Brazilian Journal of Pulmonology

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


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Year 2008 - Volume 34  - Number 9  (/September)

Original Article

2 - Reduction in the number of asthma-related hospital admissions after the implementation of a multidisciplinary asthma control program in the city of Londrina, Brazil

Redução do número de internações hospitalares por asma após a implantação de programa multiprofissional de controle da asma na cidade de Londrina

Alcindo Cerci Neto, Olavo Franco Ferreira Filho, Tatiara Bueno, Maria Amélia Talhari

J Bras Pneumol.2008;34(9):639-645

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the relationship between the reduction in the number of asthma-related hospital admissions and the changes occurring after the intervention performed in the health care system of the city of Londrina, Brazil. Methods: In 2003, an intervention was performed in the local health care system (Family Health Clinics). The steps adopted were as follows: development of a protocol based on the III Brazilian Consensus on Asthma Management; access to free inhaled corticosteroids for patients; training of health professionals; and implementation of educational measures, especially for the community. The authorizations for hospital admissions of patients diagnosed with asthma alone between 2002 and 2005 in the city of Londrina were analyzed. Results: The mean age was 14.3 ± 0.5 years, without gender predominance. The number of hospital admissions fell more markedly in 2005 than in the previous years studied. This decline was more pronounced at the Family Health Clinics where professional training occurred earlier. The post-intervention (2004-2005) rate of asthma-related hospital admissions (120/100,000 inhabitants) was significantly lower than the pre-intervention (2002-2003) rate (178/100,000 inhabitants; p < 0.01). Conclusions: The admission curve showed a tendency toward a reduction after 2003, and, aside from the intervention performed, no other factors that would explain the results obtained were identified. The rate at which the number of hospital admissions decreased was in direct proportion to the length of time elapsed since the intervention (greater decreases over time). We conclude that the intervention performed in the local health care system was responsible for the data presented.


Keywords: Asthma; Hospitalization; Public health.


3 - Clinical phenotypes of severe asthma

Fenótipos clínicos de asma grave

Roseliane de Souza Araújo Alves, Flávia de Almeida Filardo Vianna, Carlos Alberto de Castro Pereira

J Bras Pneumol.2008;34(9):646-653

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Objective: To characterize clinical phenotypes of severe asthma. Methods: A total of 111 patients were retrospectively evaluated at a specialized outpatient clinic. A systematic protocol for patient evaluation and follow-up was applied. Treatment compliance and control of the disease at the end of follow-up were defined by clinical and functional data. Patients who did not meet asthma control criteria after six months despite compliance with treatment and correct use of medication were characterized as treatment-resistant. Phenotypes were determined by factorial analysis and compared using various tests. Results: At the end of follow-up, 88 patients were considered treatment compliant and 23 were considered noncompliant. Factorial analysis of the compliant patients identified four phenotypes: phenotype 1 (28 patients) comprised patients who were treatment-resistant, more often presenting nocturnal symptoms and exacerbations, as well as more often using rescue bronchodilators; phenotype 2 (48 patients) comprised patients with persistent airflow limitation, lower ratios of forced expiratory volume in one second/forced vital capacity at baseline, more advanced age and longer duration of symptoms; phenotype 3 (42 patients) comprised patients with allergic rhinosinusitis who were nonsmokers and presented predominantly reversible airflow obstruction; and phenotype 4 (15 patients) comprised cases with a history of aspirin intolerance to acetylsalicylic acid associated with near-fatal asthma. Conclusions: A significant number of patients with severe asthma are noncompliant with treatment. Although many patients with severe asthma have persistent airflow obstruction, the most relevant clinical phenotype comprises patients who are resistant to the typical treatment.


Keywords: Asthma; Asthma/prevention & control; Asthma/treatment.


