Brazilian Journal of Pulmonology

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

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Year 2006 - Volume 32  - Number 2  (March/April)






Editorial

Original Article

3 - Using the forced oscillation technique to evaluate bronchodilator response in healthy volunteers and in asthma patients presenting a verified positive response

Técnica de oscilações forçadas na análise da resposta broncodilatadora em voluntários sadios e indivíduos portadores de asma brônquica com resposta positiva

Juliana Veiga Cavalcanti, Agnaldo José Lopes, José Manoel Jansen, Pedro Lopes de Melo

J Bras Pneumol.2006;32(2):91-98

Abstract PDF PT PDF EN Portuguese Text

Objective: To use the forced oscillation technique to evaluate asthma patients presenting positive bronchodilator responses (confirmed through spirometry) and compare the results with those obtained in healthy individuals. Methods: The study sample consisted of 53 non-smoking volunteers: 24 healthy subjects with no history of pulmonary disease and 29 asthmatics presenting positive bronchodilator response, as determined through analysis of spirometry findings. All of the subjects were submitted to forced oscillation technique and spirometry immediately before and 20 minutes after the administration of salbutamol spray (300 g). The parameters derived from the forced oscillation technique were total respiratory resistance, total respiratory reactance, resistance extrapolated to the y axis, the slope of resistance, and dynamic compliance. The parameters measured in the spirometry evaluation tests were forced expiratory volume in one second and forced vital capacity. Results: In the control group, bronchodilator use produced a significant alteration in the resistance extrapolated to the y axis (p < 0.001), although no significant differences were observed in the slope of resistance or in dynamic compliance. Analysis of the asthma patients revealed significant differences between the prebronchodilator and postbronchodilator values for all spirometry and forced oscillation technique parameters. Values of p < 0.001 were obtained for all comparisons between the two groups. Conclusion: The modifications provoked by use of the forced oscillation technique were in direct concordance with the pathophysiology of the bronchodilator response in asthma patients, indicating that the forced oscillation technique could be useful as a complement to spirometry in these patients.

 


Keywords: Asthma; Bronchial hyperreactivity; Spirometry/methods; Bronchial provocation tests; Forced expiratory volume/physiology; Oscillometry

 

4 - Respiratory muscle evaluation in elective thoracotomies and laparotomies of the upper abdomen

Avaliação muscular respiratória nas toracotomias e laparotomias superiores eletivas

Laryssa Milenkovich Bellinetti, João Carlos Thomson

J Bras Pneumol.2006;32(2):99-105

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify any possible relation between lower than predicted preoperative respiratory muscle function and the incidence of postoperative respiratory complications and death in elective thoracotomies and laparotomies of the upper abdomen. Methods: A prospective cohort study was conducted, in which 70 patients over the age of 18 were monitored in two similar hospitals. In the preoperative evaluation performed at admission, patients were classified as presenting respiratory muscle function (as determined by measurement of maximal respiratory pressures) > 75% of the predicted value (n = 50) or < 75% of the predicted value (n = 20). Patients were monitored until discharge. In both groups, the incidence of pneumonia was determined, as was that of acute respiratory failure, bronchospasm, prolonged mechanical ventilation, atelectasis, pleural effusion, pneumothorax and death. A comparative analysis was made between the groups, and relative risk was calculated. Results: In the study sample, the overall incidence of postoperative complications was 22.86% (16/70): 55% (11/20) in the group of patients presenting < 75% of the predicted value; and 10% (5/50) in the group of patients presenting > 75% of the predicted value. Patients in the < 75% of the predicted value group presented a relative risk of 5.5 (95% confidence interval between 2.19 and 13.82). Conclusion: Respiratory muscle function below the predicted value was found to be related with higher relative risk of postoperative complications in the surgical procedures studied.

