Brazilian Journal of Pulmonology

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


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Year 2008 - Volume 34  - Number 8  (/August)

Original Article

2 - Factors associated with mortality in patients hospitalized in Spain and Latin America for acute severe asthma in 1994, 1999, and 2004

Fatores associados à mortalidade em pacientes hospitalizados por asma aguda grave em 1994, 1999 e 2004 na Espanha e América Latina

Gustavo Javier Rodrigo, Vicente Plaza, Santiago Bardagí Forns, Miguel Perpiñá Tordera, Jorge Salas

J Bras Pneumol.2008;34(8):546-551

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate, for the first time, the characteristics of patients with acute asthma who died during hospitalization in Spain and Latin America, as well as to evaluate factors associated with asthma mortality. Methods: A retrospective review of hospital records of 3,038 patients with asthma (aged 15-69 years) admitted to nineteen tertiary care hospitals in Spain and in eight Latin-American countries in 1994, 1999, and 2004. Results: There were 25 deaths (0.8% of all hospitalized patients) during the three years studied. Although there was a tendency towards a reduction in in-hospital mortality (from 0.97% in 1994 to 0.69% in 2004), there were no significant differences in terms of year or geographic area. Intensive care unit admissions and cases of out of hospital cardiopulmonary arrest increased the mortality rates to 8.3% and 24.7%, respectively. The multivariate analysis showed that gender (female; OR = 25.5; 95% CI: 2.6-246.8), out of hospital cardiopulmonary arrest (OR = 22.5; 95% CI: 4.4-114.7), and arterial pH < 7.3 during hospitalization (OR = 1.0; 95% CI: 1.1-3.4) were strongly associated with asthma mortality. Conclusions: Our study on mortality in patients hospitalized for acute severe asthma showed that deaths occurred almost exclusively in female patients and in patients who suffered out of hospital cardiopulmonary arrest, confirming previous findings from studies conducted in developed countries.


Keywords: Asthma/mortality; Asthma/epidemiology; Hospitalization; Hospital mortality.


3 - Inspiratory muscle training and respiratory exercises in children with asthma

Treinamento muscular inspiratório e exercícios respiratórios em crianças asmáticas

Elisângela Veruska Nóbrega Crispim Leite Lima, Willy Leite Lima, Adner Nobre, Alcione Miranda dos Santos, Luciane Maria Oliveira Brito, Maria do Rosário da Silva Ramos Costa

J Bras Pneumol.2008;34(8):552-558

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of the present study was to evaluate the effects that inspiratory muscle training (IMT) and respiratory exercises have on muscle strength, peak expiratory flow (PEF) and severity variables in children with asthma. Methods: This was a randomized analytical study involving 50 children with asthma allocated to one of two groups: an IMT group, comprising 25 children submitted to IMT via an asthma education and treatment program; and a control group, comprising 25 children who were submitted only to monthly medical visits and education on asthma. The IMT was performed using a pressure threshold load of 40% of maximal inspiratory pressure (MIP). The results were evaluated using analysis of variance, the chi-square test and Fisher's exact test, values of p > 0.05 being considered significant. Results: In the comparative analysis, pre- and post-intervention values of MIP, maximal expiratory pressure (MEP) and PEF increased significantly in the IMT group: MIP from −48.32 ± 5.706 to −109.92 ± 18.041 (p < 0.0001); MEP from 50.64 ± 6.55 to 82.04 ± 17.006 (p < 0.0001); and PEF from 173.6 ± 50.817 to 312 ± 54.848 (p < 0.0001). In the control group, however, there were no significant differences between the two time points in terms of MIP or MEP, although PEF increased from 188 ± 43.97 to 208.80 ± 44.283 (p < 0.0001). There was a significant improvement in the severity variables in the IMT group (p < 0.0001). Conclusions: Programs involving IMT and respiratory exercises can increase mechanical efficiency of the respiratory muscles, as well as improving PEF and severity variables.


Keywords: Breathing exercises; Asthma/therapy; Asthma/rehabilitation.


