Brazilian Journal of Pulmonology

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


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Year 2009 - Volume 35  - Number 3  (/March)


1 - Smoking and asthma control

Tabagismo e controle da asma brônquica

Carlos Alberto de Assis Viegas

J Bras Pneumol.2009;35(3):197-198

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Original Article

2 - Evaluation of criteria for the diagnosis of asthma using an epidemiological questionnaire

Avaliação de critérios para o diagnóstico de asma através de um questionário epidemiológico

Neusa Falbo Wandalsen, Cássia Gonzalez, Gustavo Falbo Wandalsen, Dirceu Solé

J Bras Pneumol.2009;35(3):199-205

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Objective: To evaluate criteria for the diagnosis of asthma in an epidemiological survey. Methods: Adolescents (13-14 years of age) and legal guardians of schoolchildren (6-7 years of age) in the city of Santo André, Brazil, completed the International Study of Asthma and Allergies in Childhood (ISAAC) standard written questionnaire. Affirmative responses regarding wheezing within the last 12 months, asthma ever, bronchitis ever (question added at the end of the questionnaire), as well as the overall ISAAC score above the predefined cutoff points, were considered indicative of asthma. Results: The legal guardians of 2,180 schoolchildren and 3,231 adolescents completed the questionnaires properly. Depending on the criterion adopted, the prevalence of asthma ranged from 4.9% to 26.8% for the schoolchildren and from 8.9% to 27.9% for the adolescents. The criteria with the lowest and highest prevalences were, respectively, physician-diagnosed asthma and physician-diagnosed bronchitis. When compared with other criteria, physician-diagnosed bronchitis showed concordance levels between 71.9% and 79.4%, positive predictive values between 0.16 and 0.63 and poor concordance (kappa: 0.21-0.46). Strong concordance levels were found only between wheezing within the last 12 months and the overall ISAAC score (kappa: 0.82 and 0.98). Conclusions: The prevalence of asthma varied significantly, depending on the criterion adopted, and there was poor concordance among the criteria. Wheezing within the last 12 months and the overall ISAAC score are the best criteria for the diagnosis of asthma, whereas the question regarding bronchitis ever did not improve the questionnaire. Modifications in this instrument can make it difficult to draw comparisons and should therefore be carefully evaluated.


Keywords: Asthma; Bronchitis; Diagnosis; Epidemiology; Child; Adolescent.


3 - Incidence of asthma symptoms and decreased pulmonary function in young amateur swimmers

Frequência de sintomas de asma e de redução da função pulmonar entre crianças e adolescentes nadadores amadores

Iara Nely Fiks, Leonardo Carlos Araujo Santos, Telma Antunes, Raquel Calvo Gonçalves, Celso Ricardo Fernandes de Carvalho, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2009;35(3):206-212

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Objective: To investigate the incidence of asthma symptoms in young amateur swimmers, and to describe the clinical treatment of the children with asthma in a private sports club in the city of São Paulo, Brazil. Methods: The study included 171 amateur swimmers, ranging from 6 to14 years of age. All of the participants or their legal guardians were asked to complete the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, and 119 were submitted to pulmonary function testing at rest. Results: The overall incidence of asthma symptoms (ISAAC score ≥ 6) among the swimmers was 16.8%. Of the 119 swimmers submitted to spirometry, 39 (32.7%) presented spirometric alterations (FEV1/FVC < 0.75). Among those with an ISAAC score ≥ 6, there were 10 (31.2%) who stated that they were receiving no asthma treatment. Of those who reported receiving pharmacological treatment, 24% made use of bronchodilators but not of corticosteroids. Conclusions: The incidence of asthma symptoms and pulmonary function alterations among amateur swimmers within the 6-14 age bracket was high. In addition, a relevant proportion of these athletes were receiving no treatment.


Keywords: Asthma/therapy; Asthma/diagnosis; Child; Swimming; Exercise.


