Background: Empyema is a serious disease classically characterized by purulence within the pleural cavity. Early diagnosis demands immediate treatment, although there is still great controversy surrounding the question of what is the best therapy. Objective: To analyze the method of using thoracentesis and pleural irrigation, combined with the intrapleural application of an antimicrobial agent, to treat empyema - and to compare this method with others described in the literature. Method: Between January 1999 and May 2000, 17 patients diagnosed with loculated or diffuse pleural empyema were submitted to thoracentesis, followed by thorough washing of the pleural cavity with isotonic solution and intrapleural administration of a non-irritating antimicrobial agent to the pleura. Results: The group of patients studied consisted of 15 men and 2 women, and the average age was 44. The most common clinical symptoms were fever, productive cough, chest pain and dyspnea, and the most common cause was pneumonia. Macroscopically, 12 patients presented obviously purulent pleural fluid. In 4 (26.67%) of the patients, the etiological agent was identified, the most frequent being Staphylococcus sp. Pulmonary decortication was indicated in 2 cases, and those 2 patients were therefore excluded. The average length of hospitalization was 17.1 days, although 3 patients received the treatment as outpatients. No recurrence or mortality was observed with the use of this methodology. Conclusion: This approach reduced the need for invasive procedures, proving to be safe and efficient, with lower rates of morbidity and mortality than other modalities of treatment.

Keywords: Empyema/Pleural, Pleura/Blood Supply, Treatment Outcome, Treatment Effectiveness.

Pleural empyema carries high morbidity and mortality rates. Therapy focuses on the control of the infectious process in its initial phase when parenteral antibiotics and chest drainage are likely to be most effective. The ability of dextrans in preventing peritoneal adhesions leads one to test their potential effectiveness in reducing fibrinous proliferation in a rat model of pleural empyema. Twenty-four Wistar rats weighing 250-400 grams were anesthetized, submitted to a right thoracotomy and then randomized into 3 groups (n = 8 each). Animals in group I were given intrapleural dextran 40 (1 ml/kg) + 1 ml/kg of Staphylococcus aureus extract (1010 cells/ml) in heart-brain culture media obtained from oropharyngeal swabs of the animals. Animals in group II received saline solution (1 ml/kg) +1 ml/kg of Staphylococcus aureus extract (1010 cells/ml) in heart-brain culture media. Animals in group III (controls) were given the culture media without bacteria (1 ml/kg) in addition to saline (1 ml/kg). Upon completion, the chest was deaired, the thoracotomy wound was closed, the animals recovered, observed for 4 days, and sacrificed. Only the animals in groups I and II developed pleural effusion and empyema (average volume of 9.7 ml and 8.1 ml respectively, p > 0.05, NS). There was a significant weight loss in groups I and II compared to control animals (p = 0.004). There were no significant differences in blood work-up tests between groups. The pleural fluid of all animals in groups I and II had positive cultures for Staphylococcus aureus. The biochemical analysis of the pleural fluid in animals from groups I and II did not show any significant differences. The authors concluded that in this novel and reliable model of pleural empyema in rats, the intrapleural administration of dextran 40 at time of inoculation of bacteria did not result in any measurable reduction of the pleural reaction after 96 hours of observation.

Keywords: Empyema. Pleura. Rat. Dextrans. Staphylococcus.

