Brazilian Journal of Pulmonology

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


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Year 2009 - Volume 35  - Number 12  (/December)


1 - A national scientific treasure

Um patrimônio científico nacional

José Antônio Baddini Martinez

J Bras Pneumol.2009;35(12):1165-1167

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Original Article

2 - Risk factors for ER visits due to asthma exacerbations in patients enrolled in a program for the control of asthma and allergic rhinitis in Feira de Santana, Brazil

Fatores de risco para visitas à emergência por exacerbações de asma em pacientes de um programa de controle da asma e rinite alérgica em Feira de Santana, BA

Heli Vieira Brandão, Constança Sampaio Cruz, Murilo Cerqueira Pinheiro, Edgar Adolfo Costa, Armênio Guimarães, Adelmir Souza-Machado, Álvaro Augusto Cruz

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the risk factors for ER visits due to asthma exacerbations in patients monitored at a referral center. Methods: Prospective cohort study of 253 outpatients (children and adults) with asthma who were monitored for 12 months at the Referral Center of the Program for the Control of Asthma and Allergic Rhinitis in the city of Feira de Santana, Brazil. Results: Exacerbations were common, and 36.5% of the patients sought ER treatment within the twelve-month period. The risk factors for asthma exacerbations were being over 20 years of age (OR = 1.34: (95% CI: 1.06-1.70), residing in an urban area (OR = 1.19; 95% CI: 1.06-1.33); having a low level of education (OR = 1.53: 95% CI: 1.00-2.39); having severe asthma (OR = 1.65; 95% CI: 1.24-2.18); and having chronic rhinitis (OR = 2.20; 95% CI: 1.00-4.80). Conclusions: In this cohort, having chronic rhinitis, having asthma that is more severe and having a low level of education were the main risk factors for ER visits due to asthma exacerbations. These results are similar to those reported for asthma patients who are receiving no regular treatment.


Keywords: Asthma/etiology; Health services; Program evaluation.


3 - Diaphragmatic dysfunction and mortality in patients with COPD

Disfunção diafragmática e mortalidade em pacientes portadores de DPOC

Wellington Pereira dos Santos Yamaguti, Elaine Paulin, João Marcos Salge, Maria Cristina Chammas, Alberto Cukier, Celso Ricardo Fernandes de Carvalho

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether COPD patients with diaphragmatic dysfunction present higher risk of mortality than do those without such dysfunction. Methods: We evaluated pulmonary function, diaphragm mobility and quality of life, as well as determining the Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) index, in 42 COPD patients. The patients were allocated to two groups according to the degree to which diaphragm mobility was impaired: low mobility (LM; mobility ≤ 33.99 mm); and high mobility (HM; mobility ≥ 34.00 mm). The BODE index and the quality of life were quantified in both groups. All patients were followed up prospectively for up to 48 months in order to determine the number of deaths resulting from respiratory complications due to COPD. Results: Of the 42 patients evaluated, 20 were allocated to the LM group, and 22 were allocated to the HM group. There were no significant differences between the groups regarding age, lung hyperinflation or quality of life. However, BODE index values were higher in the LM group than in the HM group (p = 0.01). During the 48-month follow-up period, there were four deaths within the population studied, and all of those deaths occurred in the LM group (15.79%; p = 0.02). Conclusions: These findings suggest that COPD patients with diaphragmatic dysfunction, characterized by low diaphragm mobility, have a higher risk of death than do those without such dysfunction.


Keywords: Pulmonary disease, chronic obstructive/mortality; Diaphragm; Exercise tolerance; Quality of life.


4 - Prevalence of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis

Prevalência da doença do refluxo gastroesofágico em pacientes com fibrose pulmonar idiopática

Cristiane Dupont Bandeira, Adalberto Sperb Rubin, Paulo Francisco Guerreiro Cardoso, José da Silva Moreira, Mirna da Mota Machado

J Bras Pneumol.2009;35(12):1182-1189

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Objective: To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate its clinical presentation, as well as the esophageal function profile in patients with idiopathic pulmonary fibrosis (IPF). Methods: In this prospective study, 28 consecutive patients with IPF underwent stationary esophageal manometry, 24-h esophageal pH-metry and pulmonary function tests. All patients also completed a symptom and quality of life in GERD questionnaire. Results: In the study sample, the prevalence of GERD was 35.7%. The patients were then divided into two groups: GERD+ (abnormal pH-metry; n = 10) and GERD− (normal pH-metry; n = 18). In the GERD+ group, 77.7% of the patients presented at least one typical GERD symptom. The pH-metry results showed that 8 (80%) of the GERD+ group patients had abnormal supine reflux, and that the reflux was exclusively in the supine position in 5 (50%). In the GERD+ and GERD− groups, respectively, 5 (50.0%) and 7 (38.8%) of the patients presented a hypotensive lower esophageal sphincter, 7 (70.0%) and 10 (55.5%), respectively, presenting lower esophageal dysmotility. There were no significant differences between the groups regarding demographic characteristics, pulmonary function, clinical presentation or manometric findings. Conclusions: The prevalence of GERD in the patients with IPF was high. However, the clinical and functional characteristics did not differ between the patients with GERD and those without.


