Brazilian Journal of Pulmonology

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


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Year 2009 - Volume 35  - Number 7  (/July)


1 - Medications to the north, patients to the south

Medicamentos ao Norte, doentes ao Sul

Paulo Augusto Moreira Camargos, Álvaro Augusto Cruz, Jean Bousquet

J Bras Pneumol.2009;35(7):615-617

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Original Article

2 - Two-year evaluation of an educational program for adult outpatients with asthma

Avaliação de dois anos de um programa educacional para pacientes ambulatoriais adultos com asma

Luciene Angelini, Priscila Games Robles-Ribeiro, Regina Maria de Carvalho-Pinto, Marcos Ribeiro, Alberto Cukier, Rafael Stelmach

J Bras Pneumol.2009;35(7):618-627

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Objective: To evaluate the understanding of asthma and the clinical improvement in patients with moderate or severe persistent asthma prior to and after their participation in an educational program presented during the routine outpatient visits. Methods: This was a prospective pilot study involving 164 patients over a two-year period. The educational program, presented to small groups on outpatient visit days, consisted of lectures divided into three parts: pathophysiology; environmental control; and treatment, including training in the inhalation technique. The program was evaluated using standardized questionnaires on clinical improvement and understanding of the disease. Results: By the end of the first year, 120 patients had completed three visits, and 51 of those patients were revaluated at the end of the second year. The mean age of the patients was 44 years, 70% were female, and 43% had up to eight years of schooling. The educational intervention significantly increased the understanding of the disease (p < 0.001), and allowed greater clinical improvement (p < 0.05) with a decrease in the use of oral corticosteroids, fewer visits to the emergency room and fewer days missed from work or school. Conclusions: The educational program offered during the routine outpatient visits of adult patients with asthma at our clinic resulted in a progressive long-term increase in knowledge, as well as in clinical improvement.


Keywords: Asthma; Adult; Patient education as topic.


3 - Evaluation of the treatment provided to patients with asthma by the Brazilian Unified Health Care System

Avaliação da assistência ao paciente asmático no Sistema Único de Saúde

Carla Discacciati Silveira, Flávia de Barros Araújo, Luiz Fernando Ferreira Pereira, Ricardo de Amorim Corrêa

J Bras Pneumol.2009;35(7):628-634

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Objective: To determine, based on international guidelines for asthma management, the appropriateness of the treatment that the Unified Health Care System provides to patients with asthma. Methods: This was a cross-sectional study involving patients suspected of having asthma and referred to the Pulmonology Clinic of the Federal University of Minas Gerais Hospital das Clínicas, Brazil, between November of 2006 and October of 2007. Results: A total of 102 patients were included, and 70 were diagnosed with asthma. The previous treatment was consistent with the guidelines in 18.6% of the patients; 50.0% of the patients had previously been submitted to spirometry, and 34.3% had previously been submitted to PEF. The most frequently prescribed medication was short-acting β2 agonists (90.3%). Conclusions: The results show that the majority of non-specialized physicians working within the public health care system do not manage the treatment of patients with asthma in accordance with the guidelines. This situation calls for continuing medical education programs that prioritize primary care.


Keywords: Asthma; Guideline adherence; Therapeutics; Public health.


4 - The study of severe asthma in Latin America and Spain (1994-2004): characteristics of patients hospitalized with acute severe asthma

Estudo sobre Asma Grave na América Latina e Espanha (1994-2004): características dos pacientes hospitalizados com asma aguda grave

Gustavo Javier Rodrigo, Vicente Plaza, Jesús Bellido-Casado, Hugo Neffen, María Teresa Bazús, Gur Levy, Joseph Armengol

