Brazilian Journal of Pulmonology

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


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Year 2018 - Volume 44  - Number 5  (September/October)


2 - Getting to know our pneumococcus

Conhecimento do nosso pneumococo

Fernando Luiz Cavalcanti Lundgren1,2,a

J Bras Pneumol.2018;44(5):343-344

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4 - Global TB Network: working together to eliminate tuberculosis

Global TB Network: trabalhando juntos para eliminar a tuberculose

Denise Rossato Silva1,a, Adrian Rendon2,b, Jan-Willem Alffenaar3,c, Jeremiah Muhwa Chakaya4,5,d, Giovanni Sotgiu6,e, Susanna Esposito7,f, Giovanni Battista Migliori8,g

J Bras Pneumol.2018;44(5):347-349

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Continuing Education: Imaging

6 - Paravertebral mass

Massa paravertebral

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(5):352


Original Article

8 - Asthma mortality in Brazil, 1980-2012: a regional perspective

Mortalidade por asma no Brasil, 1980-2012: uma perspectiva regional

Thaís de Sá Brito1,a, Ronir Raggio Luiz2,b, José Roberto Lapa e Silva3,c, Hisbello da Silva Campos4,5,d

J Bras Pneumol.2018;44(5):354-360

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Objective: To estimate asthma mortality rates in Brazil for the period 1980-2012. Methods: On the basis of data from the Brazilian National Ministry of Health Mortality Database, we estimated mortality rates by calculating moving averages from a municipal perspective that would allow an evaluation differentiating between urban, rural, and intermediate (rurban) Brazil during the period 2002-2012. Trends were assessed using simple linear regression. Results: On average, 2,339 asthma-related deaths were reported per year during the study period. Asthma ranged from the 53rd to 95th leading cause of death. There was a decrease in asthma mortality rates in the country, from 1.92/100,000 population in 1980 to 1.21/100,000 population in 2012. From the municipal perspective, rates fell in urban and rurban Brazil, but increased in rural Brazil, except in the 5-34-year age group. Asthma mortality rates fell in the population under 25 years of age and increased among those over 74 years of age. Rates were always higher in females. Conclusions: Asthma mortality rates in Brazil have been decreasing slightly, with the decrease being more marked in the decade 2002-2012. Only the northeastern region of Brazil showed the opposite trend. Asthma mortality rates in urban and rurban Brazil showed a downward trend similar to that of the national scenario, whereas rural Brazil showed the opposite behavior. Analysis by age group showed that rates decreased among younger individuals and increased among the elderly aged ≥ 75 years.


Keywords: Asthma/mortality; Brazil; urban population; rural population.


9 - Theoretical pneumococcal vaccine coverage: analysis of serotypes isolated from inpatients at a tertiary care hospital

Cobertura vacinal pneumocócica teórica: análise de sorotipos isolados de pacientes internados em hospital terciário

Cynthia Rocha Dullius1,a, Luciana Zani2,b, José Miguel Chatkin2,c

J Bras Pneumol.2018;44(5):361-366

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Objective: To evaluate Streptococcus pneumoniae serotypes isolated from an inpatient population at a tertiary care hospital, in order to determine the theoretical coverage of the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPV23). Methods: This was a cross-sectional study involving 118 inpatients at the Hospital São Lucas, in the city of Porto Alegre, Brazil, whose cultures of blood, cerebrospinal fluid, or other sterile body fluid specimens, collected between January 2005 and December 2016, yielded pneumococcal isolates. The theoretical vaccine coverage was studied in relation to the serotypes identified in the sample and their relationship with those contained in the pneumococcal vaccines available in Brazil. Results: The majority of the population was male (n = 66; 55.9%), with a median age of 57 years (interquartile range: 33-72 years). The most common manifestation was pneumonia, and the pneumococcus was most commonly isolated from blood cultures. More than one fourth of the study population had some degree of immunosuppression (n = 34; 28.8%). Of the total sample, 39 patients (33.1%) died. There were no significant associations between mortality and comorbidity type, ICU admission, or need for mechanical ventilation. The theoretical vaccine coverage of PPV23 alone and PCV13 plus PPV23 was 31.4% and 50.8%, respectively. Conclusions: If the patients in this sample had been previously vaccinated with PCV13 plus PPV23, theoretically, 50.8% of the cases of invasive pneumococcal disease that required hospital admission could potentially have been prevented. Invasive pneumococcal disease should be prevented by vaccination not only of children and the elderly but also of adults in their economically productive years, so as to reduce the socioeconomic costs, morbidity, and mortality still associated with the disease, especially in underdeveloped countries.


