Brazilian Journal of Pulmonology

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

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Year 2016 - Volume 42  - Number 5  (September/October)






Continuing Education: Imaging

2 - Intracavitary nodule

Nódulo intracavitário

Edson Marchiori1,2, Bruno Hochhegger3,4, Gláucia Zanetti2,5

J Bras Pneumol.2016;42(5):309

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Continuing Education : Scientific Methodology

3 - Randomization: beyond tossing a coin

Randomização: mais do que o lançamento de uma moeda

Juliana Carvalho Ferreira1,2, Cecilia Maria Patino1,3

J Bras Pneumol.2016;42(5):310

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Original Article

4 - Prevalence of alpha-1 antitrypsin deficiency and allele frequency in patients with COPD in Brazil

Prevalência da deficiência de alfa-1 antitripsina e frequência alélica em pacientes com DPOC no Brasil

Rodrigo Russo1,2, Laura Russo Zillmer1, Oliver Augusto Nascimento1, Beatriz Manzano1, Ivan Teruaki Ivanaga1, Leandro Fritscher3, Fernando Lundgren4, Marc Miravitlles5, Heicilainy Del Carlos Gondim6, Gildo Santos Junior7, Marcela Amorim Alves4, Maria Vera Oliveira8, Altay Alves Lino de Souza9, Maria Penha Uchoa Sales10, José Roberto Jardim1

J Bras Pneumol.2016;42(5):311-316

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of alpha 1-antitrypsin (AAT) deficiency (AATD), as well as allele frequency, in COPD patients in Brazil. Methods: This was a cross-sectional study involving 926 COPD patients 40 years of age or older, from five Brazilian states. All patients underwent determination of AAT levels in dried blood spot (DBS) samples by nephelometry. Those with DBS AAT levels ≤ 2.64 mg/dL underwent determination of serum AAT levels. Those with serum AAT levels of < 113 mg/dL underwent genotyping. In case of conflicting results, SERPINA1 gene sequencing was performed. Results: Of the 926 COPD patients studied, 85 had DBS AAT levels ≤ 2.64 mg/dL, and 24 (2.6% of the study sample) had serum AAT levels of < 113 mg/dL. Genotype distribution in this subset of 24 patients was as follows: PI*MS, in 3 (12.5%); PI*MZ, in 13 (54.2%); PI*SZ, in 1 (4.2%); PI*SS, in 1 (4.2%); and PI*ZZ, in 6 (25.0%). In the sample as a whole, the overall prevalence of AATD was 2.8% and the prevalence of the PI*ZZ genotype (severe AATD) was 0.8% Conclusions: The prevalence of AATD in COPD patients in Brazil is similar to that found in most countries and reinforces the recommendation that AAT levels be measured in all COPD patients.

 


Keywords: alpha 1-antitrypsin deficiency/epidemiology; pulmonary disease, chronic obstructive/epidemiology; Alleles; alpha 1-antitrypsin.

 

5 - Factors associated with disease-specific survival of patients with non-small cell lung cancer

Fatores associados à sobrevida doença-específica em pacientes com câncer de pulmão de células não pequenas

Mirian Carvalho de Souza1, Oswaldo Gonçalves Cruz2, Ana Glória Godoi Vasconcelos3

J Bras Pneumol.2016;42(5):317-325

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Objective: Lung cancer is a global public health problem and is associated with high mortality. Lung cancer could be largely avoided by reducing the prevalence of smoking. The objective of this study was to analyze the effects of social, behavioral, and clinical factors on the survival time of patients with non-small cell lung cancer treated at Cancer Hospital I of the José Alencar Gomes da Silva National Cancer Institute, located in the city of Rio de Janeiro, Brazil, between 2000 and 2003. Methods: This was a retrospective hospital cohort study involving 1,194 patients. The 60-month disease-specific survival probabilities were calculated with the Kaplan-Meier method for three stage groups. The importance of the studied factors was assessed with a hierarchical theoretical model after adjustment by Cox multiple regression. Results: The estimated 60-month specific-disease lethality rate was 86.0%. The 60-month disease-specific survival probability ranged from 25.0% (stages I/II) to 2.5% (stage IV). The performance status, the intention to treat, and the initial treatment modality were the major prognostic factors identified in the study population. Conclusions: In this cohort of patients, the disease-specific survival probabilities were extremely low. We identified no factors that could be modified after the diagnosis in order to improve survival. Primary prevention, such as reducing the prevalence of smoking, is still the best method to reduce the number of people who will suffer the consequences of lung cancer.

