Objective: To determine the frequency of near-fatal asthma in a group of severe asthma patients, as well as the clinical characteristics and prognosis of these patients within a one-year follow-up period. Methods: A prospective study involving 731 low-income patients with severe asthma treated at a referral outpatient clinic located in the city of Salvador, Brazil. The patients were submitted to spirometry at admission, received medications for asthma, and were monitored regarding the frequency of asthma exacerbations during the follow-up period. A subsample of 511 patients also completed questionnaires regarding asthma symptoms and asthma-related quality of life. Results: Of the 731 patients studied, 563 (77%) were female. The median age was 47 years, and 12% were illiterate. Most of the patients had rhinitis, and 70 patients (10%) reported near-fatal asthma prior to admission. Of these 70 patients, 41 (59%) reported having been intubated previously. The patients reporting a history of near-fatal asthma at admission were more likely to have asthma exacerbations during the follow-up period and to respond poorly to therapy than were those not reporting such a history. At the end of the follow-up period, the scores on the two questionnaires were similar between the two groups of patients. Conclusions: The frequency of near-fatal asthma was high in this group of low-income patients with severe asthma. The patients with a history of near-fatal asthma had a worse prognosis than did those without such a history, although both groups had received the same kind of treatment. Curiously, the intensity of symptoms and the quality of life at the end of the study were similar between the two groups.

Keywords: Asthma/prevention and control; Asthma/complications; Quality of life; Prognosis.

Objective: To determine the frequency of near-fatal asthma in a group of severe asthma patients, as well as the clinical characteristics and prognosis of these patients within a one-year follow-up period. Methods: A prospective study involving 731 low-income patients with severe asthma treated at a referral outpatient clinic located in the city of Salvador, Brazil. The patients were submitted to spirometry at admission, received medications for asthma, and were monitored regarding the frequency of asthma exacerbations during the follow-up period. A subsample of 511 patients also completed questionnaires regarding asthma symptoms and asthma-related quality of life. Results: Of the 731 patients studied, 563 (77%) were female. The median age was 47 years, and 12% were illiterate. Most of the patients had rhinitis, and 70 patients (10%) reported near-fatal asthma prior to admission. Of these 70 patients, 41 (59%) reported having been intubated previously. The patients reporting a history of near-fatal asthma at admission were more likely to have asthma exacerbations during the follow-up period and to respond poorly to therapy than were those not reporting such a history. At the end of the follow-up period, the scores on the two questionnaires were similar between the two groups of patients. Conclusions: The frequency of near-fatal asthma was high in this group of low-income patients with severe asthma. The patients with a history of near-fatal asthma had a worse prognosis than did those without such a history, although both groups had received the same kind of treatment. Curiously, the intensity of symptoms and the quality of life at the end of the study were similar between the two groups.

Keywords: Asthma/prevention and control; Asthma/complications; Quality of life; Prognosis.

Objective: To analyze the epidemiological characteristics of sarcoidosis patients in the city of Rio de Janeiro, Brazil. Methods: A descriptive, case-control study involving 100 sarcoidosis patients under outpatient treatment between 2008 and 2010 at the Pedro Ernesto University Hospital, located in the city of Rio de Janeiro, Brazil. The diagnosis of sarcoidosis was based on clinical, radiological, biochemical, and histopathological criteria. Results: There was a predominance of females in the 35-40 year age bracket (range, 7-69 years), who accounted for 65% of the sample, although there was a second peak at approximately 55 years of age. The most common symptom was dyspnea (in 47%), and the most common radiological findings were pulmonary and lymph node involvement (stage II; in 43%), followed by stage III (in 20%), stage I (in 19%), stage 0 (in 15%), and stage IV (in 3%). No pleural effusion or digital clubbing was observed at diagnosis. The tuberculin skin test was negative in 94 patients. Spirometric findings at diagnosis were normal in 61 patients; indicative of obstructive lung disease in 21; and indicative of restrictive lung disease in 18. The most common biopsy sites were the lungs (principally by bronchoscopy) and the skin, the diagnosis being confirmed by biopsy in 56% and 29% of the cases, respectively. Treatment with prednisone was initiated in 75% of the patients and maintained for more than 2 years in 19.7%. Conclusions: This study corroborates the findings of previous studies regarding the epidemiological characteristics of sarcoidosis patients.

Keywords: Sarcoidosis/epidemiology; Sarcoidosis/diagnosis; Sarcoidosis/therapy.