4 - Use of a one-way flutter valve drainage system in the postoperative period following lung resection

Utilização da válvula unidirecional de tórax como sistema de drenagem no pós-operatório de ressecções pulmonares

Nelson de Araujo Vega, Hugo Alejandro Vega Ortega, Alfio José Tincani, Ivan Felizardo Contrera Toro

J Bras Pneumol.2008;34(8):559-566

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate pleural drainage using a one-way flutter valve following elective lung resection. Methods: This was a prospective study, with descriptive analysis, of 39 lung resections performed using a one-way flutter valve to achieve pleural drainage during the postoperative period. Patients less than 12 years of age were excluded, as were those submitted to pneumonectomy or emergency surgery, those who were considered lost to follow-up and those in whom water-seal drainage was used as the initial method of pleural drainage. Lung expansion, duration of the drainage, hospital stay and postoperative complications were noted. Results: A total of 36 patients were included and analyzed in this study. The mean duration of pleural drainage was 3.0 ± 1.6 days. At 30 days after the surgical procedure, chest X-ray results were considered normal for 34 patients (95.2%). Postoperative complications occurred in 8 patients (22.4%) and were related to the drainage system in 3 (8.4%) of those. Conclusions: The use of a one-way flutter valve following elective lung resection was effective, was well tolerated and presented a low rate of complications.


Keywords: Drainage; Postoperative complications; Thoracic surgery.


5 - Systemic effects of nocturnal hypoxemia in patients with chronic obstructive pulmonary disease without obstructive sleep apnea syndrome

Efeitos sistêmicos da hipoxemia noturna em pacientes com doença pulmonar obstrutiva crônica sem síndrome da apnéia obstrutiva do sono

Paulo de Tarso Guerrero Mueller, Marcílio Delmondes Gomes, Carlos Alberto de Assis Viegas, José Alberto Neder

J Bras Pneumol.2008;34(8):567-574

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the effects of nocturnal hypoxemia in patients with chronic obstructive pulmonary disease without obstructive sleep apnea syndrome. Methods: We studied 21 patients-10 desaturators and 11 nondesaturators-submitted to arterial blood gas analysis, polysomnography, spirometry, cardiopulmonary exercise testing (cycle ergometer), and hand-grip dynamometry, as well as measurements of maximal inspiratory pressure, maximal expiratory pressure, and C-reactive protein (CRP) levels. Patients with arterial oxygen tension > 60 mmHg were included; those with an apnea-hypopnea index > 5 events/hour of sleep were excluded. Maximal oxygen uptake, maximal power, systolic blood pressure, diastolic blood pressure (DBP), and maximal heart rate were measured during exercise in order to detect hemodynamic alterations. Patients presenting CRP levels above 3 mg/L were considered CRP-positive. Results: Minimal peripheral oxygen saturation during sleep was significantly higher among nondesaturators (p = 0.03). More desaturators presented CRP > 3 mg/L (p < 0.05). No differences were observed in terms of any variables, However, mean peripheral oxygen saturation during sleep correlated with DBP and maximal inspiratory pressure (p < 0.001 and p = 0.001, respectively). Conclusions: Although nocturnal hypoxemia does not reduce exercise capacity or hand-grip strength in patients with mild/moderate COPD, its effect on maximal exercise DBP seems to depend on the degree of hypoxemia. In addition, there is a positive relationship between maximal inspiratory pressure and mean peripheral oxygen saturation during sleep, as well as evidence of pronounced inflammatory activation in patients with nocturnal hypoxemia.


Keywords: Pulmonary disease, chronic obstructive; Exercise test; Anoxia; Respiratory function tests.


6 - Analysis of hospitalizations for respiratory diseases in Tangará da Serra, Brazil

Análise das internações por doenças respiratórias em Tangará da Serra - Amazônia Brasileira

Antonia Maria Rosa, Eliane Ignotti, Sandra de Souza Hacon, Hermano Albuquerque de Castro

J Bras Pneumol.2008;34(8):575-582

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze hospitalizations for respiratory diseases among children under 15 years of age in an area with high levels of environmental pollution. Methods: A cross-sectional study of hospitalizations due to respiratory diseases of patients residing in the city of Tangará da Serra, located in the state of Mato Grosso (Brazilian Amazon region), from 2000 to 2005. Data on hospital admissions were obtained from the Brazilian Unified Health Care System and from Brazilian Institute of Geography and Statistics population estimates. Results: In 2005, the rate of hospitalization for respiratory diseases among children under 15 years of age in the microregion of Tangará da Serra was 70.1/1,000 children. Between 2000 and 2005, there were 12,777 such admissions, of which 8,142 (63.7%) were for respiratory diseases. During the dry season (May to October), the rate of admissions for respiratory diseases was 10% higher than during the rainy season (November to April). The principal causes of admission included pneumonia (90.7%) and respiratory insufficiency (8.5%). Admissions of children under 5 years of age for pneumonia were 4 times the expected number for the city. Children under 12 months of age were the most frequently hospitalized, with an average increase of 32.4 admissions per 1,000 children per year. Conclusions: Tangará da Serra presented a high number of pediatric admissions for respiratory diseases. Therefore, it is logical to consider it a priority area for investigation and monitoring of the environmental risk factors for such diseases.


