Brazilian Journal of Pulmonology

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

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Year 2004 - Volume 30  - Number 3  (May/June)






Original Article

3 - Effects of salbutamol delivered by dry-powder inhaler on methacholine-induced bronchoconstriction

Efeito do salbutamol liberado através de inalador de pó seco sobre o broncoespasmo induzido por metacolina

Adalberto Sperb Rubin, Liliana G Pelegrin,Christiano Perin, Maurício Roux Leite, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2004;30(3):195-200

Abstract PDF PT Portuguese Text

Background: Short-acting b2 agonists delivered by metered-dose inhaler (MDIs) are the drugs usually used for the reversal of methacholine-induced bronchoconstriction. The b2 agonists that are delivered by dry-powder inhaler (DPI) can be an efficacious option. Objective: To evaluate the effectiveness and speed of action of salbutamol delivered by DPI (Pulvinal; Butoventâ), in comparison to salbutamol delivered by MDI, in reversing methacholine-induced bronchoconstriction. Method: Sixty successive methacholine-induced bronchoconstriction patients who presented a decrease of at least 20% in forced expiratory volume (FEV1) were evaluated prospectively. Of these 60 patients, we randomized 30 (first group) to receive 200 mcg of salbutamol by MDI and 30 (second group) to receive 200 mcg of salbutamol by DPI (Pulvinal). Both drugs were administered with the objective of reversing bronchoconstriction during the final phase of a bronchoprovocation test. The FEV1 values obtained at 1 and 5 minutes after bronchodilator administration were evaluated. Results: The groups were comparable in gender distribution, age, weight, dose level provoking a 20% drop in FEV1 (first group: 1.3 mg; second group: 1.19 mg; p = 0.79) and post-methacholine FEV1 (first group: 2.03 l; second group: 1.99 l; p = 0.87), with no statistically significant differences between the two groups. In the first group (MDI), the mean increase in FEV1 was 16.2% (at 1 minute) and 22.2% (at 5 minutes), and in the second group (DPI) it was 17% (at 1 minute) and 23.6% (at 5 minutes). There was no statistically significant difference between the groups (p = 0.8). Conclusion: The b2-agonists delivered by DPI (Pulvinal) present the same bronchodilator efficacy and speed of action as do those delivered by the more traditional MDI method.

 


Keywords: Asthma. Bronchodilator agents/administration & dosage. Albuterol/administration & dosage. Methacholine chloride/administration & dosage. Respiratory therapy/methods. Administration, inhalation/methods. Prospective studies.

 

4 - Immunoglobulins, complements and autoantibodies in 58 workers exposed to silica

Estudo de imunoglobulinas, complementos e auto-anticorpos em 58 trabalhadores expostos à sílica

Hermano Albuquerque de Castro, Carolina Gimenes da Silva, Alfred Lemle

J Bras Pneumol.2004;30(3):201-206

Abstract PDF PT Portuguese Text

Background: The primary work-related lung disease in Brazil is silicosis. Its pathogenic agent is the dust of crystalline free silica (SiO2; silicon dioxide). The inflammatory process of silicosis is not yet well understood. Objective: To analyze, through immunologic laboratory evaluation, including nonspecific and specific immunity, the profile of IgG, IgM, IgA, C3, C4 and autoantibodies in the serum of workers, with or without silicosis, exposed to silica. Methods: Fifty-eight male workers were studied. All had been exposed to silica. Immunologic, radiologic and functional evaluations were made. The immunoglobulins IgG, IgA, and IgM, the complement system components C3 and C4, and the autoantibodies were assessed. Results: Chest X-rays were normal in 20 of the 58 workers and compatible with silicosis in 38. Among the 38 who were positive, IgG values were, on average, higher than in the group with normal X-rays (p < 0.05). There were no significant differences in average values of IgA, IgM, C3 or C4 (p > 0.05). The percentage of autoantibody positivity was higher in the silicosis group than in the group with normal X-rays. Conclusion: The increased levels of IgG in patients with silicosis constitutes an important discovery. It may represent continuity of the granulomatous reaction, even when the individual is no longer being exposed to silica. However, further studies are necessary in order to increase understanding of the mechanism involved in the silicosis immunologic process.

