Brazilian Journal of Pulmonology

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


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Year 2015 - Volume 41  - Number 5  (September/October)


3 - Jornal de Pneumologia 1995-1998

Jornal de Pneumologia 1995-1998

Carlos Alberto de Castro Pereira1

J Bras Pneumol.2015;41(5):399

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5 - My time at the JBP

O JBP que vivi

Geraldo Lorenzi-Filho1

J Bras Pneumol.2015;41(5):401

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7 - My time at the JBP

O JBP que vivi

Carlos Roberto Ribeiro Carvalho¹

J Bras Pneumol.2015;41(5):403

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8 - The next 40 years

Os próximos 40 anos

Rogério Souza¹

J Bras Pneumol.2015;41(5):404

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Original Article

9 - Study of inhaler technique in asthma patients: differences between pediatric and adult patients

Estudio sobre la técnica inhalatoria en pacientes asmáticos: diferencias entre pacientes pediátricos y adultos

Pablo Manríquez1, Ana María Acuña2, Luis Muñoz3, Alvaro Reyes4

J Bras Pneumol.2015;41(5):405-409

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Objective: Inhaler technique comprises a set of procedures for drug delivery to the respiratory system. The oral inhalation of medications is the first-line treatment for lung diseases. Using the proper inhaler technique ensures sufficient drug deposition in the distal airways, optimizing therapeutic effects and reducing side effects. The purposes of this study were to assess inhaler technique in pediatric and adult patients with asthma; to determine the most common errors in each group of patients; and to compare the results between the two groups. Methods: This was a descriptive cross-sectional study. Using a ten-step protocol, we assessed inhaler technique in 135 pediatric asthma patients and 128 adult asthma patients. Results: The most common error among the pediatric patients was failing to execute a 10-s breath-hold after inhalation, whereas the most common error among the adult patients was failing to exhale fully before using the inhaler. Conclusions: Pediatric asthma patients appear to perform most of the inhaler technique steps correctly. However, the same does not seem to be true for adult patients.


Keywords: Administration, inhalation; Aerosols/administration & dosage; Asthma/prevention & control.


10 - Diagnostic value of endobronchial ultrasound-guided transbronchial needle aspiration in various lung diseases

Valor diagnóstico da punção aspirativa por agulha guiada por ultrassom endobrônquico em diferentes doenças pulmonares

Mediha Gonenc Ortakoylu1, Sinem Iliaz1, Ayse Bahadir1, Asuman Aslan1, Raim Iliaz2, Mehmet Akif Ozgul1, Halide Nur Urer3

J Bras Pneumol.2015;41(5):410-414

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Objective: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a new method for the diagnosis and staging of lung disease, and its use is increasing worldwide. It has been used as a means of diagnosing lung cancer in its initial stages, and there are data supporting its use for the diagnosis of benign lung disease. The aim of this study was to share our experience with EBUS-TBNA and discuss its diagnostic value. Methods: We retrospectively analyzed the results related to 159 patients who underwent EBUS-TBNA at our pulmonary medicine clinic between 2010 and 2013. We recorded the location and size of lymph nodes seen during EBUS. Lymph nodes that appeared to be affected on EBUS were sampled at least twice. We recorded the diagnostic results of EBUS-TBNA and (for cases in which EBUS-TBNA yielded an inconclusive diagnosis) the final diagnoses after further investigation and follow-up. Results: We evaluated 159 patients, of whom 89 (56%) were male and 70 (44%) were female. The mean age was 54.6 ± 14.2 years among the male patients and 51.9 ± 11.3 years among the female patients. Of the 159 patients evaluated, 115 (84%) were correctly diagnosed by EBUS. The diagnostic accuracy of EBUS-TBNA was 83% for benign granulomatous diseases and 77% for malignant diseases. Conclusions: The diagnostic value of EBUS-TBNA is also high for benign pathologies, such as sarcoidosis and tuberculosis. In patients with mediastinal disorders, the use of EBUS-TBNA should be encouraged, primarily because it markedly reduces the need for mediastinoscopy.


Keywords: Sarcoidosis; Tuberculosis, pulmonary; Lung neoplasms; Bronchoscopy; Mediastinoscopy; Endosonography.


