Brazilian Journal of Pulmonology

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


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Year 2017 - Volume 43  - Number 5  (September/October)



1 - Momentum


Rogério Souza1,2

J Bras Pneumol.2017;43(5):327

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Continuing Education: Imaging

2 - Honeycombing


Edson Marchiori1, Bruno Hochhegger2, Gláucia Zanetti1

J Bras Pneumol.2017;43(5):329

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Continuing Education : Scientific Methodology

3 - Understanding diagnostic tests. Part 1.

Entendendo os testes diagnósticos. Parte 1.

Juliana Carvalho Ferreira1,2, Cecilia Maria Patino1,3

J Bras Pneumol.2017;43(5):330

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Original Article

4 - The Quebec Sleep Questionnaire on quality of life in patients with obstructive sleep apnea: translation into Portuguese and cross-cultural adaptation for use in Brazil

Quebec Sleep Questionnaire sobre qualidade de vida em pacientes com apneia obstrutiva do sono: tradução e adaptação cultural para uso no Brasil

José Tavares de Melo Júnior1, Rosemeri Maurici1,2, Michelle Gonçalves de Souza Tavares3, Marcia Margareth Menezes Pizzichini1,4, Emilio Pizzichini1,2,5

J Bras Pneumol.2017;43(5):331-336

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To translate the Quebec Sleep Questionnaire (QSQ), a specific instrument for the assessment of quality of life in patients with sleep obstructive apnea, into Portuguese and to create a version that is cross-culturally adapted for use in Brazil. Methods: The Portuguese-language version was developed according to a rigorous methodology, which included the following steps: preparation; translation from English into Portuguese in three versions; reconciliation to a single version; back-translation of that version into English; comparison and harmonization of the back-translation with the original version; review of the Portuguese-language version; cognitive debriefing; text review; and arrival at the final version. Results: The Portuguese-language version of the QSQ for use in Brazil had a clarity score, as measured by cognitive debriefing, ranging from 0.81 to 0.99, demonstrating the consistency of translation and cross-cultural adaptation processes. Conclusions: The process of translating the QSQ into Portuguese and creating a version that is cross-culturally adapted for use in Brazil produced a valid instrument to assess the quality of life in patients with obstructive sleep apnea.


Keywords: Obstructive sleep apnea, Quality of life; Translations; Validation studies.


5 - Factors associated with malnutrition in adolescent and adult patients with cystic fibrosis

Fatores associados à desnutrição em pacientes adolescentes e adultos com fibrose cística

Gabriela Cristofoli Barni1, Gabriele Carra Forte1, Luis Felipe Forgiarini1,2, Claudine Lacerda de Oliveira Abrahão3, Paulo de Tarso Roth Dalcin1,4

J Bras Pneumol.2017;43(5):337-343

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of malnutrition in patients attending an adult cystic fibrosis (CF) program and to investigate the associations of malnutrition with the clinical characteristics of those patients. Methods: This was a cross-sectional study involving patients with clinically stable CF patients (16 years of age or older). The patients underwent clinical assessment, nutritional assessments, pulmonary function tests, and pancreatic function assessment. They also completed a questionnaire regarding diet compliance. On the basis of their nutritional status, the patients were classified divided into three groups: adequate nutrition; at nutritional risk; and malnutrition. Results: The study has included 73 patients (mean age, 25.6 ± 7.3 years), 40 of whom (54.8%) were female. The mean body mass index was 21.0 ± 3.0 kg/m2 and the mean FEV1 was 59.7 ± 30.6% of predicted. In this sample of patients, 32 (43.8%), 23 (31.5%), and 18 (24.7%) of the patients were allocated to the adequate nutrition, nutritional risk, and malnutrition groups, respectively. The logistic regression analysis identified three independent factors associated with the risk of malnutrition: Shwachman-Kulczycki score, percent predicted FEV1; and age. Conclusions: Malnutrition remains a common complication in adolescents and adults with CF, despite dietary advice. Malnutrition is associated with age, clinical severity, and lung function impairment.