 


Keywords: Lung diseases. Silicosis. Occupational diseases. Immunoglobulins

 

5 - Influence of general clinical parameters on the quality of life of chronic obstructive pulmonary disease patients

Influência de características gerais na qualidade de vida de pacientes com doença pulmonar obstrutiva crônica

Victor Zuniga Dourado, Letícia Cláudia de Oliveira Antunes, Lídia Raquel de Carvalho, Irma Godoy

J Bras Pneumol.2004;30(3):207-214

Abstract PDF PT Portuguese Text

Background: There is currently no consensus regarding which factors influence the quality of life of patients suffering from chronic obstructive pulmonary disease (COPD). However, identifying such factors could orient approaches to improving the quality of the lives of these patients. Objective: To evaluate factors that can interfere with quality of life in COPD patients selected for pulmonary rehabilitation. Methods: Twenty-one patients with moderate to severe COPD were evaluated. Maximal inspiratory pressure (MIP), 6-minute walk test (6MWT), body mass index (BMI), pulmonary function, blood gases, grip strength (measured with a dynamometer), quadriceps strength and St. George's Respiratory Questionnaire (SGRQ) scores were assessed. Results: Statistically significant negative correlations with quality of life were found for the following factors: "impact" scores of: forced expiratory volume in one second (FEV1) (r = -0.68; p = 0.004), FEV1 to forced vital capacity ratio (FEV1/FVC) (r = -0.61; p = 0.014), peak expiratory flow (PEF) (r = -0.53 (p = 0.015), 6MWT (r = -0.63; p = 0.001) and BMI (r = -0.64; p = 0.002); "activity" scores for: MIP (r = -0.57; p = 0.007), baseline arterial oxygen saturation by pulse oximetry (SpO2) (r = -0.52; p = 0.018) and 6MWT (r = -0.58; p = 0.007); "symptom" score for: BMI (r = -0.60; p = 0.005); and "total" scores for: FEV1 (r = -0.64; p = 0.01), PEF (r = -0.47; p = 0.033) and BMI (r = -0.57; p = 0.009). Multiple linear regression revealed the primary factors influencing quality of life to be: BMI, which presented a significant influence on "symptom", "impact" and "total" scores (p = 0.002, p = 0.009 and p = 0.024, respectively); and 6MWT, which had a significant influence on "activity" and "impact" scores (p = 0.048 and p = 0.010, respectively). Conclusions: The BMI and 6MWT were shown to have an influence on quality of life in the COPD patients studied. Therefore, therapeutic approaches to improving the quality of life of COPD patients should take these indices into consideration.

 


Keywords: Lung diseases, obstructive/rehabilitation. Quality of life

 

6 - Treatment of empyema using thoracentesis with irrigation and intrapleural application of an antimicrobial agent

Toracocentese esvaziadora com irrigação e uso de antimicrobiano intrapleural no tratamento do empiema

Liana Peres Duailibe, Maria Ilizabeti Donatti, Paulo de Tarso Müller, Pedro Nango Dobashi

J Bras Pneumol.2004;30(3):215-222

Abstract PDF PT Portuguese Text

Background: Empyema is a serious disease classically characterized by purulence within the pleural cavity. Early diagnosis demands immediate treatment, although there is still great controversy surrounding the question of what is the best therapy. Objective: To analyze the method of using thoracentesis and pleural irrigation, combined with the intrapleural application of an antimicrobial agent, to treat empyema - and to compare this method with others described in the literature. Method: Between January 1999 and May 2000, 17 patients diagnosed with loculated or diffuse pleural empyema were submitted to thoracentesis, followed by thorough washing of the pleural cavity with isotonic solution and intrapleural administration of a non-irritating antimicrobial agent to the pleura. Results: The group of patients studied consisted of 15 men and 2 women, and the average age was 44. The most common clinical symptoms were fever, productive cough, chest pain and dyspnea, and the most common cause was pneumonia. Macroscopically, 12 patients presented obviously purulent pleural fluid. In 4 (26.67%) of the patients, the etiological agent was identified, the most frequent being Staphylococcus sp. Pulmonary decortication was indicated in 2 cases, and those 2 patients were therefore excluded. The average length of hospitalization was 17.1 days, although 3 patients received the treatment as outpatients. No recurrence or mortality was observed with the use of this methodology. Conclusion: This approach reduced the need for invasive procedures, proving to be safe and efficient, with lower rates of morbidity and mortality than other modalities of treatment.