 


Keywords: Lung neoplasms/epidemiology; Carcinoma, non-small-cell lung; Survival analysis.

 

6 - Bronchodilator response cut-off points and FEV0.75 reference values for spirometry in preschoolers

Pontos de corte da resposta ao broncodilatador e valores de referência para VEF0,75 em espirometria de pré-escolares

Edjane Figueiredo Burity1, Carlos Alberto de Castro Pereira2, Marcus Herbert Jones3, Larissa Bouwman Sayão4, Armèle Dornelas de Andrade4, Murilo Carlos Amorim de Britto1

J Bras Pneumol.2016;42(5):326-332

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the cut-off points for FEV1, FEV0.75, FEV0.5, and FEF25-75% bronchodilator responses in healthy preschool children and to generate reference values for FEV0.75. Methods: This was a cross-sectional community-based study involving children 3-5 years of age. Healthy preschool children were selected by a standardized questionnaire. Spirometry was performed before and after bronchodilator use. The cut-off point of the response was defined as the 95th percentile of the change in each parameter. Results: We recruited 266 children, 160 (60%) of whom were able to perform acceptable, reproducible expiratory maneuvers before and after bronchodilator use. The mean age and height were 57.78 ± 7.86 months and 106.56 ± 6.43 cm, respectively. The success rate for FEV0.5 was 35%, 68%, and 70% in the 3-, 4-, and 5-year-olds, respectively. The 95th percentile of the change in the percentage of the predicted value in response to bronchodilator use was 11.6%, 16.0%, 8.5%, and 35.5% for FEV1, FEV0.75, FEV0.5, and FEF25-75%, respectively. Conclusions: Our results provide cut-off points for bronchodilator responsiveness for FEV1, FEV0.75, FEV0.5, and FEF25-75% in healthy preschool children. In addition, we proposed gender-specific reference equations for FEV0.75. Our findings could improve the physiological assessment of respiratory function in preschool children.

 


Keywords: Spirometry; Bronchodilator agents; Reference values; Child, preschool.

 

7 - Effects of passive inhalation of cigarette smoke on structural and functional parameters in the respiratory system of guinea pigs

Efeitos da inalação passiva da fumaça de cigarro em parâmetros estruturais e funcionais no sistema respiratório de cobaias

Thiago Brasileiro de Vasconcelos1, Fernanda Yvelize Ramos de Araújo1, João Paulo Melo de Pinho2, Pedro Marcos Gomes Soares1, Vasco Pinheiro Diógenes Bastos3

J Bras Pneumol.2016;42(5):333-340

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Objective: To evaluate the effects of passive inhalation of cigarette smoke on the respiratory system of guinea pigs. Methods: Male guinea pigs were divided into two groups: control and passive smoking, the latter being exposed to the smoke of ten cigarettes for 20 min in the morning, afternoon and evening (30 cigarettes/day) for five days. After that period, inflammatory parameters were studied by quantifying mesenteric mast cell degranulation, as well as oxidative stress, in BAL fluid. In addition, we determined MIP, MEP, and mucociliary transport (in vivo), as well as tracheal contractility response (in vitro). Results: In comparison with the control group, the passive smoking group showed a significant increase in mast cell degranulation (19.75 ± 3.77% vs. 42.53 ± 0.42%; p < 0.001) and in the levels of reduced glutathione (293.9 ± 19.21 vs. 723.7 ± 67.43 nM/g of tissue; p < 0.05); as well as a significant reduction in mucociliary clearance (p < 0.05), which caused significant changes in pulmonary function (in MIP and MEP; p < 0.05 for both) and airway hyperreactivity. Conclusions: Passive inhalation of cigarette smoke caused significant increases in mast cell degranulation and oxidative stress. This inflammatory process seems to influence the decrease in mucociliary transport and to cause changes in pulmonary function, leading to tracheal hyperreactivity.