 


Keywords: Postoperative complications; Thoracotomy; Laparotomy; Respiratory muscles; Respiratory insufficiency

 

5 - Evaluating physical capacity in patients with chronic obstructive pulmonary disease: comparing the shuttle walk test with the encouraged 6-minute walk test

Avaliação da capacidade de exercício em portadores de doença pulmonar obstrutiva crônica: comparação do teste de caminhada com carga progressiva com o teste de caminhada com acompanhamento

Fernanda Warken Rosa, Aquiles Camelier, Anamaria Mayer, José Roberto Jardim

J Bras Pneumol.2006;32(2):106-113

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the applicability of the incremental (shuttle) walk test in patients with chronic obstructive pulmonary disease and compare the performance of those patients on the shuttle walk test to that of the same patients on the encouraged 6-minute walk test. Methods: A cross-sectional study was conducted, in which 24 patients with chronic obstructive pulmonary disease were selected. In random order, patients were, after an initial practice period, submitted to a shuttle walk test and an encouraged 6-minute walk test. Results: The patients obtained a higher heart rate (expressed as a percentage of that predicted based on gender and age) on the encouraged 6-minute walk test (84.1 ± 11.4%) than on the shuttle walk test (76.4 ± 9.7%) (p = 0.003). The post-test sensation of dyspnea (Borg scale) was also higher on the encouraged 6-minute walk test. On average, the patients walked 307.0 ± 89.3 meters on the shuttle walk test and 515.5 ± 102.3 meters on the encouraged 6-minute walk test (p < 0.001). There was a good correlation between the two tests in terms of the distance walked (r = 0.80, p < 0.001). Conclusion: The shuttle walk test is simple and easy to implement in patients with chronic obstructive pulmonary disease. The encouraged 6-minute walk test produced higher post-test heart rate and greater post-test sensation of dyspnea than did the shuttle walk test.

 


Keywords: Pulmonary disease, chronic obstructive/rehabilitation; Exercise test; Motor activity; Reproducibility of results;

 

6 - Using the Saint George's Respiratory Questionnaire to evaluate quality of life in patients with chronic obstructive pulmonary disease: validating a new version for use in Brazil

Avaliação da qualidade de vida pelo Questionário do Hospital Saint George na Doença Respiratória em portadores de doença pulmonar obstrutiva crônica: validação de uma nova versão para o Brasil

Aquiles Camelier, Fernanda Warken Rosa, Christine Salim, Oliver Augusto Nascimento, Fábio Cardoso, José Roberto Jardim

J Bras Pneumol.2006;32(2):114-122

Abstract PDF PT PDF EN Portuguese Text

Objective: The objective of this study was to evaluate the applicability of a modified version of the Saint George's Respiratory Questionnaire. The version evaluated elicits "agree" and "do not agree", rather than "yes" and "no", responses. The intention is to facilitate the comprehension of double-negative questions and to promote better recollection of symptoms by patients by shortening their symptom histories from 12 months to 3 months. Methods: A total of 30 clinically stable patients with chronic obstructive pulmonary disease were evaluated. The Saint George's Respiratory Questionnaire and the modified version of the same were administered 15 days apart. Results: All of the patients presented health-related alterations in their quality of life. Comparing mean scores between the two questionnaires, the greatest difference was seen in the Symptoms domain. No significant differences were found in any of the remaining domains or in the total scores. In a subsequent analysis, significant correlations between the two questionnaires were found in all domains: Symptoms (r = 0.71; p < 0.001); Activity (r = 0.75; p < 0.001); Impact (r = 0.73; p < 0.001) and Total (r = 0.86; p < 0.001). Conclusion: The modified version of the Saint George's Respiratory Questionnaire is as effective as the original in gauging quality of life. However, various symptoms recollection time frames should be investigated in order to determine which would be the best time frame to employ in the analysis.

 


Keywords: Pulmonary disease, chronic obstructive; Quality of life; Reproducibility of results; Cross-cultural comparison; Questionnaires

 

7 - Influence of the technique of re-educating thoracic and abdominal muscles on respiratory muscle strength in patients with cystic fibrosis

Influência do método Reequilíbrio Toracoabdominal sobre a força muscular respiratória de pacientes com fibrose cística

Renata Claudia Zanchet, Aline Mayara Azevedo Chagas, Juliana Sarmento Melo, Patricia Yuki Watanabe, Augusto Simões-Barbosa, Gilvânia Feijó