 


Keywords: Empyema/Pleural, Pleura/Blood Supply, Treatment Outcome, Treatment Effectiveness.

 

7 - Smoking among medical students: temporal trends and related variables

Tabagismo em estudantes de Medicina: tendências temporais e fatores associados

Ana Maria Baptista Menezes, Pedro Curi Hallal, Fernando Silva, Marcos Souza, Luciene Paiva, Aline D'Ávila, Bianca Weber, Viviane Vaz, Fernando Marques, Bernardo L. Horta

J Bras Pneumol.2004;30(3):223-228

Abstract PDF PT Portuguese Text

Background: Although the prevalence of smoking among medical students declined steadily between the 1960s and 1980s, it seems to have stabilized in recent years. Objectives: To evaluate temporal trends, over the last 17 years, in the smoking habits of medical students at the Universidade Federal de Pelotas, in the state of Rio Grande do Sul, Brazil, and to identify some possible risk factors for smoking. Method: Cross-sectional surveys with comparable methodologies were conducted in 1986, 1991, 1996 and 2002. Self-administered questionnaires were used. Smokers were defined as those who were smoking at least one cigarette per day for at least one month. Descriptive analyses were carried out, as well as crude evaluations using chi-square tests for heterogeneity and linear trend. In addition, Poisson regression, adjusted for age, was used in order to evaluate the effect of medical school class year on the incidence of smoking. Results: The prevalence of smoking among UFPel medical students was 10.1%, statistically similar to values found in 1991 and 1996. No differences in smoking frequency were found relating to sex, age, or parental smoking. The prevalence of smoking was found to increase progressively over the course of medical school. Conclusions: The downward trend in smoking prevalence among UFPel medical students is being replaced by a stable rate of approximately 10-15%. Anti-smoking campaigns are still necessary in university environments, especially in medical schools.

 


Keywords: Smoking/trends. Smoking/epidemiology. Medical students/tobacco use cessation. Cross-sectional studies. Questionnaires.

 

8 - Community-acquired pneumonia in elderly patients: adherence to Brazilian guidelines for the treatment of pneumonia

Pneumonias adquiridas na comunidade em pacientes idosos: aderência ao Consenso Brasileiro sobre Pneumonias

José Roberto de Almeida, Olavo Franco Ferreira Filho

J Bras Pneumol.2004;30(3):229-236

Abstract PDF PT Portuguese Text

Background: Pneumonia is a common disease with a high mortality rate, being the sixth leading cause of death among elderly people in the USA and the fifth among those in Brazil. Initial treatment of pneumonia is usually empirical since the ethiological agent is identified in only approximately 50% of cases. Therefore, several scientific societies have defined some guidelines for initial antimicrobial therapies. Objectives: This study evaluated adherence to the guidelines set forth by the Consenso Brasileiro sobre Pneumonias (Brazilian Consensus on Pneumonia) for treatment of community-acquired pneumonia in hospitalized elderly patients. Method: Fifty-four patients, aged 60 or over, hospitalized at Londrina University Hospital with community-acquired pneumonia between 2 August 1999 and 2 August 2000 were evaluated. Whether their treatment adhered or did not adhere to guidelines, the patients were compared in terms of 30-day mortality, average time for clinical stabilization, average length of hospital stay, cost of treatment and severity score. Results: The average age was 74.1, and 61.1% of the patients were treated in accordance with the Brazilian guidelines for treatment of community-acquired pneumonia. There were no differences in length of hospital stays, cost of treatment, time to clinical stability and severity score between the two groups (adherent and non-adherent). However, there was a difference in mortality. The rate of mortality was higher in patients with pneumonia severity index (PSI) scores of IV or V who were treated according to the guidelines than in those with the same score whose treatment was non-adherent (p = 0.04). In general, PSI score was related to mortality. The mortality rate among patients with scores of II and III was 9.5%, compared with 30.3% in patients with scores of IV and V. Conclusion: Adherence to the Brazilian guidelines for treatment of community-acquired pneumonia in elderly patients was satisfactory, and there was no difference in results between both groups, except for the higher mortality rate found for patients with higher PSI scores who were treated according to the guidelines. A positive correlation was found between PSI score and mortality.