Keywords: Pulmonary fibrosis; Gastroesophageal reflux; Prevalence; Manometry; Esophageal pH monitoring.


5 - Influence that oscillating positive expiratory pressure using predetermined expiratory pressures has on the viscosity and transportability of sputum in patients with bronchiectasis

Influência da técnica de pressão expiratória positiva oscilante utilizando pressões expiratórias pré-determinadas na viscosidade e na transportabilidade do escarro em pacientes com bronquiectasia

Ercy Mara Cipulo Ramos, Dionei Ramos, Daniela Mizusaki Iyomasa, Graciane Laender Moreira, Kátia Cristina Teixeira Melegati, Luiz Carlos Marques Vanderlei, José Roberto Jardim, Adriana Siqueira de Oliveira

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the effectiveness of oscillating positive expiratory pressure (OPEP) using predetermined expiratory pressures on the viscosity and transportability of sputum in patients with bronchiectasis. Methods: The study involved 15 stable patients with bronchiectasis (7 males; mean age = 53 ± 16 years), submitted to two consecutive OPEP interventions, with a 24-h interval between the two, using positive expiratory pressures set at 15 cmH2O (P15) and 25 cmH2O (P25). The protocol consisted of a voluntary cough; another voluntary cough 20 min later, designated time zero (T0); a 10-min rest period; and two 10-min series (S1 and S2, using OPEP at P15 and P25 in both), with a 10-min interval between the two. The viscosity and transportability of sputum were evaluated by viscometry, relative transport velocity on frog palate, transport in a simulated cough machine and contact angle. Sputum samples were collected at T0, after S1 and after S2. Specific statistical tests were performed depending on the type of data distribution. Results: In comparison with the values obtained at T0, sputum viscosity decreased significantly after S1 at P15 and after S2 at P25. There were no significant differences among all of the samples in terms of transportability. Conclusions: The fact that sputum viscosity decreased whether OPEP was performed at P15 or at P25 suggests that there is no need to generate high expiratory pressure to achieve the desired result.


Keywords: Viscosity; Bronchiectasis; Physical therapy (specialty); Sputum.


6 - Knowledge of and practices related to smoking cessation among physicians in Nigeria

Conhecimento e práticas para a cessação do tabagismo entre médicos nigerianos

Olufemi Olumuyiwa Desalu, Adebowale Olayinka Adekoya, Adetokunbo Olujimi Elegbede, Adeolu Dosunmu, Tolutope Fasanmi Kolawole, Kelechukwu Chukwudi Nwogu

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the knowledge and practices of smoking cessation among physicians in Nigeria. Methods: We conducted a cross-sectional survey in Lagos and three geopolitical zones of Nigeria. A self-administered structured questionnaire was used to obtain information on tobacco use and its health effects, as well as on the knowledge and practices of smoking cessation, from 436 physicians. Results: Of the 436 physicians, 292 (67.0%) were aware of smoking cessation, but only 132 (30.3%) showed good knowledge on this topic. The prevalence of smoking among the physicians was 17.7%. In addition, 308 physicians (70.6%) reported that tobacco education in the medical school curriculum was inadequate. Of the 436 physicians, 372 (86.2%) asked their patients whether they smoked, and 172 (39.4%) asked their patients the reasons for using tobacco. As a means of smoking cessation intervention, 268 (61.5%) used brief advice/counseling (2-5 min), 12 (3.7%) prescribed antidepressants, 16 (2.8%) prescribed nicotine replacement therapy (NRT), and 76 (17.4%) arranged follow-up visits. When the physicians were questioned regarding the obstacles to smoking cessation interventions, 289 (66.3%) cited poor knowledge of the issue, 55 (12.6%) cited a lack of time, and 20 (4.6%) cited unavailability of NRT. Conclusions: The results of this study highlight the lack of knowledge among physicians in Nigeria in terms of smoking cessation, as well as their failure to apply appropriate practices. The results of this study can further the evaluation and formulation of guidelines on smoking cessation and smoking education programs for physicians. Our findings also underscore the need to offer smoking cessation programs in all treatment facilities.


