Brazilian Journal of Pulmonology

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

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Year 2017 - Volume 43  - Number 4  (July/August)

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Continuing Education: Imaging

3 - Thickening of the tracheal wall

Espessamento da parede traqueal

Edson Marchiori, Bruno Hochhegger, Gláucia Zanetti

J Bras Pneumol.2017;43(4):251

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Continuing Education : Scientific Methodology

Original Article

5 - Usefulness of radiological signs of pulmonary congestion in predicting failed spontaneous breathing trials

Utilidade de sinais radiológicos de congestão pulmonar para predizer o fracasso do teste de respiração espontânea

Ana Carolina Peçanha Antonio, Cassiano Teixeira, Priscylla Souza Castro, Ana Paula Zanardo, Marcelo Basso Gazzana, Marli Knorst

J Bras Pneumol.2017;43(4):253-258

Abstract PDF PT PDF EN Portuguese Text

Objective: Inspiratory fall in intrathoracic pressure during a spontaneous breathing trial (SBT) may precipitate cardiac dysfunction and acute pulmonary edema. We aimed to determine the relationship between radiological signs of pulmonary congestion prior to an SBT and weaning outcomes. Methods: This was a post hoc analysis of a prospective cohort study involving patients in an adult medical-surgical ICU. All enrolled individuals met the eligibility criteria for liberation from mechanical ventilation. Tracheostomized subjects were excluded. The primary endpoint was SBT failure, defined as the inability to tolerate a T-piece trial for 30-120 min. An attending radiologist applied a radiological score on interpretation of digital chest X-rays performed before the SBT. Results: A total of 170 T-piece trials were carried out; SBT failure occurred in 28 trials (16.4%), and 133 subjects (78.3%) were extubated at first attempt. Radiological scores were similar between SBT-failure and SBT-success groups (median [interquartile range] = 3 [2-4] points vs. 3 [2-4] points; p = 0.15), which, according to the score criteria, represented interstitial lung congestion. The analysis of ROC curves demonstrated poor accuracy (area under the curve = 0.58) of chest x-rays findings of congestion prior to the SBT for discriminating between SBT failure and SBT success. No correlation was found between fluid balance in the 48 h preceding the SBT and radiological score results (ρ = −0.13). Conclusions: Radiological findings of pulmonary congestion should not delay SBT indication, given that they did not predict weaning failure in the medical-surgical critically ill population. (ClinicalTrials.gov identifier: NCT02022839 [http://www.clinicaltrials.gov/])

 


Keywords: Radiography; Pulmonary edema; Ventilator weaning.

 

6 - Laryngotracheobronchial papillomatosis: chest CT findings

Papilomatose laringotraqueobrônquica: avaliação por TC de tórax

Helena Ribeiro Fortes, Felipe Mussi von Ranke, Dante Luiz Escuissato, Cesar Augusto Araujo Neto, Gláucia Zanetti, Bruno Hochhegger, Klaus Loureiro Irion, Carolina Althoff Souza, Edson Marchiori

J Bras Pneumol.2017;43(4):259-263

Abstract PDF PT PDF EN Portuguese Text

To evaluate the findings on chest CTs in 16 patients (8 men and 8 women) with laryngotracheobronchial papillomatosis. Methods: This was a retrospective study involving patients ranging from 2 to 72 years of age. The evaluation of the CT scans was independently performed by two observers, and discordant results were resolved by consensus. The inclusion criteria were presence of abnormalities on the CT scans, and the diagnosis was confirmed by anatomopathological examination of the papillomatous lesions. Results: The most common symptoms were hoarseness, cough, dyspnea, and recurrent respiratory infections. The major CT findings were nodular formations in the trachea, solid or cavitated nodules in the lung parenchyma, air trapping, masses, and consolidation. Nodular formations in the trachea were observed in 14 patients (87.5%). Only 2 patients had lesions in lung parenchyma without tracheal involvement. Only 1 patient had no pulmonary dissemination of the disease, showing airway involvement only. Solid and cavitated lung nodules were observed in 14 patients (87.5%) and 13 (81.2%), respectively. Masses were observed in 6 patients (37.5%); air trapping, in 3 (18.7%); consolidation in 3 (18.7%); and pleural effusion, in 1 (6.3%). Pulmonary involvement was bilateral in all cases. Conclusions: The most common tomography findings were nodular formations in the trachea, as well as solid or cavitated nodules and masses in the lung parenchyma. Malignant transformation of the lesions was observed in 5 cases.

