Brazilian Journal of Pulmonology

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


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Year 2019 - Volume 45  - Number 5  (September/October)


Continuing Education: Imaging

1 - Multiple, small centrilobular nodules

Pequenos nódulos centrolobulares múltiplos

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

J Bras Pneumol.2019;45(5):e20190291

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Original Article

2 - Effects of the implementation of a hand hygiene education program among ICU professionals: an interrupted time-series analysis

Efeitos da implementação de um programa de educação de higienização das mãos entre profissionais de uma UTI: análise de séries temporais interrompidas

Diana Marcela Prieto Romero1,a, Maycon Moura Reboredo1,2,b, Edimar Pedrosa Gomes1,2,c, Cristina Martins Coelho1,d, Maria Aparecida Stroppa de Paula1,e, Luciene Carnevale de Souza1,f, Fernando Antonio Basile Colugnati2,g, Bruno Valle Pinheiro1,2,hDiana Marcela Prieto Romero1,a, Maycon Moura Reboredo1,2,b, Edimar Pedrosa Gomes1,2,c, Cristina Martins Coelho1,d, Maria Aparecida Stroppa de Paula1,e, Luciene Carnevale de Souza1,f, Fernando Antonio Basile Colugnati2,g, Bruno Valle Pinheiro1,2,h

J Bras Pneumol.2019;45(5):e20180152

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU. Methods: This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days. Results: On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days). Conclusions: Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.


Keywords: Hand disinfection; Health personnel; Pneumonia, ventilator-associated; Respiration, artificial; Guideline adherence.


2 - Inflammatory lung injury in rabbits: effects of high-frequency oscillatory ventilation in the prone position

Lesão inflamatória pulmonar em coelhos: efeitos da ventilação oscilatória de alta frequência em posição prona

Jose Roberto Fioretto1,a, Rafaelle Batistella Pires2,b, Susiane Oliveira Klefens1,c, Cilmery Suemi Kurokawa1,d, Mario Ferreira Carpi1,e, Rossano César Bonatto1,f, Marcos Aurélio Moraes1,g, Carlos Fernando Ronchi1,3,h

J Bras Pneumol.2019;45(5):e20180067

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Objective: To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). Methods: Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. Results: After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. Conclusions: Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.


Keywords: Respiration, artificial/adverse effects; Prone position; Lung/physiopathology; Pneumonia; Respiratory distress syndrome, adult; Acute lung injury; Disease models, animal; Rabbits.


3 - Familial pulmonary fibrosis: a heterogeneous spectrum of presentations

Fibrose pulmonar familiar: um espectro heterogêneo de apresentações

Ana Beatriz Hortense1,a, Marcel Koenigkam dos Santos2,b, Danilo Wada3,c, Alexandre Todorovic Fabro4,d, Mariana Lima5, Silvia Rodrigues5,e, Rodrigo Tocantins Calado2,f, José Baddini-Martinez2,g

J Bras Pneumol.2019;45(5):e20180079

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To describe the clinical, functional, and radiological features of index cases of familial pulmonary fibrosis (FPF) in Brazil. Methods: We evaluated 35 patients with FPF - of whom 18 (51.4%) were women - with a median age of 66.0 years (range, 35.5-89.3 years). All of the patients completed a standardized questionnaire, as well as undergoing pulmonary function tests and HRCT of the chest. In 6 cases, lung tissue samples were obtained: from surgical biopsies in 5 cases; and from an autopsy in 1 case. Results: A history of smoking and a history of exposure to birds or mold were reported in 45.7% and 80.0% of the cases, respectively. Cough and marked dyspnea were reported by 62.8% and 48.6% of the patients, respectively. Fine crackles were detected in 91.4% of the patients. In 4 patients, the findings were suspicious for telomere disease. The median FVC and DLCO, as percentages of the predicted values, were 64.9% (range, 48.8-105.7%) and 38.9% (range, 16.0-60.0%), respectively. Nine patients had reduced DLCO despite having normal spirometry results. Regarding HRCT, patterns typical of usual interstitial pneumonia were found in 6 patients (17.1%). In 25 cases (71.5%), the HRCT features were consistent with a diagnosis other than idiopathic pulmonary fibrosis. In 11 cases (31.4%), the radiological patterns were uncharacteristic of interstitial lung disease. Of the six lung tissue samples analyzed, four showed interstitial pneumonia with bronchiolocentric accentuation, and, on the basis of the clinical and radiological data, the corresponding patients were diagnosed with hypersensitivity pneumonitis. Conclusions: Patients with FPF can present with a wide variety of clinical features. Most HRCT scans of these patients exhibit patterns not typical of usual interstitial pneumonia. The family history of fibrotic lung diseases should be investigated in all patients under suspicion, regardless of their age.


Keywords: Idiopathic pulmonary fibrosis; Respiratory function tests; Tomography, X-ray computed.


