Brazilian Journal of Pulmonology

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


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Year 2017 - Volume 43  - Number 3  (May/June)


Continuing Education: Imaging

3 - Opaque hemithorax

Hemitórax opaco

Edson Marchiori1, Bruno Hochhegger2, Gláucia Zanetti1

J Bras Pneumol.2017;43(3):161

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Original Article

5 - The impact of asthma in Brazil: a longitudinal analysis of data from a Brazilian national database system

Impacto da asma no Brasil: análise longitudinal de dados extraídos de um banco de dados governamental brasileiro

Thiago de Araujo Cardoso1, Cristian Roncada1, Emerson Rodrigues da Silva2, Leonardo Araujo Pinto1, Marcus Herbert Jones1, Renato Tetelbon Stein1, Paulo Márcio Pitrez1

J Bras Pneumol.2017;43(3):163-168

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Objective: To present official longitudinal data on the impact of asthma in Brazil between 2008 and 2013. Methods: This was a descriptive study of data collected between 2008 and 2013 from an official Brazilian national database, including data on asthma-related number of hospitalizations, mortality, and hospitalization costs. A geographical subanalysis was also performed. Results: In 2013, 2,047 people died from asthma in Brazil (5 deaths/day), with more than 120,000 asthma-related hospitalizations. During the whole study period, the absolute number of asthma-related deaths and of hospitalizations decreased by 10% and 36%, respectively. However, the in-hospital mortality rate increased by approximately 25% in that period. The geographic subanalysis showed that the northern/northeastern and southeastern regions had the highest asthma-related hospitalization and in-hospital mortality rates, respectively. An analysis of the states representative of the regions of Brazil revealed discrepancies between the numbers of asthma-related hospitalizations and asthma-related in-hospital mortality rates. During the study period, the cost of asthma-related hospitalizations to the public health care system was US$ 170 million. Conclusions: Although the numbers of asthma-related deaths and hospital admissions in Brazil have been decreasing since 2009, the absolute numbers are still high, resulting in elevated direct and indirect costs for the society. This shows the relevance of the burden of asthma in middle-income countries.


Keywords: Asthma/epidemiology; Asthma/mortality; Public health; Hospitalization.


6 - Assessment of fatigue using the Identity-Consequence Fatigue Scale in patients with lung cancer

Avaliação da fadiga utilizando a Escala de Identificação e Consequências da Fadiga em pacientes com câncer de pulmão

Ingrid Correia Nogueira1,2, Amanda Souza Araújo1,2, Maria Tereza Morano1,2,3, Antonio George Cavalcante1, Pedro Felipe de Bruin1, Johana Susan Paddison4, Guilherme Pinheiro da Silva1,3, Eanes Delgado Pereira1,2

J Bras Pneumol.2017;43(3):169-175

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Objective: To evaluate the properties of the Identity-Consequence Fatigue Scale (ICFS) in patients with lung cancer (LC), assessing the intensity of fatigue and associated factors. Methods: This was a cross-sectional study involving LC patients, treated at a teaching hospital in Brazil, who completed the ICFS. Patients with chronic heart disease (CHD) and healthy controls, matched for age and gender, also completed the scale. Initially, a Brazilian Portuguese-language version of the ICFS was administered to 50 LC patients by two independent interviewers; to test for reproducibility, it was readministered to those same patients. At baseline, the LC patients were submitted to spirometry and the six-minute walk test, as well as completing the Epworth Sleepiness Scale (ESS), Hospital Anxiety and Depression Scale (HADS), Medical Outcomes Study 36-item Short-Form Health Survey (SF-36), and Fatigue Severity Scale (FSS). Inflammatory status was assessed by blood C-reactive protein (CRP) levels. To validate the ICFS, we assessed the correlations of its scores with those variables. Results: The sample comprised 50 patients in each group (LC, CHD, and control). In the LC group, the intraclass correlation coefficients for intra-rater and inter-rater reliability regarding ICFS summary variables ranged from 0.94 to 0.76 and from 0.94 to 0.79, respectively. The ICFS presented excellent internal consistency, and Bland-Altman plots showed good test-retest reliability. The ICFS correlated significantly with FSS, HADS, and SF-36 scores, as well as with CRP levels. Mean ICFS scores in the LC group differed significantly from those in the CHD and control groups. Conclusions: The ICFS is a valid, reliable instrument for evaluating LC patients, in whom depression, quality of life, and CRP levels seem to be significantly associated with fatigue.