J Bras Pneumol.2009;35(7):635-644

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Objective: Studies assessing the characteristics and management of patients hospitalized with asthma have been limited to a small number of facilities and have evaluated short time periods. The present study evaluated long-term changes among hospitalized asthma patients at a large number of facilities. Methods: This was a retrospective, hospital-based observational case series, designated the Study of Severe Asthma in Latin America and Spain, which was conducted in Spain and in eight Latin-American countries. We reviewed the hospital records of 3,038 patients (age range, 15-69 years) hospitalized with acute severe asthma at one of nineteen tertiary-care hospitals in 1994, 1999 and 2004. Results: Over time, the use of inhaled corticosteroids and long-acting β2 agonists increased significantly, whereas the use of theophylline as a controller medication decreased. The utilization of pulmonary function tests also increased. There was a significant reduction in the mean hospital stay (8.5 days, 7.4 days and 7.1 days in 1994, 1999 and 2004, respectively, p = 0.0001) and a significant increase in the mean of the lowest arterial pH at hospital admission. In contrast, there was a significant decrease in the proportion of cases in which PEF was determined in the emergency room (48.6% in 1994 vs. 43.5% in 2004, p = 0.0001). We found the quality of asthma management and care to be generally better in Spain than in Latin America. Conclusions: Although there have been certain improvements in the management of asthma between severe exacerbations and during hospitalization, asthma management remains suboptimal in Spain and, especially, in Latin America.


Keywords: Status asthmaticus; Asthma/therapy; Hospitalization.


5 - Effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of patients with asthma

Efeito da obstrução de vias aéreas nas variações das propriedades resistivas e elásticas do sistema respiratório de asmáticos, mediadas pelo uso de salbutamol

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

J Bras Pneumol.2009;35(7):645-652

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Objective: To investigate the effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of adult patients with asthma. Methods: This study comprised 24 healthy controls and 69 patients with asthma, all of whom were nonsmokers. The patients were divided into three groups according to the severity of airway obstruction (mild, moderate or severe). Each of the three groups was divided into two subgroups according to the bronchodilator response (BR): positive (BR+) or negative (BR−). These measurements were conducted before and after albuterol use (300 µg). Airway obstruction was determined by means of spirometry, and the resistive and elastic properties were determined by means of the forced oscillation technique. Results: The resistance at the intercept (R0) presented greater reductions in the groups with higher obstruction. This reduction was more evident in the BR+ subgroups than in the BR− subgroups (p < 0.02 and p < 0.03, respectively). There was a significant difference between the control group and the BR+ subgroup with severe obstruction (p < 0.002). The reductions in dynamic elastance (Edyn) were significantly greater in proportion to the degree of obstruction, in the BR− subgroups (p < 0.03), and in the BR+ subgroups (p < 0.003). The reductions in Edyn were significantly greater in the BR− subgroup with moderate obstruction (p < 0.008) and in the BR+ subgroup with severe obstruction (p < 0.0005) than in the control group. Conclusions: In patients with asthma, increased airway obstruction results in greater reductions in R0 and Edyn after albuterol use. These reductions are greater among BR+ patients than among BR− patients.


Keywords: Asthma; Bronchodilator agents; Respiratory mechanics; Spirometry; Albuterol.


6 - Foreign body aspiration in children and adolescents: experience of a Brazilian referral center

Aspiração de corpo estranho por menores de 15 anos: experiência de um centro de referência do Brasil

Sílvia Teresa Evangelista Vidotto de Sousa, Valdinar Sousa Ribeiro, José Mário de Menezes Filho, Alcione Miranda dos Santos, Marco Antonio Barbieri, José Albuquerque de Figueiredo Neto