Keywords: Respiratory tract diseases; Pneumonia; Hospitalization; Climate; Air pollution/Brazil.


7 - Ischemic preconditioning by selective occlusion of the pulmonary artery in rats

Pré-condicionamento isquêmico por oclusão seletiva da artéria pulmonar em ratos

Eduardo Sperb Pilla, Giovani Schirmer Vendrame, Pablo Gerardo Sánchez, Gustavo Grun, Eduardo Fontena, Luiz Alberto Forgiarini Júnior, Norma Anair Possa Marroni, Cristiano Feijó Andrade, Paulo Francisco Guerreiro Cardoso

J Bras Pneumol.2008;34(8):583-589

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effect of lung ischemic preconditioning (IPC) on normothermic ischemia/reperfusion (I/R) injury in a rat model, quantifying the production of reactive oxygen species. Methods: Forty-seven male Wistar rats were randomized into four groups: control, sham, I/R and IPC. Control group animals were anesthetized and killed by decapitation, after which pneumonectomy was performed and the left lungs were stored in liquid nitrogen. Sham, IPC and I/R group rats were anesthetized, tracheostomized, ventilated, anticoagulated and submitted to left thoracotomy with dissection of the left pulmonary artery for clamping. Sham group rats underwent dissection of the left pulmonary artery, I/R group rats underwent 30 min of total hilar clamping, and IPC group rats underwent 5-min clamping of the left pulmonary artery followed by 30 min of total hilar clamping. Lungs were reperfused for 90 min and ventilated with the same parameters, with additional positive end-expiratory pressure of 1 cmH2O. Hemodynamic and blood gas values were obtained prior to thoracotomy, prior to total hilar clamping, after 30 min of reperfusion and after 90 min of reperfusion. Lipid peroxidation was determined by measuring levels of thiobarbituric acid reactive substances. Results: There were no significant differences among the groups in terms of the levels of thiobarbituric acid reactive substances. Nor were there any significant differences among the sham, I/R and IPC groups in terms of arterial oxygen tension, arterial carbon dioxide tension or hemodynamic values. Conclusions: In an in situ I/R rat model, 5-min IPC of the left pulmonary artery does not attenuate I/R injury.


Keywords: Ischemia; Reperfusion; Organ preservation; Reactive oxygen species.


8 - Descriptive study of the frequency of nontuberculous mycobacteria in the Baixada Santista region of the state of São Paulo, Brazil

Estudo descritivo da freqüência de micobactérias não tuberculosas na Baixada Santista

Liliana Aparecida Zamarioli, Andréa Gobetti Vieira Coelho, Clemira Martins Pereira, Ana Carolina Chiou Nascimento, Suely Yoko Mizuka Ueki, Erica Chimara

J Bras Pneumol.2008;34(8):590-594

Abstract PDF PT PDF EN Portuguese Text

Objective: The present study aims at describing the frequency of nontuberculous mycobacteria (NTM) species identified through laboratory testing of samples collected from non-sterile sites (sputum), as well as its frequency in HIV-infected and non-HIV-infected individuals in the Baixada Santista region of the state of São Paulo, Brazil, in the period from 2000 to 2005. Methods: Retrospective analysis of sputum smear microscopy results and culture was conducted based on the records on file at the Instituto Adolfo Lutz-Santos, the regional tuberculosis laboratory. Results: We analyzed 194 NTM strains isolated from 125 individuals, of whom 73 (58.4%) were HIV-negative and 52 (41.6%) were HIV-positive. Thirteen different species were identified: Mycobacterium kansasii; M. avium complex; M. fortuitum; M. peregrinum; M. gordonae; M. terrae; M. nonchromogenicum; M. intracellulare; M. flavescens; M. bohemicum; M. chelonae; M. shimoidei; and M. lentiflavum. In 19.2% of the cases, the bacteriological diagnosis was confirmed by isolation of the same species in at least two consecutive samples. Conclusions: Our results show the importance of including systematic identification of NTM in the laboratory routine, and that its integration into the clinical routine could improve the characterization of the disease, thereby informing the planning of effective control measures in specific populations, such as individuals presenting tuberculosis/HIV co-infection.


Keywords: Mycobacteria, atypical; Laboratory techniques and procedures; HIV; Tuberculosis.


