Brazilian Journal of Pulmonology

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


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Year 2006 - Volume 32  - Number 3  (May/June)

Original Article

3 - Compliance with environmental control measures in the homes of children and adolescents with asthma

Adesão às medidas de controle ambiental em lares de crianças e adolescentes asmáticos

Nulma Souto Jentzsch, Paulo Augusto Moreira Camargos, Elza Machado de Melo

J Bras Pneumol.2006;32(3):189-194

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine, through home visits, the rate of compliance with environmental control measures in the homes of children with asthma. Methods: This study involved 98 asthma patients between the ages of 4 and 15. The parents of those children and adolescents received instruction in how to carry out environmental control measures and were encouraged to perform such measures continuously for a period of 90 days. Home visits, which included direct inspection of the domicile and administration of a questionnaire, were made before and after this 90-day period. In cases of noncompliance, parents were asked to explain why they did not carry out the control measures. Statistical analysis was performed using the McNemar test. Results: Overall compliance with the various items studied was 11.1%, ranging from -4.1% (for curtain control, p = 0.63) to 22.6% (for stuffed toys, p < 0.001). Passive smoking was reduced to 9.7% (p = 0.02). Among the families studied, the mean monthly income was 2.5 times the national minimum wage. When asked why they had not adopted the recommended measures, noncompliant parents gave, among others, the following explanations: "economic hardship" (60.1%); "the measures were too difficult to carry out" (6.1%); "nonparticipation of the father" (4%); and "lack of time on the part of the mother" (4%). Conclusion: Environmental control measures were carried out sporadically, possibly reflecting the influence of socioeconomic and cultural factors.


Keywords: Asthma; Allergens; Environmental exposure; Hypersensivity/prevention & control; Compliance


4 - Bronchial hyperresponsiveness to hypertonic saline challenge in children and adolescents

Avaliação da hiperresponsividade brônquica à solução salina hipertônica em crianças e adolescentes

Paulo Kussek, Nelson Augusto Rosário Filho, Mônica Cat

J Bras Pneumol.2006;32(3):195-201

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess airway hyperresponsiveness to 4.5% hypertonic saline solution in comparison to that obtained through challenge with other bronchoconstriction agents and in relation to patient allergic sensitization. Methods: A cross-sectional, experimental study was conducted, initially involving 85 subjects. After exclusions, the final sample consisted of 62 patients, divided into two groups: a study group of those with asthma (n = 45) and a control group of those with no asthma or allergies (n = 17). Hypertonic saline was nebulized using an ultrasonic nebulizer and administered successively for 0.5, 1, 2, 4 and 8 minutes until a drop in forced expiratory volume in one second of = 15% was achieved in relation to the baseline value. The level of specific immunoglobulin E to Dermatophagoides pteronyssinus level was determined by ImmunoCAP assay and was considered positive when > 0.35 kU/L. Results: In the 36 asthma group subjects presenting a response, the mean drop in forced expiratory volume in one second after hypertonic saline nebulization was 27.4%. None of control group subjects (immunoglobulin E < 0.35 kU/L) presented a positive response to hypertonic saline. The mean forced expiratory volume in one second for control group subjects was 9%. The results of a bronchial provocation test were negative in 9 of the asthma group subjects. The frequency of bronchial provocation test positivity was higher in the subjects presenting elevated levels of specific immunoglobulin E, indicating that there is a relationship between bronchial hyperresponsiveness and the level of specific immunoglobulin E. The sensitivity and specificity of the test were 80% and 92%, respectively. Conclusion: Bronchial provocation with hypertonic saline presents satisfactory sensitivity and specificity. Therefore, in addition to being a low cost procedure that requires very little equipment, it is a useful means of assessing hyperresponsiveness in children and adolescents.


Keywords: Bronchial provocation tests; Bronchial hyperreactivity; Saline solution, hypertonic; Administration, inhalation;


5 - Efficacy of inhaled formoterol in reversing bronchoconstriction

Eficácia do formoterol na reversão imediata do broncoespasmo

Adalberto Sperb Rubin, Christiano Perin, Liliana Pelegrin, Juliana Cardozo Fernandes, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2006;32(3):202-206