Keywords: Smoking cessation; Tobacco; Physicians; Nigeria; Health knowledge, attitudes, practice.


7 - Random sample survey on the prevalence of smoking in the major cities of Brazil

Levantamento randomizado sobre a prevalência de tabagismo nos maiores municípios do Brasil

Fernando Sergio Leitão Filho, José Carlos Fernandes Galduróz, Ana Regina Noto, Solange Aparecida Nappo, Elisaldo Araújo Carlini, Oliver Augusto Nascimento, Sérgio Ricardo Santos, José Roberto Jardim

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Objective: To provide access to the results of a randomized cross-sectional study conducted by the Brazilian Center for Information on Psychotropic Drugs in 2001. Methods: This survey involved a random sample of individuals ranging from 12 to 65 years of age and residing in the 107 largest cities (over 200,000 inhabitants) in Brazil, which represented 27.7% of the Brazilian population, estimated to be 169,799,170 inhabitants at the time. A total of 8,589 interviews were conducted. The Substance Abuse and Mental Health Services Administration questionnaire, translated and adapted for use in Brazil, was used in the interviews. Results: Of the sample as a whole, 41.1% of the interviewees reported having experimented with tobacco products. The prevalence of daily smokers was 17.4% (20.3% among males and 14.8% among females). We found that 9% of the sample (10.1% of the men and 7.9% of the women) were nicotine-dependent, according to the criteria of the National Household Survey on Drug Abuse. Conclusions: The prevalence of current smoking in the 107 largest cities of Brazil is significantly lower in this decade than was the national prevalence at the end of last century.


Keywords: Smoking/epidemiology; Tobacco use disorder; Smoking cessation.


8 - Cord factor detection and macroscopic evaluation of mycobacterial colonies: an efficient combined screening test for the presumptive identification of Mycobacterium tuberculosis complex on solid media

Detecção do fator corda e avaliação do aspecto macroscópico das colônias de micobactérias: um eficiente teste de triagem combinado para a identificação presuntiva do complexo Mycobacterium tuberculosis em meios sólidos

Fernanda Cristina dos Santos Simeão, Erica Chimara, Rosângela Siqueira Oliveira, Jonas Umeoka Yamauchi, Fábio Oliveira Latrilha, Maria Alice da Silva Telles

J Bras Pneumol.2009;35(12):

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Objective: The rapid differentiation between Mycobacterium tuberculosis and nontuberculous mycobacteria is fundamental for patients co-infected with tuberculosis and HIV. To that end, we use two methods in our laboratory: detection of cord factor and PCR-restriction enzyme analysis (PRA). The objective of this study was to evaluate the accuracy of a screening test on solid medium as a rapid method for the presumptive identification of M. tuberculosis complex, considering costs and turnover time. Methods: A total of 152 strains were submitted to a combined screening test, consisting of the detection of cord factor under microscopy (Ziehl-Neelsen staining) and evaluation of the macroscopic aspect of colonies, as well as to PRA, which was used as the gold standard. Costs were estimated by calculating the price of all of the materials needed for each test. Results: The overall accuracy of cord factor detection alone was 95.4% (95% CI: 90.7-98.1%), and that of the combined screening test was 99.3% (95% CI: 96.4-100%). Cord factor detection costs US$ 0.25, whereas the PRA costs US$ 7.00. Results from cord factor detection are ready in 2 days, whereas PRA requires 4 days to yield results. Conclusions: The presumptive identification of M. tuberculosis using the macroscopic evaluation of colonies combined with cord factor detection under microscopy is a simple, rapid and inexpensive test. We recommend the combined screening test to rapidly identify M. tuberculosis in resource-poor settings and in less well-equipped laboratories while awaiting a definite identification by molecular or biochemical methods.


Keywords: Tuberculosis; Mycobacterium/classification; Polymerase chain reaction; Diagnostic tests, routine.


Brief Communication

9 - Evolução do estado nutricional de pacientes desnutridos ou com excesso de peso candidatos a transplante pulmonar

Giuliana Bastos Esteves, Alessandra Macedo, Miyoko Nakasato, Maria Lúcia Mendes Bruno

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

A retrospective study using anthropometric data to assess the evolution of nutritional status in lung transplant candidates who are initially malnourished or overweight. We included patients with an initial body mass index (BMI) < 17 kg/m2 (malnourished, n = 10) or > 27 kg/m2 (overweight, n = 20). Each patient subsequently had three appointments with a nutritionist (nutritional interventions). In the malnourished group, there were no significant post-intervention changes in the anthropometric variables. In the overweight group, however, nutritional intervention had a positive impact on weight, BMI and waist circumference.