 


Keywords: Papilloma; Tomography, X-ray computed; Lung diseases.

 

7 - Translation and cultural adaptation of a specific instrument for measuring asthma control and asthma status: the Asthma Control and Communication Instrument

Tradução e adaptação cultural de um instrumento específico para medir o controle e estado da asma: Asthma Control and Communication Instrument

Michelle Gonçalves de Souza Tavares, Carolina Finardi Brümmer, Gabriela Valente Nicolau, José Tavares de Melo Jr, Nazaré Otilia Nazário, Leila John Marques Steidle, Cecília Maria Patino, Marcia Margaret Menezes Pizzichini, Emílio Pizzichini

J Bras Pneumol.2017;43(4):264-269

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To translate the Asthma Control and Communication Instrument (ACCI) to Portuguese and adapt it for use in Brazil. Methods: The ACCI was translated to Portuguese and adapted for use in Brazil in accordance with internationally accepted guidelines. The protocol included the following steps: permission and rights of use granted by the original author; translation of the ACCI from English to Portuguese; reconciliation; back-translation; review and harmonization of the back-translation; approval from the original author; review of the Portuguese version of the ACCI by an expert panel; cognitive debriefing (the clarity, understandability, and acceptability of the translated version being tested in a sample of the target population); and reconciliation and preparation of the final version. Results: During the cognitive debriefing process, 41 asthma patients meeting the inclusion criteria completed the ACCI and evaluated the clarity of the questions/statements. The clarity index for all ACCI items was > 0.9, meaning that all items were considered to be clear. Conclusions: The ACCI was successfully translated to Portuguese and culturally adapted for use in Brazil, the translated version maintaining the psychometric properties of the original version. The ACCI can be used in clinical practice because it is easy to understand and easily applied.

 


8 - High-resolution computed tomography findings of pulmonary tuberculosis in lung transplant recipients

Achados de tuberculose pulmonar na tomografia computadorizada de alta resolução em transplantados de pulmão

Irai Luis Giacomelli, Roberto Schuhmacher Neto, Carlos Schuller Nin, Priscilla de Souza Cassano, Marisa Pereira, José da Silva Moreira, Douglas Zaione Nascimento, Bruno Hochhegger

J Bras Pneumol.2017;43(4):270-273

Abstract PDF PT PDF EN Portuguese Text

Objective: Respiratory infections constitute a major cause of morbidity and mortality in solid organ transplant recipients. The incidence of pulmonary tuberculosis is high among such patients. On imaging, tuberculosis has various presentations. Greater understanding of those presentations could reduce the impact of the disease by facilitating early diagnosis. Therefore, we attempted to describe the HRCT patterns of pulmonary tuberculosis in lung transplant recipients. Methods: From two hospitals in southern Brazil, we collected the following data on lung transplant recipients who developed pulmonary tuberculosis: gender; age; symptoms; the lung disease that led to transplantation; HRCT pattern; distribution of findings; time from transplantation to pulmonary tuberculosis; and mortality rate. The HRCT findings were classified as miliary nodules; cavitation and centrilobular nodules with a tree-in-bud pattern; ground-glass attenuation with consolidation; mediastinal lymph node enlargement; or pleural effusion. Results: We evaluated 402 lung transplant recipients, 19 of whom developed pulmonary tuberculosis after transplantation. Among those 19 patients, the most common HRCT patterns were ground-glass attenuation with consolidation (in 42%); cavitation and centrilobular nodules with a tree-in-bud pattern (in 31.5%); and mediastinal lymph node enlargement (in 15.7%). Among the patients with cavitation and centrilobular nodules with a tree-in-bud pattern, the distribution was within the upper lobes in 66.6%. No pleural effusion was observed. Despite treatment, one-year mortality was 47.3%. Conclusions: The predominant HRCT pattern was ground-glass attenuation with consolidation, followed by cavitation and centrilobular nodules with a tree-in-bud pattern. These findings are similar to those reported for immunocompetent patients with pulmonary tuberculosis and considerably different from those reported for AIDS patients with the same disease.