Objective: To develop a set of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) for use in Brazil and to investigate the usefulness of these descriptors in four distinct clinical conditions that can be accompanied by dyspnea. Methods: We collected 111 dyspnea descriptors from 67 patients and 10 health professionals. These descriptors were analyzed and reduced to 15 based on their frequency of use, similarity of meaning, and potential pathophysiological value. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. Results: The use of this set of descriptors led to a solution with seven clusters, designated sufoco (suffocating), aperto (tight), rápido (rapid), fadiga (fatigue), abafado (stuffy), trabalho/inspiração (work/inhalation), and falta de ar (shortness of breath). Overlapping of descriptors was quite common among the patients, regardless of their clinical condition. Asthma was significantly associated with the sufoco and trabalho/inspiração clusters, whereas COPD and heart failure were associated with the sufoco, trabalho/inspiração, and falta de ar clusters. Obesity was associated only with the falta de ar cluster. Conclusions: In Brazil, patients who are accustomed to perceiving dyspnea employ various descriptors in order to describe the symptom, and these descriptors can be grouped into similar clusters. In our study sample, such clusters showed no usefulness in differentiating among the four clinical conditions evaluated.

Keywords: Dyspnea; Pulmonary disease, chronic obstructive; Asthma; Heart failure.

Objective: To investigate the usefulness of descriptive terms applied to the sensation of dyspnea (dyspnea descriptors) that were developed in English and translated to Brazilian Portuguese in patients with four distinct clinical conditions that can be accompanied by dyspnea. Methods: We translated, from English to Brazilian Portuguese, a list of 15 dyspnea descriptors reported in a study conducted in the USA. Those 15 descriptors were applied in 50 asthma patients, 50 COPD patients, 30 patients with heart failure, and 50 patients with class II or III obesity. The three best descriptors, as selected by the patients, were studied by cluster analysis. Potential associations between the identified clusters and the four clinical conditions were also investigated. Results: The use of this set of descriptors led to a solution with nine clusters, designated expiração (exhalation), fome de ar (air hunger), sufoco (suffocating), superficial (shallow), rápido (rapid), aperto (tight), falta de ar (shortness of breath), trabalho (work), and inspiração (inhalation). Overlapping of the descriptors was quite common among the patients, regardless of their clinical condition. Asthma, COPD, and heart failure were significantly associated with the inspiração cluster. Heart failure was also associated with the trabalho cluster, whereas obesity was not associated with any of the clusters. Conclusions: In our study sample, the application of dyspnea descriptors translated from English to Portuguese led to the identification of distinct clusters, some of which were similar to those identified in a study conducted in the USA. The translated descriptors were less useful than were those developed in Brazil regarding their ability to generate significant associations among the clinical conditions investigated here.

Keywords: Dyspnea; Pulmonary disease, chronic obstructive; Asthma; Heart failure.

Objective: To evaluate the acceptability and reproducibility of spirometry in preschool children; to estimate the effect size of early termination of exhalation (ETE) on FVC, FEV1 and FEV0.5; and to evaluate the validity of FEV0.5 in curves with ETE. Methods: Spirometric data were obtained from 240 healthy preschool children, who were selected by simple sampling. On the basis of the best curve from each child according to the end of exhalation, three groups were formed: no ETE (nETE); ETE and flow ≤ 10% of the highest PEF (ETE≤10); and ETE and flow > 10% of the highest PEF value (ETE>10). The reproducibility of FVC, FEV1 and FEV0.5 was compared among the three groups. The effect of ETE on FVC, FEV1, and FEV0.5 was assessed. Results: Of the 240 children tested, 112 (46.5%)-82 (34.0%) of those in the nETE group and 30 (12.5%) of those in the ETE≤10 group-had acceptable curves for all the parameters. In 64 (27.0%) of those in the ETE>10 group, the curves were acceptable only for FEV0.5, increasing the proportion of children with valid FEV0.5 to 73.0%. There were no significant differences between the nETE and ETE≤10 groups in terms of the mean values of the parameters assessed. Conclusions: Maneuvers with ETE and flow ≤ 10% of the highest PEF are valid. In individuals with a flow > 10% of the highest PEF value, these maneuvers are only valid for FEV0.5.

Keywords: Spirometry; Child, preschool; Vital capacity; Forced expiratory volume; Reproducibility of results.