4 - Compensatory sweating after thoracoscopic sympathectomy: characteristics, prevalence and influence on patient satisfaction

Hiperhidrose compensatória após simpatectomia toracoscópica: características, prevalência e influência na satisfação do paciente

Carlos Alberto Almeida de Araújo, Ítalo Medeiros Azevedo, Maria Angela Fernandes Ferreira, Hylas Paiva da Costa Ferreira, Jorge Lúcio Costa de Medeiros Dantas, Aldo Cunha Medeiros

J Bras Pneumol.2009;35(3):213-220

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Objective: This prospective study aimed at investigating predictive factors for compensatory sweating after thoracoscopic sympathectomy. Methods: From 2000 to 2002, 80 patients (53 females and 27 males) underwent thoracoscopic sympathectomy to treat hyperhidrosis. Patient ages ranged from 12 to 56 years, and the mean post-operative follow-up period was 42.51 ± 5.98 months. Patient satisfaction with the results was evaluated through the use of a rating scale. The procedure was performed bilaterally: at the T2 level for facial hyperhidrosis; at the T3-T4 level for axillary hyperhidrosis; and at the T3 level for palmar hyperhidrosis. Results: Post-operatively, 68 patients (85.0%) presented compensatory sweating, which was classified as mild in 23 (33.8%), moderate in 23 (33.8%) and severe in 22 (32.4%). Considering the final surgical results, 70 patients (87.5%) were satisfied with the outcome of the operation, whereas 10 patients (12.5%) were dissatisfied. The level of patient satisfaction varied according to gender, age, body mass index (BMI) and extent of denervation. The compensatory sweating was more severe on the abdomen and back than on the legs. Conclusions: Although compensatory sweating, which is a common adverse effect of sympathectomy, occurred in the majority of cases, the level of patient satisfaction was high. The best candidates for thoracoscopic sympathectomy are young adult women with a BMI ≤ 24.9 kg/m2.


Keywords: Sympathectomy; Hyperhidrosis; Thoracoscopy; Postoperative complications;Thoracic surgery, video-assisted.


5 - Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil

Prevalência de pectus carinatum e pectus excavatum em escolares de Manaus

Fernando Luiz Westphal, Luiz Carlos de Lima, José Corrêia Lima Neto, Altair Rodrigues Chaves, Vítor Lazarini dos Santos Júnior, Brena Luize Cunha Ferreira

J Bras Pneumol.2009;35(3):221-226

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Objective: To determine the prevalence of congenital anterior chest wall deformities in 11- to 14-year-old students. Methods: Students participating in the study were recruited from public schools in the city of Manaus, Brazil. The statistically significant sample (precision, 1%; 95% CI) comprised 1,332 students. Pectus deformities were identified by physical examination of the chest, and the individuals with one of these deformities completed a questionnaire regarding heredity and symptoms resulting from the chest abnormality. Results: The mean age of the participants was 11.7 years. The prevalence of pectus abnormalities was 1.95% (pectus excavatum: 1.275%; pectus carinatum: 0.675%). Of the 26 students with a pectus deformity, 17 (65.4%) had pectus excavatum, and 18 (69.2%) were male. Concomitant scoliosis was observed in 3 cases (11.5%). A family history of pectus was reported by 17 students (65.4%), and 17 (65.4%) reported chest pain, dyspnea or palpitations. Conclusions: In this study, the prevalence of pectus deformities (1.95%) was lower than that reported in other studies conducted in Brazil (3.6-4.9%) but was higher than that reported in the literature (mean, 1%).


Keywords: Musculoskeletal abnormalities; Prevalence; Funnel chest.


6 - Postintubation injuries and open surgical tracheostomy: should we always perform isthmectomy?

Sequelas pós-intubação e traqueostomia cirúrgica aberta: devemos sempre fazer a istmectomia?

Alexandre Garcia de Lima, Ariovaldo Marques, Ivan Felizardo Contrera Toro

J Bras Pneumol.2009;35(3):227-233

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Objective: To evaluate the influence of the surgical team (general surgery or thoracic surgery) and the surgical technique (with or without isthmectomy) on the incidence of postintubation injuries in the airways of tracheostomized patients. Methods: Between January 1st and August 31st, 2007, 164 patients admitted to the adult intensive care unit and tracheally intubated for more than 24 h were studied prospectively at the Sumaré State Hospital, located in the city of Sumaré, Brazil. When tracheostomy was necessary, these patients were randomly assigned to thoracic or general surgery teams. All of the patients were submitted to fiberoptic tracheoscopy for decannulation or late evaluation of the airway. Results: Of the 164 patients in the study, 90 (54.88%) died (due to causes unrelated to the procedure), 67 (40.85%) completed follow-up, and 7 (4.27%) were lost to follow-up. Of the 67 patients who completed follow-up, 32 had undergone tracheostomy (21 by the general surgery team and 11 by the thoracic surgery team), and 22 had been submitted to isthmectomy (11 by the general surgery team and 11 by the thoracic surgery team). There was no difference between the surgical teams in terms of the incidence of stoma complications. However, there was a significant difference when the surgical techniques (with or without isthmectomy) were compared. Conclusions: Not performing isthmectomy in parallel with tracheostomy leads the surgeon to open the tracheal stoma more distally than expected. In such cases, there were more stoma complications.