 


Keywords: Lung transplantation; Diagnostic imaging; Mycobacterium infections; Thoracic diseases; Tomography, X-Ray computed/methods; Tuberculosis, pulmonary.

 

9 - Pneumonia mortality trends in all Brazilian geographical regions between 1996 and 2012

Tendência de mortalidade por pneumonia nas regiões brasileiras no período entre 1996 e 2012

Rosemeire de Olanda Ferraz, Jane Kelly Oliveira-Friestino, Priscila Maria Stolses Bergamo Francisco

J Bras Pneumol.2017;43(4):274-279

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the temporal trends in pneumonia mortality rates (standardized by age, using the 2010 population of Brazil as the standard) in all Brazilian geographical regions between 1996 and 2012. Methods: This was an ecological time-series study examining secondary data from the Mortality Database maintained by the Information Technology Department of the Brazilian Unified Health Care System. Polynomial and joinpoint regression models, and corresponding 95% CIs, were used for trend analysis. Results: The pneumonia mortality rates in the South, Southeast, and Central-West showed a decreasing behavior until 2000, followed by increases, whereas, in the North and Northeast, they showed increasing trends virtually throughout the period studied. There was variation in annual percent change in pneumonia mortality rates in all regions except the North. The Central-West had the greatest decrease in annual percent change between 1996 and 2000, followed by an increase of the same magnitude until 2005. The 80 years and over age group was the one most influencing the trend behavior of pneumonia mortality rates in all regions. Conclusions: In general, pneumonia mortality trends reversed, with an important increase occurring in the years after 2000.

 


Keywords: Pneumonia/mortality; Pneumonia/epidemiology; Time series studies.

 

10 - Can the six-minute walk distance predict the occurrence of acute exacerbations of COPD in patients in Brazil?

A distância percorrida no teste de caminhada de seis minutos pode predizer a ocorrência de exacerbações agudas da DPOC em pacientes brasileiros?

Fernanda Kazmierski Morakami, Andrea Akemi Morita, Gianna Waldrich Bisca, Josiane Marques Felcar, Marcos Ribeiro, Karina Couto Furlanetto, Nidia Aparecida Hernandes, Fabio Pitta

J Bras Pneumol.2017;43(4):280-284

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate whether a six-minute walk distance (6MWD) of < 80% of the predicted value can predict the occurrence of acute exacerbations of COPD in patients in Brazil over a 2-year period. Methods: This was a retrospective cross-sectional study involving 50 COPD patients in Brazil. At enrollment, anthropometric data were collected and patients were assessed for pulmonary function (by spirometry) and functional exercise capacity (by the 6MWD). The patients were subsequently divided into two groups: 6MWD ≤ 80% of predicted and 6MWD > 80% of predicted. The occurrence of acute exacerbations of COPD over 2 years was identified by analyzing medical records and contacting patients by telephone. Results: In the sample as a whole, there was moderate-to-severe airflow obstruction (mean FEV1 = 41 ± 12% of predicted) and the mean 6MWD was 469 ± 60 m (86 ± 10% of predicted). Over the 2-year follow-up period, 25 patients (50%) experienced acute exacerbations of COPD. The Kaplan-Meier method showed that the patients in whom the 6MWD was ≤ 80% of predicted were more likely to have exacerbations than were those in whom the 6MWD was > 80% of predicted (p = 0.01), whereas the Cox regression model showed that the former were 2.6 times as likely to have an exacerbation over a 2-year period as were the latter (p = 0.02). Conclusions: In Brazil, the 6MWD can predict acute exacerbations of COPD over a 2-year period. The risk of experiencing an acute exacerbation of COPD within 2 years is more than twice as high in patients in whom the 6MWD is ≤ 80% of predicted.

 


Keywords: Pulmonary disease, chronic obstructive; Risk groups; Exercise.