 


Keywords: Pneumonia. Health Planning Guidelines. Community-Acquired Infections. Health Services for the Aged.

 

9 - Percutaneous Tracheostomy in Critically-ill Patients: The Experience of a Medical Intensive Care Unit

Traqueostomia percutânea no doente crítico: a experiência de uma unidade de terapia intensiva clínica

Marcelo Park, Leonardo Brauer, Ricardo Reis Sanga, André Carlos Kajdacsy-Balla Amaral, José Paulo Ladeira, Luciano Cesar Pontes de Azevedo, Leandro Utino Taniguchi, Luiz Monteiro da Cruz-Neto

J Bras Pneumol.2004;30(3):237-242

Abstract PDF PT Portuguese Text

Background: Tracheostomy is a procedure commonly required in the intensive care unit. In the last two decades, the use of the percutaneous method has increased in parallel with improvements in the technique. Objective: To describe our experience in employing the percutaneous method over the last 3.5 years. Methods: We created, retrospectively, a database of prospective tracheostomy data related to 78 patients evaluated between January 2000 and July 2003. We used the percutaneous tracheostomy techniques of either progressive dilatation (in 36 patients) or forceps dilatation (in 42 patients). Data are expressed as number of occurrences or median with interquartile ranges. Results: The mean age of the patients was 66 (range, 43-75), and the median APACHE II score was 16 (range, 12-21). The median time spent on mechanical ventilation prior to tracheostomy was 14 days (range, 10-17 days). Of the 78 patients studied, 18 (23%) died while in the intensive care unit. The most common cause of admission was acute central nervous system disturbance (in 45%). Most of the tracheostomies performed were indicated due to difficulty in weaning from mechanical ventilation (in 50%) or to Glasgow Coma scores consistently lower than 8 (in 49%). Bronchoscopy was used in all but 6 of the procedures. There were complications in 33% of the procedures. The most common complication was light bleeding, without need for transfusion. No patient died due to complications arising from the procedure. Conclusion: Percutaneous tracheostomy is reasonable and safe when performed in an intensive care unit.

 


Keywords: Tracheostomy/methods. Respiration, Artificial/methods. Respiratory insufficiency/therapy. Respiratory insufficiency/complications.

 

10 - Clinical and epidemiological characteristics of contagious adult of tuberculosis in children

Características clínicas e epidemiológicas do adulto contagiante da criança com tuberculose

João Ab Lima, Edgar Enrique Sarria Icaza, Beatriz G. Menegotto, Gilberto Bueno Fischer, Sérgio Saldanha Menna Barreto

J Bras Pneumol.2004;30(3):243-252

Abstract PDF PT Portuguese Text

Background: Tuberculosis in children generally occurs as a direct result of cohabitation with a contagious adult. Objective: To create a profile of a typical adult with contagious tuberculosis (as identified through the public health system) living with a child who has been diagnosed with tuberculosis. Method: Case study. Children younger than 14 years of age who were diagnosed with tuberculosis were included. Parents were interviewed using structured questionnaires. Means and standard deviations were analyzed using the Student's t-test. Fisher's exact test or the Dz test was used for comparisons. Results: Fifty children, representing 96% of those diagnosed with tuberculosis in the Porto Alegre health care system between July 20, 2001 and August 10, 2002, were included. The mean age was 76 months, and 60% were girls. The classic forms of pulmonary presentation (consolidation or cavitation) were seen in 38%. The majority of the children were diagnosed in the hospital and came from homes in which there were (a mean of) 6 cohabitants and a total family income less than 2 times the local minimum wage. Using ELISA, HIV co-infection was identified in 25% (although not all were tested). The children regularly visited places other than their homes. In 78% of cases, the contagious adult was identified. These contagious adults were mostly males (56%), and the mean age was 32. In most cases (79%), the contagious adult was a relative, usually a parent. Within this group of adults with contagious tuberculosis, HIV co-infection was identified in 43% of those tested. Conclusions: Adults with contagious tuberculosis living in the home continue to be the most likely source of tuberculosis infection in children. Co-infection with HIV in these pediatric patients, as well as in the cohabiting adults with contagious tuberculosis, is a significant finding. It must be emphasized that the possibility of contact with contagious individuals in the home should be explored in every diagnosed case of pediatric tuberculosis.