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effectiveness and onset of action of formoterol delivered by dry-powder inhaler in reversing methacholine-induced bronchoconstriction. Methods: Patients presenting a drop in forced expiratory volume in one second > 20% after methacholine inhalation were included. A total of 84 patients were evaluated. All of the participating patients presented respiratory symptoms of unknown origin, which were being investigated. The patients were randomized to receive 200 µg of spray fenoterol (n = 41) or 12 µg of dry-powder inhaler formoterol (n = 43), both administered in order to achieve immediate reversal of methacholine-induced bronchoconstriction. We evaluated the decrease in forced expiratory volume in one second (in relation to the baseline value) after methacholine challenge and the dose of methacholine required to provoke a drop of 20% in forced expiratory volume in one second, as well as the increase in forced expiratory volume in one second (in relation to the baseline value) at five and ten minutes after bronchodilator use. Results: There were no significant differences related to gender, age, weight, height or dose of methacholine required to provoke a drop of 20% in forced expiratory volume in one second. Nor were there any significant differences in terms of baseline or post-methacholine forced expiratory volume in one second. In the fenoterol group, the mean postbronchodilator increase in forced expiratory volume in one second increase was 34% (at five minutes) and 50.1% (at ten minutes), compared with 46.5% (at five minutes) and 53.2% (at ten minutes) in the formoterol group. Conclusion: The bronchodilator effect of formoterol at five and ten minutes after methacholine-induced bronchoconstriction was similar to that of fenoterol. Despite being a long-acting bronchodilator, formoterol also has a rapid onset of action, which suggests that it could be employed as a relief medication in cases of bronchoconstriction occurring during asthma attacks.


Keywords: Asthma; Formoterol; Fenoterol; Inhalation therapy; Bronchodilation, Methacoline


6 - Nocturnal desaturation: predictors and the effect on sleep patterns in patients with chronic obstructive pulmonary disease and concomitant mild daytime hypoxemia

Dessaturação noturna: preditores e influência no padrão do sono de pacientes portadores de doença pulmonar obstrutiva crônica com hipoxemia leve em vigília

Renata Claudia Zanchet, Carlos Alberto de Assis Viegas

J Bras Pneumol.2006;32(3):207-212

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the nocturnal oximetry pattern in chronic obstructive pulmonary disease patients having no sleep apnea and presenting mild daytime hypoxemia, to identify probable daytime parameters capable of predicting nocturnal desaturation, and to evaluate the influence of nocturnal desaturation on the sleep pattern of these patients. Methods: Twenty-five patients were divided into two groups: those with nocturnal desaturation and those without. Results: Comparing the first group (52%) with the second, we found the following: age, 63 + 5 years versus 63 + 6 years; forced expiratory volume in the first second = 53 + 31% versus 56 + 19% predicted; ratio of forced expiratory volume in the first second to forced vital capacity, 49 + 14% versus 52 + 10%; arterial oxygen tension, 68 + 8 mmHg versus 72 + 68 mmHg; and arterial oxygen saturation, 93 + 2% versus 94 + 1%. Patients in the nocturnal desaturation group presented lower daytime arterial oxygen saturation and nocturnal arterial oxygen saturation by pulse oximetry. There was no difference between the two groups in terms of the sleep patterns observed. The ratio of forced expiratory volume in the first second to forced vital capacity was found to correlate with forced vital capacity, daytime arterial oxygen tension and daytime arterial oxygen saturation. In addition, arterial oxygen saturation by pulse oximetry during exercise was found to correlate with nocturnal arterial oxygen saturation by pulse oximetry. However, only daytime arterial oxygen saturation was predictive of nocturnal desaturation. Conclusion: The only variable capable of predicting nocturnal desaturation was daytime arterial oxygen saturation. Nocturnal desaturation did not influence the sleep patterns of patients with chronic obstructive pulmonary disease accompanied by mild daytime hypoxemia.


Keywords: Sleep, REM; Pulmonary disease, chronic obstructive; Anoxemia; Spirometry; Wakefulness


7 - Using the forced oscillation technique to evaluate respiratory resistance in individuals with silicosis

Avaliação das características resistivas do sistema respiratório de indivíduos portadores de silicose pela técnica de oscilações forçadas

Jayme Alves de Mesquita Júnior, Agnaldo José Lopes, José Manoel Jansen, Pedro Lopes de Melo

J Bras Pneumol.2006;32(3):213-220

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the resistance values obtained through the use of the forced oscillation technique in patients with varying degrees of airway obstruction resulting from silicosis. Methods: A total of 40 never-smoking volunteers were analyzed: 10 were healthy subjects with no history of pulmonary disease or silica exposure, and 30 had silicosis. The forced oscillation technique was used to examine the subjects, and spirometry was used as a reference in order to classify the obstruction by degree. This classification resulted in five groups: control (n = 10); normal exam, composed of individuals diagnosed clinically and radiologically with silicosis but presenting normal spirometry results (n = 7); mild obstruction (n = 10); moderate obstruction (n = 8); and severe obstruction (n = 5). Results: The reduction observed in the spirometric values corresponded to a significant increase in the total respiratory resistance (p < 0.001), as well as in airway resistance (p < 0.003). A significant reduction in ventilation homogeneity was also observed (p < 0.004). Conclusion: In individuals with silicosis, the additional respiratory resistance-related data obtained through the use of the forced oscillation technique can complement spirometric data. Therefore, the forced oscillation technique presents great potential for the analysis of such patients.