Keywords: Keywords: Pneumococcal infections; Serotyping; Tertiary care centers.


10 - Electronic cigarette awareness and use among students at the Federal University of Mato Grosso, Brazil

Conhecimento e uso do cigarro eletrônico entre estudantes da Universidade Federal de Mato Grosso

Wemerson José Corrêa de Oliveira1,a, Alexandre Figueiredo Zobiole1,b, Claudia Bonadiman de Lima1,c, Rebeca Melo Zurita1,d, Pedro Eduarto Muniz Flores1,e, Luís Guilherme Val Rodrigues1,f, Raissa Carolina de Assis Pinheiro1,g, Victor Francisco Figueiredo Rocha Soares e Silva1,h

J Bras Pneumol.2018;44(5):367-369

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Objective: To analyze the prevalence of electronic cigarette (e-cigarette) awareness and experimentation among university students, as well as the characteristics associated with that awareness. Methods: This was a cross-sectional study, conducted in 2015, in which 489 university students at the Federal University of Mato Grosso (Cuiabá campus), Brazil, were interviewed with the use of a specific questionnaire. We estimated the prevalence of e-cigarette awareness and use, as well as analyzing the major characteristics associated with that awareness and use. Results: The prevalence of e-cigarette awareness was 37%, and the rate of e-cigarette experimentation was 2.7%. Awareness of e-cigarettes was found to be associated with marital status, work status, the level of parental education, and the presence or absence of smokers in the family. Conclusions: A high proportion of university students were aware of e-cigarettes. Although the prevalence of those who had experimented with e-cigarettes was low, there is concern that there could be an increase in the use of these types of device. There is a need for measures targeting university students, in order to build awareness of and prevent e-cigarette use.


Keywords: Electronic Nicotine Delivery Systems; Young adult; Smoking.


11 - Functional capacity measurement: reference equations for the Glittre Activities of Daily Living test

Avaliação da capacidade funcional: equações de referência para o teste Glittre Activities of Daily Living

Cardine Martins dos Reis1,2,a, Manuela Karloh1,3,b, Fernanda Rodrigues Fonseca1,2,c, Roberta Rodolfo Mazzali Biscaro1,2,d, Giovana Zarpellon Mazo4,5,e, Anamaria Fleig Mayer1,2,3,5,f

J Bras Pneumol.2018;44(5):370-377

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Objective: To develop reference equations for the Glittre Activities of Daily Living test (Glittre ADL-test) on the basis of anthropometric and demographic variables in apparently healthy individuals. A secondary objective was to determine the reliability of the equations in a sample of COPD patients. Methods: This was a cross-sectional study including 190 apparently healthy individuals (95 males; median age, 54.5 years [range, 42-65]; median FEV1 = 97% [range, 91-105.2]; and median FVC = 96% [range, 88.5-102]) recruited from the general community and 74 COPD patients (55 males; mean age, 65 ± 8 years; body mass index [BMI] = 25.9 ± 4.7 kg/m2; FEV1 = 36.1 ± 14.1%; and FVC = 62.7 ± 16.1%) recruited from a pulmonary rehabilitation center. Results: The mean time to complete the Glittre ADL-test was 2.84 ± 0.45 min. In the stepwise multiple linear regression analysis, age and height were selected as Glittre ADL-test performance predictors, explaining 32.1% (p < 0.01) of the total variance. Equation 1 was as follows: Glittre ADL-testpredicted = 3.049 + (0.015 × ageyears) + (−0.006 × heightcm). Equation 2 included age and BMI and explained 32.3% of the variance in the test, the equation being as follows: Glittre ADL-testpredicted = 1.558 + (0.018 × BMI) + (0.016 × ageyears). Conclusions: The reference equations for the time to complete the Glittre ADL-test were based on age, BMI, and height as independent variables and can be useful for predicting the performance of adult individuals. The predicted values appear to be reliable when applied to COPD patients.


Keywords: Activities of daily living; Exercise test; Reference values.


12 - Does methylene blue attenuate inflammation in nonischemic lungs after lung transplantation?

O azul de metileno atenua a inflamação em pulmões não isquêmicos após transplante pulmonar?