J Bras Pneumol.2006;32(2):123-129

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the effect that re-education of the thoracic and abdominal muscles has on the respiratory muscle strength of patients with cystic fibrosis evaluated over time at the Cystic Fibrosis Outpatient Clinic of the Universidade Católica de Brasília (Catholic University of Brasília). Methods: The sample consisted of 29 cystic fibrosis patients, characterized based on anthropometric, genetic and bacterial colonization data. The patients were submitted to physical therapy sessions, involving re-education of the respiratory muscles, twice a week for four months. Spirometry, pressure manometry and anthropometry were performed before and after each session. Results: Comparing baselines values to those obtained after physical therapy, increases in maximum inspiratory pressure and maximum expiratory pressure were observed in all patients, those without any obstructive respiratory disease and those with mild obstructive respiratory disease (p < 0.05). A positive correlation between age and maximum expiratory pressure was observed for most of the patients. Maximum inspiratory pressure correlated positively with age only in the group with mild obstructive respiratory disease (p = 0.012; r = 0.817). In female patients and in the group of patients without obstructive respiratory disease, a negative correlation was observed between maximum expiratory pressure and colonization with Pseudomonas aeruginosa (p = 0.036; r = -0.585). Conclusion: Use of the thoracic and abdominal muscle re-education technique increased respiratory muscle strength in the cystic fibrosis patients studied, a finding that underscores the importance of including physical therapy in the treatment of these patients.

 


Keywords: Cystic fibrosis/rehabilitation; Physical therapy technique; Respiratory muscles; Forced expiratory volume; Inspiratory capacity; Vital capacity

 

8 - Yoga versus aerobic activity: effects on spirometry results and maximal inspiratory pressure

Ioga versus atividade aeróbia: efeitos sobre provas espirométricas e pressão inspiratória máxima

Dagoberto Vanoni de Godoy, Raquel Lonchi Bringhenti, Andréi Severa, Ricardo de Gasperi, Leonardo Vieira Poli

J Bras Pneumol.2006;32(2):130-135

Abstract PDF PT PDF EN Portuguese Text

Objective: To clarify whether, in healthy individuals, practicing yoga can modify maximal inspiratory pressure and spirometric indices when compared with the practice of aerobic exercise. Methods: A controlled clinical trial. A total of 31 healthy volunteers were allocated to practice aerobic exercise (n = 15) or to practice yoga (n = 16). Those in the first group served as controls and engaged in aerobic exercise for 45-60 minutes, twice a week for three months. Those in the second group practiced selected yogic techniques, also in sessions of 45-60 minutes, twice a week for three months. Forced vital capacity, forced expiratory volume in one second and maximal inspiratory pressure were measured before and after the three months of training. Results: No significant alterations were seen in the spirometric indices. A slight, although not significant, improvement in maximal inspiratory pressure was seen in both groups. However, there was a significant difference, seen in both genders, between the absolute delta (final value minus baseline value) of maximal inspiratory pressure for the group practicing yoga and that obtained for the group engaging in aerobic exercise (males: 19.5 cm H2O versus 2.8 cm H2O, p = 0.05; females: 20 cm H2O versus 3.9 cm H2O, p = 0.01). Conclusion: Neither yoga nor aerobic exercise provided a statistically significant improvement in maximal inspiratory pressure after three months. However, the absolute variation in maximal inspiratory pressure was greater among those practicing yoga.

 


Keywords: Yoga; Exercise; Respiratory muscles; Respiratory function tests; Maximal voluntary ventilation; Spirometry; Inspiratory capacity/physiology

 

9 - Lung abscess: analysis of 252 consecutive cases diagnosed between 1968 and 2004

Abscesso pulmonar de aspiração: análise de 252 casos consecutivos estudados de 1968 a 2004

José da Silva Moreira, José de Jesus Peixoto Camargo, José Carlos Felicetti, Paulo Roberto Goldenfun, Ana Luiza Schneider Moreira, Nelson da Silva Porto

J Bras Pneumol.2006;32(2):136-143

Abstract PDF PT PDF EN Portuguese Text

Objective: To relate the experience of the staff at a health care facility specializing in the management of patients with aspiration lung abscess. Methods: Diagnostic aspects and therapeutic results of 252 consecutive cases of lung abscess seen in patients hospitalized between 1968 and 2004. Results: Of the 252 patients, 209 were male, and 43 were female. The mean age was 41.4 years, and 70.2% were alcoholic. Cough, expectoration, fever and overall poor health were seen over 97% of patients. Chest pain was reported by 64%, 30.2% presented digital clubbing, 82.5% had dental disease, 78.6% reported having lost consciousness at least once, and 67.5% presented foul smelling sputum. In 85.3% of the patients, the lung lesions were located either in the posterior segments of the upper lobe or in the superior segments of the lower lobe, and 96.8% were unilateral. Concomitant pleural empyema was seen in 24 (9.5%) of the patients. Mixed flora was identified in the bronchopulmonary or pleural secretions of 182 patients (72.2%). All patients were initially treated with antibiotics (mainly penicillin or clindamycin), and postural drainage was performed in 98.4% of cases. Surgical procedures were performed in 52 (20.6%) of the patients (drainage of empyema in 24, pulmonary resection in 22 and drainage of the abscess in 6). Cure was obtained in 242 patients (96.0%), and 10 (4.0%) died. Conclusion: Lung abscess occurred predominantly in male adults presenting dental disease and having a history of loss of consciousness (especially as a result of alcohol abuse). Most of the patients were treated clinically with antibiotics and postural drainage, although some surgical procedure was required in one-fifth of the study sample.

