Brazilian Journal of Pulmonology

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


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Year 2018 - Volume 44  - Number 6  (November/December)


Continuing Education: Imaging

2 - Pleural calcifications

Calcificações pleurais

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2018;44(6):

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Continuing Education : Scientific Methodology

Original Article

4 - Spirometry reference values for Black adults in Brazil

Valores de referência para espirometria forçada em adultos negros no Brasil

Tarciane Aline Prata1,a, Eliane Mancuzo2,3,b, Carlos Alberto de Castro Pereira4,c,Silvana Spíndola de Miranda2,d, Larissa Voss Sadigursky5,e, Camila Hirotsu6,f, Sérgio Tufik6,g

J Bras Pneumol.2018;44(6):449-455

Abstract PDF PT PDF EN Portuguese Text

Objective: To derive reference equations for spirometry in healthy Black adult never smokers in Brazil, comparing them with those published in 2007 for White adults in the country. Methods: The examinations followed the standards recommended by the Brazilian Thoracic Association, and the spirometers employed met the technical requirements set forth in the guidelines of the American Thoracic Society/European Respiratory Society. The lower limits were defined as the 5th percentile of the residuals. Results: Reference equations and limits were derived from a sample of 120 men and 124 women, inhabitants of eight Brazilian cities, all of whom were evaluated with a flow spirometer. The predicted values for FVC, FEV1 , FEV1 /FVC ratio, and PEF were better described by linear equations, whereas the flows were better described by logarithmic equations. The FEV1 and FVC reference values derived for Black adults were significantly lower than were those previously derived for White adults, regardless of gender. Conclusions: The fact that the predicted spirometry values derived for the population of Black adults in Brazil were lower than those previously derived for White adults in the country justifies the use of an equation specific to the former population.


Keywords: Spirometry; Reference values; African continental ancestry group.


5 - Longitudinal follow-up of cardiac vagal activity in individuals undergoing endoscopic thoracic sympathectomy

Acompanhamento longitudinal da atividade vagal cardíaca de indivíduos submetidos à simpatectomia torácica endoscópica

Ana Paula Ferreira1,2,3,a, Plinio dos Santos Ramos1,2,3,b, Jorge Montessi2,3,4,c, Flávia Duarte Montessi2,3,d, Eveline Montessi Nicolini3,4,e, Edmilton Pereira de Almeida4,f, Djalma Rabelo Ricardo1,2,3,g

J Bras Pneumol.2018;44(6):456-460

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Objective: To conduct a longitudinal investigation of cardiac vagal activity (CVA) by measuring resting HR and calculating the cardiac vagal index (CVI) in individuals undergoing sympathectomy for the treatment of primary hyperhidrosis. Methods: This was a descriptive longitudinal study involving 22 patients, 13 of whom were female. The mean age was 22.5 ± 8.8 years. The palms, soles, and axillae were the most commonly affected sites. Resting HR was measured by an electrocardiogram performed 20 min before the 4-second exercise test (4sET), which was used in order to evaluate CVA at three different time points: before surgery, one month after surgery, and four years after surgery. Results: Resting HR (expressed as mean ± SE) was found to have decreased significantly at 1 month after surgery (73.1 ± 1.6 bpm before surgery vs. 69.7 ± 1.2 bpm at one month after surgery; p = 0.01). However, the HR values obtained at four years after surgery tended to be similar to those obtained before surgery (p = 0.31). The CVI (expressed as mean ± SE) was found to have increased significantly at one month after surgery (1.44 ± 0.04 before surgery vs. 1.53 ± 0.03 at one month after surgery; p = 0.02). However, the CVI obtained at four years after surgery tended to be similar to that obtained before surgery (p = 0.10). Conclusions: At one month after sympathectomy for primary hyperhidrosis, patients present with changes in resting HR and CVA, both of which tend to return to baseline at four years after surgery.