Marcus da Matta Abreu1,a, Francine Maria de Almeida1,b, Kelli Borges dos Santos2,c, Emílio Augusto Campos Pereira de Assis3,d, Rafael Kenji Fonseca Hamada4,e, Fabio Biscegli Jatene1,f, Paulo Manuel Pêgo-Fernandes1,g, Rogerio Pazetti1,h

J Bras Pneumol.2018;44(5):378-382

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Objective: To evaluate whether methylene blue (MB) could minimize the effects of ischemia-reperfusion injury in the nonischemic lung on a lung transplantation rodent model. Methods: Forty female Sprague-Dawley rats were divided into 20 donors and 20 recipients. The 20 recipient rats were divided into two groups (n = 10) according to the treatment (0.9% saline vs. 1% MB solutions). All animals underwent unilateral lung transplantation. Recipients received 2 mL of saline or MB intraperitoneally prior to transplantation. After 2 h of reperfusion, the animals were euthanized and histopathological and immunohistochemical analyses were performed in the nonischemic lung. Results: There was a significant decrease in inflammation-neutrophil count and intercellular adhesion molecule-1 (ICAM-1) expression in lung parenchyma were higher in the saline group in comparison with the MB group-and in apoptosis-caspase-3 expression was higher in the saline group and Bcl-2 expression was higher in MB group. Conclusions: MB is an effective drug for the protection of nonischemic lungs against inflammation and apoptosis following unilateral lung transplantation in rats.


Keywords: Reperfusion injury; Methylene blue; Lung transplantation; Apoptosis; Inflammation.


13 - The patient profile of individuals with Alpha-1 antitrypsine gene mutations at a referral center in Brazil

Perfil dos pacientes com mutação no gene da alfa-1 antitripsina em um centro de referência no Brasil

Manuela Brisot Felisbino1,a, Frederico Leon Arrabal Fernandes2,b, Maria Cecília Nieves Maiorano de Nucci2,c, Regina Maria de Carvalho Pinto2,d, Emilio Pizzichini1,e, Alberto Cukier2,f

J Bras Pneumol.2018;44(5):383-389

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Objective: The clinical, functional, radiological and genotypic descriptions of patients with an alpha-1 antitrypsin (A1AT) gene mutation in a referral center for COPD in Brazil. Methods: A cross-sectional study of patients with an A1AT gene mutation compatible with deficiency. We evaluated the A1AT dosage and genotypic, demographic, clinical, tomographic, and functional characteristics of these patients. Results: Among the 43 patients suspected of A1AT deficiency (A1ATD), the disease was confirmed by genotyping in 27 of them. The A1AT median dosage was 45 mg/dL, and 4 patients (15%) had a normal dosage. Median age was 54, 63% of the patients were male, and the respiratory symptoms started at the age of 40. The median FEV1 was 1.37L (43% predicted). Tomographic emphysema was found in 77.8% of the individuals. The emphysema was panlobular in 76% of them and 48% had lower lobe predominance. The frequency of bronchiectasis was 52% and the frequency of bronchial thickening was 81.5%. The most common genotype was Pi*ZZ in 40.7% of participants. The other genotypes found were: Pi*SZ (18.5%), PiM1Z (14.8%), Pi*M1S (7.4%), Pi*M2Z (3.7%), Pi*M1I (3.7%), Pi*ZMnichinan (3.7%), Pi*M3Plowell (3.7%), and Pi*SF (3.7%). We did not find any significant difference in age, smoking load, FEV1, or the presence of bronchiectasis between the groups with a normal and a reduced A1AT dosage, neither for 1 nor 2-allele mutation for A1ATD. Conclusions: Our patients presented a high frequency of emphysema, bronchiectasis and bronchial thickening, and early-beginning respiratory symptoms. The most frequent genotype was Pi*ZZ. Heterozygous genotypes and normal levels of A1AT also manifested significant lung disease.


Keywords: Alpha-1 antitrypsin; Emphysema; Alleles.