 

11 - Sleep quality in medical students: a comparison across the various phases of the medical course

Qualidade de sono em estudantes de medicina: comparação das diferentes fases do curso

Camila de Castro Corrêa, Felipe Kazan de Oliveira, Diego Scherlon Pizzamiglio, Erika Veruska Paiva Ortolan, Silke Anna Theresa Weber

J Bras Pneumol.2017;43(4):285-289

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate and compare subjective sleep quality in medical students across the various phases of the medical course. Methods: This was a cross-sectional study involving medical undergraduates at one medical school in the city of Botucatu, Brazil. All first- to sixth-year students were invited to complete the Pittsburgh Sleep Quality Index, which has been validated for use in Brazil. Participants were divided into three groups according to the phase of the medical course: group A (first- and second-years); group B (third- and fourth-years); and group C (fifth- and sixth-years). The results obtained for the instrument components were analyzed for the total sample and for the groups. Results: Of the 540 students invited to participate, 372 completed the instrument fully. Of those, 147 (39.5%) reported their sleep quality to be either very or fairly bad; 110 (29.5%) reported taking more than 30 min to fall asleep; 253 (68.0%) reported sleeping 6-7 h per night; 327 (87.9%) reported adequate sleep efficiency; 315 (84.6%) reported no sleep disturbances; 32 (8.6%) reported using sleeping medication; and 137 (36.9%) reported difficulty staying awake during the day at least once a week. Group comparison revealed that students in group A had worse subjective sleep quality and greater daytime dysfunction than did those in groups B and C. Conclusions: Medical students seem to be more exposed to sleep disturbance than other university students, and first- and second-years are more affected than those in other class years because they have worse subjective sleep quality. Active interventions should be implemented to improve sleep hygiene in medical students.

 


Keywords: Pulmonary disease, chronic obstructive; Risk groups; Exercise.

 

Special Article

12 - Recommendations for the pharmacological treatment of COPD: questions and answers

Recomendações para o tratamento farmacológico da DPOC: perguntas e respostas

Frederico Leon Arrabal Fernandes1, Alberto Cukier1, Aquiles Assunção Camelier2,3, Carlos Cezar Fritscher4, Cláudia Henrique da Costa5, Eanes Delgado Barros Pereira6, Irma Godoy7, José Eduardo Delfini Cançado8, José Gustavo Romaldini8, Jose Miguel Chatkin4, José Roberto Jardim9, Marcelo Fouad Rabahi10, Maria Cecília Nieves Maiorano de Nucci11, Maria da Penha Uchoa Sales12, Maria Vera Cruz de Oliveira Castellano13, Miguel Abidon Aidé14, Paulo José Zimermann Teixeira15,16, Renato Maciel17, Ricardo de Amorim Corrêa18, Roberto Stirbulov8, Rodrigo Abensur Athanazio1, Rodrigo Russo19, Suzana Tanni Minamoto7, Fernando Luiz Cavalcanti Lundgren20

J Bras Pneumol.2017;43(4):290-301

Abstract PDF PT PDF EN Portuguese Text

The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.

 


Keywords: Pulmonary disease, chronic obstructive/drug therapy; pulmonary disease, chronic obstructive/prevention & control; pulmonary disease, chronic obstructive/therapy.

 

Meta-analysis

13 - Long-acting muscarinic antagonists vs. long-acting β2 agonists in COPD exacerbations: a systematic review and meta-analysis

Antagonistas muscarínicos de longa duração vs. β2-agonistas de longa duração em exacerbações da DPOC: revisão sistemática e meta-análise

Israel Silva Maia1, Mariângela Pimentel Pincelli1, Victor Figueiredo Leite2, João Amadera3, Anna Maria Buehler4

J Bras Pneumol.2017;43(4):302-312

Abstract PDF PT PDF EN Portuguese Text Appendix

The objective of this systematic review was to characterize chest CT findings in patients with dysphagia and pulmonary aspiration, identifying the characteristics and the methods used. The studies were selected from among those indexed in the Brazilian Virtual Library of Health, LILACS, Indice Bibliográfico Español de Ciencias de la Salud, Medline, Cochrane Library, SciELO, and PubMed databases. The search was carried out between June and July of 2016. Five articles were included and reviewed, all of them carried out in the last five years, published in English, and coming from different countries. The sample size in the selected studies ranged from 43 to 56 patients, with a predominance of adult and elderly subjects. The tomographic findings in patients with dysphagia-related aspiration were varied, including bronchiectasis, bronchial wall thickening, pulmonary nodules, consolidations, pleural effusion, ground-glass attenuation, atelectasis, septal thickening, fibrosis, and air trapping. Evidence suggests that chest CT findings in patients with aspiration are diverse. In this review, it was not possible to establish a consensus that could characterize a pattern of pulmonary aspiration in patients with dysphagia, further studies of the topic being needed.