 


Keywords: Tuberculosis/epidemiology. Children. Communicable diseases/etiology.

 

Upgrading

11 - Pulmonary Medicine residency in Brazil

A residência médica em Pneumologia no Brasil

Evandro Guimarães de Sousa

J Bras Pneumol.2004;30(3):253-259

Abstract PDF PT Portuguese Text

Background: A residency in Pulmonary Medicine represents the best source of training for those who wish to specialize in the area. In Brazil, the Comissão Nacional de Residência Médica (National Committee of Medical Residency) regulates such programs. Objective: To analyze the number of programs and their levels state of accreditation, the number of residents and the distribution of these programs and residents among the various institutions throughout Brazil. Methods: The list of programs furnished by the National Committee of Medical Residency in April 2003 was analyzed, and the basic criteria for accreditation in the area (according to the legislation currently in effect) were reviewed. Results: Of the 58 accredited programs, 35 are offered in hospitals in the southeastern region of Brazil, and 133 of the residents are also there. In contrast, there is only 1 accredited program, and there are only 3 residents enrolled in that program. Conclusion: Although all 58 programs are accredited, most are clustered in the southeastern region. It is therefore necessary that the Comissão Nacional de Residência Médica and the Sociedade Brasileira de Pneumologia e Tisiologia (Brazilian Society of Pulmonology and Phthisiology) begin a joint project in order to manage the creation of new programs. Thus, the number of programs and residents required for each of the various regions could be determined.

 


Keywords: Residency/Medical, Pulmonary Disease (Specialty), Internship and Residency

 

Case Report

12 - Shrinking lung syndrome in systemic lupus erythematosus

Síndrome do pulmão encolhido no lúpus eritematoso sistêmico

Cíntia Andrade Costa, Dálvaro Oliveira de Castro Jr., Sérgio Jezler, Mettermayer Santiago

J Bras Pneumol.2004;30(3):260-263

Abstract PDF PT Portuguese Text

Systemic lupus erythematosus (SLE) may involve the respiratory tract in several ways, such as through pleuritis, pneumonitis, interstitial disease or pulmonary hypertension. In rare cases, SLE patients present a syndrome characterized by dyspnea, chest pain and abnormalities in pulmonary function testing, although there may be no evidence of major parenchymal lung disease on computerized tomography scans. This condition has come to be known as shrinking lung syndrome. We report a case that meets these diagnostic criteria, emphasizing the pathogenesis proposed, as well as the therapeutic options available.

 


Keywords: Lupus Erythematosus/Systemic, Respiratory System, Shrinking Lung Syndrome

 

13 - Severe form of hantavirus cardiopulmonary syndrome managed with continuous positive airway plessure through facial mask

Forma grave da síndrome pulmonar e cardiovascular por hantavírus tratada com pressurização positiva através de máscara facial

Mariangela Pimentel Pincelli, Carlos Roberto Ribeiro de Carvalho, Luis Tadeu Moraes Figueiredo, Antônio Delfino de Oliveira Júnior, Ana Lúcia Bernardo Soares, Carmen Sílvia Valente Barbas

J Bras Pneumol.2004;30(3):264-269

Abstract PDF PT Portuguese Text

In 1993 the first Brazilian cluster of Hantavirus Cardiopulmonary Syndrome (HCPS) was described in Juquitiba, SP. Since then, there have been descriptions of new cases specially on the southeast and south states of Brazil. Only in 2002 there were observed the first three cases of HCPS in our city: São Carlos. One of our patients was successfully supported with CPAP through facial mask. This is the first severe case of acute respiratory failure induced by Hantavirus that was successfully managed with this kind of respiratory strategy.

 


Keywords: Noninvasive Ventilation, CPAP, Hantavirus Pulmonary and Cardiovascular Syndrome, Acute Hipoxemic Respiratory Failure.