J Bras Pneumol.2009;35(7):653-659

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Objective: To describe the clinical, radiological and endoscopic characteristics of foreign body aspiration among individuals under the age of 15 treated at a referral center in the city of São Luís, Brazil. Methods: This was a descriptive study using data from the medical charts of patients treated for foreign body aspiration at the Hospital Universitário Materno Infantil between 1995 and 2005. We investigated 72 confirmed cases of foreign body aspiration, evaluating the place of residence, as well as biological, clinical, radiological and endoscopic variables. We used the chi-square test to identify statistically significant differences in frequency among the variables studied. Results: The majority of the patients were from outlying areas (55.6%). The following variables presented the highest frequencies: 0-3 year age bracket (81.9%); male gender (63.9%); evolution > 24 h (66.7%); hypotransparency on chest X-ray (57.7%); foreign body in the right lung (41.2%) or in the larynx (20.5%); organic nature of the foreign body (83.3%); complication in the form of localized inflammation (59.4%); glottal edema as an endoscopic complication (47.6%); and seeds (46.6%), fish bone (28.3%) or plastics (25.5%) as the type of foreign body. There were no deaths. Conclusions: Preventive care should be a priority for male children under the age of 3 living in outlying areas. Such children should not be given access to substances that can be aspirated, including certain foodstuffs. Simple and easily accessible radiological tests have been underused, which jeopardizes the quality of the initial treatment.


Keywords: Foreign bodies; Inhalation; Bronchoscopy.


7 - Thoracoscopy in children with complicated parapneumonic pleural effusion at the fibrinopurulent stage: a multi-institutional study

Toracoscopia em crianças com derrame pleural parapneumônico complicado na fase fibrinopurulenta: estudo multi-institucional

Sérgio Freitas, José Carlos Fraga, Fernanda Canani

J Bras Pneumol.2009;35(7):660-668

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Objective: To determine the efficacy of thoracoscopy in the management of children with complicated parapneumonic pleural effusion at the fibrinopurulent stage. Methods: Retrospective study of 99 children submitted to thoracoscopy for the treatment of complicated parapneumonic pleural effusion at the fibrinopurulent stage between November of 1995 and July of 2005. The mean age was 2.6 years (range, 0.4-12 years), and 60% were males. Thoracoscopy was performed at three different hospitals following the same treatment algorithm. Results: Thoracoscopy was effective for 87 children (88%). In 12 (12%), a second surgical procedure was required: another thoracoscopy (n = 6) or thoracotomy/thoracostomy (n = 6). Mean duration of chest tube drainage following successful thoracoscopy was 3 days vs. 10 days in patients submitted to a second procedure (p < 0.001). In all of the children, the pleural infection resolved after treatment. Thoracoscopy-related complications included air leak (30%), chest tube bleeding (12%), subcutaneous emphysema associated with trocar insertion (2%) and surgical wound infection (2%). None of the children required additional surgical procedures due to the complications. Conclusions: The effectiveness of thoracoscopy in children with parapneumonic pleural effusion at the fibrinopurulent stage was 88%. The procedure was safe, with a low rate of severe complications. Thoracoscopy should be the first-choice treatment for children with parapneumonic pleural effusion at the fibrinopurulent stage.


Keywords: Thoracoscopy; Pleural effusion; Empyema, pleural.


8 - Proteinuria in cystic fibrosis: a possible correlation between genotype and renal phenotype

Proteinúria na fibrose cística: possível correlação entre genótipo e fenótipo renal

Jessica Cemlyn-Jones, Fernanda Gamboa

J Bras Pneumol.2009;35(7):669-675

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Objective: To assess proteinuria in patients with cystic fibrosis (CF), and to correlate proteinuria with genotype, CF-related diabetes and disease severity. Methods: A prospective study was carried out over a six-month period and involving 22 CF patients. After the collection and analysis of 24-h urine samples, the patients were divided into two subgroups: protein excretion < 150 mg/day (low-proteinuria); and protein excretion ≥ 150 mg/day (high-proteinuria). Patient charts were reviewed to obtain data on genotype and CF-related diabetes. Disease severity was assessed based on acute exacerbations in the last six months and FEV1 measured during the study period. To assess the correlation between genotype and proteinuria, the two main mutations (ΔF508 and R334W) were evaluated. Due to the existence of genotype ΔF508/R334W, two categories were created to enable statistical analysis, ΔF508 being evaluated in category 1 and R334W being evaluated in category 2. Results: The ΔF508 mutation tended to be associated with normal protein excretion: 100% of the low-proteinuria subgroup patients were considered ΔF508 in category 1, compared with 86.7% in category 2. Protein excretion tended to be higher in patients with the R334W mutation: 60.0% of the high-proteinuria subgroup patients were considered R334W in category 1, compared with 80.0% in category 2 (p = 0.009 and p = 0.014, respectively). No significant association was found for any of the other variables. Conclusions: The results suggest that genotype is associated with renal phenotype, depending on the mechanism by which the genotype alters the function of the cystic fibrosis transmembrane conductance regulator gene.