Keywords: Pneumoconiosis; Silicosis; Forced expiratory volume; Oscillometry; Respiratory function tests


8 - Early diagnosis of lung cancer: the great challenge. Epidemiological variables, clinical variables, staging and treatment

Diagnóstico precoce do câncer de pulmão: o grande desafio. Variáveis epidemiológicas e clínicas, estadiamento e tratamento

João Adriano Barros, Geraldo Valladares, Adriane Reichert Faria, Erika Megumi Fugita, Ana Paula Ruiz, André Gustavo Daher Vianna, Guilherme Luís Trevisan, Fabrício Augusto Martinelli de Oliveira

J Bras Pneumol.2006;32(3):221-227

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate confirmed cases of lung cancer, reviewing epidemiological variables, clinical variables, staging and treatment. Methods: The cases of 263 patients were studied. All of the patients had been treated at the Universidade Federal do Paraná (Federal University of Paraná) Hospital de Clínicas or at the Hospital Erasto Gaertner, two institutions that, together, serve a significant portion of the patients seeking treatment in the city of Curitiba, located in the state of Paraná. This was a retrospective study, involving the administration of questionnaires. The descriptive analysis of the data obtained was performed using the Epi-Info program. Results: There was a predominance of male patients (76%). At the time of diagnosis, the majority of patients (90%) were smokers or former smokers. In 87% of the cases, there was no history of lung disease. The most common initial symptoms were cough (142 cases) and chest pain (92 cases). Non-small cell lung cancer was found in 87% of the patients, and the most common histological type was spinocellular carcinoma, which was found in 49% of all of the patients. Smoking was found to be the most significant predisposing factor. Conclusion: The characteristics of lung cancer progression, such as the nonspecificity of the initial symptoms, the duration of tumor growth and the course of the tumor, together with the lack of tracking programs, are the principal factors that hinder the early detection of lung cancer, making it difficult to treat lung cancer patients and to increase their survival.


Keywords: Lung neoplasms/diagnosis; Lung neoplasms/epidemiology; Lung neoplasms/surgery; Early diagnosis; Neoplasms staging


9 - Radiographic alterations in patients presenting human immunodeficiency virus/tuberculosis coinfection: correlation with CD4+ T cell counts

Alterações radiográficas em pacientes com a co-infecção vírus da imunodeficiência humana/tuberculose: relação com a contagem de células TCD4+

Rosemeri Maurici da Silva, Lígia da Rosa, Renata Nunes Lemos

J Bras Pneumol.2006;32(3):228-233

Abstract PDF PT PDF EN Portuguese Text

Objective: To look for correlations between radiological patterns and CD4+ T cell counts in patients coinfected with tuberculosis and human immunodeficiency virus. Methods: Patients included were selected from among those presenting human immunodeficiency virus/tuberculosis coinfection and admitted to the Nereu Ramos Hospital, located in Florianópolis, Brazil, between January of 2000 and December of 2003. Results: A total of 87 patients were included. The mean age was 34 + 8 years, and 6.8% were non-Caucasian. The mean CD4+ T cell count was 220.2 cells/mm3 (median, 144 cells/mm3), and 56.4% of the patients presented less than 200 cells/mm3. We identified the following radiographic patterns and related them to the CD4+ T cell counts: the alveolar pattern in 50.6% of the cases (56.8% CD4+ T cells < 200); the interstitial pattern in 32.2% (53.6% CD4+ T cells < 200); pleural effusion in 24.1% (47.6% CD4+ T cells < 200); cavitation in 24.1% (57.1% CD4+ T cells < 200); enlarged mediastinal or hilar lymph nodes in 11.5% (90% CD4+ T cells < 200); and a normal pattern in 11.5% (60% CD4+ T cells < 200). The mean CD4+ T cell counts for the radiologic patterns isolated were as follows: 235.2/mm3 (alveolar consolidation); 208.8/mm3 (interstitial); 243.3/mm3 (pleural effusion); 265/mm3 (cavitation); 115.1/mm3 (enlarged mediastinal or hilar lymph nodes) (p < 0.05); and 205.5/mm3 (presenting no radiological alterations). As noted, mediastinal/hilar lymph node enlargement was the only pattern that correlated with the degree of cell-mediated immunity in a statistically significant way. Conclusion: With the exception of mediastinal/hilar lymph node enlargement, the radiographic patterns were randomly distributed in relation to the CD4+ T cell counts.