Keywords: Cystic fibrosis; Malnutrition; Exocrine pancreatic insufficiency; Respiratory function tests.


6 - Parapneumonic pleural effusion: early versus late thoracoscopy

Derrame pleural parapneumônico: comparação entre toracoscopia precoce e tardia

Rodrigo Romualdo Pereira1, Cristina Gonçalves Alvim2, Cláudia Ribeiro de Andrade2, Cássio da Cunha Ibiapina2

J Bras Pneumol.2017;43(5):344-350

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the best time to perform thoracoscopy for the treatment of complicated parapneumonic pleural effusion in the fibrinopurulent phase in patients ≤ 14 years of age, regarding the postoperative evolution and occurrence of complications. Methods: This was a retrospective comparative study involving patients with parapneumonic pleural effusion presenting with septations or loculations on chest ultrasound who underwent thoracoscopy between January of 2000 and January of 2013. The patients were divided into two groups: early thoracoscopy (ET), performed by day 5 of hospitalization; and late thoracoscopy (LT), performed after day 5 of hospitalization. Results: We included 60 patients, 30 in each group. The mean age was 3.4 years; 28 patients (46.7%) were male; and 47 (78.3%) underwent primary thoracoscopy (no previous simple drainage). The two groups were similar regarding gender, age, weight, and type of thoracoscopy (p > 0.05 for all). There was a significant difference between the ET and the LT groups regarding the length of the hospital stay (14.5 days vs. 21.7 days; p < 0.001). There were also significant differences between the groups regarding the duration of fever in days; the total number of days from admission to the initiation of drainage; and the total number of days with the drain in place. Eight patients (13.6%) had at least one post-thoracoscopy complication, there being no difference between the groups. There were no deaths. Conclusions: Performing ET by day 5 of hospitalization was associated with shorter hospital stays, shorter duration of drainage, and shorter duration of fever, although not with a higher frequency of complications, requiring ICU admission, or requiring blood transfusion.


Keywords: Empyema, pleural; Thoracoscopy; Pneumonia.


7 - Frequency of COPD in health care workers who smoke

Frequência de DPOC em profissionais de saúde que fumam

Ivan Kopitovic1,2, Aleksandar Bokan1,2, Ilija Andrijevic1,2, Miroslav Ilic1,2, Sanja Marinkovic3, Dragana Milicic1,2, Marija Vukoja1,2

J Bras Pneumol.2017;43(5):351-356

Abstract PDF PT PDF EN Portuguese Text

Objective: COPD is one of the major causes of morbidity and mortality worldwide. Health care providers should counsel their smoking patients with COPD to quit smoking as the first treatment step. However, in countries with high prevalences of smoking, health care workers may also be smokers. The aim of this study was to determine the frequency and severity of COPD in health care workers who smoke. Methods: This was a cross-sectional study. All health care workers who smoke, from nine health care centers in Serbia, were invited to participate in the study and perform spirometry. The diagnosis of COPD was based on a post-bronchodilator FEV1/FVC ratio of < 0.70. All patients completed the COPD Assessment Test and the Fagerström Test for Nicotine Dependence. Results: The study involved 305 subjects, and 47 (15.4%) were male. The mean age of the participants was 49.0 ± 6.5 years. Spirometry revealed obstructive ventilatory defect in 33 subjects (10.8%); restrictive ventilatory defect, in 5 (1.6%); and small airway disease, in 96 (31.5%). A diagnosis of COPD was made in 29 patients (9.5%), 25 (86.2%) of whom were newly diagnosed. On the basis of the Global Initiative for COPD guidelines, most COPD patients belonged to groups A or B (n = 14; 48.2%, for both); 1 belonged to group D (3.6%); and none, to group C. Very high nicotine dependence was more common in those with COPD than in those without it (20.7% vs. 5.4%, p = 0.01). Conclusions: In this sample of health care workers, the frequency of COPD was comparable with that in the general population. The presence of COPD in health care workers who smoke was associated with higher nicotine dependence.