Keywords: Proteinuria; Cystic fibrosis; Genotype.


9 - Semiquantitative analysis of surgical biopsies of distinct lung lobes of patients with usual interstitial pneumonia/idiopathic pulmonary fibrosis

Análise semiquantitativa de biópsias cirúrgicas de diferentes lobos pulmonares de pacientes com pneumonia intersticial usual/fibrose pulmonar idiopática

José Júlio Saraiva Gonçalves, Luiz Eduardo Villaça Leão, Rimarcs Gomes Ferreira, Renato Oliveira, Luiz Hirotoshi Ota, Ricardo Sales dos Santos

J Bras Pneumol.2009;35(7):676-682

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Objective: To evaluate the differences between surgical biopsies of distinct lung lobes in terms of the histopathological features of usual interstitial pneumonia, using a semiquantitative score. Methods: We selected all of the patients diagnosed with idiopathic pulmonary fibrosis and submitted to surgical biopsy in two distinct lobes between 1995 and 2005 at the Hospital São Paulo and other hospitals operated by the Federal University of São Paulo. In the histological evaluation of the specimens, we used a semiquantitative method based on previous studies, assigning a score to each of the biopsied sites. Results: In this sample of patients, we found no statistically significant differences that would alter the stage of the disease, based on the score used. This finding was independent of the biopsy site (middle lobe or lingular segment). Conclusions: No significant histological differences were found between the lung lobes studied. The definitive histological diagnosis of usual interstitial pneumonia did not alter the stage of the disease.


Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Thoracic surgery; Pathology; Thoracic surgery, ­video-assisted.


10 - Modified Reasons for Smoking Scale: translation to Portuguese, cross‑cultural adaptation for use in Brazil and evaluation of test-retest reliability

Escala Razões Para Fumar Modificada: tradução e adaptação cultural para o português para uso no Brasil e avaliação da confiabilidade teste-reteste

Elisa Sebba Tosta de Souza, José Alexandre de Souza Crippa, Sonia Regina Pasian, José Antonio Baddini Martinez

J Bras Pneumol.2009;35(7):683-689

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Objective: To translate the Modified Reasons for Smoking Scale (MRSS) to Portuguese, to submit it to cross-cultural adaptation for use in Brazil and to evaluate the test-retest reliability of the translated version. Methods: An English-language version of the MRSS was translated to Portuguese by Brazilian doctors who have thorough knowledge of the English language. A consensus version was produced by a multidisciplinary group including two pulmonologists, a psychiatrist and a psychologist. This version was back-translated to English by an American translator. Cross-cultural adaptation of the final version was evaluated in a sample of 20 healthy smokers. Test-retest reliability was evaluated by applying the translated version of the scale in 54 healthy smokers on two distinct occasions, 15 days apart. Results: This translated version of the MRSS was well understood by 95% of the smokers, indicating excellent cross-cultural equivalence. The degree of reliability of the answers in two different occasions was almost perfect for two questions, substantial for ten questions, moderate for eight questions, and low for one question. The intraclass correlation coefficients of the motivational factors obtained on the two different occasions, calculated according to previously published theoretical models, were higher than 0.7 for six of the seven subscales. Conclusions: The Portuguese-language version of the MRSS shows satisfactory cross-cultural equivalence and test-retest reliability. It can be a useful tool in the evaluation and treatment of smokers in Brazil.