Keywords: Fatigue; Lung neoplasms; Symptom assessment.


7 - Sleep-disordered breathing in patients with COPD and mild hypoxemia: prevalence and predictive variables

Prevalência e variáveis preditivas de distúrbios respiratórios do sono em pacientes com DPOC e hipoxemia leve

José Laerte Rodrigues Silva Júnior1,4, Marcus Barreto Conde2,3, Krislainy de Sousa Corrêa4, Helena Rabahi4, Arthur Alves Rocha5, Marcelo Fouad Rabahi1,4

J Bras Pneumol.2017;43(3):176-182

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Objective: To infer the prevalence and variables predictive of isolated nocturnal hypoxemia and obstructive sleep apnea (OSA) in patients with COPD and mild hypoxemia. Methods: This was a cross-sectional study involving clinically stable COPD outpatients with mild hypoxemia (oxygen saturation = 90-94%) at a clinical center specializing in respiratory diseases, located in the city of Goiânia, Brazil. The patients underwent clinical evaluation, spirometry, polysomnography, echocardiography, arterial blood gas analysis, six-minute walk test assessment, and chest X-ray. Results: The sample included 64 patients with COPD and mild hypoxemia; 39 (61%) were diagnosed with sleep-disordered breathing (OSA, in 14; and isolated nocturnal hypoxemia, in 25). Correlation analysis showed that PaO2 correlated moderately with mean sleep oxygen saturation (r = 0.45; p = 0.0002), mean rapid eye movement (REM) sleep oxygen saturation (r = 0.43; p = 0.001), and mean non-REM sleep oxygen saturation (r = 0.42; p = 0.001). A cut-off point of PaO2 ≤ 70 mmHg in the arterial blood gas analysis was significantly associated with sleep-disordered breathing (OR = 4.59; 95% CI: 1.54-13.67; p = 0.01). The model showed that, for identifying sleep-disordered breathing, the cut-off point had a specificity of 73.9% (95% CI: 51.6-89.8%), a sensitivity of 63.4% (95% CI: 46.9-77.9%), a positive predictive value of 81.3% (95% CI: 67.7-90.0%), and a negative predictive value of 53.1% (95% CI: 41.4-64.4%), with an area under the ROC curve of 0.69 (95% CI: 0.57-0.80), correctly classifying the observations in 67.2% of the cases. Conclusions: In our sample of patients with COPD and mild hypoxemia, the prevalence of sleep-disordered breathing was high (61%), suggesting that such patients would benefit from sleep studies.


Keywords: Pulmonary disease, chronic obstructive/complications; Sleep wake disorders/epidemiology; Anoxia/etiology.


8 - Simple motor tasks independently predict extubation failure in critically ill neurological patients

Tarefas motoras simples predizem independentemente a falha de extubação em pacientes neurológicos críticos

Fernanda Machado Kutchak1,2,3,4, Marcelo de Mello Rieder1,2,4, Josué Almeida Victorino1,4, Carla Meneguzzi4, Karla Poersch3, Luiz Alberto Forgiarini Junior5, Marino Muxfeldt Bianchin1,2,6

J Bras Pneumol.2017;43(3):183-189

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Objective: To evaluate the usefulness of simple motor tasks such as hand grasping and tongue protrusion as predictors of extubation failure in critically ill neurological patients. Methods: This was a prospective cohort study conducted in the neurological ICU of a tertiary care hospital in the city of Porto Alegre, Brazil. Adult patients who had been intubated for neurological reasons and were eligible for weaning were included in the study. The ability of patients to perform simple motor tasks such as hand grasping and tongue protrusion was evaluated as a predictor of extubation failure. Data regarding duration of mechanical ventilation, length of ICU stay, length of hospital stay, mortality, and incidence of ventilator-associated pneumonia were collected. Results: A total of 132 intubated patients who had been receiving mechanical ventilation for at least 24 h and who passed a spontaneous breathing trial were included in the analysis. Logistic regression showed that patient inability to grasp the hand of the examiner (relative risk = 1.57; 95% CI: 1.01-2.44; p < 0.045) and protrude the tongue (relative risk = 6.84; 95% CI: 2.49-18.8; p < 0.001) were independent risk factors for extubation failure. Acute Physiology and Chronic Health Evaluation II scores (p = 0.02), Glasgow Coma Scale scores at extubation (p < 0.001), eye opening response (p = 0.001), MIP (p < 0.001), MEP (p = 0.006), and the rapid shallow breathing index (p = 0.03) were significantly different between the failed extubation and successful extubation groups. Conclusions: The inability to follow simple motor commands is predictive of extubation failure in critically ill neurological patients. Hand grasping and tongue protrusion on command might be quick and easy bedside tests to identify neurocritical care patients who are candidates for extubation.