4 - Aggressive treatment using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy

Tratamento agressivo com retalho muscular e/ou omentopexia nas infecções do esterno e mediastino anterior em pós-operatório de esternotomia

Alexandre Heitor Moreschi, Amarilio Vieira de Macedo Neto, Gilberto Venossi Barbosa, Mauricio Guidi Saueressig

J Bras Pneumol.2008;34(9):654-660

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the impact of an aggressive treatment approach using muscle flaps or omentopexy in infections of the sternum and anterior mediastinum following sternotomy on mortality, as compared to that of a conservative treatment approach. Methods: Data were collected prior to, during and after the surgical procedures. Group A (n = 44) included patients submitted to conservative treatment- debridement together with resuture or continuous irrigation with polyvinylpyrrolidone-iodine solutions, or even with second-intention wound healing (retrospective data). Group B (n = 9) included patients in whom infection was not resolved with conservative treatment, and who therefore underwent aggressive treatment (intermediate phase). Group C (n = 28) included patients primarily submitted to aggressive treatment (prospective data). Results: Postoperative hospital stays were shorter in the patients submitted to aggressive treatment (p < 0.046). There were 7 deaths in group A, 1 in group B, and 2 in group C. However, the classical level of significance of α = 0.05 was not reached. Conclusion: Aggressive treatment also proved to be effective when the infection was not resolved with conservative treatment. These findings demonstrate that the proposed treatment provides excellent results.


Keywords: Surgical flaps; Osteomyelitis; Mediastinitis; Thoracic surgery.


5 - Surgical treatment of 60 patients with pulmonary malformations: What have we learned?

Tratamento operatório de 60 pacientes com malformações pulmonares: O que aprendemos?

Altair da Silva Costa Júnior, João Aléssio Juliano Perfeito, Vicente Forte

J Bras Pneumol.2008;34(9):661-666

Abstract PDF PT PDF EN Portuguese Text

Objective: To retrospectively analyze the medical charts of patients with pulmonary malformations submitted to surgical treatment and to investigate the clinical evolution prior to the definitive diagnosis. Methods: We analyzed the medical charts of patients with pulmonary malformations operated on at the São Paulo Hospital-Federal University of São Paulo/Paulista School of Medicine-from 1969 to 2004. Each medical chart was analyzed as to the following aspects: clinical profile; diagnosis; previous treatment; surgical treatment; and nosocomial complications. The inclusion criteria were having received a diagnosis of pulmonary malformation, having undergone pulmonary resection, and chart data being complete. Results: The analysis of the medical charts revealed that 60 patients diagnosed with pulmonary malformations-27 cases of bronchogenic cyst, 14 cases of congenital lobar emphysema, 10 cases of pulmonary sequestration, and 9 cases of cystic adenomatoid malformation-underwent surgery. Ages ranged from 4 days to 62 years (mean, 17.9 years). There was a predominance of males (55%). Ninety-two percent of the patients presented symptoms (mean duration, 15.37 months). Of the 60 patients undergoing surgery, 27 (45%) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23%, and mortality was 3.3%. Surgical times ranged from 1 to 8 h (mean, 3.2 h). Conclusions: Misdiagnosis or delayed diagnosis of pulmonary malformations resulted in unnecessary treatments and hospitalizations, as well as in frequent, recurrent infectious complications. We believe that the definitive treatment is surgery, which is curative and has low morbidity and mortality rates.


Keywords: Bronchogenic cyst; Bronchopulmonary sequestration; Cystic adenomatoid malformation of lung, congenital; Respiratory tract infections; Thoracic surgery.


6 - Comparative study of respiratory symptoms and lung function alterations in patients with chronic obstructive pulmonary disease related to the exposure to wood and tobacco smoke

Estudo comparativo de sintomas respiratórios e função pulmonar em pacientes com doença pulmonar obstrutiva crônica relacionada à exposição à fumaça de lenha e de tabaco

Maria Auxiliadora Carmo Moreira, Maria Rosedália de Moraes, Daniela Graner Schwartz Tannus Silva, Thayssa Faria Pinheiro, Huber Martins Vasconcelos Júnior, Lanucy Freita de Lima Maia, Daine Vargas do Couto