Keywords: Smoking cessation; Scales; Translations; Validation studies.


11 - Performance of nested PCR in the specific detection of Mycobacterium tuberculosis complex in blood samples of pediatric patients

Desempenho da técnica nested PCR na detecção específica do complexo Mycobacterium tuberculosis em amostras sanguíneas de pacientes pediátricos

Juliana Figueirêdo da Costa Lima, Lílian Maria Lapa Montenegro, Rosana de Albuquerque Montenegro, Marta Maciel Lyra Cabral, Andrea Santos Lima, Frederico Guilherme Coutinho Abath (in memoriam), Haiana Charifker Schindler

J Bras Pneumol.2009;35(7):690-697

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Objective: To evaluate the performance of nested PCR (nPCR) in detecting the Mycobacterium tuberculosis complex in blood samples of patients suspected of having TB, in order to determine its potential for use as an auxiliary tool in the laboratory diagnosis of TB in children. Methods: Detection of the M. tuberculosis complex in blood samples using as a target the insertion sequence IS6110 of the genomic DNA of the bacillus. Blood samples of 120 patients were evaluated. All of the patients were under 15 years of age at the time of their treatment at public hospitals in the city of Recife, Brazil (between January of 2003 and August of 2005). Attending physicians at the hospitals diagnosed TB based on the criteria recommended by the American Thoracic Society. The nPCR amplified a 123-bp fragment with outer oligonucleotides (IS1/IS2) and, in the subsequent reaction, using inner oligonucleotides (IS3/IS4), generating an 81-bp amplicon. Results: Active or latent TB was found in 65 patients, TB was ruled out in 28 suspected cases, and 27 patients were TB-free (controls). The sensitivity of nPCR was 26.15% and was significantly higher for the extrapulmonary form of the disease (55.56%) than for the pulmonary form (18.18%). The specificity was 92.73%. Conclusions: Despite the difficulties in diagnosing TB in children and the low number of cases evaluated in the present study, nPCR in blood samples proved to be a rapid and specific technique, albeit one with low sensitivity. In order to establish its true usefulness in the diagnosis of paucibacillary forms, especially extrapulmonary TB, further studies need to be carried out with a larger sample of children and analyzing biological specimens other than blood.


Keywords: Tuberculosis; Diagnosis; Blood; Polymerase chain reaction.


Review Article

12 - Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications

Manifestações respiratórias do transtorno de pânico: causas, consequências e implicações terapêuticas

Aline Sardinha, Rafael Christophe da Rocha Freire, Walter Araújo Zin, Antonio Egidio Nardi

J Bras Pneumol.2009;35(7):698-708

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Multiple respiratory abnormalities can be found in anxiety disorders, especially in panic disorder (PD). Individuals with PD experience unexpected panic attacks, characterized by anxiety and fear, resulting in a number of autonomic and respiratory symptoms. Respiratory stimulation is a common event during panic attacks. The respiratory abnormality most often reported in PD patients is increased CO2 sensitivity, which has given rise to the hypothesis of fundamental abnormalities in the physiological mechanisms that control breathing in PD. There is evidence that PD patients with dominant respiratory symptoms are more sensitive to respiratory tests than are those who do not manifest such symptoms, and that the former group constitutes a distinct subtype. Patients with PD tend to hyperventilate and to panic in response to respiratory stimulants such as CO2, triggering the activation of a hypersensitive fear network. Although respiratory physiology seems to remain normal in these subjects, recent evidence supports the idea that they present subclinical abnormalities in respiration and in other functions related to body homeostasis. The fear network, composed of the hippocampus, the medial prefrontal cortex, the amygdala and its brain stem projections, might be oversensitive in PD patients. This theory might explain why medication and cognitive-behavioral therapy are both clearly effective. Our aim was to review the relationship between respiration and PD, addressing the respiratory subtype of PD and the hyperventilation syndrome, with a focus on respiratory challenge tests, as well as on the current mechanistic concepts and the pharmacological implications of this relationship.