11 - Sarcopenia in COPD: relationship with COPD severity and prognosis

Sarcopenia na DPOC: relação com a gravidade e o prognóstico da DPOC

Tatiana Munhoz da Rocha Lemos Costa1,2, Fabio Marcelo Costa3, Carolina Aguiar Moreira1,2, Leda Maria Rabelo3, César Luiz Boguszewski1, Victória Zeghbi Cochenski Borba1,2

J Bras Pneumol.2015;41(5):415-421

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Objective: To evaluate the prevalence of sarcopenia in COPD patients, as well as to determine whether sarcopenia correlates with the severity and prognosis of COPD. Methods: A cross-sectional study with COPD patients followed at the pulmonary outpatient clinic of our institution. The patients underwent dual-energy X-ray absorptiometry. The diagnosis of sarcopenia was made on the basis of the skeletal muscle index, defined as appendicular lean mass/height2 only for low-weight subjects and adjusted for fat mass in normal/overweight subjects. Disease severity (COPD stage) was evaluated with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. The degree of obstruction and prognosis were determined by the Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity (BODE) index. Results: We recruited 91 patients (50 females), with a mean age of 67.4 ± 8.7 years and a mean BMI of 25.8 ± 6.1 kg/m2. Sarcopenia was observed in 36 (39.6%) of the patients, with no differences related to gender, age, or smoking status. Sarcopenia was not associated with the GOLD stage or with FEV1 (used as an indicator of the degree of obstruction). The BMI, percentage of body fat, and total lean mass were lower in the patients with sarcopenia than in those without (p < 0.001). Sarcopenia was more prevalent among the patients in BODE quartile 3 or 4 than among those in BODE quartile 1 or 2 (p = 0.009). The multivariate analysis showed that the BODE quartile was significantly associated with sarcopenia, regardless of age, gender, smoking status, and GOLD stage. Conclusions: In COPD patients, sarcopenia appears to be associated with unfavorable changes in body composition and with a poor prognosis.


Keywords: Sarcopenia; Body composition; Pulmonary disease, chronic obstructive; Severity of illness index.


12 - Determining respiratory system resistance and reactance by impulse oscillometry in obese individuals

Resistência e reatância do sistema respiratório por oscilometria de impulso em indivíduos obesos

Cláudio Gonçalves de Albuquerque1, Flávio Maciel Dias de Andrade1, Marcus Aurélio de Almeida Rocha1, Alina Farias França de Oliveira1, Waldemar Ladosky1, Edgar Guimarães Victor1, José Ângelo Rizzo1

J Bras Pneumol.2015;41(5):422-426

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Objective: To evaluate peripheral respiratory system resistance and reactance (Rrs and Xrs, respectively) in obese individuals. Methods: We recruited 99 individuals, dividing them into four groups by body mass index (BMI): < 30.0 kg/m2 (control, n = 31); 30.0-39.9 kg/m2 (obesity, n = 13); 40.0-49.9 kg/m2 (severe obesity, n = 28); and ≥ 50.0 kg/m2 (morbid obesity, n = 13). Using impulse oscillometry, we measured total Rrs, central Rrs, and Xrs. Peripheral Rrs was calculated as the difference between total Rrs and central Rrs. All subjects also underwent spirometry. Results: Of the 99 individuals recruited, 14 were excluded because they failed to perform forced expiratory maneuvers correctly during spirometry. The individuals in the severe obesity and morbid obesity groups showed higher peripheral Rrs and lower Xrs in comparison with those in the two other groups. Conclusions: Having a BMI ≥ 40 kg/m2 was associated with a significant increase in peripheral Rrs and with a decrease in Xrs.


Keywords: Obesity; Airway obstruction; Oscillometry; Respiratory function tests.


13 - Lung function and left ventricular hypertrophy in morbidly obese candidates for bariatric surgery

Função pulmonar e hipertrofia ventricular esquerda em obesos mórbidos candidatos a cirurgia bariátrica

Paulo de Tarso Müller1,2, Hamilton Domingos3, Luiz Armando Pereira Patusco1,2, Gabriel Victor Guimarães Rapello1

J Bras Pneumol.2015;41(5):427-432

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Objective: To look for correlations between lung function and cardiac dimension variables in morbidly obese patients, in order to test the hypothesis that the relative size of the small airways is independently correlated with left ventricular hypertrophy. Methods: This was a retrospective study involving 192 medical records containing a clinical protocol employed in candidates for bariatric surgery between January of 2006 and December of 2010. Results: Of the 192 patients evaluated, 39 (10 males and 29 females) met the inclusion criteria. The mean BMI of the patients was 49.2 ± 7.6 kg/m2, and the mean age was 35.5 ± 7.7 years. The FEF25-75/FVC, % correlated significantly with left ventricular posterior wall thickness and relative left ventricular posterior wall thickness, those correlations remaining statistically significant (r = −0.355 and r = −0.349, respectively) after adjustment for weight, gender, and history of systemic arterial hypertension. Stepwise multivariate linear regression analysis showed that FVC and FEV1 were the major determinants of left ventricular mass (in grams or indexed to body surface area). Conclusions: A reduction in the relative size of the small airways appears to be independently correlated with obesity-related cardiac hypertrophy, regardless of factors affecting respiratory mechanics (BMI and weight), gender, or history of systemic arterial hypertension. However, FEV1 and FVC might be important predictors of left ventricular mass in morbidly obese individuals.