 

14 - Acute disseminated histoplasmosis in an immunocompetent patient

Histoplasmose disseminada aguda em indivíduo imunocompetente

Simone Castelo Branco Fortaleza, Silvia Karine de Albuquerque Lopes, Tereza de Jesus Bandeira, Teresa Neuma Albuquerque Gomes Nogueira, Marcelo Alcântata Holanda

J Bras Pneumol.2004;30(3):270-273

Abstract PDF PT Portuguese Text

Histoplasmosis is a fungal disease caused by inhalation of Histoplasma capsulatum fungus. The disease does not normally affect immunocompetent individuals after a single, transient inhalation exposure. However, longer exposure may cause chronic or disseminated acute pulmonary infection. In immunocompromised patients, the infection is disseminated and severe. We report the case of a 13-year-old immunocompetent patient, presenting with fever, cough and dyspnea for one month. The chest X-ray and computed tomography scan revealed interstitial infiltrate and diffuse micronodules. The patient reported having had close and prolonged contact with birds. He was submitted to an open lung biopsy and the tissue culture was positive for Histoplasma capsulatum sp. He was treated with amphotericin B for 28 days, followed by treatment with itraconazole for 6 months, and there was complete resolution of the disease.

 


Keywords: Histoplasmosis, Immunocompetence, Birds.

 

Review Article

15 - Economic evaluation of the impact of chronic obstructive pulmonary disease and its acute exacerbations on Latin America

Avaliação econômica da doença pulmonar obstrutiva crônica e de suas agudizações. Aplicação na América Latina

Marc Miravitlles

J Bras Pneumol.2004;30(3):274-285

Abstract PDF PT Portuguese Text

Chronic obstructive pulmonary disease is highly prevalent the world over. An estimated 7% to 10% of the global adult population is affected. In Brazil, the incidence of chronic bronchitis is 12.7% among individuals over the age of 40. Economic studies have great relevance in devising policies for dealing with diseases of such high prevalence. The majority of data related to the costs of chronic obstructive pulmonary disease is culled from national health databases. There have been only a few studies evaluating the direct public health costs of the disease. In analyzing those studies, one can conclude that a chronic obstructive pulmonary disease patient generates a direct annual expenditure of 1200 to 1800 USD. However, the cost is correlated with the severity of the disease. Patients suffering from the more severe forms can require as much as double that expenditure, and early diagnosis is therefore vital. The most cost-effective strategy is early detection of the disease, in concert with anti-smoking campaigns. In the most advanced stages of the disease, the greatest costs are incurred due to hospitalization. In such cases, correct treatment of the acute exacerbations of the disease is crucial to minimizing costs. The average cost of a hospital stay in Brazil is 2761 Brazilian reals, which is equal to that of one full year of outpatient treatment. Antibiotic therapy accounts for only a small fraction of the total cost of treating such acute exacerbations. The use of more efficacious antibiotics may represent a more cost-effective strategy for reducing the rate of treatment failure. Economic analysis should allow for the identification and implementation of the most cost-effective strategies for treating this disease.

 


Keywords: Smoking/adverse effects. Tobacco use cessation/methods. Pregnancy.

 

16 - Critical analysis of scoring systems used in the assessment of Cystic Fibrosis severity: State of the art

Análise crítica dos escores de avaliação de gravidade da fibrose cística: Estado da arte

Camila Isabel da Silva Santos, José Dirceu Ribeiro, Antônio Fernando Ribeiro, Gabriel Hessel

J Bras Pneumol.2004;30(3):286-

Abstract PDF PT Portuguese Text

This study carries out a descriptive and comparative analysis of the various types of cystic fibrosis severity scores described in the literature and contextualizes the origin and objective of each. A total of 16 scoring systems were found: 8 are used predominantly for clinical evaluation, 5 for radiographic findings, 2 for tomographic findings and 1 for scintigraphic findings. Despite the criticism and controversy regarding these instruments of assessment, they have contributed to a better understanding of the disease and to the development of more effective therapeutic procedures.

 


Keywords: Severity of illness index. Cystic fibrosis. Review literature.

 

 


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