J Bras Pneumol.2008;34(9):661-666

Abstract PDF PT PDF EN Portuguese Text

Objective: To describe and analyze clinical symptoms and spirometric alterations of patients with chronic obstructive pulmonary disease (COPD) and history of exposure to wood and tobacco smoke. Methods: We retrospectively evaluated data related to 170 patients distributed into 3 groups: 34 exposed only to wood smoke, 59 patients exposed only to tobacco smoke and 77 patients exposed to both. Results: The groups did not differ significantly in terms of age (p = 0.225) or degree of exposure, considering each type of exposure in isolation or in combination (p = 0.164 and p = 0.220, respectively). Females predominated in the group exposed to wood smoke. There were no differences among the groups regarding respiratory symptoms (p > 0.05), and moderate dyspnea predominated in the three groups (p = 0.141). The group exposed to wood smoke presented higher percentages of forced expiratory volume in one second/forced vital capacity ratio and of forced expiratory volume in one second (p < 0.05). Positive results on bronchodilator testing occurred more frequently in the group exposed to tobacco smoke. The percentage of severe and extremely severe obstruction was significantly higher in the group exposed to tobacco smoke (44.1%) than in that exposed to wood smoke (11.8%; p = 0.006). Conclusions: Respiratory symptoms and pulmonary function alterations consistent with COPD were observed in the groups of patients exposed to wood smoke. However, those alterations were not as significant as the alterations observed in the groups exposed to tobacco smoke. This study emphasizes the importance of prospective studies in evaluating the risk of wood-smoke-related COPD in Brazil, as well as the need for preventive measures in this area.


Keywords: Pulmonary disease, chronic obstructive; Smoking; Air pollution, indoor; Smoke.


7 - Comparison of spirometric changes in the response to bronchodilators of patients with asthma or chronic obstructive pulmonary disease

Comparação da variação de resposta ao broncodilatador através da espirometria em portadores de asma ou doença pulmonar obstrutiva crônica

Isabella Correia Silvestri, Carlos Alberto de Castro Pereira, Sílvia Carla Sousa Rodrigues

J Bras Pneumol.2008;34(9):675-682

Abstract PDF PT PDF EN Portuguese Text

Objective: Making the differential diagnosis between asthma and chronic obstructive pulmonary disease (COPD) based on the response to inhaled bronchodilators by means of spirometry is controversial.The objective of this study was to identify the most useful spirometric variables in order to distinguish between asthma and COPD. Methods: Retrospective study conducted from April of 2004 to January of 2006, comparing the spirometric parameters of 103 nonsmoking patients with asthma to those of 108 patients with COPD who were smokers for more than 10 pack-years. All of the patients included in the study were older than 40 and presented stable disease at the time of the test. Results: Initial forced expiratory volume in one second (FEV1) was the same in the two groups (pre-bronchodilator FEV1 = 51%). However, patients with COPD were older (66 ± 9 years vs. 59 ± 11 years, p < 0.001) and more frequently male (73% vs. 27%, p < 0,001).After the use of the bronchodilator, the median absolute difference in FEV1 was 0.25 L (range, −0.09 to 1.13 L) in patients with asthma and 0.09 L (range, −0.1 to 0.73 L) in those with COPD (p < 0.001).The highest sensitivity (55%), specificity (91%) and likelihood ratio (6.1) for asthma diagnosis was obtained when the percentage increase in postbronchodilator FEV1 in relation to the predicted FEV1 (Δ%predFEV1) was equal to or greater than 10%.Isolated significant increases in forced vital capacity were more common in patients with COPD. Conclusions: In patients over the age of 40 and presenting obstructive lung disease, a Δ%predFEV1 ≥ 10% is the best spirometric parameter to distinguish asthma from COPD.


Keywords: Spirometry; Respiratory function tests; Lung diseases, obstructive.