Background: Antimicrobial treatment of community-acquired respiratory tract infections (CARTI) is usually empiric and antibiotics are chosen on the basis of surveillance studies. The SENTRY Program was designed to monitor antimicrobial resistance via a worldwide surveillance network of sentinel laboratories. Three sites in Brazil participated in the 1997 and 1998 SENTRY Program. Methods: A total of 344 bacterial isolates, collected from patients with CARTI in 1997 and 1998, were tested against more than 20 antimicrobial agents by the broth microdilution method. Results: Among S. pneumoniae (176 isolates), 71.6% were susceptible to penicillin. High level resistance to penicillin and resistance to cefotaxime was found in 2.3 and 4.0%, respectively. The newer quinolones, levofloxacin, (MIC90 of 2 mg/mL) and gatifloxacin (MIC90 of 0.5 mg/mL) were active against 100% of the isolates tested. Among the other non-b-lactam drugs tested, the rank order of pneumococci activity was (% susceptible): chloramphenicol (97.5%) > clindamycin (94.0%) > azithromycin (90.3%) > clarithromycin (89.4%) > tetracycline (76.4%) > trimethoprim/sulfamethoxazole (60.2%). The percentage of Haemophilus influenzae (101 isolates) susceptible to amoxicillin was 90.1%, whereas among Moraxella catarrhalis (67 isolates) only 9.0% were susceptible. Clavulanic acid restored the activity of amoxicillin against both H. influenzae and M. catarrhalis. However, H. influenzae showed increased levels of resistance to trimethoprim/sulfametoxazole (55.1% susceptibility), clarithromycin (80.4% susceptibility), and cefaclor (88.2%) susceptibility). All H. influenzae and M. catarrhalis isolates were susceptible to levofloxacin (MIC90, < 0.5 mg/mL for both) and gatifloxacin (MIC90, < 0.06 mg/mL for both) with very low MICs. Conclusion: Results indicate that the rate of S. pneumoniae showing high-level penicillin resistance is still low in Brazil. However, intermediate resistance to penicillin associated with resistance to other classes of antimicrobial agents was relatively high. On the other hand, the new quinolones were highly active against 100% of the respiratory pathogens tested.

Keywords: Respiratory tract infections. Bacterial pneumonia. Microbial drug resistance. Program evaluation. Microbial sensibility tests.

Objective: To report the results obtained in three patients with diffuse pulmonary emphysema during the pre- and post-operative periods following a new surgical technique: collateral ventilation with lung parenchyma drainage. Methods: Patients suffering from pulmonary failure and disabling dyspnea, despite having received the gold standard treatment, including pulmonary rehabilitation, were selected for the evaluation of pulmonary drainage. During the pre- and post-operative periods, patients were submitted to plethysmography and six-minute walk tests, as well as completing the following quality of life questionnaires: Medical Outcomes Study 36-item Short-Form Health Survey, Saint George's Respiratory Questionnaire, Eastern Cooperative Oncology Group Performance Status and Medical Research Council Scale. In all three cases, the post-operative follow-up period was at least 300 days. The tests were performed at the following time points: during the pre-operative period; between post-operative days 30 and 40; and on post-operative day 300. Data were analyzed using profile plots of the means. Results: When the results obtained in the pre-operative period were compared to those obtained at the two post-operative time points evaluated, improvements were observed in all parameters studied. Conclusions: The results suggest that the surgical technique proposed for the treatment of patients suffering from severe diffuse emphysema successfully reduces the debilitating symptoms of these patients, improving their quality of life considerably.

Keywords: Pulmonary emphysema; Lung diseases, obstructive; Lung, hyperlucent.

Objective: To evaluate the results of thoracoscopy for the treatment of pleural empyema in pediatric patients. Methods: A retrospective study of 117 patients who underwent mediastinoscopy or video-assisted thoracoscopy for pleural empyema treatment. General anesthesia and single-lumen oral intubation were used. Surgery was indicated when there was pleural effusion and no clinical and radiological response to clinical treatment (antibiotics, physiotherapy and thoracocentesis) or severe sepsis, together with loculated pleural effusion (confirmed through ultrasound or computed tomography of the chest). Results: Between February of 1983 and July of 2006, 117 thoracoscopies were performed in patients ranging in age from 5 months to 17 years (mean, 4 years). Mean time for thoracic drainage was 9 days (range, 2-33 days), and mean period of hospitalization was 16.4 days (range, 4 to 49 days). One patient (0.8%) died after surgery, and persistent fistula was observed in 33 patients (28%). In 7 cases (6%), open thoracotomy with pulmonary decortication was performed due to the disposition of the empyema. Conclusions: Management of pleural empyema in this age bracket is still controversial, and surgical indication is often delayed, particularly when there are multiple loculations or severe sepsis. Early thoracoscopy yields a better clinical outcome for pediatric patients with pleural empyema, with apparent decreased morbidity and mortality, earlier chest tube removal, earlier hospital discharge and improved response to antibiotic therapy.