Keywords: Pulmonary disease, chronic obstructive/prevention & control; Smoking; Health personnel.


8 - Quality of Communication Questionnaire para pacientes com DPOC em cuidados paliativos: tradução e adaptação cultural para uso no Brasil

Quality of Communication Questionnaire para pacientes com DPOC em cuidados paliativos: tradução e adaptação cultural para uso no Brasil

Flávia Del Castanhel1, Suely Grosseman2

J Bras Pneumol.2017;43(5):357-362

Abstract PDF PT PDF EN Portuguese Text

Objetivo: Realizar a tradução para a língua portuguesa e a adaptação cultural para uso no Brasil do Quality of Communication Questionnaire (QOC) para pacientes com DPOC em cuidados paliativos. Métodos: Após a aprovação do autor do questionário e do comitê de ética da instituição, a versão original do QOC com 13 itens foi traduzida, de forma independente, por dois tradutores brasileiros com fluência na língua inglesa. Uma síntese das duas traduções foi realizada por uma médica bilíngue e os dois tradutores, que chegaram a um consenso, gerando uma versão na língua portuguesa. Essa versão foi retraduzida por dois tradutores nativos de países de língua inglesa com fluência na língua portuguesa. Para resolver quaisquer discrepâncias, um comitê de especialistas comparou a versão original com todas as versões produzidas e, assim, obteve-se a versão pré-final do QOC. O pré-teste foi aplicado em 32 pacientes internados em UTIs de três hospitais públicos da grande Florianópolis (SC) para avaliar a clareza e a aceitabilidade cultural da versão pré-final do QOC. Resultados: A média de idade dos pacientes foi de 48,5 ± 18,8 anos. A maioria dos itens foi bem compreendida e aceita, recebendo pontuações ≥ 8. Um item, sobre morte, suscitou dificuldades na compreensão dos participantes do pré-teste. Ao submeter a retradução ao autor do QOC, ele solicitou alterações em dois itens, que foram acatadas. Após essas alterações, a versão final foi aprovada. Conclusões: A tradução e a adaptação cultural do QOC para uso no Brasil foi concluída com sucesso.


Keywords: Doença pulmonar obstrutiva crônica; Inquéritos e questionários; Comunicação; Unidades de terapia intensiva.


9 - Lung cancer: changes in histology, gender, and age over the last 30 years in Brazil

Câncer de pulmão: mudanças na histologia, sexo e idade nos últimos 30 anos no Brasil

Maria Teresa Ruiz Tsukazan1,2, Álvaro Vigo2, Vinícius Duval da Silva3, Carlos Henrique Barrios4, Jayme de Oliveira Rios1, José Antônio de Figueiredo Pinto1

J Bras Pneumol.2017;43(5):363-367

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the trends in tumor histology, gender and age among patients with non-small cell lung cancer (NSCLC) treated with lung resection. The histology of lung cancer has changed in developed countries, and there is still little information available on the topic for developing countries. Methods: This was a retrospective study of 1,030 patients with NSCLC treated with lung resection between 1986 and 2015 at a university hospital in southern Brazil. Differences in histology, stage, and type of surgery were analyzed by gender and for three periods (1986-1995, 1996-2005, and 2006-2015). Results: Most (64.5%) of the patients were males, and the main histological types were squamous cell carcinoma (in 40.6%) and adenocarcinoma (in 44.5%). The mean age at surgery during the first period was 56.4 years for women and 58.9 years for men, compared with 62.2 for women and 64.6 for men in the third period (p < 0.001). The proportion of females increased from 26.6% in the first period to 44.1% in the third. From the first to the third period, the proportion of patients with squamous cell carcinoma decreased from 49.6% to 34.8% overall (p < 0.001), decreasing to an even greater degree (from 38.9% to 23.2%) among men. Among the NSCLC patients in our sample, females with adenocarcinoma accounted for 11.9% in the first period and 24.0% in the third period (p < 0.001). Conclusions: As has been seen in developed countries, the rates of lung cancer in females in southern Brazil have been rising over the last three decades, although they have yet to surpass those observed for males in the region. The incidence of squamous cell carcinoma has decreased in males, approaching adenocarcinoma rates, whereas adenocarcinoma has significantly increased among women.


