Brazilian Journal of Pulmonology

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


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Year 2014 - Volume 40  - Number 5  (September/October)

Special Article

3 - Brazilian recommendations of mechanical ventilation 2013. Part 2

Recomendações brasileiras de ventilação mecânica 2013. Parte 2

Essas recomendações são uma iniciativa conjunta do Comitê de Ventilação Mecânica da Associação de Medicina Intensiva Brasileira (AMIB) e da Comissão de Terapia Intensiva da Sociedade Brasileira de Pneumologia e Tisiologia (SBPT).

J Bras Pneumol.2014;40(5):458-486

Abstract PDF PT PDF EN Portuguese Text

Perspectives on invasive and noninvasive ventilatory support for critically ill patients are evolving, as much evidence indicates that ventilation may have positive effects on patient survival and the quality of the care provided in intensive care units in Brazil. For those reasons, the Brazilian Association of Intensive Care Medicine (Associação de Medicina Intensiva Brasileira - AMIB) and the Brazilian Thoracic Society (Sociedade Brasileira de Pneumologia e Tisiologia - SBPT), represented by the Mechanical Ventilation Committee and the Commission of Intensive Therapy, respectively, decided to review the literature and draft recommendations for mechanical ventilation with the goal of creating a document for bedside guidance as to the best practices on mechanical ventilation available to their members. The document was based on the available evidence regarding 29 subtopics selected as the most relevant for the subject of interest. The project was developed in several stages, during which the selected topics were distributed among experts recommended by both societies with recent publications on the subject of interest and/or significant teaching and research activity in the field of mechanical ventilation in Brazil. The experts were divided into pairs that were charged with performing a thorough review of the international literature on each topic. All the experts met at the Forum on Mechanical Ventilation, which was held at the headquarters of AMIB in São Paulo on August 3 and 4, 2013, to collaboratively draft the final text corresponding to each sub-topic, which was presented to, appraised, discussed and approved in a plenary session that included all 58 participants and aimed to create the final document.


Keywords: Recommendations; Mechanical Ventilation; Respiratory Insufficiency.


Original Article

4 - Level of asthma control and its relationship with medication use in asthma patients in Brazil

Nível de controle da asma e sua relação com o uso de medicação em asmáticos no Brasil

Josiane Marchioro, Mariana Rodrigues Gazzotti, Oliver Augusto Nascimento, Federico Montealegre, James Fish, José Roberto Jardim

J Bras Pneumol.2014;40(5):487-494

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess asthma patients in Brazil in terms of the level of asthma control, compliance with maintenance treatment, and the use of rescue medication. Methods: We used data from a Latin American survey of a total of 400 asthma patients in four Brazilian state capitals, all of whom completed a questionnaire regarding asthma control and treatment. Results: In that sample, the prevalence of asthma was 8.8%. Among the 400 patients studied, asthma was classified, in accordance with the Global Initiative for Asthma criteria, as controlled, partially controlled, and uncontrolled in 37 (9.3%), 226 (56.5%), and 137 (34.3%), respectively. In those three groups, the proportion of patients on maintenance therapy in the past four weeks was 5.4%, 19.9%, and 41.6%, respectively. The use of rescue medication was significantly more common in the uncontrolled asthma group (86.9%; p < 0.001). Conclusions: Our findings suggest that, in accordance with the established international criteria, asthma is uncontrolled in the vast majority of asthma patients in Brazil. Maintenance medications are still underutilized in Brazil, and patients with partially controlled or uncontrolled asthma are more likely to use rescue medications and oral corticosteroids.


Keywords: Asthma/therapy; Asthma/prevention and control; Medication adherence.


5 - Utility of the combination of serum highly-sensitive C-reactive protein level at discharge and a risk index in predicting readmission for acute exacerbation of COPD

Utilidade de se combinar o nível sérico de proteína C reativa de alta sensibilidade no momento da alta com um índice de risco para prever a reinternação por exacerbação aguda da DPOC