14 - Impact of adherence to long-term oxygen therapy on patients with COPD and exertional hypoxemia followed for one year

Impacto da adesão à oxigenoterapia de longa duração em pacientes com DPOC e hipoxemia decorrente do esforço acompanhados durante um ano

Carolina Bonfanti Mesquita1,a, Caroline Knaut1,b, Laura Miranda de Oliveira Caram1,c, Renata Ferrari1,d, Silmeia Garcia Zanati Bazan2,e, Irma Godoy1,f, Suzana Erico Tanni3,g

J Bras Pneumol.2018;44(5):390-397

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Objective: To determine the impact of adherence to long-term oxygen therapy (LTOT) on quality of life, dyspnea, and exercise capacity in patients with COPD and exertional hypoxemia followed for one year. Methods: Patients experiencing severe hypoxemia during a six-minute walk test (6MWT) performed while breathing room air but not at rest were included in the study. At baseline and after one year of follow-up, all patients were assessed for comorbidities, body composition, SpO2, and dyspnea, as well as for anxiety and depression, having also undergone spirometry, arterial blood gas analysis, and the 6MWT with supplemental oxygen. The Saint George's Respiratory Questionnaire (SGRQ) was used in order to assess quality of life, and the Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity (BODE) index was calculated. The frequency of exacerbations and the mortality rate were noted. Treatment nonadherence was defined as LTOT use for < 12 h per day or no LTOT use during exercise. Results: A total of 60 patients with COPD and exertional hypoxemia were included in the study. Of those, 10 died and 11 experienced severe hypoxemia during follow-up, 39 patients therefore being included in the final analysis. Of those, only 18 (46.1%) were adherent to LTOT, showing better SGRQ scores, higher SpO2 values, and lower PaCO2 values than did nonadherent patients. In all patients, SaO2, the six-minute walk distance, and the BODE index worsened after one year. There were no differences between the proportions of adherence to LTOT at 3 and 12 months of follow-up. Conclusions: Quality of life appears to be lower in patients with COPD and exertional hypoxemia who do not adhere to LTOT than in those who do. In addition, LTOT appears to have a beneficial effect on COPD symptoms (as assessed by SGRQ scores). (Brazilian Registry of Clinical Trials - ReBEC; identification number RBR‑9b4v63 [])


Keywords: Respiratory insufficiency; Pulmonary disease, chronic obstructive; Patient compliance; Hypoxia; Oxygen inhalation therapy.


15 - Noncompliance with the law prohibiting the sale of cigarettes to minors in Brazil: an inconvenient truth

Descumprimento da lei que proíbe a venda de cigarros para menores de idade no Brasil: uma verdade inconveniente

André Salem Szklo1,a,Tânia Maria Cavalcante2,b

J Bras Pneumol.2018;44(5):398-404

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Objective: To draw up an up-to-date scenario of compliance with the law prohibiting the sale of cigarettes to minors. Methods: We used data about youth access to cigarette purchase that were obtained through a nationwide survey conducted in 2015 among students aged 13-17 years. We estimated simple proportions of attempts to buy cigarettes, success of attempts, purchase of cigarettes on a regular basis, and purchase of cigarettes on a regular basis in a store or bar. All estimates were stratified by gender, age group, and Brazilian macro-region. Crude absolute difference and adjusted absolute difference in the proportion of smokers in each category by variable of interest were analyzed by a generalized linear model with binomial distribution and identity link function. Results: Approximately 7 in every 10 adolescent smokers attempted to buy cigarettes at least once in the 30 days prior to the survey. Of those, approximately 9 in every 10 were successful, and individuals aged 16-17 years (vs. those aged 13-15 years) were less often prevented from buying cigarettes (adjusted absolute difference, 8.1%; p ≤ 0.05). Approximately 45% of all smokers aged 13-17 years in Brazil reported buying their own cigarettes on a regular basis without being prevented from doing so, and, of those, 80% reported buying them in a store or bar (vs. from a street vendor). Conclusions: Our findings raise an important public health concern and may contribute to supporting educational and surveillance measures to enforce compliance with existing anti-tobacco laws in Brazil, which have been disregarded.


Keywords: Smoking/epidemiology; Smoking/legislation & jurisprudence; Adolescent behavior; Public health.


Special Article

16 - 2018 recommendations for the management of community acquired pneumonia

Recomendações para o manejo da pneumonia adquirida na comunidade 2018

Ricardo de Amorim Corrêa1,a, Andre Nathan Costa2,b, Fernando Lundgren3.c, Lessandra Michelim4,d, Mara Rúbia Figueiredo5,e, Marcelo Holanda6,f, Mauro Gomes7,g, Paulo José Zimermann Teixeira8,h, Ricardo Martins9,i, Rodney Silva10,j, Rodrigo Abensur Athanazio2,k, Rosemeri Maurici da Silva11,l, Mônica Corso Pereira12,m