Keywords: Ventilator weaning; Airway extubation/adverse effects; Critical care; Neurosurgery.


9 - Ultrasound-guided intrapleural positioning of pleural catheters: influence on immediate lung expansion and pleurodesis in patients with recurrent malignant pleural effusion

Posicionamento intrapleural, guiado por ultrassonografia, de cateteres pleurais: influência na expansão pulmonar imediata e na pleurodese em pacientes com derrame pleural maligno recorrente

Pedro Henrique Xavier Nabuco de Araujo1, Ricardo Mingarini Terra1, Thiago da Silva Santos1, Rodrigo Caruso Chate2, Antonio Fernando Lins de Paiva2, Paulo Manuel Pêgo-Fernandes1

J Bras Pneumol.2017;43(3):190-194

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Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.


Keywords: Pleurodesis; Pleural effusion, malignant; Tomography; Catheters.


10 - Hearing thresholds in patients with drug-resistant tuberculosis: baseline audiogram configurations and associations

Limiares auditivos em pacientes com tuberculose resistente: configurações do audiograma basal e associações

Olusola Ayodele Sogebi1, Muse Olatunbosun Fadeyi2, Bolanle Olufunlola Adefuye3, Festus Olukayode Soyinka4

J Bras Pneumol.2017;43(3):195-201

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Objective: To use baseline audiogram parameters in order to ascertain whether drug-resistant tuberculosis (DR-TB) has effects on hearing, as well as to describe the configurations of the audiograms and to determine whether there are parameters that can be associated with those configurations. Methods: This was a prospective study involving patients diagnosed with DR-TB at a tuberculosis treatment center in the state of Ogun, in Nigeria. The patients included in the study were submitted to pure tone audiometry at baseline (within two weeks after treatment initiation). For comparative analyses, data regarding demographic and clinical characteristics were collected from the medical records of the patients. Results: The final sample comprised 132 patients. The mean age of the patients was 34.5 ± 12.6 years (range, 8-82 years), and the male:female ratio was 2:1. Of the 132 patients, 103 (78.0%) resided in neighboring states, 125 (94.7%) had previously experienced antituberculosis treatment failure, and 18 (13.6%) were retroviral-positive. Normal audiograms were found in 12 patients (9.1%), whereas sensorineural hearing loss was identified in 104 (78.8%), the two most common configurations being ascending, in 54 (40.9%), and sloping, in 26 (19.7%). Pure-tone averages at low frequencies (0.25-1.0 kHz) and high frequencies (2.0-8.0 kHz) were 33.0 dB and 40.0 dB, respectively. Regarding the degree of hearing loss in the better ear, 36 patients (27.3%) were classified as having normal hearing and 67 (50.8%) were classified as having mild hearing loss (26-40 dB), whereas 29 (21.9%) showed moderate or severe hearing loss. Among the variables studied (age, gender, retroviral status, previous treatment outcome, and weight at admission), only male gender was associated with audiometric configurations. Conclusions: In this sample of patients with DR-TB, most presented with bilateral, mild, suboptimal sensorineural hearing loss, and ascending/sloping audiometric configurations were associated with male gender.


Keywords: Audiometry, pure-tone; Hearing loss, high-frequency; Drug-related side effects and adverse reactions; Tuberculosis, multidrug-resistant.