 


Keywords: Lung abscess; Pneumonia, aspiration; Bacteria, anaerobic; Bacterial infections; Drainage, postural

 

10 - Prevalence of risk factors for obstructive sleep apnea syndrome in interstate bus drivers

Prevalência de fatores de risco para a síndrome da apnéia obstrutiva do sono em motoristas de ônibus interestadual

Carlos Alberto de Assis Viegas, Haroldo Willuweit de Oliveira

J Bras Pneumol.2006;32(2):144-149

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of risk factors for obstructive sleep apnea syndrome in interstate bus drivers. Methods: This study involved 262 professional interstate bus drivers employed by a Brazilian company headquartered in the Federal District. The drivers were evaluated using a questionnaire designed to assess respiratory sleep disorders, the Epworth Sleepiness Scale, test of sustained attention, test of divided attention and anthropometric measurements. Results: Body weight was found to be above the ideal in 68% of the drivers evaluated, 34% of which had a neck circumference = 42 cm. During the study period, the drivers reported using tobacco (27%), cola-based soft drinks (55%), alcohol (65%) and coffee (88%). The Epworth Sleepiness Scale score was = 10 points in 28%. Snoring was reported by 36%, sleep apnea by 5%, a sensation of suffocation during sleep by 12%, restless sleep by 29% and drowsiness while driving by 48%. There were 42% who had been involved in transit accidents, 7.6% of which were attributed to hypersomnolence. Those scoring higher than 10 of the Epworth Sleepiness Scale presented lower levels of sustained attention. In addition, a reduction in divided attention was found to correlate with greater daytime sleepiness and larger neck circumference. Conclusion: The rate of stimulant use found in the group of drivers evaluated is alarming. The high prevalence of daytime sleepiness indicates that attentiveness is reduced in this population.

 


Keywords: Automobile driving; Sleep apnea, obstructive; Work schedule tolerance; Psychometrics; Risk factors; Attention; Questionnaires

 

Review Article

11 - Extraesophageal manifestations of gastroesophageal reflux disease

Manifestações extra-esofágicas da doença do refluxo gastroesofágico

Richard Ricachenevski Gurski, André Ricardo Pereira da Rosa, Enio do Valle, Marcelo Antonio de Borba, André Alves Valiati

J Bras Pneumol.2006;32(2):150-160

Abstract PDF PT PDF EN Portuguese Text

Gastroesophageal reflux disease often presents as heartburn and acid reflux, the so-called "typical" symptoms. However, a subgroup of patients presents a collection of signs and symptoms that are not directly related to esophageal damage. These are known collectively as the extraesophageal manifestations of gastroesophageal reflux disease. Principal among such manifestations are bronchospasm, chronic cough and laryngitis, which are classified as atypical symptoms. These manifestations comprise a heterogeneous group. However, some generalizations can be made regarding all of the subgroups. First, although the correlation between gastroesophageal reflux disease and the extraesophageal manifestations has been well established, a cause-and-effect relationship has yet to be definitively elucidated. In addition, the main proposed pathogenic mechanisms of extraesophageal reflux are direct injury of the extraesophageal tissue (caused by contact with gastric acid) and the esophagobronchial reflex, which is mediated by the vagus nerve. Furthermore, gastroesophageal reflux disease might not be considered in the differential diagnosis of patients presenting only the atypical symptoms. In this article, we review the extraesophageal manifestations of gastroesophageal reflux disease, discussing its epidemiology, pathogenesis, diagnosis and treatment. We focus on the most extensively studied and well-established presentations.