Keywords: Hyperhidrosis; Sympathectomy; Autonomic nervous system; Exercise test;


6 - Prevalence of latent Mycobacterium tuberculosis infection in renal transplant recipients

Prevalência da infecção latente por Mycobacterium tuberculosis em transplantados renais

Mônica Maria Moreira Delgado Maciel1,2,a, Maria das Graças Ceccato3,b, Wânia da Silva Carvalho3,c, Pedro Daibert de Navarro1,d, Kátia de Paula Farah1,e, Silvana Spindola de Miranda1,f

J Bras Pneumol.2018;44(6):461-467

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Objective: To estimate the prevalence of latent Mycobacterium tuberculosis infection (LTBI) in renal transplant recipients and to assess sociodemographic, behavioral, and clinical associations with positive tuberculin skin test (TST) results. Methods: This was a cross-sectional study of patients aged ≥ 18 years who underwent renal transplantation at the Renal Transplant Center of the Federal University of Minas Gerais Hospital das Clínicas, located in the city of Belo Horizonte, Brazil. We included renal transplant recipients who underwent the TST between January 2011 and July 2013. If the result of the first TST was negative, a second TST was administered. Bivariate and multivariate analyses using logistic regression were used to determine factors associated with positive TST results. Results: The sample included 216 patients. The prevalence of LTBI was 18.5%. In the multivariate analysis, history of contact with a tuberculosis case and preserved graft function (estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2) were associated with positive TST results. TST induration increased by 5.8% from the first to the second test, which was considered significant (p = 0.012). Conclusions: The prevalence of LTBI was low in this sample of renal transplant recipients. The TST should be administered if renal graft function is preserved. A second TST should be administered if the first TST is negative.


Keywords: Tuberculosis; Tuberculin test; Immunocompromised host.


7 - Impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer

Impacto da radioterapia torácica na função respiratória e capacidade de exercício em pacientes com câncer de mama

Milena Mako Suesada1,a, Heloisa de Andrade Carvalho2,b, André Luis Pereira de Albuquerque1,c, João Marcos Salge1,d, Silvia Radwanski Stuart2,e, Teresa Yae Takagaki1,f

J Bras Pneumol.2018;44(6):469-476

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Objective: To evaluate the impact of thoracic radiotherapy on respiratory function and exercise capacity in patients with breast cancer. Methods: Breast cancer patients in whom thoracic radiotherapy was indicated after surgical treatment and chemotherapy were submitted to HRCT, respiratory evaluation, and exercise capacity evaluation before radiotherapy and at three months after treatment completion. Respiratory muscle strength testing, measurement of chest wall mobility, and complete pulmonary function testing were performed for respiratory evaluation; cardiopulmonary exercise testing was performed to evaluate exercise capacity. The total radiotherapy dose was 50.4 Gy (1.8 Gy/fraction) to the breast or chest wall, including supraclavicular lymph nodes (SCLN) or not. Dose-volume histograms were calculated for each patient with special attention to the ipsilateral lung volume receiving 25 Gy (V25), in absolute and relative values, and mean lung dose. Results: The study comprised 37 patients. After radiotherapy, significant decreases were observed in respiratory muscle strength, chest wall mobility, exercise capacity, and pulmonary function test results (p < 0.05). DLCO was unchanged. HRCT showed changes related to radiotherapy in 87% of the patients, which was more evident in the patients submitted to SCLN irradiation. V25% significantly correlated with radiation pneumonitis. Conclusions: In our sample of patients with breast cancer, thoracic radiotherapy seemed to have caused significant losses in respiratory and exercise capacity, probably due to chest wall restriction; SCLN irradiation represented an additional risk factor for the development of radiation pneumonitis.


Keywords: Breast neoplasms; Radiotherapy; Radiation pneumonitis; Respiratory function tests; Exercise test.