Keywords: Tuberculosis, pulmonary; HIV infections; Lung/radiography; AIDS-related opportunistic infections; CD4 lymphocyte count; T-lymphocytes, helper-inducer


10 - Evaluation of polymerase chain reaction in the diagnosis of pulmonary tuberculosis in indigenous and non-indigenous patients

Avaliação da reação em cadeia da polimerase no diagnóstico da tuberculose pulmonar em pacientes indígenas e não indígenas

Rose Mary Corrêa Santos, Mauricio Morishi Ogusku, José de Moraes Miranda, Maria Cristina Dos-Santos, Julia Ignez Salem

J Bras Pneumol.2006;32(3):234-240

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the accuracy of bacteriological methods and of polymerase chain reaction (with primers specific for IS6110 of the Mycobacterium tuberculosis complex) in testing sputum samples from indigenous (Amerindian) and non-indigenous patients. Methods: A total of 214 sputum samples (154 from indigenous patients and 60 from non-indigenous patients) were analyzed in order to determine the accuracy of smear microscopy (direct and concentrated versions) for acid-fast bacilli, culture, and polymerase chain reaction. Results: Both microscopy methods presented low sensitivity in comparison with culture and polymerase chain reaction. Specificity ranged from 91% to 100%, the concentrated acid-fast smear technique being the least specific. Nontuberculous mycobacteria were isolated three times more frequently in samples from indigenous patients than in those from non-indigenous patients. False-positive and false-negative polymerase chain reaction results were more common in the indigenous population. Conclusion: Positivity and isolation of nontuberculous mycobacteria in the acid-fast smear in conjunction with polymerase chain reaction positivity raise the following hypotheses: nontuberculous mycobacteria species with DNA regions homologous to, or even still possessing, the M. tuberculosis IS6110 exist in the Amazon; colonization of the oropharynx or of a tuberculous lesion accelerates the growth of the nontuberculous mycobacteria present in the sputum samples, making it impossible to isolate M. tuberculosis; A history of tuberculosis results in positivity for M. tuberculosis DNA. The absence of bacteriological positivity in the presence of polymerase chain reaction positivity raises questions regarding the inherent technical characteristics of the bacteriological methods or regarding patient history of tuberculosis.


Keywords: Tuberculosis, pulmonary/diagnosis; Mycobacterium tuberculosis, Polymerase chain reaction/methods; Indians, south american


Review Article

11 - Cellular and biochemical bases of chronic obstructive pulmonary disease

Bases celulares e bioquímicas da doença pulmonar obstrutiva crônica

Rogério Rufino, José Roberto Lapa e Silva

J Bras Pneumol.2006;32(3):241-248

Abstract PDF PT PDF EN Portuguese Text

Chronic obstructive pulmonary disease is an inflammatory disease. Together with oxidant stimuli, which directly affect lung structures, macrophages, neutrophils and CD8+ lymphocytes actively participate in the pathogenesis of the disease and promote biochemical reactions that result in progressive alteration of the upper airways and irreversible lung remodeling. The release of substances promoted by inflammatory cell recruitment and by oxidative stress lead to a temporary imbalance in the pulmonary defense mechanisms. Understanding the long-term maintenance of this imbalance is key to understanding the current physiopathology of the disease. The present study explores the cellular and molecular alterations seen in chronic obstructive pulmonary disease.