Keywords: Empyema, pleural; Pediatrics/instrumentation; Thoracoscopy; Thoracic surgery, video-assisted.

Objective: To investigate the clinical application of CT and CT-guided percutaneous transthoracic needle biopsy (CT-PTNB) in patients with indeterminate pulmonary nodules (IPNs). Methods: We retrospectively studied 113 patients with PNs undergoing CT and CT-PTNB. Variables such as gender, age at diagnosis, smoking status, CT findings, and CT-PTNB techniques were analyzed. Data analysis was performed with the Student's t-test for independent samples the chi-square test, and normal approximation test for comparison of two proportions. Results: Of the 113 patients studied, 68 (60.2%) were male and 78 (69%) were smokers. The diameter of malignant lesions ranged from 2.6 cm to 10.0 cm. Most of the IPNs (85%) were located in the peripheral region. The biopsied IPNs were found to be malignant in 88 patients (77.8%) and benign in 25 (22.2%). Adenocarcinoma was the most common malignant tumor, affecting older patients. The IPN diameter was significantly greater in patients with malignant PNs than in those with benign IPNs (p < 0.001). Having regular contour correlated significantly with an IPN being benign (p = 0.022), whereas spiculated IPNs and bosselated IPNs were more often malignant (in 50.7% and 28.7%, respectively). Homogeneous attenuation and necrosis were more common in patients with malignant lesions (51.9% and 26.9%, respectively) Conclusions: In our sample, CT and CT-PTNB were useful in distinguishing between malignant and benign IPNs. Advanced age and smoking were significantly associated with malignancy. Certain CT findings related to IPNs (larger diameter, spiculated borders, homogeneous attenuation, and necrosis) were associated with malignancy.

Keywords: Solitary pulmonary nodule; Tomography; Image-guided biopsy.

The surgical treatment of patients with tracheobronchial stenosis requires individualized attention due to the complexity of its origin though tracheoplasty is considered to be the ideal procedure. The most common causes of stenosis are tracheal intubation and the development of neoplasias. These are the very conditions that most benefit from endoscopic treatment when surgical correction is not indicated. Today, endoscopic procedures include the application of different kinds of laser and dilators usually delivered with a rigid bronchoscope, as well as radiotherapy and stents that may be used separately or associated. Basically, there are two types of stents, metal or silicone. The metallic ones are more frequently indicated in cases of tracheomalacia and extrinsic compressive stenosis. Silicone are more applicable in cases of tracheobronchial obstruction resultant from acute inflammation or endoluminal tumor. Although these methods can be used interchangeably in some cases, the best way to correct tracheobronchial stenosis is to correctly decide upon the treatment as early as the preliminary steps.

Keywords: Tracheal stenosis. Orthopedics fixation devices. Angioplasty.