4 - Accuracy of chest auscultation in detecting abnormal respiratory mechanics in the immediate postoperative period after cardiac surgery

Acurácia da ausculta torácica na detecção de mecânica respiratória anormal no pós-operatório imediato de cirurgia cardíaca

Glaciele Xavier1,2,a, César Augusto Melo-Silva1,3,b, Carlos Eduardo Ventura Gaio dos Santos1,4,c, Veronica Moreira Amado1,4,d

J Bras Pneumol.2019;45(5):e20180032

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the accuracy of chest auscultation in detecting abnormal respiratory mechanics. Methods: We evaluated 200 mechanically ventilated patients in the immediate postoperative period after cardiac surgery. We assessed respiratory system mechanics - static compliance of the respiratory system (Cst,rs) and respiratory system resistance (R,rs) - after which two independent examiners, blinded to the respiratory system mechanics data, performed chest auscultation. Results: Neither decreased/abolished breath sounds nor crackles were associated with decreased Cst,rs (≤ 60 mL/cmH2O), regardless of the examiner. The overall accuracy of chest auscultation was 34.0% and 42.0% for examiners A and B, respectively. The sensitivity and specificity of chest auscultation for detecting decreased/abolished breath sounds or crackles were 25.1% and 68.3%, respectively, for examiner A, versus 36.4% and 63.4%, respectively, for examiner B. Based on the judgments made by examiner A, there was a weak association between increased R,rs (≥ 15 cmH2O/L/s) and rhonchi or wheezing (ϕ = 0.31, p < 0.01). The overall accuracy for detecting rhonchi or wheezing was 89.5% and 85.0% for examiners A and B, respectively. The sensitivity and specificity for detecting rhonchi or wheezing were 30.0% and 96.1%, respectively, for examiner A, versus 10.0% and 93.3%, respectively, for examiner B. Conclusions: Chest auscultation does not appear to be an accurate diagnostic method for detecting abnormal respiratory mechanics in mechanically ventilated patients in the immediate postoperative period after cardiac surgery.


Keywords: Diagnostic tests, routine; Physical examination; Respiratory sounds; Respiratory mechanics; Data accuracy; Respiration, artificial.


5 - Bronchial carcinoid tumors: second primary neoplasms and outcomes of surgical treatment

Tumores carcinoides brônquicos: segunda neoplasia primária e desfechos do tratamento cirúrgico

Jefferson Luiz Gross1,a, Marcel Adalid Tapia Vega1,b, Guilherme Strambi Frenhi1,c, Silvio Melo Torres1,d, Antonio Hugo José Froes Marques Campos1,e, Clovis Antonio Lopes Pinto1,f, Felipe D'Almeida Costa1,g, Fabio José Haddad1,h

J Bras Pneumol.2019;45(5):e20180140

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Objective: To analyze determinants of prognosis in patients with bronchial carcinoid tumors treated surgically and the potential concomitance of such tumors with second primary neoplasms. Methods: This was a retrospective analysis of 51 bronchial carcinoid tumors treated surgically between 2007 and 2016. Disease-free survival (DFS) was calculated by the Kaplan-Meier method, and determinants of prognosis were evaluated. Primary neoplasms that were concomitant with the bronchial carcinoid tumors were identified by reviewing patient charts. Results: The median age was 51.2 years, 58.8% of the patients were female, and 52.9% were asymptomatic. The most common histology was typical carcinoid (in 80.4%). Five-year DFS was 89.8%. Ki-67 expression was determined in 27 patients, and five-year DFS was better among the patients in whom Ki-67 expression was ≤ 5% than among those in whom it was > 5% (100% vs. 47.6%; p = 0.01). Concomitant primary neoplasms were observed in 14 (27.4%) of the 51 cases. Among the concomitant primary neoplasms that were malignant, the most common was lung adenocarcinoma, which was observed in 3 cases. Concomitant primary neoplasms were more common in patients who were asymptomatic and in those with small tumors. Conclusions: Surgical resection is the mainstay treatment of bronchopulmonary carcinoid tumors and confers a good prognosis. Bronchial carcinoid tumors are likely to be accompanied by second primary neoplasms.


Keywords: Carcinoid tumor/diagnosis; Carcinoid tumor/surgery; Neoplasms, second primary; Lung neoplasms.


6 - Translation and cultural adaptation of the King's Brief Interstitial Lung Disease health status questionnaire for use in Brazil

Tradução e adaptação cultural do King's Brief Interstitial Lung Disease health status questionnaire

Karoline Silveira1,a, Leila John Marques Steidle2,b, Darlan Laurício Matte3,c, Pedro Heliodoro Tavares4,d, Mariangela Pimentel Pincelli2,e, Marcia Margaret Menezes Pizzichini2,f, Emilio Pizzichini2,5,6,g, Surinder Singh Birringer7,h, Michelle Gonçalves de Souza Tavares1,3,i