Keywords: Obesity; Spirometry; Echocardiography; Body mass index.


14 - Depression, anxiety, stress, and motivation over the course of smoking cessation treatment

Depressão, ansiedade, estresse e motivação em fumantes durante o tratamento para a cessação do tabagismo

Maritza Muzzi Cardozo Pawlina1, Regina de Cássia Rondina2, Mariano Martinez Espinosa3, Clóvis Botelho4

J Bras Pneumol.2015;41(5):433-439

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Objective: To evaluate changes in the levels of patient anxiety, depression, motivation, and stress over the course of smoking cessation treatment. Methods: This cohort study involved patients enrolled in a smoking cessation program in Cuiabá, Brazil. We selected patients who completed the program in six months or less (n = 142). Patient evaluations were conducted at enrollment (evaluation 1 [E1]); after 45 days of treatment with medication and cognitive-behavioral therapy (E2); and at the end of the six-month study period (E3). Patients were evaluated with a standardized questionnaire (to collect sociodemographic data and determine smoking status), as well as with the University of Rhode Island Change Assessment scale, Beck Anxiety Inventory, Beck Depression Inventory, and Lipp Inventory of Stress Symptoms for Adults. The data were analyzed with the nonparametric Wilcoxon test for paired comparisons. To compare treatment success (smoking cessation) with treatment failure, the test for two proportions was used. Results: Among the 142 patients evaluated, there were improvements, in terms of the levels of anxiety, depression, motivation, and stress, between E1 and E2, as well as between E1 and E3. In addition, treatment success correlated significantly with the levels of motivation and anxiety throughout the study period, whereas it correlated significantly with the level of depression only at E2 and E3. Conclusions: We conclude that there are in fact changes in the levels of patient anxiety, depression, motivation, and stress over the course of smoking cessation treatment. Those changes appear to be more pronounced in patients in whom the treatment succeeded.


Keywords: Anxiety; Depression; Motivation; Cognitive therapy; Smoking cessation.


15 - Factors predictive of obstructive sleep apnea in patients undergoing pre-operative evaluation for bariatric surgery and referred to a sleep laboratory for polysomnography

Fatores preditivos para apneia obstrutiva do sono em pacientes em avaliação pré-operatória de cirurgia bariátrica e encaminhados para polissonografia em um laboratório do sono

Ricardo Luiz de Menezes Duarte1,2, Flavio José Magalhães-da-Silveira1

J Bras Pneumol.2015;41(5):440-448

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Objective: To identify the main predictive factors for obtaining a diagnosis of obstructive sleep apnea (OSA) in patients awaiting bariatric surgery. Methods: Retrospective study of consecutive patients undergoing pre-operative evaluation for bariatric surgery and referred for in-laboratory polysomnography. Eight variables were evaluated: sex, age, neck circumference (NC), BMI, Epworth Sleepiness Scale (ESS) score, snoring, observed apnea, and hypertension. We employed ROC curve analysis to determine the best cut-off value for each variable and multiple linear regression to identify independent predictors of OSA severity. Results: We evaluated 1,089 patients, of whom 781 (71.7%) were female. The overall prevalence of OSA-defined as an apnea/hypopnea index (AHI) ≥ 5.0 events/h-was 74.8%. The best cut-off values for NC, BMI, age, and ESS score were 42 cm, 42 kg/m2, 37 years, and 10 points, respectively. All eight variables were found to be independent predictors of a diagnosis of OSA in general, and all but one were found to be independent predictors of a diagnosis of moderate/severe OSA (AHI ≥ 15.0 events/h), the exception being hypertension. We devised a 6-item model, designated the NO-OSAS model (NC, Obesity, Observed apnea, Snoring, Age, and Sex), with a cut-off value of ≥ 3 for identifying high-risk patients. For a diagnosis of moderate/severe OSA, the model showed 70.8% accuracy, 82.8% sensitivity, and 57.9% specificity. Conclusions: In our sample of patients awaiting bariatric surgery, there was a high prevalence of OSA. At a cut-off value of ≥ 3, the proposed 6-item model showed good accuracy for a diagnosis of moderate/severe OSA.


Keywords: Polysomnography; Sleep apnea, obstructive; Bariatric surgery.