9 - Lung cancer: histology, staging, treatment and survival

Câncer de pulmão: histologia, estádio, tratamento e sobrevida

Fabiola Trocoli Novaes, Daniele Cristina Cataneo, Raul Lopes Ruiz Junior, Júlio Defaveri, Odair Carlito Michelin, Antonio José Maria Cataneo

J Bras Pneumol.2008;34(8):595-600

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze principal histological types of lung cancer, as well as the staging, treatment and survival of lung cancer patients. Methods: This was a retrospective study based on the analysis of medical charts of patients treated at the Botucatu School of Medicine Hospital das Clínicas over a six-year period. Results: From January of 2000 to January of 2006, 240 patients with lung cancer, most (64%) of whom were male, were treated. The most common histological type was squamous cell carcinoma (37.5%), followed by adenocarcinoma (30%), neuroendocrine carcinoma (19.6%) and large cell carcinoma (6.6%). Only 131 patients (54.6%) were treated. Of those, 52 patients (39.7%) received only chemotherapy, 32 (24.4%) were treated with chemotherapy combined with radiotherapy, and 47 (35.9%) were submitted to surgery alone or surgery accompanied by chemotherapy, with or without radiotherapy. Only 27 patients (20.6%) were submitted to surgery alone. Concerning staging, 34.4% presented stage IV at the time of diagnosis, 20.6% presented stage IIIB, 16.8% presented stage IIIA, and the remaining 28.2% were classified as stage I or II. Five-year survival was 65% for those in stage I and 25% for those in the remaining stages. Conclusions: Of the various histological types, the most common was squamous cell carcinoma and the least common was large cell carcinoma. Most cases presented advanced stages at the moment of diagnosis, and less than 30% of the cases presented early stages. This accounts for the low survival rate and the small number of patients submitted to surgical treatment alone, the majority being submitted to chemotherapy alone.


Keywords: Carcinoma, bronchogenic; Lung neoplasms/histology; Lung neoplasms/drug therapy; Lung neoplasms/radiotherapy; Surgery; Survival.


10 - Tuberculosis-related mortality in the state of Espírito Santo, Brazil, 1985-2004

Mortalidade específica por tuberculose no estado do Espírito Santo, no período de 1985 a 2004

Cláudia Maria Marques Moreira, Eliana Zandonade, Reynaldo Dietze, Ethel Leonor Noia Maciel

J Bras Pneumol.2008;34(8):601-606

Abstract PDF PT PDF EN Portuguese Text

Objective: The purpose of this study was to describe tuberculosis-related mortality in Espírito Santo, Brazil, evaluating its tendencies in relation to clinical presentation, gender and age bracket. Methods: We conducted a retrospective, descriptive study based on secondary data. For the 1985-2004 period, we investigated all deaths of residents of Espírito Santo in which tuberculosis was given as the underlying cause, as reported in the Brazilian National Mortality Database. Results: The adjusted mortality rates for all forms of tuberculosis paralleled the overall mortality rates in the state, decreasing from 5.6/100,000 inhabitants in 1985 to 2.0/100,000 inhabitants in 2004. Pulmonary tuberculosis was the predominant form of the disease (89.7% of tuberculosis-related deaths) throughout the period studied, and the male/ female mortality rate ratio ranged from 1.1 in 1998 to 3.19 in 2004. Conclusions: We observed a decrease in the mortality rates in all age brackets. Predominance of the pulmonary form, male gender and advanced age was similar to that of overall tuberculosis-related mortality in Brazil.


Keywords: Tuberculosis/epidemiology; Mortality; Information systems.


11 - Epidemiological profile of tuberculosis cases reported among health care workers at the University Hospital in Vitoria, Brazil

Perfil epidemiológico dos casos notificados de tuberculose entre os profissionais de saúde no Hospital Universitário em Vitória (ES) Brasil

Thiago Nascimento do Prado, Heleticia Scabelo Galavote, Ana Paula Brioshi, Thamy Lacerda, Geisa Fregona, Valdério do Valle Detoni, Rita de Cássia Duarte Lima, Reynaldo Dietze, Ethel Leonor Noia Maciel