Chun Chang, Hong Zhu, Ning Shen, Xiang Han, Yahong Chen, Bei He

J Bras Pneumol.2014;40(5):495-503

Abstract PDF PT PDF EN Portuguese Text

Objective: Frequent readmissions for acute exacerbations of COPD (AECOPD) are an independent risk factor for increased mortality and use of health-care resources. Disease severity and C-reactive protein (CRP) level are validated predictors of long-term prognosis in such patients. This study investigated the utility of combining serum CRP level with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) exacerbation risk classification for predicting readmission for AECOPD. Methods: This was a prospective observational study of consecutive patients hospitalized for AECOPD at Peking University Third Hospital, in Beijing, China. We assessed patient age; gender; smoking status and history (pack-years); lung function; AECOPD frequency during the last year; quality of life; GOLD risk category (A-D; D indicating the greatest risk); and serum level of high-sensitivity CRP at discharge (hsCRP-D). Results: The final sample comprised 135 patients. Of those, 71 (52.6%) were readmitted at least once during the 12-month follow-up period. The median (interquartile) time to readmission was 78 days (42-178 days). Multivariate analysis revealed that serum hsCRP-D ≥ 3 mg/L and GOLD category D were independent predictors of readmission (hazard ratio = 3.486; 95% CI: 1.968-6.175; p < 0.001 and hazard ratio = 2.201; 95% CI: 1.342-3.610; p = 0.002, respectively). The ordering of the factor combinations by cumulative readmission risk, from highest to lowest, was as follows: hsCRP-D ≥ 3 mg/L and GOLD category D; hsCRP-D ≥ 3 mg/L and GOLD categories A-C; hsCRP-D < 3 mg/L and GOLD category D; hsCRP-D < 3 mg/L and GOLD categories A-C. Conclusions: Serum hsCRP-D and GOLD classification are independent predictors of readmission for AECOPD, and their predictive value increases when they are used in combination.


Keywords: Pulmonary disease, chronic obstructive/epidemiology; Acute disease; Acute-phase proteins; Hospitalization; Patient readmission; Inflammation.


6 - Barriers associated with reduced physical activity in COPD patients

Barreiras associadas à menor atividade física em portadores de DPOC

Priscila Batista Amorim, Rafael Stelmach, Celso Ricardo Fernandes Carvalho, Frederico Leon Arrabal Fernandes, Regina Maria Carvalho-Pinto, Alberto Cukier

J Bras Pneumol.2014;40(5):504-512

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score. Methods: In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT. Results: We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5  25.8 min/day vs. 105.2  49.4 min/day; p < 0.001), as was the distance walked (3.9  1.9 km/day vs. 6.4  3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results. Conclusions: Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures.


Keywords: Pulmonary disease, chronic obstructive; Activities of daily living; Exercise tolerance.


7 - Assessment of inhaler techniques employed by patients with respiratory diseases in southern Brazil: a population-based study

Avaliação da técnica de utilização de dispositivos inalatórios no tratamento de doenças respiratórias no sul do Brasil: estudo de base populacional

Paula Duarte de Oliveira, Ana Maria Baptista Menezes, Andréa Dâmaso Bertoldi, Fernando César Wehrmeister, Silvia Elaine Cardozo Macedo

J Bras Pneumol.2014;40(5):513-520

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify incorrect inhaler techniques employed by patients with respiratory diseases in southern Brazil and to profile the individuals who make such errors. Methods: This was a population-based, cross-sectional study involving subjects ≥ 10 years of age using metered dose inhalers (MDIs) or dry powder inhalers (DPIs) in 1,722 households in the city of Pelotas, Brazil. Results: We included 110 subjects, who collectively used 94 MDIs and 49 DPIs. The most common errors in the use of MDIs and DPIs were not exhaling prior to inhalation (66% and 47%, respectively), not performing a breath-hold after inhalation (29% and 25%), and not shaking the MDI prior to use (21%). Individuals ≥ 60 years of age more often made such errors. Among the demonstrations of the use of MDIs and DPIs, at least one error was made in 72% and 51%, respectively. Overall, there were errors made in all steps in 11% of the demonstrations, whereas there were no errors made in 13%.Among the individuals who made at least one error, the proportion of those with a low level of education was significantly greater than was that of those with a higher level of education, for MDIs (85% vs. 60%; p = 0.018) and for DPIs (81% vs. 35%; p = 0.010).Conclusions: In this sample, the most common errors in the use of inhalers were not exhaling prior to inhalation, not performing a breath-hold after inhalation, and not shaking the MDI prior to use. Special attention should be given to education regarding inhaler techniques for patients of lower socioeconomic status and with less formal education, as well as for those of advanced age, because those populations are at a greater risk of committing errors in their use of inhalers.