J Bras Pneumol.2018;44(5):405-423

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Community-acquired pneumonia (CAP) is the leading cause of death worldwide. Despite the vast diversity of respiratory microbiota, Streptococcus pneumoniae remains the most prevalent pathogen among etiologic agents. Despite the significant decrease in the mortality rates for lower respiratory tract infections in recent decades, CAP ranks third as a cause of death in Brazil. Since the latest Guidelines on CAP from the Sociedade Brasileira de Pneumologia e Tisiologia (SBPT, Brazilian Thoracic Association) were published (2009), there have been major advances in the application of imaging tests, in etiologic investigation, in risk stratification at admission and prognostic score stratification, in the use of biomarkers, and in the recommendations for antibiotic therapy (and its duration) and prevention through vaccination. To review these topics, the SBPT Committee on Respiratory Infections summoned 13 members with recognized experience in CAP in Brazil who identified issues relevant to clinical practice that require updates given the publication of new epidemiological and scientific evidence. Twelve topics concerning diagnostic, prognostic, therapeutic, and preventive issues were developed. The topics were divided among the authors, who conducted a nonsystematic review of the literature, but giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. All authors had the opportunity to review and comment on all questions, producing a single final document that was approved by consensus.


Keywords: Pneumonia/diagnosis; Pneumonia/prevention & control; Pneumonia/therapy; Pneumonia/drug therapy.


Review Article

17 - The pulmonary microbiome: challenges of a new paradigm

Microbioma pulmonar: desafios de um novo paradigma

André Nathan Costa1,a, Felipe Marques da Costa1,b, Silvia Vidal Campos1,c, Roberta Karla Salles1,d, Rodrigo Abensur Athanazio1,e

J Bras Pneumol.2018;44(5):424-432

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The study of the human microbiome-and, more recently, that of the respiratory system-by means of sophisticated molecular biology techniques, has revealed the immense diversity of microbial colonization in humans, in human health, and in various diseases. Apparently, contrary to what has been believed, there can be nonpathogenic colonization of the lungs by microorganisms such as bacteria, fungi, and viruses. Although this physiological lung microbiome presents low colony density, it presents high diversity. However, some pathological conditions lead to a loss of that diversity, with increasing concentrations of some bacterial genera, to the detriment of others. Although we possess qualitative knowledge of the bacteria present in the lungs in different states of health or disease, that knowledge has advanced to an understanding of the interaction of this microbiota with the local and systemic immune systems, through which it modulates the immune response. Given this intrinsic relationship between the microbiota and the lungs, studies have put forth new concepts about the pathophysiological mechanisms of homeostasis in the respiratory system and the potential dysbiosis in some diseases, such as cystic fibrosis, COPD, asthma, and interstitial lung disease. This departure from the paradigm regarding knowledge of the lung microbiota has made it imperative to improve understanding of the role of the microbiome, in order to identify possible therapeutic targets and to develop innovative clinical approaches. Through this new leap of knowledge, the results of preliminary studies could translate to benefits for our patients.


Keywords: Microbiota; Microbiology; Immune system.


Images in Pulmonary Medicine

18 - Hamman's syndrome

Síndrome de Hamman

João Filipe Alves Mesquita Rosinhas1,a, Sara Maria Castelo Branco Soares1,b, Adelina Branca Madeira Pereira2,c

J Bras Pneumol.2018;44(5):433

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Author's reply

20 - Authors' reply

Resposta dos autores

José Tadeu Colares Monteiro1,a

J Bras Pneumol.2018;44(5):435

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22 - Omalizumab as add-on therapy in patients with asthma and allergic bronchopulmonary aspergillosis

Omalizumabe como terapia adicional no tratamento da aspergilose broncopulmonar alérgica em asmáticos

Fernanda Sales da Cunha1,a, Solange Oliveira Rodrigues Valle1,b, José Elabras Filho1,c, Sérgio Duarte Dortas Júnior1,2,d, Alfeu Tavares França1,e

J Bras Pneumol.2018;44(5):439-441

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23 - Lung transplantation with extracorporeal membrane oxygenation as intraoperative support

Transplante pulmonar com oxigenação extracorpórea por membrana como suporte intraoperatório

Mariana Schettini-Soares1,a, Pedro Henrique Cunha Leite1,b, Ludhmila Abrahão Hajjar2,c, André Nathan Costa3,d, Paulo Manuel Pêgo-Fernandes1,e, Marcos Naoyuki Samano1,f

J Bras Pneumol.2018;44(5):442-444

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