8 - Community-acquired staphylococcal pneumonia

Pneumonia estafilocócica adquirida na comunidade

José Wellington Alves dos Santos, Douglas Zaione Nascimento, Vinicius André Guerra, Vanessa da Silva Rigo, Gustavo Trindade Michel, Tiago Chagas Dalcin

J Bras Pneumol.2008;34(9):683-689

Abstract PDF PT PDF EN Portuguese Text

Objective: Staphylococcal pneumonia typically presents high rates of morbidity and mortality. It typically occurs in cases of influenza (airborne transmission) or during episodes of bacteremia (blood-borne transmission). Methods: A retrospective and descriptive study was conducted in patients admitted to our hospital between January of 1992 and December of 2003. All of he patients included had been diagnosed with community-acquired pneumonia caused by Staphylococcus aureus. All were older than 14 years of age, and none were intravenous drug users. Results: Community-acquired pneumonia was identified in 332 cases, of which 24 (7.3%) were identified as cases of staphylococcal pneumonia. Age ranged from 14 to 89 years. Fifteen patients were male, and nine were female. Twelve patients met the criteria for severe pneumonia. Chest X-rays showed unilateral consolidation in 14 cases, bilateral consolidation in 10, pleural effusion in 15, rapid radiological progression of pulmonary lesions in 14, cavitation in 6 and pneumothorax in 1. Most of the patients presented comorbidities, of which diabetes mellitus was the most common. Twelve patients presented complications such as empyema and septic shock. Four patients died, translating to a mortality rate of 16.6% in our sample. Conclusions: The clinical presentation of pneumonia caused by S. aureus is similar to that of pneumonia caused by other etiological agents. Radiological findings, epidemiological data and risk factors provide important clues to the diagnosis. These factors are important for clinical suspicion, since S. aureus is not typically addressed in empirical treatment.


Keywords: Staphylococcal pneumonia; Staphylococcal infections; Community-acquired infections.


9 - Impact of heated humidification with automatic positive airway pressure in obstructive sleep apnea therapy

Impacto da umidificação aquecida com pressão positiva automática em vias aéreas na terapia do síndroma de apneia obstrutiva do sono

Sara Moreira da Silva Trindade Salgado, José Pedro Correia Fernandes Boléo-Tomé, Cristina Maria Sardinha Canhão, Ana Rita Tavares Dias, Joana Isaac Teixeira, Paula Maria Gonçalves Pinto, Maria Cristina de Brito Eusébio Bárbara Prista Caetano

J Bras Pneumol.2008;34(9):690-694

Abstract PDF PT PDF EN Portuguese Text

Objective: To study the impact that heated humidification instituted in the beginning of automatic positive airway pressure (APAP) therapy has on compliance with and the side effects of the treatment. Methods: Thirty-nine treatment-naïve patients with obstructive sleep apnea were randomized into two groups to receive APAP using one of two modalities: with heated humidification (APAPwith group); and without heated humidification (APAPw/o group).Patients were evaluated at 7 and 30 days after APAP initiation. The following parameters were analyzed: compliance with treatment (mean number of hours/night); side effects (dry nose or mouth, nasal obstruction and rhinorrhea); daytime sleepiness (Epworth sleepiness scale score) and subjective comfort (visual analog scale score). Patients were also evaluated in terms of residual apnea-hypopnea index (AHI), as well as mean pressures and leaks registered in the ventilators. Results: There were no differences between the two groups in terms of mean age (APAPwith: 57.4 ± 9.2; APAPw/o: 56.5 ± 10.7 years), AHI (APAPwith: 28.1 ± 14.0; APAPw/o: 28.8 ± 20.5 events/hour of sleep), baseline Epworth score (APAPwith: 11.2 ± 5.8; APAPw/o: 11.9 ± 6.3) and initial nasal symptoms. Compliance was similar in both groups (APAPwith: 5.3 ± 2.4; APAPw/o: 5.2 ± 2.3 h/night). There were no differences in any of the other parameters analyzed. Conclusions: The introduction of heated humidification at the beginning of APAP therapy provided no advantage in terms of treatment compliance or side effects of treatment.