11 - Effective tobacco control measures: agreement among medical students

Medidas eficazes de controle do tabagismo: concordância entre estudantes de medicina

Stella Regina Martins1, Renato Batista Paceli1, Marco Antônio Bussacos2, Frederico Leon Arrabal Fernandes1, Gustavo Faibischew Prado1, Elisa Maria Siqueira Lombardi1, Mário Terra-Filho1, Ubiratan Paula Santos1

J Bras Pneumol.2017;43(3):202-207

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Objective: To determine the level of agreement with effective tobacco control measures recommended by the World Health Organization and to assess the attitudes toward, knowledge of, and beliefs regarding smoking among third-year medical students at University of São Paulo School of Medicine, located in the city of São Paulo, Brazil. Methods: Between 2008 and 2012, all third-year medical students were invited to complete a self-administered questionnaire based on the Global Health Professionals Student Survey and its additional modules. Results: The study sample comprised 556 students. The level of agreement with the World Health Organization recommendations was high, except for the components "received smoking cessation training" and "raising taxes is effective to reduce the prevalence of smoking". Most of the students reported that they agree with banning tobacco product sales to minors (95%), believe that physicians are role models to their patients (84%), and believe that they should advise their patients to quit cigarette smoking (96%) and using other tobacco products (94%). Regarding smoking cessation methods, most of the students were found to know more about nicotine replacement therapy than about non-nicotine therapies (93% vs. 53%). Only 37% of the respondents were aware of the importance of educational antismoking materials, and only 31% reported that they believe in the effectiveness of encouraging their patients, during medical visits. In our sample, the prevalence of current cigarette smoking was 5.23%; however, 43.82% of the respondents reported having experimented with water-pipe tobacco smoking. Conclusions: Our results revealed the need to emphasize to third-year medical students the importance of raising the prices of and taxes on tobacco products. We also need to make students aware of the dangers of experimenting with tobacco products other than cigarettes, particularly water-pipe tobacco smoking.


Keywords: Tobacco products; Health policy; Education, medical, undergraduate; Health knowledge, attitudes, practice.


12 - Effects of emissions from sugar cane burning on the trachea and lungs of Wistar rats

Efeitos das emissões geradas pela queima da cana-de-açúcar em traqueia e pulmões de ratos Wistar

Verena Sampaio Barbosa Matos1, Felipe da Silva Gomes2, Tarcio Macena Oliveira2, Renata da Silva Schulz1, Lídia Cristina Villela Ribeiro3, Astria Dias Ferrão Gonzales3,4, Januário Mourão Lima4, Marcos Lázaro da Silva Guerreiro3,4

J Bras Pneumol.2017;43(3):208-214

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Objective: To evaluate the effects of exposure to emissions from sugar cane burning on inflammatory mechanisms in tissues of the trachea and lung parenchyma in Wistar rats after different periods of exposure. Methods: This was an experimental open randomized study. The animals were divided into four groups: a control group (CG) underwent standard laboratory conditions, and three experimental groups were exposed to emissions from sugar cane burning over different periods of time, in days-1 (EG1), 7 (EG7), and 21 (EG21). After euthanasia with 200 mg/kg of ketamine/xylazine, fragments of trachea and lung were collected and fixed in 10% formalin. Histological analyses were performed with H&E and picrosirius red staining. Results: No inflammatory infiltrates were found in the tissues of CG rats. The histological examination of tissues of the trachea and lung parenchyma revealed that the inflammatory process was significantly more intense in EG7 than in the CG (p < 0.05 and p < 0.01, respectively). In comparison with the CG and EG1, angiogenesis in the lung parenchyma and collagen deposition in tracheal tissues were significantly greater only in EG21 (p < 0.001 and p < 0.01, respectively). Conclusions: In this sample, emissions from sugar cane burning induced acute focal and diffuse inflammation in the lamina propria of tracheal tissues, with no loss of ciliated epithelial tissue. In the lung parenchyma of the animals in the experimental groups, there was interstitial and alveolar edema, together with polymorphonuclear cell infiltrates.


Keywords: Saccharum; Smoke; Inflammation; Respiratory system.