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


Review Article

10 - Genetic associations with asthma and virus-induced wheezing: a systematic review

Associação genética da asma e da sibilância induzida por vírus: uma revisão sistemática

Leonardo Araujo Pinto, Renato Tetelbom Stein, José Dirceu Ribeiro

J Bras Pneumol.2009;35(12):

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Various wheezing phenotypes can be identified based on differences in natural histories, risk factors and responses to treatment. In epidemiologic studies, atopic asthma or virus-induced wheezing can be discriminated by the presence or the absence of sensitization to allergens. Children with asthma have been shown to present lower levels of lung function. Patients with viral respiratory infections evolve from normal lung function to enhanced airway reactivity. The objective of this study was to identify genes and polymorphisms associated with different wheezing phenotypes. Using data obtained from the Genetic Association Database, we systematically reviewed studies on genes and polymorphisms that have been associated with virus-induced wheezing or atopic asthma. The research was carried out in February of 2009. Genes associated with the studied outcomes in more than three studies were included in the analysis. We found that different genes and loci have been associated with virus-induced wheezing or atopic asthma. Virus-induced wheezing has frequently been associated with IL-8 polymorphisms, whereas atopic asthma and atopy have frequently been associated with Th2 cytokine gene (CD14 and IL-13) polymorphisms on chromosome 5. This review provides evidence that different wheezing disorders in childhood can be differently affected by genetic variations, considering their role on airway inflammation and atopy. Future studies of genetic associations should consider the different wheezing phenotypes in infancy. In addition, stratified analyses for atopy can be useful for elucidating the mechanisms of the disease.


Keywords: Genetics; Polymorphism, genetic; Asthma; Interleukins; Respiratory syncytial viruses.


11 - The role of oxidative stress in COPD: current concepts and perspectives

O papel do estresse oxidativo na DPOC: conceitos atuais e perspectivas

Antonio George de Matos Cavalcante, Pedro Felipe Carvalhedo de Bruin

J Bras Pneumol.2009;35(12):1227-1237

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Worldwide, COPD is a major cause of morbidity and mortality. The clinical and functional manifestations of COPD result from lung injury occurring through various mechanisms, including oxidative stress, inflammation, protease-antiprotease imbalance and apoptosis. Oxidative stress is central to the pathogenesis of COPD, since it can directly damage lung structures and exacerbate the other mechanisms involved. The cellular and molecular events involved in such lung injury are believed to occur long before the clinical and functional expression of COPD. Although the use of bronchodilators is currently the principal treatment for COPD, bronchodilators have little or no effect on disease progression. A better understanding of the pathogenesis of COPD, together with renewed efforts in basic and clinical research, will allow the diagnosis of COPD at a pre-clinical stage and provide more appropriate monitoring of disease activity, as well as leading to the development of novel therapeutic agents that will effectively prevent the progression of the disease.


Keywords: Pulmonary disease, chronic obstructive; Oxidative stress; Oxidants; Antioxidants; Inflammation.


Update Course - Mycoses

12 - Chapter 5 - Aspergillosis: from diagnosis to treatment

Capítulo 5 - Aspergilose: do diagnóstico ao tratamento

Maria da Penha Uchoa Sales

J Bras Pneumol.2009;35(12):

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Aspergillosis is a multifaceted disease whose clinical manifestations (allergic, saprophytic and invasive forms) are determined by the host immune response. Allergic bronchopulmonary aspergillosis is characterized by corticosteroid-dependent asthma, fever, hemoptysis and destruction of the airways, which can evolve to fibrosis with honeycombing. The treatment consists of the combined use of a corticosteroid and itraconazole. Invasive pulmonary aspergillosis, which has a worse prognosis, is diagnosed based on histopathological documentation and positive culture of a sterile specimen. The treatment response obtained with voriconazole is better, in terms of survival and safety, than that obtained with amphotericin B. In patients with chronic pulmonary disease who are mildly immunocompromised, chronic necrotizing pulmonary aspergillosis causes progressive destruction of the lung. Such patients are treated with oral itraconazole. Chronic cavitary pulmonary aspergillosis causes multiple cavities, with or without aspergilloma, accompanied by pulmonary and systemic symptoms. In patients with chronic pulmonary disease, the aspergilloma is characterized by chronic productive cough and hemoptysis, together with a cavity containing a rounded, sometimes mobile, mass separated from the cavity wall by airspace. Surgical resection is the definitive treatment for both types of aspergillosis. Triazole fungicides provide long-term treatment benefits with minimal risk.