 


Keywords: Inflammation; Inhalation exposure; Tobacco smoke pollution.

 

8 - Lung volumes and airway resistance in patients with a possible restrictive pattern on spirometry

Volumes pulmonares e resistência das vias aéreas em pacientes com possível padrão restritivo à espirometria

Kenia Schultz1,2, Luiz Carlos D'Aquino3, Maria Raquel Soares4, Andrea Gimenez5, Carlos Alberto de Castro Pereira4,5

J Bras Pneumol.2016;42(5):341-347

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: Many patients with proportional reductions in FVC and FEV1 on spirometry show no reduction in TLC. The aim of this study was to evaluate the role that measuring lung volumes and airway resistance plays in the correct classification of patients with a possible restrictive pattern on spirometry. Methods: This was a prospective study involving adults with reduced FVC and FEV1, as well as an FEV1/FV(C) ratio within the predicted range. Restrictive lung disease (RLD) was characterized by TLC below the 5th percentile, as determined by plethysmography. Obstructive lung disease (OLD) was characterized by high specific airway resistance, significant changes in post-bronchodilator FEV1, or an FEF25-75% < 50% of predicted, together with a high RV/TLC ratio. Nonspecific lung disease (NLD) was characterized by TLC within the predicted range and no obstruction. Combined lung disease (CLD) was characterized by reduced TLC and findings indicative of airflow obstruction. Clinical diagnoses were based on clinical suspicion, a respiratory questionnaire, and the review of tests of interest. Results: We included 300 patients in the study, of whom 108 (36%) were diagnosed with RLD. In addition, 120 (40%) and 72 (24%) were diagnosed with OLD/CLD and NLD, respectively. Among the latter, 24 (33%) were clinically diagnosed with OLD. In this sample, 151 patients (50.3%) were obese, and obesity was associated with all patterns of lung disease. Conclusions: Measuring lung volumes and airway resistance is often necessary in order to provide an appropriate characterization of the pattern of lung disease in patients presenting with a spirometry pattern suggestive of restriction. Airflow obstruction is common in such cases.

 


Keywords: Spirometry; Airway resistance; Lung volume measurements.

 

9 - Prevalence of latent Mycobacterium tuberculosis infection in prisoners

Prevalência da infecção latente por Mycobacterium tuberculosis em pessoas privadas de liberdade

Pedro Daibert de Navarro1,2, Isabela Neves de Almeida1, Afrânio Lineu Kritski3, Maria das Graças Ceccato4, Mônica Maria Delgado Maciel1, Wânia da Silva Carvalho4, Silvana Spindola de Miranda5

J Bras Pneumol.2016;42(5):348-355

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Objective: To determine the prevalence of and the factors associated with latent Mycobacterium tuberculosis infection (LTBI) in prisoners in the state of Minas Gerais, Brazil. Methods: This was a cross-sectional cohort study conducted in two prisons in Minas Gerais. Tuberculin skin tests were performed in the individuals who agreed to participate in the study. Results: A total of 1,120 individuals were selected for inclusion in this study. The prevalence of LTBI was 25.2%. In the multivariate analysis, LTBI was associated with self-reported contact with active tuberculosis patients within prisons (adjusted OR = 1.51; 95% CI: 1.05-2.18) and use of inhaled drugs (adjusted OR = 1.48; 95% CI: 1.03-2.13). Respiratory symptoms were identified in 131 (11.7%) of the participants. Serological testing for HIV was performed in 940 (83.9%) of the participants, and the result was positive in 5 (0.5%). Two cases of active tuberculosis were identified during the study period. Conclusions: Within the prisons under study, the prevalence of LTBI was high. In addition, LTBI was associated with self-reported contact with active tuberculosis patients and with the use of inhaled drugs. Our findings demonstrate that it is necessary to improve the conditions in prisons, as well as to introduce strategies, such as chest X-ray screening, in order to detect tuberculosis cases and, consequently, reduce M. tuberculosis infection within the prison system.