Keywords: Lung neoplasms; Epidemiology; Histology; Adenocarcinoma; Carcinoma, non-small-cell lung; Carcinoma, squamous cell.


10 - Epidemiological trends of allergic diseases in adolescents

Tendência epidemiológica das prevalências de doenças alérgicas em adolescentes

Silvia de Souza Campos Fernandes1, Cláudia Ribeiro de Andrade1, Cristina Gonçalves Alvim1, Paulo Augusto Moreira Camargos1, Cássio da Cunha Ibiapina1

J Bras Pneumol.2017;43(5):368-372

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the prevalences of asthma, allergic rhinitis, and allergic rhinoconjunctivitis in adolescents in the city of Belo Horizonte, Brazil, in 2012 by administering the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, as well as to compare the observed prevalences with those found in studies performed 10 years earlier and employing the same methodology used here. Methods: This was a cross-sectional study conducted between May and December of 2012 and involving adolescents in the 13- to 14-year age bracket. Participants were randomly selected from among adolescents studying at public schools in Belo Horizonte and completed the ISAAC questionnaire. Proportions were calculated in order to assess the prevalences of asthma, allergic rhinitis, and allergic rhinoconjunctivitis in the sample as a whole, and the chi-square goodness-of-fit test was used in order to compare the prevalences observed in 2012 with those found in 2002. Results: The prevalences of symptoms of asthma, allergic rhinitis, and allergic rhinoconjunctivitis in 2012 were 19.8%, 35.3%, and 16.3%, respectively, being significantly higher than those found in 2002 (asthma, p = 0.006; allergic rhinitis, p < 0.01; and allergic rhinoconjunctivitis, p = 0.002). Conclusions: The prevalences of asthma, allergic rhinitis, and allergic rhinoconjunctivitis among adolescents in 2012 were found to be high, having increased in comparison with those found 10 years earlier, despite efforts in prevention, diagnosis, and treatment.


Keywords: Asthma; Rhinitis, allergic; Prevalence; Adolescent.


11 - Effects of continuous positive airway pressure on blood pressure in patients with resistant hypertension and obstructive sleep apnea: a systematic review and meta-analysis of six randomized controlled trials

Efeitos da pressão positiva contínua nas vias aéreas na pressão arterial em pacientes com hipertensão resistente e apneia obstrutiva do sono: revisão sistemática e meta-análise de seis ensaios clínicos controlados aleatórios

Qiang Lei1, Yunhui Lv2, Kai Li1, Lei Ma1, Guodong Du1, Yan Xiang1, Xuqing Li1

J Bras Pneumol.2017;43(5):373-379

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate systematically the effects of continuous positive airway pressure (CPAP) on blood pressure in patients with resistant hypertension and obstructive sleep apnea (OSA). Methods: The Cochrane Library, PubMed, ScienceDirect, and the Web of Science were searched for studies investigating the effects of CPAP on blood pressure in patients with resistant hypertension and OSA. The selected studies underwent quality assessment and meta-analysis, as well as being tested for heterogeneity. Results: Six randomized controlled trials were included in the meta-analysis. The pooled estimates of the changes in mean systolic blood pressure and mean diastolic blood pressure (as assessed by 24-h ambulatory blood pressure monitoring) were −5.40 mmHg (95% CI: −9.17 to −1.64; p = 0.001; I2 = 74%) and −3.86 mmHg (95% CI: −6.41 to −1.30; p = 0.00001; I2 = 79%), respectively. Conclusions: CPAP therapy can significantly reduce blood pressure in patients with resistant hypertension and OSA.


