almeida2

J Bras Pneumol.2015;41(4):395-396

PDF PT PDF EN Portuguese Text


 


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