Keywords: Pulmonary disease, chronic obstructive/physiopathology; Lung/metabolism; Inflammation; Oxydants; Antioxidants; Oxidative stress


12 - Idiopathic pulmonary fibrosis: a decade of progress

Fibrose pulmonar idiopática: uma década de progressos

Jeffrey J. Swigris, Kevin K. Brown

J Bras Pneumol.2006;32(3):249-260

Abstract PDF PT PDF EN Portuguese Text

Although idiopathic pulmonary fibrosis remains a devastating diagnosis, recent advances have improved our understanding of many facets of this disease. These breakthroughs, combined with the increased general availability of therapeutic trials, hold the promise of a brighter future for idiopathic pulmonary fibrosis patients. For example, we now have a more comprehensive understanding of the diagnostic criteria and natural history of the disease. Several studies have shown that simple measurement of pulmonary physiology or gas exchange can be used to predict patient survival. By identifying several molecular pathways that play significant roles in the pathogenesis of idiopathic pulmonary fibrosis, investigators have produced a growing list of novel potential therapeutic targets for the disease. Several prospective, controlled therapeutic trials have been conducted. Others are ongoing or are still in the planning stages. These efforts have advanced our current knowledge of idiopathic pulmonary fibrosis and have raised new important questions, as well as having generated the interest and momentum needed to gain additional ground in the fight against this challenging disease. This article offers the reader a view of the recent advances in idiopathic pulmonary fibrosis research, with a focus on natural history, pathogenesis and treatment.


Keywords: Pulmonary fibrosis/diagnosis; Pulmonary fibrosis/drug therapy; Fibroblasts; Transforming growth factor beta; Lung/pathology, Anti-inflammatory agents/therapeutic use


Case Series

13 - Pulmonary alveolar proteinosis: four cases

Proteinose alveolar pulmonar: série de quatro casos

João Carlos Thomson, Marina Kishima, Mariana Ulbricht Gomes, Mariano de Almeida Menezes, José Perandré Neto, Paula Tapia Gomes Pereira

J Bras Pneumol.2006;32(3):261-266

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of this study was to present the evolution of four patients presenting pulmonary alveolar proteinosis and treated at the State University of Londrina School of Medicine. We focus on the importance of whole-lung lavage as the treatment of choice. Methods: A retrospective study of four patients, three females and one male, 22 to 34 years old, presenting similar histories of progressive dyspnea and dry cough. The final diagnosis was established through open-lung biopsy. Three of the patients underwent whole-lung lavage in the Department of Surgery. The procedures were performed under general anesthesia and using a double-lumen endotracheal tube. Results: One patient presented spontaneous regression of the pulmonary alveolar proteinosis without the need for whole-lung lavage. In the other three cases, the number of lavages varied: in one patient, a single unilateral lavage resulted in complete remission of the bilateral process; in another patient, three lavages yielded no significant improvement; in the remaining patient, four lavages provided intervening periods of transient improvement. Conclusion: In the cases evaluated, whole-lung lavage proved an efficient treatment for pulmonary alveolar proteinosis. Although some patients presented a certain resistance to the procedure, it might lead to complete remission of the disease in others.


Keywords: Pulmonary alveolar proteinosis /diagnosis; Bronchoalveolar lavage; Macrophages, alveolar;


Case Report

14 - Alveolar adenoma

Adenoma alveolar

Eduardo Haruo Saito, Luciana Ribeiro de Araújo, Leonardo Hoehl Carneiro, Antonio Ambrosio de Oliveira Neto, João Carlos Corrêa, Luiz Sérgio Carvalho Teixeira

J Bras Pneumol.2006;32(3):

Abstract PDF PT PDF EN Portuguese Text

Alveolar adenoma is a rare benign neoplasm of the lungs, and very few cases have been described in the literature. Patients with alveolar adenoma are frequently asymptomatic and are diagnosed through the accidental discovery of a singular, well-delineated nodule on a routine chest X-ray. The definitive diagnosis is made histologically, and the treatment consists of surgical resection of the nodule..


Keywords: Adenoma; Lung neoplasms; Pulmonary alveoli/pathology; Coin lesion, pulmonary;


15 - Dendriform pulmonary ossification

Ossificação pulmonar dendriforme

Andrezza Araújo de Oliveira Duarte, Jorge Nakatani, Moacyr Pezati Rigueiro, Tânia Saad

J Bras Pneumol.2006;32(3):270-273

Abstract PDF PT PDF EN Portuguese Text

Diffuse pulmonary ossification is a rare condition of unknown pathogenesis in which mature bone is found in the pulmonary parenchyma. It is almost invariably discovered as an incidental finding at autopsy. Most commonly, it affects middle-aged men and is asymptomatic. We present the case of a 75-year-old man in which the chest X-ray showed diffuse interstitial infiltrate. Diagnosis was based on histopathological examination by open-lung biopsy, which revealed interstitial fibrosis with pulmonary ossification.


Keywords: Ossification, heterotopic; Lung diseases; Lung/radiography; Pulmonary fibrosis/pathology;



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