J Bras Pneumol.2019;45(5):e20180194

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To translate the King's Brief Interstitial Lung Disease (K-BILD) questionnaire to Portuguese and culturally adapt it for use in Brazil. The K-BILD quantifies the health status of patients with ILD. Methods: The process involved the following steps: authorization from the author of the original (English-language) questionnaire; translation of the questionnaire to Portuguese by three translators, working independently; merging of the translations by a committee of specialists; back-translation of the questionnaire to English; revision and readjustment of the back-translation by the committee of specialists; evaluation by the original author; revision of the back-translation; cognitive debriefing (verification of the clarity and acceptability of the Portuguese-language version in the target population-i.e., patients with ILD); and finalization of the Portuguese-language version. Results: In the cognitive debriefing step, 20 patients with ILD were interviewed. After the interviews, the clarity and acceptability index of each question was ≥ 0.8, which is considered acceptable. Conclusions: The Portuguese-language version of K-BILD appears to be easily administered to and understood by patients with ILD in Brazil. To our knowledge, this is the only instrument in Brazilian Portuguese that is designed to evaluate the impact that ILD has on the various aspects of the lives of those it affects.


Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Surveys and questionnaires.


7 - Safety and tolerability of nintedanib in patients with idiopathic pulmonary fibrosis in Brazil

Segurança e tolerabilidade de Nintedanibe em pacientes com fibrose pulmonar idiopática no Brasil

Carlos Alberto de Castro Pereira1,a, José Antonio Baddini-Martinez2,b, Bruno Guedes Baldi3,c, Sérgio Fernandes de Oliveira Jezler4,d, Adalberto Sperb Rubin5,e, Rogerio Lopes Rufino Alves6,f, Gilmar Alves Zonzin7,g, Manuel Quaresma8,h, Matthias Trampisch9,i, Marcelo Fouad Rabahi10,j

J Bras Pneumol.2019;45(5):e20180414

Abstract PDF PT PDF EN Portuguese Text

Objective: Clinical trials have shown that nintedanib 150 mg twice daily (bid) reduces disease progression in patients with idiopathic pulmonary fibrosis (IPF), with an adverse event profile that is manageable for most patients. Prior to the approval of nintedanib as a treatment for IPF in Brazil, an expanded access program (EAP) was initiated to provide early access to treatment and to evaluate the safety and tolerability of nintedanib in this patient population. Methods: Patients with a diagnosis of IPF within the previous five years, forced vital capacity (FVC) ≥ 50% predicted and diffusing capacity of the lungs for carbon monoxide (DLco) 30% to 79% predicted were eligible to participate in the EAP. Patients received nintedanib 150 mg bid open-label. Safety assessments included adverse events leading to permanent discontinuation of nintedanib and serious adverse events. Results: The EAP involved 57 patients at eight centers. Most patients were male (77.2%) and white (87.7%). At baseline, mean (SD) age was 70.7 (7.5) years and FVC was 70.7 (12.5) % predicted. Mean (SD) exposure to nintedanib was 14.4 (6.2) months; maximum exposure was 22.0 months. The most frequently reported adverse events considered by the investigator to be related to nintedanib treatment were diarrhea (45 patients, 78.9%) and nausea (25 patients, 43.9%). Adverse events led to permanent discontinuation of nintedanib in 16 patients (28.1%). Sixteen patients (28.1%) had a serious adverse event. Conclusion: In the Brazilian EAP, nintedanib had an acceptable safety and tolerability profile in patients with IPF, consistent with data from clinical trials.


Keywords: Drug tolerance; Expanded access program; Interstitial lung disease; Tyrosine kinase inhibitor.


Letters to the Editor

8 - Prescribing trends in and perceptions of the treatment of asthma: a survey among pulmonologists in Brazil

Tendências prescritivas e percepções no tratamento da asma: um inquérito entre pneumologistas brasileiros

José Eduardo Delfini Cançado1,a, Rodrigo Abensur Athanazio2,b, Luis Fernando Rensi Cunha3,c, Marcia Margaret Menezes Pizzichini4,d

J Bras Pneumol.2019;45(5):e20190083

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9 - Diffuse pulmonary lymphangiomatosis

Linfangiomatose pulmonar difusa

Igor Biscotto1,a, Rosana Souza Rodrigues1,2,b, Danielle Nunes Forny1,c, Miriam Menna Barreto1,d, Edson Marchiori1,e

J Bras Pneumol.2019;45(5):20180412

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Images in Pulmonary Medicine

10 - An unusual cause of pleural effusion in a patient with heart failure

Causa incomum de derrame pleural em paciente com insuficiência cardíaca

Daniel Bruno Takizawa1,a, Philippe de Figueiredo Braga Colares1,b, Olívia Meira Dias1,c

J Bras Pneumol.2019;45(5):e20180343

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Letters to the Editor

11 - Biodegradable stent in a patient with recurrent stenosis after lung transplantation

Stent biodegradável em paciente com estenose recorrente após transplante de pulmão

Hugo Goulart de Oliveira1,a, Diogo Martins de Oliveira2,b, Camila Greggianin3,c, Cristiano Feijó Andrade4,d, Fábio Munhoz Svartman4,e

J Bras Pneumol.2019;45(5):e20190078

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