 


Keywords: Prisons; Tuberculin test; Latent tuberculosis, HIV.

 

10 - Staphylococcal superantigen-specific IgE antibodies: degree of sensitization and association with severity of asthma

Anticorpos IgE específicos para superantígenos estafilocócicos: grau de sensibilização e associação com a gravidade da asma

José Elabras Filho1,2, Fernanda Carvalho de Queiroz Mello2, Omar Lupi1,3, Blanca Elena Rios Gomes Bica1, José Angelo de Souza Papi1, Alfeu Tavares França1

J Bras Pneumol.2016;42(5):356-361

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Objective: To determine the presence of staphylococcal superantigen-specific IgE antibodies and degree of IgE-mediated sensitization, as well as whether or not those are associated with the severity of asthma in adult patients. Methods: This was a cross-sectional study involving outpatients with asthma under treatment at a tertiary care university hospital in the city of Rio de Janeiro, Brazil. Consecutive patients were divided into two groups according to the severity of asthma based on the Global Initiative for Asthma criteria: mild asthma (MA), comprising patients with mild intermittent or persistent asthma; and moderate or severe asthma (MSA). We determined the serum levels of staphylococcal toxin-specific IgE antibodies, comparing the results and performing a statistical analysis. Results: The study included 142 patients: 72 in the MA group (median age = 46 years; 59 females) and 70 in the MSA group (median age = 56 years; 60 females). In the sample as a whole, 62 patients (43.7%) presented positive results for staphylococcal toxin-specific IgE antibodies: staphylococcal enterotoxin A (SEA), in 29 (20.4%); SEB, in 35 (24.6%); SEC, in 33 (23.2%); and toxic shock syndrome toxin (TSST), in 45 (31.7%). The mean serum levels of IgE antibodies to SEA, SEB, SEC, and TSST were 0.96 U/L, 1.09 U/L, 1.21 U/L, and 1.18 U/L, respectively. There were no statistically significant differences between the two groups in terms of the qualitative or quantitative results. Conclusions: Serum IgE antibodies to SEA, SEB, SEC, and TSST were detected in 43.7% of the patients in our sample. However, neither the qualitative nor quantitative results showed a statistically significant association with the clinical severity of asthma.

 


Keywords: Asthma; Immunoglobulin E; Superantigens; Bacterial toxins; Staphylococcus aureus.

 

11 - Gel pillow designed specifically for obstructive sleep apnea treatment with continuous positive airway pressure

Travesseiro de gel com formato específico para o tratamento de apneia obstrutiva do sono com pressão positiva contínua nas vias aéreas

Adriana Salvaggio1, Anna Lo Bue1, Serena Iacono Isidoro1, Salvatore Romano1, Oreste Marrone1, Giuseppe Insalaco1

J Bras Pneumol.2016;42(5):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether the use of a gel pillow with side cutouts designed to accommodate a continuous positive airway pressure (CPAP) mask and reduce head temperature improves the efficacy of and adherence to auto-CPAP therapy. Methods: Twenty-three consecutive CPAP-naïve patients with obstructive sleep apnea were enrolled in the study. Patients were given an auto-CPAP machine with an appropriate CPAP mask and were instructed to use CPAP for 15 nights. They were instructed to sleep with their own pillow (the control pillow) from nights 1 to 5 and with either a foam pillow or a gel pillow, both of which had side cutouts, for 5 consecutive nights each, in random order. After night 15, auto-CPAP machine data were downloaded and patients rated their satisfaction with each pillow on a visual analog scale. Results: Twenty-two patients completed the protocol. The pressures administered, residual apnea-hypopnea index, air leaks, and mean duration of CPAP use did not differ among the periods during which each pillow was used. Patients were significantly more satisfied with the gel pillow than with the control pillow and the foam pillow (p = 0.022 and p = 0.004, respectively), their level of satisfaction with the gel pillow correlating significantly with excessive daytime sleepiness (r2 = 0.19; p = 0.0443). Conclusions: Among obstructive sleep apnea patients treated with nasal CPAP, the use of a gel pillow with side cutouts appears to have no impact on treatment effectiveness. Nevertheless, such patients seem to prefer a gel pillow over other types of pillows.