Objective: To evaluate submaximal exercise tolerance and respiratory muscle strength in relation to forward head posture (FHP) and respiratory mode in children, comparing mouth-breathing (MB) children with nasal-breathing (NB) children. Methods: This was a controlled, analytical cross-sectional study involving children in the 8-12 year age bracket with a clinical otorhinolaryngology diagnosis of MB, recruited between October of 2010 and January of 2011 from the Mouth Breather Clinic at the State University of Campinas Hospital de Clínicas, located in the city of Campinas, Brazil. The exclusion criteria were obesity, asthma, chronic respiratory diseases, heart disease, and neurological or orthopedic disorders. All of the participants underwent postural assessment and the six-minute walk test (6MWT), together with determination of MIP and MEP. Results: Of the 92 children in the study, 30 presented with MB and 62 presented with NB. In the MB group, the differences between those with moderate or severe FHP and those with normal head posture, in terms of the mean MIP, MEP and six-minute walk distance (6MWD), were not significant (p = 0.079, p = 0.622, and p = 0.957, respectively). In the NB group, the mean values of MIP and MEP were higher in the children with moderate FHP than in those with normal head posture (p = 0.003 and p = 0.004, respectively). The mean MIP, MEP, and 6MWD were lower in the MB group than in the NB group. Values of MIP and MEP were highest in the children with moderate FHP. Conclusions: Respiratory biomechanics and exercise capacity were negatively affected by MB. The presence of moderate FHP acted as a compensatory mechanism in order to improve respiratory muscle function.

Keywords: Mouth breathing; Posture; Exercise tolerance; Respiratory mechanics.

Objective: To determine the prevalence of smoking and the frequency of smoking cessation counseling among patients at a university hospital, as well as to compare smokers and former smokers in terms of smoking history. Methods: A cross-sectional study involving 629 patients at the Federal University of Paraná Hospital de Clínicas, located in the city of Curitiba, Brazil. Results: Of the 629 patients, 206 (32.7%) were male, 76 (12.1%) were smokers, 179 (28.5%) were former smokers, and 374 (59.5%) were nonsmokers. The mean age of the patients was 49.9 ± 15.0 years (range, 18-84 years). Of the 76 smokers and 179 former smokers, 72 (94.7%) and 166 (92.7%), respectively, were questioned about tobacco use. Smoking history and degree of nicotine dependence were higher among the former smokers (p = 0.0292 and p = 0.0125, respectively). Gender, age at smoking initiation, physician inquiry about tobacco use, and smoking cessation counseling were comparable between the two groups. The smoking cessation rate was 0.70. The prevalence of heavy smoking varied by gender and by age bracket, being higher in males and in the 41-70 year age bracket. Conclusions: The smoking prevalence in this group of patients was lower than that reported for patients at another university hospital, for adults in Curitiba, and for adults in Brazil. The smoking cessation rate was higher in these patients than in the general population of Curitiba. Smokers and former smokers differed regarding age, smoking history, and degree of nicotine dependence. Heavy smoking and a moderate or high degree of nicotine dependence were not obstacles to smoking cessation.

Keywords: Smoking/prevention & control; Smoking cessation; Hospitalization/statistics & numerical data.

Objective: To determine the prevalence and characteristics of smoking among inpatients at a university hospital, as well as to evaluate their motivation, interest, and need for help in quitting smoking. Methods: A prospective study involving inpatients treated between May of 2008 and April of 2009 on the cardiovascular disease wards at the Antonio Pedro University Hospital, located in the city of Niterói, Brazil. All inpatients were asked to complete a questionnaire designed to collect data regarding demographics, reasons for admission, and smoking status. The smokers also responded to additional questions regarding their smoking habits. The level of nicotine dependence was determined with the Fagerström Test for Nicotine Dependence. Results: Of the 136 inpatients who participated in the study, 68 (50.0%) were male. The mean age was 60.7 years. The prevalence of smoking was 13.2%. Among the 49 patients with coronary disease, 36 (73.5%) were smokers or former smokers. The majority of the patients presented with a high level of nicotine dependence and reported withdrawal symptoms during hospitalization. Although most smokers were motivated to quit smoking, they admitted that they needed help to do so. Conclusions: Because smoking is forbidden in the hospital environment and most inpatients who smoke are highly motivated to quit, health professionals should view the hospitalization period as an opportunity to promote smoking cessation.

Keywords: Smoking; Inpatients; Smoking cessation.