Brief Communication

16 - Control measures to trace ≤ 15-year-old contacts of index cases of active pulmonary tuberculosis

Medidas de controle dispensadas a contatos ≤ 15 anos de casos índices com tuberculose pulmonar ativa

Cláudia Di Lorenzo Oliveira1, Angelita Cristine de Melo2, Lílian Ruth Silva de Oliveira3, Emerson Lopes Froede1, Paulo Camargos3

J Bras Pneumol.2015;41(5):449-453

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This was descriptive study carried out in a medium-sized Brazilian city. In ≤ 15-year-old contacts of index cases of active pulmonary tuberculosis, we assessed compliance with the Brazilian national guidelines for tuberculosis control. We interviewed 43 contacts and their legal guardians. Approximately 80% of the contacts were not assessed by the municipal public health care system, and only 21% underwent tuberculin skin testing. The results obtained with the Chi-square Automatic Interaction Detector method suggest that health care teams have a biased attitude toward assessing such contacts and underscore the need for training health professionals regarding tuberculosis control programs.


Keywords: Tuberculosis, pulmonary\epidemiology, Tuberculosis, pulmonary\prevention and control; Contact tracing.


Review Article

17 - Control measures to trace ≤ 15-year-old contacts of index cases of active pulmonary tuberculosis

Atualização no diagnóstico e tratamento da fibrose pulmonar idiopática

José Baddini-Martinez1, Bruno Guedes Baldi2, Cláudia Henrique da Costa3, Sérgio Jezler4, Mariana Silva Lima5, Rogério Rufino3,6

J Bras Pneumol.2015;41(5):454-466

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Idiopathic pulmonary fibrosis is a type of chronic fibrosing interstitial pneumonia, of unknown etiology, which is associated with a progressive decrease in pulmonary function and with high mortality rates. Interest in and knowledge of this disorder have grown substantially in recent years. In this review article, we broadly discuss distinct aspects related to the diagnosis and treatment of idiopathic pulmonary fibrosis. We list the current diagnostic criteria and describe the therapeutic approaches currently available, symptomatic treatments, the action of new drugs that are effective in slowing the decline in pulmonary function, and indications for lung transplantation.


Keywords: Idiopathic pulmonary fibrosis/diagnosis; Idiopathic pulmonary fibrosis/therapy; Idiopathic pulmonary fibrosis/rehabilitation.


18 - 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

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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.


Case Report

19 - Acute invasive pulmonary aspergillosis, shortly after occupational exposure to polluted muddy water, in a previously healthy subject

Aspergilose pulmonar invasiva aguda, logo após exposição ocupacional a água poluída barrenta, em indivíduo previamente saudável

Vikas Pilaniya, Kamal Gera, Rajesh Gothi, Ashok Sha

J Bras Pneumol.2015;41(5):473-477

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Invasive pulmonary aspergillosis (IPA) predominantly occurs in severely neutropenic immunocompromised subjects. The occurrence of acute IPA after brief but massive exposure to Aspergillus conidia in previously healthy subjects has been documented, although only six such cases have been reported. The diagnosis was delayed in all six of the affected patients, five of whom died. We report the case of a 50-year-old HIV-negative male, a water pipeline maintenance worker, who presented with acute-onset dyspnea and fever one day after working for 2 h in a deep pit containing polluted, muddy water. Over a one-month period, his general condition deteriorated markedly, despite antibiotic therapy. Imaging showed bilateral diffuse nodules with cavitation, some of which were surrounded by ground-glass opacity suggestive of a halo sign (a hallmark of IPA). Cultures (of sputum/bronchial aspirate samples) and serology were positive for Aspergillus fumigatus. After being started on itraconazole, the patient improved. We conclude that massive exposure to Aspergillus conidia can lead to acute IPA in immunocompetent subjects.


Keywords: Environmental exposure; Azoles; Water pollution; Immunocompetence; Invasive pulmonary aspergillosis.


21 - BCGitis: A rare complication after intravesical BCG therapy

BCGite: Uma complicação rara da terapia intravesical com BCG

Maria João Oliveira, Daniel Vaz, Aurora Carvalho, Rosário Braga, Raquel Duarte

J Bras Pneumol.2015;41(5):480-481

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22 - Bronchiectasis caused by common variable immunodeficiency

Bronquiectasia por imunodeficiência comum variável

Paulo Henrique do Amor Divino, José Henrique de Carvalho Basilio, Renato Moraes Alves Fabbri, Igor Polônio Bastos, Wilma Carvalho Neves Forte

J Bras Pneumol.2015;41(5):482-483

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Continuing Education: Imaging

23 - Diffuse lung cysts

Cistos pulmonares difusos

Edson Marchiori, Gláucia Zanetti, Bruno Hochhegger

J Bras Pneumol.2015;41(5):484

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Continuing Education : Scientific Methodology

24 - What does the p value really mean?

O que realmente significa o valor-p?

Juliana Carvalho Ferreira, Cecilia Maria Patino

J Bras Pneumol.2015;41(5):485

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Images in Pulmonary Medicine


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