Keywords: Continuous positive airway pressure; Sleep apnea, obstructive; Hypertension; Meta-analysis.


Special Article

12 - Current use and acceptability of novel diagnostic tests for active tuberculosis: a worldwide survey

Uso atual e aceitabilidade de novos testes diagnósticos para tuberculose ativa: um inquérito mundial

Massimo Amicosante1,2A, Lia D'Ambrosio3,4, Marcela Munoz5, Fernanda Carvalho de Queiroz Mello6, Marc Tebruegge7,8,9, Novel Njweipi Chegou10, Fouad Seghrouchni11, Rosella Centis3, Delia Goletti12, Graham Bothamley13, Giovanni Battista Migliori3; TB Diagnostic Survey Working Group

J Bras Pneumol.2017;43(5):380-392

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the current use and potential acceptance (by tuberculosis experts worldwide) of novel rapid tests for the diagnosis of tuberculosis that are in line with World Health Organization target product profiles. Methods: A multilingual survey was disseminated online between July and November of 2016. Results: A total of 723 individuals from 114 countries responded to the survey. Smear microscopy was the most commonly used rapid tuberculosis test (available to 90.9% of the respondents), followed by molecular assays (available to 70.7%). Only a small proportion of the respondents in middle- and low-income countries had access to interferon-gamma-release assays. Serological and lateral flow immunoassays were used by more than a quarter (25.4%) of the respondents. Among the respondents who had access to molecular tests, 46.7% were using the Xpert assay overall, that proportion being higher in lower middle-income countries (55.6%) and low-income countries (76.6%). The data also suggest that there was some alignment of pricing for molecular assays. Respondents stated they would accept novel rapid tuberculosis tests if available, including molecular assays (acceptable to 86.0%) or biomarker-based serological assays (acceptable to 81.7%). Simple biomarker-based assays were more commonly deemed acceptable in middle- and low-income countries. Conclusions: Second-generation molecular assays have become more widely available in high- and low-resource settings. However, the development of novel rapid tuberculosis tests continues to be considered important by tuberculosis experts. Our data also underscore the need for additional training and education of end users.


Keywords: Tuberculosis/diagnosis; Surveys and questionnaires; Income; Mycobacterium tuberculosis/isolation & purification; Molecular diagnostic techniques/methods; Serologic tests/methods.


Ensaio Pictórico

13 - Usual interstitial pneumonia: typical, possible, and

Pneumonia intersticial usual: padrões típico, possível e inconsistente

Pedro Paulo Teixeira e Silva Torres1, Marcelo Fouad Rabahi2, Maria Auxiliadora Carmo Moreira2, Gustavo de Souza Portes Meirelles3, Edson Marchiori4

J Bras Pneumol.2017;43(5):393-398

Abstract PDF PT PDF EN Portuguese Text

Idiopathic pulmonary fibrosis is a severe and progressive chronic fibrosing interstitial lung disease, a definitive diagnosis being established by specific combinations of clinical, radiological, and pathological findings. According to current international guidelines, HRCT plays a key role in establishing a diagnosis of usual interstitial pneumonia (UIP). Current guidelines describe three UIP patterns based on HRCT findings: a typical UIP pattern; a pattern designated "possible UIP"; and a pattern designated "inconsistent with UIP", each pattern having important diagnostic implications. A typical UIP pattern on HRCT is highly accurate for the presence of histopathological UIP, being currently considered to be diagnostic of UIP. The remaining patterns require further diagnostic investigation. Other known causes of a UIP pattern include drug-induced interstitial lung disease, chronic hypersensitivity pneumonitis, occupational diseases (e.g., asbestosis), and connective tissue diseases, all of which should be included in the clinical differential diagnosis. Given the importance of CT studies in establishing a diagnosis and the possibility of interobserver variability, the objective of this pictorial essay was to illustrate all three UIP patterns on HRCT.


Keywords: Tomography, X-ray computed; Lung diseases, interstitial; Pulmonary fibrosis.


Letters to the Editor


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