Objective: Levels of procalcitonin, midregional pro-atrial natriuretic peptide (MR-proANP), C-terminal provasopressin (copeptin), and C-reactive protein (CRP), as well as Sequential Organ Failure Assessment (SOFA) scores, are associated with severity and described as predictors of outcome in ventilator-associated pneumonia (VAP). This study sought to compare the predictive value of these biomarkers for mortality in VAP. Methods: An observational study of 71 patients with VAP. Levels of procalcitonin, MR-proANP, copeptin, and CRP, together with SOFA scores, were determined at VAP onset, designated day 0 (D0), and on day 4 of treatment (D4). Patients received empirical antimicrobial therapy, with modifications based on culture results. Patients who died before D28 were classified as nonsurvivors. Results: Of the 71 patients evaluated, 45 were classified as survivors. Of the 45 survivors, 35 (77.8%) received appropriate antimicrobial therapy, compared with 18 (69.2%) of the 26 nonsurvivors (p = 0.57). On D0 and D4, the levels of all biomarkers (except CRP), as well as SOFA scores, were lower in eventual survivors than in eventual nonsurvivors. For D0 and D4, the area under the ROC curve was largest for procalcitonin. On D0, MR-proANP had the highest positive likelihood ratio (2.71) and positive predictive value (0.60), but procalcitonin had the highest negative predictive value (0.87). On D4, procalcitonin had the highest positive likelihood ratio (3.46), the highest positive predictive value (0.66), and the highest negative predictive value (0.93). Conclusions: The biomarkers procalcitonin, MR-proANP, and copeptin can predict mortality in VAP, as can the SOFA score. Procalcitonin alone has the greatest predictive power for such mortality.

Keywords: Pneumonia, ventilator-associated/mortality; Biological markers/analysis; Health Status Indicators.

Objective: To describe the outcomes of retreatment in tuberculosis patients receiving the regimen known, in Brazil, as regimen 3 (streptomycin, ethambutol, ethionamide, and pyrazinamide for 3 months + ethambutol and ethionamide for 9 months) after treatment failure with the basic regimen (rifampin, isoniazid, and pyrazinamide for 2 months + rifampin and isoniazid for 4 months). Methods: A descriptive, uncontrolled, historical cohort study involving adult tuberculosis patients treated with regimen 3. We evaluated adverse drug effects, recurrence, treatment outcomes, and associated factors. Results: The study included 229 patients. The overall cure rate was 62%. For the patients who used the medications regularly and those who did not, the cure rate was 88% and 31%, respectively. Adverse events occurred in 95 patients (41.5%), and most of those events were related to the gastrointestinal tract. In the five-year follow-up period, relapse occurred in 17 cases (12.0%). Conclusions: Overall, the outcomes of treatment with regimen 3 were unsatisfactory, in part because this regimen was administered to a selected population of patients at high risk for noncompliance with treatment, as well as because it presents high rates of adverse effects, especially those related to the gastrointestinal tract, which might be caused by ethionamide. However, for those who took the medications regularly, the cure rate was satisfactory. The recurrence rate was higher than that recommended in international consensus guidelines, which might be attributable to the short (12-month) treatment period. We believe that regimen 3, extended to 18 months, represents an option for patients with proven treatment compliance.

Keywords: Tuberculosis, pulmonary/therapy; Treatment outcome; Retreatment.

Objective: To estimate the total time elapsed between symptom onset and diagnosis of pulmonary tuberculosis (patient delay plus health care system delay), analyzing the factors associated with delayed diagnosis in the state of Rio de Janeiro, Brazil. Methods: We conducted a questionnaire-based survey involving 218 pulmonary tuberculosis patients treated for two months at 20 health care clinics and 3 hospitals in eight cities within the state of Rio de Janeiro. We collected socioeconomic and demographic data, as well as data regarding the health care system and the medical history of the patients. Results: The median time elapsed from the onset of symptoms to diagnosis was 68 days (interquartile range [IQR]: 35-119 days). The median patient delay (time from symptom onset to initial medical visit) was 30 days (IQR: 15-60 days), and the median health care system delay (time from initial medical visit to diagnosis) was 21 days (IQR: 8-47 days). A cut-off point of 21 days was adopted. The factors independently associated with patient delay were female gender, cough, and unemployment [adjusted OR (95% CI) = 2.7 (1.3-5.6); 11.6 (2.3-58.8); and 2.0 (1.0-3.8), respectively], whereas only female gender was independently associated with health care system delay (OR= 3.2; 95% CI: 1.7-6.0). Conclusions: Delayed diagnosis of pulmonary tuberculosis remains a problem in Rio de Janeiro, increasing the risk of transmission and mortality, that risk being greater for women and the socioeconomically disadvantaged. Patients might not recognize the significance of chronic cough as a health problem. Tuberculosis education programs targeting women might improve this situation.

Keywords: Lung neoplasms; Neoplasm metastasis; Antineoplastic combined chemotherapy protocols; Radiotherapy, computer-assisted.