Keywords: Asthma; Pulmonary disease, chronic obstructive; Dry powder inhalers; Metered dose inhalers.


8 - Effects of Pilates mat exercises on muscle strength and on pulmonary function in patients with cystic fibrosis

Efeitos do método Pilates na força muscular e na função pulmonar de pacientes com fibrose cística

Caroline Buarque Franco, Antonio Fernando Ribeiro, André Moreno Morcillo, Mariana Porto Zambon, Marina Buarque Almeida, Tatiana Rozov

J Bras Pneumol.2014;40(5):521-527

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the effects of Pilates mat exercises in patients with cystic fibrosis (CF). Methods: This was a clinical trial involving 19 CF patients recruited from either the CF Outpatient Clinic of the State University at Campinas Hospital de Clínicas or the Children's Institute of the University of São Paulo School of Medicine Hospital das Clínicas. All of the patients performed Pilates mat exercises for four months (one 60-min session per week). The variables studied (before and after the intervention) were respiratory muscle strength, MIP, MEP, FVC, and FEV1. Results: After the intervention, MIP was significantly higher in the male patients (p = 0.017), as were MIP and MEP in the female patients (p = 0.005 and p = 0.007, respectively). There were no significant differences between the pre- and post-intervention values of FVC or FEV1, neither in the sample as a whole nor among the patients of either gender. Conclusions: Our results show that Pilates mat exercises have beneficial effects on respiratory muscle strength in CF patients. (Brazilian Registry of Clinical Trials - ReBEC; identification number RBR-86vp8x [])


Keywords: Cystic fibrosis; Muscle strength; Exercise movement techniques; Respiratory function tests.


9 - Air stacking: effects on pulmonary function in patients with spinal muscular atrophy and in patients with congenital muscular dystrophy

Efeitos do treinamento de empilhamento de ar na função pulmonar de pacientes com amiotrofia espinhal e distrofia muscular congênita

Tanyse Bahia Carvalho Marques, Juliana de Carvalho Neves, Leslie Andrews Portes, João Marcos Salge, Edmar Zanoteli, Umbertina Conti Reed

J Bras Pneumol.2014;40(5):528-534

Abstract PDF PT PDF EN Portuguese Text

Objective: Respiratory complications are the main causes of morbidity and mortality in patients with neuromuscular disease (NMD). The objectives of this study were to determine the effects that routine daily home air-stacking maneuvers have on pulmonary function in patients with spinal muscular atrophy (SMA) and in patients with congenital muscular dystrophy (CMD), as well as to identify associations between spinal deformities and the effects of the maneuvers. Methods: Eighteen NMD patients (ten with CMD and eight with SMA) were submitted to routine daily air-stacking maneuvers at home with manual resuscitators for four to six months, undergoing pulmonary function tests before and after that period. The pulmonary function tests included measurements of FVC; PEF; maximum insufflation capacity (MIC); and assisted and unassisted peak cough flow (APCF and UPCF, respectively) with insufflations. Results: After the use of home air-stacking maneuvers, there were improvements in the APCF and UPCF. In the patients without scoliosis, there was also a significant increase in FVC. When comparing patients with and without scoliosis, the increases in APCF and UPCF were more pronounced in those without scoliosis. Conclusions: Routine daily air-stacking maneuvers with a manual resuscitator appear to increase UPCF and APCF in patients with NMD, especially in those without scoliosis.


Keywords: Neuromuscular diseases; Cough; Respiratory function tests; Respiratory therapy.


10 - Thoracic textilomas: CT findings

Textilomas intratorácicos: achados tomográficos

Dianne Melo Machado, Gláucia Zanetti, Cesar Augusto Araujo Neto, Luiz Felipe Nobre, Gustavo de Souza Portes Meirelles, Jorge Luiz Pereira e Silva, Marcos Duarte Guimarães, Dante Luiz Escuissato, Arthur Soares Souza Jr, Bruno Hochhegger, Edson Marchiori