 


Keywords: Gastroesophageal reflux/complications; Asthma; Laryngitis; Cough; Fundoplication; Respiration disorders/etiology

 

12 - Systemic manifestations in chronic obstructive pulmonary disease

Manifestações sistêmicas na doença pulmonar obstrutiva crônica

Victor Zuniga Dourado, Suzana Erico Tanni, Simone Alves Vale, Márcia Maria Faganello, Fernanda Figueirôa Sanches, Irma Godoy

J Bras Pneumol.2006;32(2):161-171

Abstract PDF PT PDF EN Portuguese Text

Chronic obstructive pulmonary disease is progressive and is characterized by abnormal inflammation of the lungs in response to inhalation of noxious particles or toxic gases, especially cigarette smoke. Although this infirmity primarily affects the lungs, diverse extrapulmonary manifestations have been described. The likely mechanisms involved in the local and systemic inflammation seen in this disease include an increase in the number of inflammatory cells (resulting in abnormal production of inflammatory cytokines) and an imbalance between the formation of reactive oxygen species and antioxidant capacity (leading to oxidative stress). Weakened physical condition secondary to airflow limitation can also lead to the development of altered muscle function. Chronic obstructive pulmonary disease presents diverse systemic effects including nutritional depletion and musculoskeletal dysfunction (causing a reduction in exercise tolerance), as well as other effects related to the comorbidities generally observed in these patients. These manifestations have been correlated with survival and overall health status in chronic obstructive pulmonary disease patients. In view of these facts, the aim of this review was to discuss findings in the literature related to the systemic manifestations of chronic obstructive pulmonary disease, emphasizing the role played by systemic inflammation and evaluating various therapeutic strategies.

 


Keywords: Pulmonary disease, chronic obstructive/complications; Nutritional status; Exercise tolerance;

 

Case Report

13 - Resection of a mediastinal schwannoma using video-assisted thoracoscopy

Ressecção de schwannoma mediastinal por cirurgia torácica videoassistida

Leonardo Ortigara, Nelson Rosemberg, Rafael Siqueira, Francisco Neto

J Bras Pneumol.2006;32(2):172-175

Abstract PDF PT PDF EN Portuguese Text

Schwannomas are tumors that are typically benign. They are derived from Schwann cells (glial cells of the peripheral nervous system that serve to separate and isolate nerve cells from adjacent structures). The most common type of schwannoma is a benign tumor of cranial nerve VIII and is referred to as an acoustic neuroma. When extradural, such tumors usually present as masses that can invade adjacent structures, thereby becoming symptomatic, as in the case of intrathoracic schwannomas (typically found in the posterior mediastinum). Herein, we present a case of a schwannoma treated through video-assisted thoracoscopy, and we review the literature on the subject.

 


Keywords: Mediastinal neoplasms/surgery; Neurilemmoma; Thoracic surgery, video-assisted; Case reports

 

14 - Claude Bernard-Horner syndrome resulting from pleural empyema

Síndrome de Claude Bernard-Horner associada ao empiema pleural

Fernando Luiz Westphal, Luiz Carlos de Lima, Arteiro Queiroz Menezes, Dirany Leite Sacramento e Silva

J Bras Pneumol.2006;32(2):176-179

Abstract PDF PT PDF EN Portuguese Text

Claude Bernard-Horner syndrome presents various etiologies and occurs as the direct result of interrupted nerve signaling at any point along the nerve trajectory, be it intrathoracic or extrathoracic. Herein, we report a case of Claude Bernard-Horner syndrome caused by loculated pleural empyema located in the paravertebral region of the upper third of the right hemithorax. The patient was submitted to thoracotomy in order to drain the infected fluids. The end result was satisfactory, including resolution of the infection, pulmonary expansion, and remission of the syndrome.

 


Keywords: Pleural empyema/complications; Horner syndrome/etiology; Blepharoptosis; Thoracotomy;

 

15 - Mounier-Kuhn syndrome

Síndrome de Mounier-Kühn

Fabrício Piccoli Fortuna, Klaus Irion, Cesare Wink, Jorge Luis Boemo

J Bras Pneumol.2006;32(2):180-183

Abstract PDF PT PDF EN Portuguese Text

Mounier-Kuhn syndrome, or tracheobronchomegaly, is a rare clinical entity characterized by abnormal dilation of the trachea and main bronchi. The diagnosis can usually be made by measuring the tracheal diameter. We report the case of a 40-year-old black man with refractory lower respiratory tract infection. Tracheobronchomegaly was confirmed through computed tomography.

 


Keywords: Tracheobronchomegaly/diagnosis; Tomography, X-ray computed; Tracheobronchomegaly/rehabilitation;

 

 


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