Keywords: Tracheostomy; Intensive care units; Tracheal stenosis.


7 - Video-assisted thoracoscopy for the diagnosis of diffuse parenchymal lung disease

A videotoracoscopia no diagnóstico das doenças difusas do parênquima pulmonar

Renato Tadao Ishie, João José de Deus Cardoso, Rafael José Silveira, Lucas Stocco

J Bras Pneumol.2009;35(3):234-241

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Objective: To evaluate the role of video-assisted thoracoscopy in the diagnosis of diffuse parenchymal lung diseases. Methods: The medical charts of patients suspected of having diffuse parenchymal lung disease were retrospectively reviewed, as were the results of the anatomopathological examination of lung biopsy specimens collected through video-assisted thoracoscopy. Results: Of the 48 patients included in the study, 25 (52.08%) were female and 23 (47.92%) were male. The mean age was 58.77 years (range, 20-76 years). A total of 54 biopsy fragments were submitted to anatomopathological examination: 24 (44.44%) from the lingula; 10 (18.52%) from the left lower lobe; 7 (12.96%) from the right middle lobe; 6 (11.11%) from the right lower lobe; 5 (9.26%) from the left upper lobe; and 2 (3.71%) from the right upper lobe. The mean duration of thoracic drainage was 2.2 days. Adverse events included conversion to thoracotomy, in 2 patients (4.17%), and residual pneumothorax, in 1 (2.08%). The definitive diagnosis was made in 46 patients (95.83%), and idiopathic interstitial pneumonia was the predominant diagnosis (in 54.18%). The most common diagnoses were usual interstitial pneumonia (in 29.27%), nonspecific interstitial pneumonia (in 16.67%) and hypersensitivity pneumonia (in 12.50%). Conclusions: Lung biopsy through video-assisted thoracoscopy is a safe, effective and viable procedure for the diagnosis of diffuse parenchymal lung diseases.


Keywords: Lung diseases, interstitial; Thoracoscopy; Diagnosis.


8 - Nutritional profile of lung transplant candidates

Perfil nutricional de pacientes candidatos ao transplante de pulmão

Sabrina Monteiro Pereira de Souza, Miyoko Nakasato, Maria Lúcia Mendes Bruno, Alessandra Macedo

J Bras Pneumol.2009;35(3):242-247

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Objective: To determine the nutritional profile of lung transplant candidates. Methods: A retrospective cross-sectional study involving lung transplant candidates at a public hospital in the city of São Paulo, Brazil. Data related to gender, age and underlying lung disease were compiled for the participants. For the assessment of the nutritional profile of the patients, body mass index (BMI), mid-arm muscle circumference (MAMC), waist circumference and triceps skinfold thickness (TST) were determined during the first outpatient visit. Results: We included 117 patients, 69 of which (59%) were male. The mean age of the participants was 42.5 ± 15.2 years. The most prevalent underlying disease, seen in 29 patients (24.8%), was pulmonary emphysema. The nutritional profile was considered normal in 48.3% of the patients with pulmonary emphysema, 55% of those with cystic fibrosis, 56% of those with bronchiectasis and 50% of those with other lung diseases. The majority (51.7%) of the patients with pulmonary fibrosis were classified as overweight. The TSTs indicated that the risk of depletion was highest (64.7%) among the patients with cystic fibrosis, followed by those with bronchiectasis (52.6%). Conclusions: Patients with pulmonary fibrosis presented the highest BMIs, although the corresponding TSTs and MAMCs were normal. Patients with cystic fibrosis and bronchiectasis presented the highest prevalence of nutritional depletion, based on TST and MAMC.


Keywords: Lung transplantation; Nutritional status; Body mass index.