J Bras Pneumol.2014;40(5):535-542

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of this study was to analyze chest CT scans of patients with thoracic textiloma. Methods: This was a retrospective study of 16 patients (11 men and 5 women) with surgically confirmed thoracic textiloma. The chest CT scans of those patients were evaluated by two independent observers, and discordant results were resolved by consensus. Results: The majority (62.5%) of the textilomas were caused by previous heart surgery. The most common symptoms were chest pain (in 68.75%) and cough (in 56.25%). In all cases, the main tomographic finding was a mass with regular contours and borders that were well-defined or partially defined. Half of the textilomas occurred in the right hemithorax and half occurred in the left. The majority (56.25%) were located in the lower third of the lung. The diameter of the mass was ≤ 10 cm in 10 cases (62.5%) and > 10 cm in the remaining 6 cases (37.5%). Most (81.25%) of the textilomas were heterogeneous in density, with signs of calcification, gas, radiopaque marker, or sponge-like material. Peripheral expansion of the mass was observed in 12 (92.3%) of the 13 patients in whom a contrast agent was used. Intraoperatively, pleural involvement was observed in 14 cases (87.5%) and pericardial involvement was observed in 2 (12.5%). Conclusions: It is important to recognize the main tomographic aspects of thoracic textilomas in order to include this possibility in the differential diagnosis of chest pain and cough in patients with a history of heart or thoracic surgery, thus promoting the early identification and treatment of this postoperative complication.


Keywords: Foreign-body reaction; Tomography, spiral computed; Thoracic surgery.


11 - Spatial analysis of deaths from pulmonary tuberculosis in the city of São Luís, Brazil

Análise espacial dos óbitos por tuberculose pulmonar em São Luís, Maranhão

Marcelino Santos-Neto, Mellina Yamamura, Maria Concebida da Cunha Garcia, Marcela Paschoal Popolin, Tatiane Ramos dos Santos Silveira, Ricardo Alexandre Arcêncio

J Bras Pneumol.2014;40(5):543-551

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Objective: To characterize deaths from pulmonary tuberculosis, according to sociodemographic and operational variables, in the city of São Luís, Brazil, and to describe their spatial distribution. Methods: This was an exploratory ecological study based on secondary data from death certificates, obtained from the Brazilian Mortality Database, related to deaths from pulmonary tuberculosis. We included all deaths attributed to pulmonary tuberculosis that occurred in the urban area of São Luís between 2008 and 2012. We performed univariate and bivariate analyses of the sociodemographic and operational variables of the deaths investigated, as well as evaluating the spatial distribution of the events by kernel density estimation. Results: During the study period, there were 193 deaths from pulmonary tuberculosis in São Luís. The median age of the affected individuals was 52 years. Of the 193 individuals who died, 142 (73.60%) were male, 133 (68.91%) were Mulatto, 102 (53.13%) were single, and 64 (33.16%) had completed middle school. There was a significant positive association between not having received medical care prior to death and an autopsy having been performed (p = 0.001). A thematic map by density of points showed that the spatial distribution of those deaths was heterogeneous and that the density was as high as 8.12 deaths/km2. Conclusions: The sociodemographic and operational characteristics of the deaths from pulmonary tuberculosis evaluated in this study, as well as the identification of priority areas for control and surveillance of the disease, could promote public health policies aimed at reducing health inequities, allowing the optimization of resources, as well as informing decisions regarding the selection of strategies and specific interventions targeting the most vulnerable populations.


Keywords: Tuberculosis, pulmonary/mortality; Communicable disease control; Spatial analysis.



12 - Effects of prednisone on eosinophilic bronchitis in asthma: a systematic review and meta-analysis

Efeitos da prednisona na bronquite eosinofílica na asma: uma revisão sistemática e meta-análise

Thiago Mamôru Sakae, Rosemeri Maurici, Daisson José Trevisol, Marcia Margaret Menezes Pizzichini, Emílio Pizzichini

J Bras Pneumol.2014;40(5):552-563

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effect size of oral corticosteroid treatment on eosinophilic bronchitis in asthma, through systematic review and meta-analysis. Methods: We systematically reviewed articles in the Medline, Cochrane Controlled Trials Register, EMBASE, and LILACS databases. We selected studies meeting the following criteria: comparing at least two groups or time points (prednisone vs. control, prednisone vs. another drug, or pre- vs. post-treatment with prednisone); and evaluating parameters before and after prednisone use, including values for sputum eosinophils, sputum eosinophil cationic protein (ECP), and sputum IL-5-with or without values for post-bronchodilator FEV1-with corresponding 95% CIs or with sufficient data for calculation. The independent variables were the use, dose, and duration of prednisone treatment. The outcomes evaluated were sputum eosinophils, IL-5, and ECP, as well as post-bronchodilator FEV1. Results: The pooled analysis of the pre- vs. post-treatment data revealed a significant mean reduction in sputum eosinophils (8.18%; 95% CI: 7.69-8.67; p < 0.001), sputum IL-5 (83.64 pg/mL; 95% CI: 52.45-114.83; p < 0.001), and sputum ECP (267.60 µg/L; 95% CI: 244.57-290.63; p < 0.0001), as well as a significant mean increase in post-bronchodilator FEV1 (8.09%; 95% CI: 5.35-10.83; p < 0.001). Conclusions:In patients with moderate-to-severe eosinophilic bronchitis, treatment with prednisone caused a significant reduction in sputum eosinophil counts, as well as in the sputum levels of IL-5 and ECP. This reduction in the inflammatory response was accompanied by a significant increase in post-bronchodilator FEV1.