 


Keywords: Respiratory aspiration; Tomography, X-ray computed; Lung.

 

Review Article

14 - Chest CT findings in patients with dysphagia and aspiration: a systematic review

Achados de TC de tórax em pacientes com disfagia e aspiração pulmonar: uma revisão sistemática

Betina Scheeren1, Erissandra Gomes2, Giordano Alves3, Edson Marchiori3, Bruno Hochhegger1

J Bras Pneumol.2017;43(4):313-318

Abstract PDF PT PDF EN Portuguese Text

The objective of this systematic review was to characterize chest CT findings in patients with dysphagia and pulmonary aspiration, identifying the characteristics and the methods used. The studies were selected from among those indexed in the Brazilian Virtual Library of Health, LILACS, Indice Bibliográfico Español de Ciencias de la Salud, Medline, Cochrane Library, SciELO, and PubMed databases. The search was carried out between June and July of 2016. Five articles were included and reviewed, all of them carried out in the last five years, published in English, and coming from different countries. The sample size in the selected studies ranged from 43 to 56 patients, with a predominance of adult and elderly subjects. The tomographic findings in patients with dysphagia-related aspiration were varied, including bronchiectasis, bronchial wall thickening, pulmonary nodules, consolidations, pleural effusion, ground-glass attenuation, atelectasis, septal thickening, fibrosis, and air trapping. Evidence suggests that chest CT findings in patients with aspiration are diverse. In this review, it was not possible to establish a consensus that could characterize a pattern of pulmonary aspiration in patients with dysphagia, further studies of the topic being needed.

 


Keywords: Respiratory aspiration; Tomography, X-ray computed; Lung.

 

Images in Pulmonary Medicine

Case Report

16 - Pulmonary foreign body granulomatosis in a chronic user of powder cocaine

Granulomatose pulmonar de corpo estranho em um usuário crônico de cocaína em pó

Shruti Khurana1, Ankit Chhoda2, Sandeep Sahay3, Priyanka Pathania4

J Bras Pneumol.2017;43(4):320-321

Abstract PDF PT PDF EN Portuguese Text

We describe the case of a 33-year-old man, a chronic user of powder cocaine, who presented with dyspnea, fever, night sweats, and significant weight loss. Chest HRCT revealed centrilobular nodules, giving an initial impression of miliary tuberculosis. Therefore, he was started on an empirical, four-drug antituberculosis treatment regimen. Four weeks later, despite the tuberculosis treatment, he continued to have the same symptoms. We then performed transbronchial lung biopsy. Histopathological analysis of the biopsy sample revealed birefringent foreign body granuloma. A corroborative history of cocaine snorting, the presence of centrilobular nodules, and the foreign body-related histopathological findings led to a diagnosis of pulmonary foreign body granulomatosis. This report underscores the fact that pulmonary foreign body granulomatosis should be included in the differential diagnosis of clinical profiles resembling tuberculosis.

 


Keywords: Lung; Granuloma, foreign-body; Cocaine-related disorders.

 

Letters to the Editor

17 - The reversed halo sign: also think about chronic eosinophilic pneumonia

Sinal do halo invertido: pense também em pneumonia eosinofílica crônica

Gaetano Rea1, Giorgia Dalpiaz2, Alessandro Vatrella3, Stefania Damiani4, Edson Marchiori5,6

J Bras Pneumol.2017;43(4):322-323

PDF PT PDF EN Portuguese Text


18 - Pneumothorax: between the beach and the stratosphere

Pneumotórax: entre a praia e a estratosfera

Eduardo Kaiser Ururahy Nunes Fonseca1, Adham do Amaral e Castro1, Yoshino Tamaki Sameshima1

J Bras Pneumol.2017;43(4):324-325

PDF PT PDF EN Portuguese Text


 


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