 


Keywords: Sleep; Continuous positive airway pressure; Sleep apnea, obstructive; Masks.

 

12 - Effects of indacaterol versus tiotropium on exercise tolerance in patients with moderate COPD: a pilot randomized crossover study

Efeitos do indacaterol versus tiotrópio na tolerância ao exercício em pacientes com DPOC moderada: estudo cruzado randomizado piloto

Danilo Cortozi Berton1, Álvaro Huber dos Santos2, Ivo Bohn Jr.2, Rodrigo Quevedo de Lima2, Vanderléia Breda2, Paulo José Zimermann Teixeira2,3,4

J Bras Pneumol.2016;42(5):362-366

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare a once-daily long-acting β2 agonist (indacaterol 150 µg) with a once-daily long-acting anticholinergic (tiotropium 5 µg) in terms of their effects on exercise endurance (limit of tolerance, Tlim) in patients with moderate COPD. Secondary endpoints were their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Methods: This was a randomized, single-blind, crossover pilot study involving 20 patients (mean age, 60.9 ± 10.0 years; mean FEV1, 69 ± 7% of predicted). Spirometric parameters, Transition Dyspnea Index scores, Tlim, and exertional dyspnea were compared after three weeks of each treatment (with a one-week washout period between treatments). Results: Nineteen patients completed the study (one having been excluded because of COPD exacerbation). Improvement in Tlim from baseline tended to be greater after treatment with tiotropium than after treatment with indacaterol (96 ± 163 s vs. 8 ± 82 s; p = 0.06). Tlim significantly improved from baseline after treatment with tiotropium (having increased from 396 ± 319 s to 493 ± 347 s; p = 0.010) but not after treatment with indacaterol (having increased from 393 ± 246 to 401 ± 254 s; p = 0.678). There were no differences between the two treatments regarding improvements in Borg dyspnea scores and lung hyperinflation at "isotime" and peak exercise. There were also no significant differences between treatments regarding Transition Dyspnea Index scores (1.5 ± 2.1 vs. 0.9 ± 2.3; p = 0.39). Conclusions: In patients with moderate COPD, tiotropium tends to improve Tlim in comparison with indacaterol. No significant differences were observed between the two treatments regarding their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Future studies, including a larger number of patients, are required in order to confirm our findings and explore mechanistic explanations. (ClinicalTrials.gov identifier: NCT01693003 [http://www.clinicaltrials.gov/])

 


Keywords: Pulmonary disease, chronic obstructive; Exercise; Bronchodilator agents.

 

Review Article

13 - Is there a rationale for pulmonary rehabilitation following successful chemotherapy for tuberculosis?

Existe razão para reabilitação pulmonar após o tratamento quimioterápico bem-sucedido para tuberculose?

Marcela Muñoz-Torrico1, Adrian Rendon2, Rosella Centis3, Lia D'Ambrosio3,4, Zhenia Fuentes5, Carlos Torres-Duque6, Fernanda Mello7, Margareth Dalcolmo8, Rogelio Pérez-Padilla9, Antonio Spanevello10,11, Giovanni Battista Migliori3