Objective: To evaluate the role of intrapleural positioning of a pleural catheter in early lung expansion and pleurodesis success in patients with recurrent malignant pleural effusion (RMPE). Methods: This was a retrospective study nested into a larger prospective cohort study including patients with RMPE recruited from a tertiary university teaching hospital between June of 2009 and September of 2014. The patients underwent pleural catheter insertion followed by bedside pleurodesis. Chest CT scans were performed twice: immediately before pleurodesis (iCT) and 30 days after pleurodesis (CT30). Catheter positioning was categorized based on iCT scans as posterolateral, anterior, fissural, and subpulmonary. We used the pleural volume on iCT scans to estimate early lung expansion and the difference between the pleural volumes on CT30 and iCT scans to evaluate radiological success of pleurodesis. Clinical pleurodesis success was defined as no need for any other pleural procedure. Results: Of the 131 eligible patients from the original study, 85 were included in this nested study (64 women; mean age: 60.74 years). Catheter tip positioning was subpulmonary in 35 patients (41%), anterior in 23 (27%), posterolateral in 17 (20%), and fissural in 10 (12%). No significant differences were found among the groups regarding early lung expansion (median residual pleural cavity = 377 mL; interquartile range: 171-722 mL; p = 0.645), radiological success of pleurodesis (median volume = 33 mL; interquartile range: −225 to 257 mL; p = 0.923), and clinical success of pleurodesis (85.8%; p = 0.676). Conclusions: Our results suggest that the position of the tip of the pleural catheter influences neither early lung expansion nor bedside pleurodesis success in patients with RMPE.

Keywords: Pleurodesis; Pleural effusion, malignant; Tomography; Catheters.

Objective: Thoracentesis is one of the bedside procedures most commonly associated with iatrogenic complications, particularly pneumothorax. Various risk factors for complications associated with thoracentesis have recently been identified, including an inexperienced operator; an inadequate or inexperienced support team; the lack of a standardized protocol; and the lack of ultrasound guidance. We sought to determine whether ultrasound-guided thoracentesis can reduce the risk of pneumothorax and improve outcomes (fewer procedures without fluid removal and greater volumes of fluid removed during the procedures). In our comparison of thoracentesis with and without ultrasound guidance, all procedures were performed by a team of expert pulmonologists, using the same standardized protocol in both conditions. Methods: A total of 160 participants were randomly allocated to undergo thoracentesis with or without ultrasound guidance (n = 80 per group). The primary outcome was pneumothorax following thoracentesis. Secondary outcomes included the number of procedures without fluid removal and the volume of fluid drained during the procedure. Results: Pneumothorax occurred in 1 of the 80 patients who underwent ultrasound-guided thoracentesis and in 10 of the 80 patients who underwent thoracentesis without ultrasound guidance, the difference being statistically significant (p = 0.009). Fluid was removed in 79 of the 80 procedures performed with ultrasound guidance and in 72 of the 80 procedures performed without it. The mean volume of fluid drained was larger during the former than during the latter (960  500 mL vs. 770  480 mL), the difference being statistically significant (p = 0.03). Conclusions: Ultrasound guidance increases the yield of thoracentesis and reduces the risk of post-procedure pneumothorax. (Chinese Clinical Trial Registry identifier: ChiCTR-TRC-12002174 [http://www.chictr.org/en/])

Keywords: Pneumothorax; Ultrasonography; Thoracic surgical procedures.

Primary ciliary dyskinesia (PCD) is a genetic disorder that is typically inherited in an autosomal recessive manner. It is clinically characterized by recurrent respiratory infections. However, its repercussions for patient quality of life should not be overlooked. Studies have shown that PCD has a significant impact on the lives of patients, although there are as yet no PCD-specific markers of quality of life. To address that problem, researchers in the United Kingdom developed a quality-of-life questionnaire for patients with PCD. The present communication focuses on the process of translating that questionnaire into Brazilian Portuguese, through a partnership between researchers in Brazil and those in the United Kingdom, as well as its subsequent application in patients in Brazil.

Keywords: Quality of life; Kartagener syndrome; Surveys and questionnaires.