J Bras Pneumol.2008;34(8):607-613

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe the epidemiological profile of tuberculosis cases reported among health care workers in the Tuberculosis Control Program of the Cassiano Antonio of Moraes University Hospital in Vitoria, Brazil. Methods: A retrospective descriptive study of secondary data was conducted between 2002 and 2006. Results: Twenty-five cases of health care workers with tuberculosis were reported: 8 in nursing technicians (32%); 4 in doctors (16%); 3 in nurses (12%); 2 in radiology technicians (8%) and 8 in professionals from other categories (32%). Of those 25 health care workers, 14 (56%) were male and 11 (44%) were female. The incidence of the disease was highest among those from 35 to 39 years of age. The predominant clinical presentation was extrapulmonary (12 cases, 48%), followed by pulmonary (11 cases, 44%) and a combination of the two (2 cases, 8%). Regarding comorbidities, AIDS, alcoholism and smoking, respectively, were present in 33.3% of the study population. Outcomes were as follows: 22 cases of cure (88%); 2 transfers (8%); and 1 death (4%). The proportion of health care workers diagnosed with tuberculosis in the period studied was 2.53%. Conclusions: The results show the need for heath care workers who work in the tuberculosis control program to fill out the field "professional occupation" on the tuberculosis case registry database reporting forms. In addition, this situation draws attention to the need to implement an occupational tuberculosis control program.


Keywords: Health profile; Tuberculosis/epidemiology; Health personnel; Prevalence.


Review Article

12 - Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Métodos empregados na verificação da adesão à corticoterapia inalatória em crianças e adolescentes: taxas encontradas e suas implicações para a prática clínica

Nulma Souto Jentzsch, Paulo Augusto Moreira Camargos

J Bras Pneumol.2008;34(8):614-621

Abstract PDF PT PDF EN Portuguese Text

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis. Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil. The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.


Keywords: Patient compliance; Asthma/therapy; Asthma/prevention & control.


Case Report

13 - Adult respiratory distress syndrome due to fat embolism in the postoperative period following liposuction and fat grafting

Síndrome da angústia respiratória do adulto por embolia gordurosa no período pós-operatório de lipoaspiração e lipoenxertia

André Nathan Costa, Daniel Melo Mendes, Carlos Toufen, Gino Arrunátegui, Pedro Caruso, Carlos Roberto Ribeiro de Carvalho

J Bras Pneumol.2008;34(8):622-625

Abstract PDF PT PDF EN Portuguese Text

Fat embolism is defined as mechanical blockage of the vascular lumen by circulating fat globules. Although it primarily affects the lungs, it can also affect the central nervous system, retina, and skin. Fat embolism syndrome is a dysfunction of these organs caused by fat emboli. The most common causes of fat embolism and fat embolism syndrome are long bone fractures, although there are reports of its occurrence after cosmetic procedures. The diagnosis is made clinically, and treatment is still restricted to support measures. We report the case of a female patient who developed adult respiratory distress syndrome due to fat embolism in the postoperative period following liposuction and fat grafting. In this case, the patient responded well to alveolar recruitment maneuvers and protective mechanical ventilation. In addition, we present an epidemiological and pathophysiological analysis of fat embolism syndrome after cosmetic procedures.


Keywords: Respiratory distress syndrome, adult; Embolism, fat; Lipectomy.


14 - Castleman's disease accompanied by pleural effusion

Doença de Castleman associada a derrame pleural

Valéria Góes Ferreira Pinheiro, Geórgea Hermógenes Fernandes, Lia Cavalcante Cezar, Newton de Albuquerque Alves, Dalgimar Beserra de Menezes

J Bras Pneumol.2008;34(8):626-630

Abstract PDF PT PDF EN Portuguese Text

Castleman's disease is a rare disorder of the lymphoid tissue. We report the case of a female patient with bilateral otosclerosis, no respiratory symptoms, and pleural effusion discovered as an incidental finding on a chest X-ray. Computed tomography of the chest revealed a mediastinal mass. The biopsy findings demonstrated that it was a plasmacytic variant of Castleman's disease. The patient underwent mediastinal mass resection. This resulted in near-total resolution of the effusion, which remained as a small loculation within the left pleural space.


Keywords: Giant lymph node hyperplasia; Pleural effusion; Case reports.


15 - Mediastinal teratoma with malignant degeneration

Teratoma de mediastino com degeneração maligna

Fabiano Alves Squeff, Eduardo Salvador Gerace, Roberto Saad Júnior, Márcio Botter, Roberto Gonçalves, Juliana Fracalossi Paes

J Bras Pneumol.2008;34(8):631-634

Abstract PDF PT PDF EN Portuguese Text

Here, we report the case of a patient with a slowly-progressing anterior mediastinal teratoma submitted to surgical resection. The anatomopathological examination of the sample revealed malignant degeneration to carcinoid tumor. Such evolution is very rare, and we have found only three related studies in the literature. We describe the clinicopathological features of the tumor and discuss the treatment administered. The evolution was satisfactory, and the patient was submitted to oncological treatment.


Keywords: Mediastinal neoplasms; Teratoma; Carcinoid tumor; Mediastinum/surgery.



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