Keywords: Aspergillosis; Pulmonary aspergillosis; Lung diseases, fungal.


13 - Chapter 6 - Paracoccidioidomycosis

Capítulo 6 - Paracoccidioidomicose

Bodo Wanke, Miguel Abidon Aidê

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Paracoccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis. The disease is restricted to Latin America. It is the principal systemic mycosis in Brazil, with higher incidences in the southern, southeastern and central regions. The disease is acquired by inhaling fungal propagules. In endemic areas, the primary infection occurs during childhood and involves the immune system. The most common chronic form of paracoccidioidomycosis in adults is the multifocal form, in which there is dissemination to the lungs, lymph nodes, skin and mucosae. This form of the disease has a chronic progression, and the diagnosis is typically delayed. Cough, dyspnea and weight loss due to cutaneous and mucosal lesions are evident and are the principal complaints reported by paracoccidioidomycosis patients. Chest X-rays reveal diffuse reticulonodular infiltrates, which are more evident in the upper lobes. The etiologic diagnosis is based on the identification of P. brasiliensis in clinical specimens, such as lymph node aspirates or BAL fluid, by direct microscopy and culture. Histopathological testing of tissue samples reveals the thick birefringent cell wall of the fungus and the typical pattern of multiple budding around the mother cell. Double agar gel immunodiffusion is useful for the diagnosis when the fungus cannot be detected through mycological tests. Although paracoccidioidomycosis is most often treated with the sulfamethoxazole-trimethoprim combination, itraconazole is preferable. Amphotericin B is used in severe cases.


Keywords: Paracoccidioidomycosis; Mycosis; Lung diseases, fungal.


Case Report

14 - Complex tracheal lesion: correction with an intercostal muscle pedicle flap

Lesão complexa da traqueia: correção com retalho pediculado de músculo intercostal

Hylas Paiva da Costa Ferreira, Carlos Alberto Almeida de Araújo, Jeancarlo Fernandes Cavalcante, Ronnie Peterson de Melo Lima

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Esophageal reconstruction is one of the most complex types of gastrointestinal surgery, principally when it is performed using minimally invasive techniques. The procedure is associated with various complications, such as anastomotic dehiscence, chylothorax, esophageal necrosis and fistulae. We report the case of a patient diagnosed with epidermoid carcinoma in the distal third of the esophagus. The patient was submitted to esophagectomy by video-assisted thoracoscopy and laparoscopy. During the operation, the left main bronchus was injured, and this required immediate surgical correction. In the postoperative period, the patient presented with acute respiratory failure and profuse air leak through the thoracic drains and through the cervical surgical wound. The patient underwent a second surgical procedure, during which a large lesion was discovered in the membranous wall of the trachea. The lesion was corrected with an intercostal muscle pedicle flap.


Keywords: Trachea; Esophageal fistula; Respiratory tract fistula; Intercostal muscles; Esophagectomy.


15 - Hard metal lung disease in an oil industry worker

Doença pulmonar por metal duro em trabalhador da indústria petrolífera

Patrícia Nunes Bezerra, Ana Giselle Alves Vasconcelos, Lílian Loureiro Albuquerque Cavalcante,Vanessa Beatriz de Vasconcelos Marques, Teresa Neuma Albuquerque Gomes Nogueira,Marcelo Alcantara Holanda

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Hard metal lung disease, which manifests as giant cell interstitial pneumonia, is caused by exposure to hard metal dust. We report the case of an oil industry worker diagnosed with hard metal lung disease. The diagnosis was based on the clinical, radiological and anatomopathological analysis, as well as on pulmonary function testing.


Keywords: Alloys/adverse effects; Cobalt; Tungsten; Occupational exposure; Lung diseases, interstitial.


16 - Primary complex of paracoccidioidomycosis and hypereosinophilia

Complexo primário da paracoccidioidomicose e hipereosinofilia

Roberto Martinez, Maria Janete Moya

J Bras Pneumol.2009;35(12):

Abstract PDF PT PDF EN Portuguese Text

Primary infection with Paracoccidioides brasiliensis has rarely been observed. A 28-year-old male patient presented with a three-month history of fever, respiratory symptoms and malaise. Chest X-rays revealed bilateral apical infiltrates, right pleuritis and hilar lymphadenomegaly. The patient presented with leukocytosis, severe eosinophilia and increasing titers of anti-P. brasiliensis antibodies in serum. To our knowledge, this is the first report of the primary pulmonary lymph node complex of paracoccidioidomycosis accompanied by hypereosinophilia and affecting a previously healthy adult.


Keywords: Paracoccidioidomycosis; Eosinophilia; Lung diseases, fungal.


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