Objective: Many biologic agents cause some degree of immunosuppression, which can increase the risk of reactivation of tuberculosis infection (TBI). This risk is variable between individual biologics. We aimed to assess current (and recommended) clinical practice of TBI screening and treatment among patients initiating treatment with biologic agents. Methods: An online questionnaire was distributed via email to members of the Global Tuberculosis Network and associated professional organisations to seek insights into the screening for and treatment of TBI in patients treated with biologics. Results: A total of 163 respondents in 27 countries answered at least one question. For all biologics described in the questionnaire, respondents advised increasing screening relative to current practice. Observed and supported TBI screening rates in patients treated with TNF-a inhibitors were high, especially for older TNF-a inhibitors. Most participants supported TBI screening in patients treated with B- or T-cell inhibitors but not in those treated with interleukin inhibitors. Guideline awareness was higher for TNF-a inhibitors than for other biologic classes (79% vs. 34%). Conclusions: Although respondents stated that TBI screening rates are lower than what they consider ideal, there was a tendency to recommend TBI screening in patients treated with biologics not known to be associated with an increased risk of TBI. As a result, there is a potential risk of over-screening and over-treatment of TBI, potentially causing harm, in patients treated with biologics other than TNF-a inhibitors. There is a need to research the risk of TBI associated with biologics and for guidelines to address the spectrum of TBI risk across all types of biologics.

Keywords: Latent tuberculosis; Biological products; Immunosuppression therapy; Recurrence; Mass screening.

Over the last five years, knowledge in the field of pulmonary hypertension has grown consistently and significantly. On the basis of various clinical studies showing the usefulness of new diagnostic tools, as well as the efficacy of new medications and drug combinations, new diagnostic and treatment algorithms have been developed. Likewise, in order to simplify the clinical management of patients, the classification of pulmonary hypertension has been changed in an attempt to group the various forms of pulmonary hypertension in which the diagnostic and therapeutic approaches are similar. The objective of this review was to discuss these modifications, based on the 2005 Brazilian guidelines for the management of pulmonary hypertension, emphasizing what has been added to the international guidelines.

Keywords: Hypertension, pulmonary/diagnosis; Hypertension, pulmonary/therapy; Clinical protocols.

Bronchogenic cysts of the mediastinum are benign congenital lesions, usually found in adults. When surgery is indicated, the classical approach is resection of the lesion by thoracotomy or thoracoscopy. Herein, we describe the complete resection of a paratracheal bronchogenic cyst by cervical mediastinoscopy. We also include a brief review and discussion of the literature.

Objective: To describe the incidence of active tuberculosis and the occurrence of adverse events after isoniazid treatment in patients with latent tuberculosis infection (LTBI) who also had chronic inflammatory diseases and were treated with immunobiologic agents in an endemic area in Brazil. Methods: The diagnosis of LTBI was based on anamnesis, clinical examination, chest X-ray, and a tuberculin skin test (TST). Patients received prophylactic treatment (isoniazid for six months) in accordance with the Brazilian guidelines. Results: A total of 101 patients were evaluated between July of 2011 and July of 2015. Of those, 55 (54.46%) were women (mean age, 53.16 ± 1.76 years) and 46 (45.54%) were men (mean age, 45.39 ± 2.13 years). A total of 79 patients (78.22%) were being treated with immunobiologic agents and 22 (21.78%) were being treated with immunomodulatory or immunosuppressive agents. In the screening for LTBI, 53 patients (52.48%) had a TST induration ≥ 10 mm. Chest X-ray findings consistent with LTBI were observed in 36 patients (35.64%). Isoniazid preventive therapy was effective in 96 (95.05%) of the 101 patients evaluated. It is of note that 84 (83.17%) of the patients experienced no adverse effects from the use of isoniazid and that 83 (98.81%) of those patients completed the prophylactic treatment (p = 0.002). Active tuberculosis was diagnosed in 5 (6.33%) of the 79 patients treated with immunobiologic agents and in 1 (4.55%) of the 22 patients treated with other immunomodulators/immunosuppressants. Conclusions: A six-month course of isoniazid proved to be safe and effective in the treatment of LTBI, which is essential to reducing the risk of developing active tuberculosis.

Keywords: Latent tuberculosis; Tuberculin test; Tumor necrosis factors/antagonists & inhibitors; Isoniazid.

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

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

Objective: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. Methods: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. Results: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. Conclusions: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Keywords: Pulmonary ventilation; Respiration, artificial; Lung transplantation; Dogs; Organ preservation.