9 - Correlation between clinical parameters and health-related quality of life in women with COPD

Correlação entre parâmetros clínicos e qualidade de vida relacionada à saúde em mulheres com DPOC

Nilton Maciel Mangueira, Isabel Lucena Viega, Melissa de Almeida Melo Maciel Mangueira, Alcimar Nunes Pinheiro, Maria do Rosário da Silva Ramos Costa

J Bras Pneumol.2009;35(3):248-255

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Objective: To correlate health-related quality of life (HRQL) of women with COPD with clinical parameters and with the six-minute walk distance (6MWD; six-minute walk test). Methods: Cross-sectional study involving 30 female patients diagnosed with mild or moderate COPD treated at the Respiratory Outpatient Clinic of the Presidente Dutra University Hospital. Patients completed the Saint George's Respiratory Questionnaire (SGRQ) and were evaluated in terms of respiratory pressures, spirometry parameters and 6MWD. Descriptive statistical analysis was carried out, as were Student's t-tests for dependent variables, together with Pearson's and Spearman's correlation coefficients for numerical and ordinal variables, respectively. Results: According to the SGRQ total scores, HRQL was impaired, to some extent, in most of the participants. Most SGRQ total scores were between the second and the third quartiles, reflecting poor HRQL. The participants also presented poor functional capacity. Mean 6MWD (317.7 m), inspiratory muscle strength (−53.48 cmH2O) and expiratory muscle strength (69.5 cmH2O) were all below reference values. We found that HRQL was not correlated with body mass index or pulmonary function. However, HRQL presented a negative linear correlation with age, MIP and 6MWD, as well as a positive correlation with the sensation of dyspnea and fatigue. Conclusions: In this study, HRQL, determined using the SGRQ, was severely impaired in COPD patients, who presented severe limitations in functional capacity, breath control and personal life.


Keywords: Quality of life; Pulmonary disease, chronic obstructive; Women.


Brief Communication

10 - Noninvasive determination of inspiratory pressure in patients with spinal cord injury: what is the best method?

Determinação não-invasiva da pressão inspiratória em pacientes com lesão medular traumática: qual é o melhor método?

Andrea Ponte Rocha, Sergio Ricardo Menezes Mateus, Thomas Anthony Horan, Paulo Sérgio Siebra Beraldo

J Bras Pneumol.2009;35(3):256-260

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The aim of the study was to evaluate the performance of sniff nasal inspiratory pressure (SNIP) and MIP in individuals with spinal cord injury. We evaluated 26 patients with spinal cord injury. Mean FVC in those with tetraplegia was 52 ± 19% of predicted, compared with 78 ± 23% of predicted in those with paraplegia (p < 0.05). In contrast, the percentage of predicted SNIP was lower in those with tetraplegia than in those with paraplegia (p < 0.05). In all participants, SNIP correlated significantly with the level of the injury (r = 0.489; 95% CI: 0.125‑0.737). The impact that the greater discriminatory power of SNIP has on the diagnosis of impaired pulmonary function in spinal cord-injured patients should be investigated further.


Keywords: Spinal cord injuries; Respiratory function tests; Respiratory muscles; respiratory paralysis.


11 - Prevalence of active and passive smoking in a population of patients with asthma

Prevalência de tabagismo ativo e passivo em uma população de asmáticos

Sérvulo Azevedo Dias-Júnior, Regina Carvalho Pinto, Luciene Angelini, Frederico Leon Arrabal Fernandes, Alberto Cukier, Rafael Stelmach

J Bras Pneumol.2009;35(3):261-265

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Smoking causes an intense inflammatory reaction in the airways and is associated with worse clinical outcomes in patients with asthma. The objective of this study was to determine the prevalence of active and passive smoking in a population of patients with asthma. The sample of asthma patients (n = 100) consisted of 47 nonsmokers, 33 former smokers, 17 passive smokers and 3 active smokers. Most had moderate or severe asthma. Mean exhaled CO was 9.34 ppb in smokers, 4.19 ppb in passive smokers, 3.98 ppb in nonsmokers and 3.98 ppb in former smokers. We conclude that the prevalence of exposure to tobacco smoke is high among asthma patients.


Keywords: Smoking; Asthma; Prevalence.


Review Article

12 - Computed tomography findings of postoperative complications in lung transplantation

Achados tomográficos nas complicações pós-operatórias do transplante pulmonar

Bruno Hochhegger, Klaus Loureiro Irion, Edson Marchiori, Rodrigo Bello, José Moreira, José Jesus Camargo

J Bras Pneumol.2009;35(3):266-274

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Due to the increasing number and improved survival of lung transplant recipients, radiologists should be aware of the imaging features of the postoperative complications that can occur in such patients. The early treatment of complications is important for the long-term survival of lung transplant recipients. Frequently, HRCT plays a central role in the investigation of such complications. Early recognition of the signs of complications allows treatment to be initiated earlier, which improves survival. The aim of this pictorial review was to demonstrate the CT scan appearance of pulmonary complications such as reperfusion edema, acute rejection, infection, pulmonary thromboembolism, chronic rejection, bronchiolitis obliterans syndrome, cryptogenic organizing pneumonia, post-transplant lymphoproliferative disorder, bronchial dehiscence and bronchial stenosis.