Keywords: Panic disorder; Anxiety; Respiration; Hyperventilation; Carbon dioxide.


Case Report

13 - Sternal osteomyelitis caused by infection with Mycobacterium tuberculosis

Osteomielite esternal por Mycobacterium tuberculosis

Diego Michelon De Carli, Mateus Dornelles Severo, Carlos Jesus Pereira Haygert, Marcelo Guollo, Alex Omairi, Vinícius Dallagasperina Pedro, Eduardo Pedrolo Silva, Arnaldo Teixeira Rodrigues

J Bras Pneumol.2009;35(7):709-712

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We report the case of a 74-year-old male patient with a one-year history of chest pain in the suprasternal notch associated with erythema, edema and drainage of purulent material from a fistulous lesion. The patient was HIV-negative with no history of TB. A CT scan of the chest showed an osteolytic lesion in the sternum, and a biopsy revealed caseous granuloma, which, in the microbiological evaluation, was negative for fungi and acid-fast bacilli. The diagnosis of sternal osteomyelitis caused by Mycobacterium tuberculosis was confirmed using PCR.


Keywords: Thorax; Mycobacterium infections; Tuberculosis, osteoarticular; Sternum; Diagnosis.


14 - Bronchial casts attributed to the use of pegylated interferon and ribavirin

Molde brônquico devido ao uso de interferon peguilado e ribavirina

Eduardo Garcia, Ângelo Ferreira da Silva Junior, Fabíola Schorr, Milene Hota, Ricardo Gondim Brizzi, André Barreto da Silva

J Bras Pneumol.2009;35(7):713-716

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We report the case of a 53-year-old male patient with a rare profile: bronchial casts associated with the use of pegylated interferon and ribavirin. The patient sought treatment in a pulmonology clinic with a history of progressive dyspnea for four months that had evolved to progressive cough followed by frequent and abundant elimination of bronchial casts. The patient was initially treated with bronchodilators, as well as with oral and inhaled corticosteroids. Fiberoptic bronchoscopy, bronchoalveolar lavage and sputum analysis were carried out but did not contribute to the elucidation of the diagnosis. The symptoms developed while the patient was receiving pegylated interferon and ribavirin for the treatment of hepatitis C. The symptoms resolved 30 days after the discontinuation of the treatment. To our knowledge, this is the first report of bronchial casts caused by the use of pegylated interferon and ribavirin.


Keywords: Bronchitis; Interferons/adverse effects; Ribavirin/adverse effects.


15 - inflamSoft tissue Rosai-Dorfman disease of the posterior mediastinum

Doença de Rosai-Dorfman de partes moles no mediastino posterior

Antônio Luiz Penna Costa, Natália Oliveira e Silva, Marina Pamponet Motta, Rodrigo Abensur Athanazio, Daniel Abensur Athanazio, Paulo Roberto Fontes Athanazi

J Bras Pneumol.2009;35(7):717-720

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Rosai-Dorfman disease (RDD) consists of sinus histiocytosis with massive lymphadenopathy. Extranodal involvement occurs in up to 43% of cases. However, isolated soft tissue RDD is rare. Isolated mediastinal RDD is exceedingly rare, and there have been only three previous reports. Involvement of the posterior mediastinum in RDD has been reported only in the context of disseminated RDD. Here, we report the case of a 49-year-old female patient with a two-year history of cervical pain and lymphadenomegaly, which resolved spontaneously. A CT scan revealed a left paravertebral mass with a diameter of 6 cm. The patient was submitted to surgical excision of the mass. Microscopic examination and immunophenotyping of the surgical specimen led to a diagnosis of RDD. During a 12-month follow-up period, the patient complained of mild cough and chest pain. Periodic imaging tests showed no sign of recurrence, and no postoperative cervical lymphadenomegaly was detected.


Keywords: Histiocytosis, sinus; Soft tissue neoplasms; Mediastinal neoplasms; Mediastinum.



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