Objective: To identify nontuberculous mycobacteria (NTM) isolated from sterile sites in patients hospitalized between 2001 and 2006 at the Clementino Fraga Filho University Hospital, located in the city of Rio de Janeiro, Brazil. Methods: During the study period, 34 NTM isolates from sterile sites of 14 patients, most of whom were HIV-positive, were submitted to phenotypic identification and hsp65 PCR-restriction enzyme analysis (PRA). Results: Most isolates were identified as Mycobacterium avium, followed by M. monacense, M. kansasii, and M. abscessus. Conclusions: The combination of PRA, a relatively simple and inexpensive method, with the evaluation of a few phenotypic characteristics can allow NTM to be accurately identified in the routine of clinical laboratories.

Keywords: Mycobacteria, atypical; Molecular biology; Polymerase chain reaction.

Approximately seven million Brazilians over 40 years of age have COPD. In recent years, major advances have been made in the pharmacological treatment of this condition. We performed a systematic review including original articles on pharmacological treatments for COPD. We reviewed articles written in English, Spanish, or Portuguese; published between 2005 and 2009; and indexed in national and international databases. Articles with a sample size < 100 individuals were excluded. The outcome measures were symptoms, pulmonary function, quality of life, exacerbations, mortality, and adverse drug effects. Articles were classified in accordance with the Global Initiative for Chronic Obstructive Lung Disease criteria for the determination of the level of scientific evidence (grade of recommendation A, B, or C). Of the 84 articles selected, 40 (47.6%), 18 (21.4%), and 26 (31.0%) were classified as grades A, B, and C, respectively. Of the 420 analyses made in these articles, 236 were regarding the comparison between medications and placebos. Among these 236 analyses, the most commonly studied medications (in 66, 48, and 42 analyses, respectively) were long-acting anticholinergics; the combination of long-acting 2 agonists and inhaled corticosteroids; and inhaled corticosteroids in isolation. Pulmonary function, adverse effects, and symptoms as outcomes generated 58, 54, and 35 analyses, respectively. The majority of the studies showed that the medications evaluated provided symptom relief; improved the quality of life and pulmonary function of patients; and prevented exacerbations. Few studies analyzed mortality as an outcome, and the role that pharmacological treatment plays in this outcome has yet to be fully defined. The medications studied are safe to use in the management of COPD and have few adverse effects.

Keywords: Pulmonary disease, chronic obstructive/therapy; Pulmonary disease, chronic obstructive/mortality; Review.

Pulmonary rehabilitation programs are aimed at providing benefits to COPD patients, in various aspects. Our objective was to review the literature on COPD patient rehabilitation. This systematic review involved articles written in English, Spanish, or Portuguese; published between 2005 and 2009; and indexed in national and international databases. Articles were classified in accordance with the Global Initiative for Chronic Obstructive Lung Disease criteria for the determination of the level of scientific evidence (grade of recommendation A, B, or C). The outcome measures were exercise, quality of life, symptoms, exacerbations, mortality, and pulmonary function. Treatments were classified as standard rehabilitation, partial rehabilitation, strength exercises, and resistance exercises. Of the 40 articles selected, 4, 18, and 18 were classified as grades A, B, and C, respectively. Of the 181 analyses made in these articles, 61, 50, 23, 23, 20, and 4, respectively, were related to the outcome measures quality of life, exercise, symptoms, exacerbations, pulmonary function, and mortality. The standard rehabilitation programs showed positive effects on all of the outcomes evaluated, except for mortality (because of the small number of analyses). However, we found no differences among the various rehabilitation programs regarding their effects on the outcomes studied. Rehabilitation programs can be considered important tools for the treatment of COPD. Therefore, health administrators should implement public policies including such programs in the routine of health care facilities.

Keywords: Rehabilitation; Pulmonary disease, chronic obstructive; Review.

We report the case of a 58-year-old male patient who was referred for oncology consultation due to an epigastric mass that had been growing rapidly for three months. Diagnostic investigation revealed that the mass was a metastasis of stage IV lung adenocarcinoma. The patient received five cycles of chemotherapy with cisplatin and gemcitabine as a first-line treatment, which was interrupted due to major adverse events. Although the pulmonary disease stabilized, the cutaneous disease progressed. The patient then received pemetrexed as a second-line chemotherapy, together with concurrent external radiotherapy, which was well tolerated. There was complete remission of the epigastric mass. However, the patient died three months after the treatment. Here, we emphasize the importance of a multidisciplinary approach and of its role in individualizing the treatment.

Keywords: Lung neoplasms; Neoplasm metastasis; Antineoplastic combined chemotherapy protocols; Radiotherapy, computer-assisted.