Keywords: Humidity; Positive-pressure respiration/adverse effects; Patient compliance.


10 - Profile of smokers seeking a smoking cessation program

Perfil dos fumantes que procuram um centro de cessação de tabagismo

Sergio Ricardo Santos, Maria Stela Gonçalves, Fernando Sergio Studart Leitão Filho, José Roberto Jardim

J Bras Pneumol.2008;34(9):695-701

Abstract PDF PT PDF EN Portuguese Text

Objective: To define the profile of smokers who seek professional assistance through a smoking cessation program and to compare smoker profiles among males, females and elderly people. Methods: Two-hundred and three smokers were prospectively evaluated. The participants completed questionnaires related to smoking history, history of psychiatric disorders, depression, anxiety and nicotine dependence as well as a general self-report questionnaire. Results: In this sample, 58.6% of the individuals were female (119). The mean age was 45.3 ± 12.0 years, with no statistically significant difference between genders (p = 0.391). The majority of the individuals in the sample (84.2%) presented socioeconomic class C or above. Sixty-three percent had at least a high school education. Depression was more often referred to by women, and the difference between genders was borderline significant (p = 0.069). However, when depression was evaluated using the Beck Depression Inventory, there was no statistically significant difference between genders and between elderly and nonelderly people. Conclusions: In the profile of the smokers who sought assistance, we identified aspects (such as being female and having been diagnosed with depression) that are known predictors of treatment failure. This shows the importance of carrying out a complete pre-evaluation of the profile of a smoker who seeks a smoking cessation program. Thus, procedures can be adopted prior to and during the treatment of the smoker, with the objective of increasing treatment success rates.


Keywords: Anxiety; Depression; Smoking.


Brief Communication

11 - Assessing the impact that external factors have on respiratory mechanics assessed using a specific photogrammetric model

Impacto de fatores externos sobre a mecânica respiratória avaliada por um modelo fotogramétrico específico: biofotogrametria

Denise da Vinha Ricieri, Nelson Augusto Rosário Filho

J Bras Pneumol.2008;34(9):702-706

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This is a report on a methodological adaptation of the photogrammetric technique, which is used in other medical specialties, for use in analyzing respiratory movements. Photogrammetry and a model of photogrammetry designated biofotogrametria para análise da mecânica respiratória (BAMER, photogrammetric analysis of respiratory mechanics) were tested under previously described pathophysiological conditions: post-exercise dynamic hyperinflation using positive end-expiratory pressure. The BAMER model identified an increase in the thoraco-abdominal area following exercise using positive end-expiratory pressure. These results are comparable to those obtained with more robust systems of respiratory kinematics. The use of photogrammetry has value in many areas, since it produces quantitative data, being particularly relevant in pediatrics, in which monitoring resources are scarce.


Keywords: Biomechanics; Photogrammetry; Respiratory mechanics; Thoracic wall.


Review Article

12 - Oral hygiene with chlorhexidine in preventing pneumonia associated with mechanical ventilation

Higiene bucal com clorexidina na prevenção de pneumonia associada à ventilação mecânica

Carolina Contador Beraldo, Denise de Andrade

J Bras Pneumol.2008;34(9):707-714

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Ventilator-associated pneumonia (VAP) is a common infection in intensive care units (ICUs), and oral antiseptic is used as a preventive measure. We reviewed meta-analyses and randomized clinical trials indexed in the Medical Literature Analysis and Retrieval System and Cumulative Index to Nursing and Allied Health Literature databases regarding the topical use of chlorhexidine in the prevention of VAP. Eight publications were analyzed. In seven (87.5%) chlorhexidine diminished the colonization of the oropharynx, and in four (50%) there was a reduction of VAP. Chlorhexidine seems to reduce colonization, thus reducing the incidence of VAP.


Keywords: Pneumonia, ventilator-associated; Oral hygiene; Chlorhexidine.