13 - Frequency of indeterminate results from an interferon-gamma release assay among HIV-infected individuals

Taxa de resultados indeterminados de ensaio de liberação de interferon-gama entre pessoas infectadas pelo HIV

Sandra Maria do Valle Leone de Oliveira1,2, Anete Trajman3,4, Anamaria Mello Miranda Paniago1, Ana Rita Coimbra Motta-Castro1,2, Antonio Ruffino-Netto5, Ethel Leonor Noia Maciel6, Julio Croda2,7, Maria da Gloria Bonecini-Almeida8

J Bras Pneumol.2017;43(3):215-218

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Objective: To evaluate the frequency of and factors associated with indeterminate interferon-gamma release assay (IGRA) results in people living with HIV/AIDS (PLWHA). Methods: We tested 81 PLWHA in the central-west region of Brazil, using the tuberculin skin test and an IGRA. Information on sociodemographic and clinical variables was gathered through the use of questionnaires and from medical records. The association of those variables with indeterminate results was analyzed by calculating the adjusted ORs in a multivariate logistic regression model. Concordance was evaluated by determining the kappa statistic. Results: Among the 81 patients evaluated, the tuberculin skin test results were positive in 18 (22.2%) of the patients, and the IGRA results were positive in 10 (12.3%), with a kappa of 0.62. The IGRA results were indeterminate in 22 (27.1%) of the patients (95% CI: 17.8-38.1%). The odds of obtaining indeterminate results were significantly higher in smokers (adjusted OR = 6.0; 95% CI: 1.4-26.7) and in samples stored for less than 35 days (adjusted OR = 14.0; 95% CI: 3.1-64.2). Patients with advanced immunosuppression (CD4+ T-cell count < 200 cells/mm3) were at a higher risk for indeterminate results (OR adjusted for smoking and inadequate duration of sample storage = 4.7; 95% CI: 0.91-24.0), although the difference was not significant. Conclusions: The high prevalence of indeterminate results can be a major limitation for the routine use of IGRAs in PLWHA. The need to repeat the test increases its costs and should be taken into account in cost-effectiveness studies. The processing of samples can significantly alter the results.


Keywords: Interferon-gamma release tests; Interferon-gamma; Tuberculosis; HIV; Latent tuberculosis; Tuberculin test.


Special Article

14 - Brazilian guidelines for the diagnosis and treatment of cystic fibrosis

Diretrizes brasileiras de diagnóstico e tratamento da fibrose cística

Rodrigo Abensur Athanazio1*, Luiz Vicente Ribeiro Ferreira da Silva Filho2,3*, Alberto Andrade Vergara4, Antônio Fernando Ribeiro5, Carlos Antônio Riedi6, Elenara da Fonseca Andrade Procianoy7, Fabíola Villac Adde2, Francisco José Caldeira Reis4, José Dirceu Ribeiro5, Lídia Alice Torres8, Marcelo Bicalho de Fuccio9, Matias Epifanio10, Mônica de Cássia Firmida11, Neiva Damaceno12, Norberto Ludwig-Neto13,14, Paulo José Cauduro Maróstica7,15, Samia Zahi Rached1, Suzana Fonseca de Oliveira Melo4; Grupo de Trabalho das Diretrizes Brasileiras de Diagnóstico e Tratamento da Fibrose Cística.

J Bras Pneumol.2017;43(3):219-245

Abstract PDF PT PDF EN Portuguese Text Appendix

Cystic fibrosis (CF) is an autosomal recessive genetic disorder characterized by dysfunction of the CFTR gene. It is a multisystem disease that most often affects White individuals. In recent decades, various advances in the diagnosis and treatment of CF have drastically changed the scenario, resulting in a significant increase in survival and quality of life. In Brazil, the current neonatal screening program for CF has broad coverage, and most of the Brazilian states have referral centers for the follow-up of individuals with the disease. Previously, CF was limited to the pediatric age group. However, an increase in the number of adult CF patients has been observed, because of the greater number of individuals being diagnosed with atypical forms (with milder phenotypic expression) and because of the increase in life expectancy provided by the new treatments. However, there is still great heterogeneity among the different regions of Brazil in terms of the access of CF patients to diagnostic and therapeutic methods. The objective of these guidelines was to aggregate the main scientific evidence to guide the management of these patients. A group of 18 CF specialists devised 82 relevant clinical questions, divided into five categories: characteristics of a referral center; diagnosis; treatment of respiratory disease; gastrointestinal and nutritional treatment; and other aspects. Various professionals working in the area of CF in Brazil were invited to answer the questions devised by the coordinators. We used the PubMed database to search the available literature based on keywords, in order to find the best answers to these questions.


Keywords: Cystic fibrosis/diagnosis; Cystic fibrosis/therapy; Cystic fibrosis/complications; Practice guideline.



16 - .

Edital de Seleção

Fernando Lundgren, Rogerio Souza

J Bras Pneumol.2017;43(3):

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