Keywords: Meta-analysis; Bronchitis; Asthma; Pulmonary eosinophilia; Evidence-based medicine; Prednisone.


Review Article

13 - The electronic cigarette: the new cigarette of the 21st century?

Cigarro eletrônico: o novo cigarro do século 21?

Marli Maria Knorst, Igor Gorski Benedetto, Mariana Costa Hoffmeister, Marcelo Basso Gazzana

J Bras Pneumol.2014;40(5):564-573

Abstract PDF PT PDF EN Portuguese Text

The electronic nicotine delivery system, also known as the electronic cigarette, is generating considerable controversy, not only in the general population but also among health professionals. Smokers the world over have been increasingly using electronic cigarettes as an aid to smoking cessation and as a substitute for conventional cigarettes. There are few available data regarding the safety of electronic cigarettes. There is as yet no evidence that electronic cigarettes are effective in treating nicotine addiction. Some smokers have reported using electronic cigarettes for over a year, often combined with conventional cigarettes, thus prolonging nicotine addiction. In addition, the increasing use of electronic cigarettes by adolescents is a cause for concern. The objective of this study was to describe electronic cigarettes and their components, as well as to review the literature regarding their safety; their impact on smoking initiation and smoking cessation; and regulatory issues related to their use.


Keywords: Smoking; Tobacco Products; Nicotine.


Case Report

14 - Chiari malformation and central sleep apnea syndrome: efficacy of treatment with adaptive servo-ventilation

Malformação de Chiari e síndrome de apneia central do sono: eficácia do tratamento com servoventilação adaptativa

Jorge Marques do Vale, Eloísa Silva, Isabel Gil Pereira, Catarina Marques, Amparo Sanchez-Serrano, António Simões Torres

J Bras Pneumol.2014;40(5):574-578

Abstract PDF PT PDF EN Portuguese Text

The Chiari malformation type I (CM-I) has been associated with sleep-disordered breathing, especially central sleep apnea syndrome. We report the case of a 44-year-old female with CM-I who was referred to our sleep laboratory for suspected sleep apnea. The patient had undergone decompressive surgery 3 years prior. An arterial blood gas analysis showed hypercapnia. Polysomnography showed a respiratory disturbance index of 108 events/h, and all were central apnea events. Treatment with adaptive servo-ventilation was initiated, and central apnea was resolved. This report demonstrates the efficacy of servo-ventilation in the treatment of central sleep apnea syndrome associated with alveolar hypoventilation in a CM-I patient with a history of decompressive surgery.


Keywords: Sleep apnea, central; Arnold-Chiari malformation; Noninvasive ventilation.


Letters to the Editor

15 - Digital drainage system: how far can we go?

Sistema de drenagem digital: até onde podemos chegar?

Altair da Silva Costa Jr, Luiz Eduardo Villaça Leão, Jose Ernesto Succi, Erika Rymkiewicz, Juliana Folador, Thamara Kazantzis

J Bras Pneumol.2014;40(5):579-581

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16 - Battery ingestion: an unusual cause of mediastinitis

Ingestão de bateria: uma causa incomum de mediastinite

Rosana Souza Rodrigues, Fátima Aparecida Ferreira Figueiredo, César Augusto Amorim, Gláucia Zanetti, Edson Marchiori

J Bras Pneumol.2014;40(5):582-583

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Author's reply

18 - Authors' reply

Resposta dos autores

Leonardo de Assis, Mauro César Isoldi

J Bras Pneumol.2014;40(5):586-587

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19 - Errata

J Bras Pneumol.2014;40(5):588

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