J Bras Pneumol.2016;42(5):367-373

Abstract PDF PT PDF EN Portuguese Text

The role of tuberculosis as a public health care priority and the availability of diagnostic tools to evaluate functional status (spirometry, plethysmography, and DLCO determination), arterial blood gases, capacity to perform exercise, lesions (chest X-ray and CT), and quality of life justify the effort to consider what needs to be done when patients have completed their treatment. To our knowledge, no review has ever evaluated this topic in a comprehensive manner. Our objective was to review the available evidence on this topic and draw conclusions regarding the future role of the "post-tuberculosis treatment" phase, which will potentially affect several million cases every year. We carried out a non-systematic literature review based on a PubMed search using specific keywords (various combinations of the terms "tuberculosis", "rehabilitation", "multidrug-resistant tuberculosis", "pulmonary disease", "obstructive lung disease", and "lung volume measurements"). The reference lists of the most important studies were retrieved in order to improve the sensitivity of the search. Manuscripts written in English, Spanish, and Russian were selected. The main areas of interest were tuberculosis sequelae following tuberculosis diagnosis and treatment; "destroyed lung"; functional evaluation of sequelae; pulmonary rehabilitation interventions (physiotherapy, long-term oxygen therapy, and ventilation); and multidrug-resistant tuberculosis.The evidence found suggests that tuberculosis is definitively responsible for functional sequelae, primarily causing an obstructive pattern on spirometry (but also restrictive and mixed patterns), and that there is a rationale for pulmonary rehabilitation. We also provide a list of variables that should be discussed in future studies on pulmonary rehabilitation in patients with post-tuberculosis sequelae.

 


Keywords: Tuberculosis/complications; Tuberculosis/rehabilitation, Tuberculosis/therapy; Quality of life; Diagnostic imaging; Respiratory function tests.

 

Case Report

15 - Applications for a hybrid operating room in thoracic surgery: from multidisciplinary procedures to ­­image-guided video-assisted thoracoscopic surgery

Usos da sala híbrida em cirurgia torácica: de procedimentos multidisciplinares à cirurgia toracoscópica videoassistida guiada por imagem

Ricardo Mingarini Terra1,2, Juliano Ribeiro Andrade2, Alessandro Wasum Mariani1,2, Rodrigo Gobbo Garcia2, Jose Ernesto Succi2,3, Andrey Soares2,4, Paulo Marcelo Zimmer2

J Bras Pneumol.2016;42(5):387-390

Abstract PDF PT PDF EN Portuguese Text

The concept of a hybrid operating room represents the union of a high-complexity surgical apparatus with state-of-the-art radiological tools (ultrasound, CT, fluoroscopy, or magnetic resonance imaging), in order to perform highly effective, minimally invasive procedures. Although the use of a hybrid operating room is well established in specialties such as neurosurgery and cardiovascular surgery, it has rarely been explored in thoracic surgery. Our objective was to discuss the possible applications of this technology in thoracic surgery, through the reporting of three cases.

 


Keywords: Thoracic surgery, video-assisted; Bronchoscopy; Thoracoscopy; Radiology, interventional.

 

Letters to the Editor

16 - An uncommon chest mass: oleothorax

Uma massa torácica incomum: oleotórax

Bruno Hochhegger1, Gláucia Zanetti2, Edson Marchiori2

J Bras Pneumol.2016;42(5):391

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17 - A rare case of hemorrhagic pneumonia due to Cladosporium cladosporioides

Um caso raro de pneumonia hemorrágica por Cladosporium cladosporioides

Sérgio Grava1,2, Francisco Antonio Dias Lopes3, Rodrigo Silva Cavallazzi4, Melyssa Fernanda Norman Negri Grassi5, Terezinha Inez Estivalet Svidzinski1,2,5

J Bras Pneumol.2016;42(5):392-394

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Author's reply

19 - Author's replay

Resposta dos autores

Fábio José Fabrício de Barros Souza1, Anne Rosso Evangelista2, Juliana Veiga Silva2, Grégory Vinícius Périco3, Kristian Madeira4,5

J Bras Pneumol.2016;42(5):396

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Author's reply

21 - Author's replay

Resposta dos autores

Andre Luis Pereira de Albuquerque1,2, Marco Quaranta3, Biswajit Chakrabarti4, Andrea Aliverti3, Peter M. Calverley4

J Bras Pneumol.2016;42(5):398

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