Keywords: Tomography, X-ray computed; Lung transplantation; Postoperative complications.


Case Report

13 - Pulmonary and extrapulmonary coccidioidomycosis: three cases in an endemic area in the state of Ceará, Brazil

Coccidioidomicose pulmonar e extrapulmonar: três casos em zona endêmica no interior do Ceará

Ricardo Hideo Togashi, Fernando Moreira Batista Aguiar, Dalton Barros Ferreira, Camille Matos de Moura, Monique Teixeira Montezuma Sales, Nikaelle Ximenes Rios

J Bras Pneumol.2009;35(3):275-279

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Coccidioidomycosis, a fungal illness acquired by the inhalation of arthroconidia of Coccidioides sp., was first described in 1894. Coccidioidomycosis is mainly restricted to areas with arid climate, alkaline soil and low rainfall. Consequently, most of the reported cases in Brazil have occurred in the northeastern region. We report three cases of pulmonary coccidioidomycosis occurring between 2005 and 2006 in an endemic area in the state of Ceará, Brazil. The three patients were immunocompetent adult males, hunters of armadillos (Dasypus novemcinctus), with complaints of cough, fever, dyspnea and pleuritic pain. All three patients presented pulmonary involvement, and one also presented cutaneous lesions. Chest X-rays and CT scans of the patients revealed characteristic coccidioidomycosis lesions. The diagnosis was confirmed by serological testing. All of the patients evolved to cure after antifungal treatment.


Keywords: Coccidioidomycosis; Lung diseases, fungal; Coccidioides.


14 - Mucoepidermoid carcinoma of the trachea mimicking asthma

Carcinoma mucoepidermoide da traqueia mimetizando asma brônquica

Ricardo Kalaf Mussi, Ivan Felizardo Contrera Toro, Mônica Corso Pereira

J Bras Pneumol.2009;35(3):280-284

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In cases of recent asthma in which clinical control with the usual treatment (corticosteroids and bronchodilator) is unsatisfactory, it is important to consider other diagnoses, such as congestive heart failure, gastroesophageal reflux or other forms of airway obstruction. We report the case of a female patient with mucoepidermoid carcinoma of the trachea mimicking asthma. The patient presented cough and wheezing, as well as abnormal spirometry results with an obstructive pattern that was responsive to bronchodilators. One year later, the patient presented clinical and spirometric worsening. The chest X-ray revealed no abnormalities. A CT scan showed a vegetative lesion obstructing the tracheal lumen and located 1 cm from the carina. Fiberoptic bronchoscopy showed a finding similar to a bronchial carcinoid tumor. The anatomopathological diagnosis made after surgical resection was low-grade mucoepidermoid carcinoma, without lymph node involvement. Although the flow-volume curve was not suggestive of upper airway obstruction, the spirometry performed after the surgery showed a significant reduction in the degree of obstruction and greater reversibility after bronchodilator use. There was no evidence of recurrence of the disease or of the symptoms after a two-year follow-up period.


Keywords: Bronchial hyperreactivity; Carcinoma, mucoepidermoid; Trachea; Asthma; Lung diseases, obstructive.


15 - Osteitis after BCG vaccination

Osteíte por BCG

André Fukunishi Yamada, Juliana Barbosa Pellegrini, Luciana Menezes Cunha, Artur da Rocha Corrêa Fernandes

J Bras Pneumol.2009;35(3):285-289

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The authors report the case of a 21-month-old boy with an osteolytic lesion in the proximal region of the right humerus. Based on the clinical history and histological findings, the authors suspected osteitis following BCG vaccination. Symptoms remitted after antituberculosis therapy was initiated, and the patient presented radiological improvement. The authors describe this uncommon entity in pediatric practice and call attention to possible complications of BCG vaccination.


Keywords: Infant; Osteitis; BCG vaccine; Tuberculosis.


Letters to the Editor

Author's reply

17 - Author's reply

Resposta dos autores

Paulo de Tarso Roth Dalcin

J Bras Pneumol.2009;35(3):291-292

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