Special Article

13 - High-resolution computed tomography patterns of diffuse interstitial lung disease with clinical and pathological correlation

Padrões tomográficos das doenças intersticiais pulmonares difusas com correlação clínica e patológica

Brett Elicker, Carlos Alberto de Castro Pereira, Richard Webb, Kevin O. Leslie

J Bras Pneumol.2008;34(9):715-744

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High-resolution computed tomography (HRCT) is the radiological imaging technique best suited to revealing changes in lung structure. Various HRCT findings, taken together, can represent typical patterns. These patterns, in conjunction with the anatomical distribution of findings and with clinical data, can narrow the differential diagnosis of diffuse interstitial lung disease and, in many cases, indicate the correct diagnosis with a high degree of accuracy. The most common HRCT patterns seen in cases of diffuse interstitial lung diseases are the nodular pattern, linear/reticular opacities, cystic lesions, ground-glass opacities and consolidations. This article reviews the correlations between HRCT patterns and pathologic findings, summarizing the most common causes, as well as detailing the methods of investigation employed in order to diagnose the most common types of chronic diffuse lung disease.


Keywords: Lung diseases, interstitial/pathology; Tomography, X-Ray computed; Diagnostic techniques, respiratory system.


Case Report

14 - Cutaneous leukocytoclastic vasculitis accompanied by pulmonary tuberculosis

Vasculite leucocitoclástica cutânea associada à tuberculose pulmonar

Maurício Carvalho, Robson Luiz Dominoni, Denise Senchechen, Artur Furlaneto Fernandes, Ismael Paulo Burigo, Eloisa Doubrawa

J Bras Pneumol.2008;34(9):745-748

Abstract PDF PT PDF EN Portuguese Text

We report the case of a 50-year-old male with a rare combination: pulmonary tuberculosis and cutaneous leukocytoclastic vasculitis. The patient sought emergency treatment presenting with headache, arthralgia, cutaneous rash, and weight loss (4 kg) in the last 20 days. A chest X-ray, performed in a previous outpatient visit, revealed cavitation in the middle and upper lobes of the right lung, as confirmed by computed tomography. Sputum smear microscopy (Ziehl-Neelsen staining) was positive in three consecutive samples, and the result of the skin lesion biopsy was consistent with cutaneous leukocytoclastic vasculitis. The patient was therefore diagnosed with cutaneous leukocytoclastic vasculitis accompanied by pulmonary tuberculosis. Our objective was to describe a combination rarely reported in the medical literature and to discuss the possible pathogenic mechanisms of this combination.


Keywords: Vasculitis, hypersensitivity; Tuberculosis; Hypersensitivity.


15 - Pulmonary veno-occlusive disease: diagnostic and therapeutic alternatives

Doença veno-oclusiva pulmonar: alternativas diagnósticas e terapêuticas

Carlos Eduardo Galvão Barboza, Carlos Viana Poyares Jardim, André Luís Dressler Hovnanian, Bruno Arantes Dias, Rogério Souza

J Bras Pneumol.2008;34(9):749-752

Abstract PDF PT PDF EN Portuguese Text

Pulmonary veno-occlusive disease (PVOD) is a rare cause of pulmonary hypertension. Surgical biopsy was usually required for diagnostic confirmation. However, the morbidity, mortality and limited benefit of this procedure have generated discussion regarding noninvasive diagnostic techniques. We present the case of a female patient with progressive dyspnea, hypoxemia and pulmonary hypertension, the last diagnosed via catheterization. Computed tomography revealed septal thickening and diffuse micronodules. Bronchoalveolar lavage revealed occult alveolar hemorrhage. Treatment with an endothelin antagonist was started, resulting in symptomatic and functional improvement. Occult alveolar hemorrhage differentiates PVOD from idiopathic pulmonary hypertension. We believe that this finding, in combination with characteristic tomographic findings, is sufficient to establish a diagnosis of PVOD.


Keywords: Hypertension, pulmonary; Pulmonary veno-occlusive disease; Bronchoalveolar lavage; Receptors, endothelin/antagonists & inhibitors.



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