8 - Self-reported smoking status and urinary cotinine levels in patients with asthma

Tabagismo entre asmáticos: avaliação por autorrelato e dosagem de cotinina urinária

Gabriela Pimentel Pinheiro1,2,a, Carolina de Souza-Machado1,3,b, Andréia Guedes Oliva Fernandes4,c, Raquel Cristina Lins Mota5,d, Liranei Limoeiro Lima2,e, Diego da Silva Vasconcellos6,f, Ives Pereira da Luz Júnior7,g, Yvonbergues Ramon dos Santos Silva7,h, Valmar Bião Lima1,4,i, Sérgio Telles de Oliva8,j, Luane Marques de Mello9,k, Ricardo David Couto10,l, José Miguel Chatkin11,m, Constança Margarida Sampaio Cruz12,13,n, Álvaro Augusto Cruz1,14,o

J Bras Pneumol.2018;44(6):477-485

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Objective: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. Methods: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. Results: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. Conclusions: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.


Keywords: Asthma; Smoking; Cotinine.


9 - Mitomycin C in the endoscopic treatment of tracheal stenosis: a prospective cohort study

Mitomicina C no tratamento endoscópico de estenose traqueal: estudo prospectivo de coorte

Daniele Cristina Cataneo1,a, Aglaia Moreira Garcia Ximenes2,b, Antônio José Maria Cataneo1,c

J Bras Pneumol.2018;44(6):486-490

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Objective: To evaluate the efficacy of mitomycin C (MMC) in the endoscopic treatment of tracheal stenosis. Methods: Patients with laryngotracheal, tracheal, or tracheobronchial stenosis were treated with dilation and topical MMC. The inclusion criteria were as follows: being ineligible for surgery (for medical reasons) at the time of evaluation; membranous stenosis responding well to dilation; and postoperative stenosis at the anastomosis site. Etiology of stenosis and indication for treatment with MMC, as well as site, length, and percentage of stenosis, together with presence of tracheostomy and duration of follow-up, were analyzed. The outcomes evaluated were symptom-free interval ≥ 12 months, number of dilations with topical application of MMC, and complications. Results: Twenty-two patients (15 men and 7 women) were treated between 2003 and 2010. Stenosis was due to endotracheal intubation in 15 patients and surgery in 8. Pure tracheal stenosis was encountered in 13 patients, subglottic stenosis was encountered in 4, tracheobronchial stenosis was encountered in 3, and complex stenosis was encountered in 2. The length of stenosis ranged from 0.5 cm to 2.5 cm, and the percentage of stenosis ranged from 40% to 100%. Nine patients had undergone tracheostomy and had a Montgomery T-tube in situ. Treatment was successful in 14 patients, who remained free of symptoms for at least 12 months. The number of topical applications of MMC ranged from 1 to 5, and complications included fungal infection, keloid scarring, granuloma, and mediastinal emphysema. Conclusions: MMC appears to be effective in the endoscopic treatment of tracheal stenosis.


Keywords: Tracheal stenosis; Mitomycin; Endoscopy.


10 - Trend of self-reported asthma prevalence in Brazil from 2003 to 2013 in adults and factors associated with prevalence

Tendência da prevalência de asma autorreferida no Brasil de 2003 a 2013 em adultos e fatores associados à prevalência

Felipe Moraes dos Santos1,a, Karynna Pimentel Viana1,b, Luciana Tarbes Saturnino1,c, Evelyn Lazaridis1,d, Mariana Rodrigues Gazzotti1,e, Rafael Stelmach2,f, Claudia Soares1,g

J Bras Pneumol.2018;44(6):491-497

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Objectives: To determine the trend of self-reported asthma diagnosed prevalence and to describe the factors associated with asthma in Brazilian adults. Method: Epidemiological cross-sectional study based on databases analysis from three national household surveys: Pesquisa Nacional por Amostra de Domicílios (PNAD) 2003, PNAD 2008 and Pesquisa Nacional de Saúde (PNS) 2013. Participants between 18-45 years old were included. Trend analysis of asthma diagnosed prevalence was conducted using a logistic general linear model. A hierarchical logistic regression model was used to select factors significantly associated with asthma prevalence. Results: Asthma diagnosed prevalence was 3.6% (2003), 3.7% (2008) and 4.5% (2013), showing a statistically significant increased trend. Asthma diagnosed prevalence also increased when analysed by gender (annual change for men: 2.47%, p < 0.003; women: 2.16%, p < 0.001), urban area (annual change for urban: 2.15%, p < 0.001; rural: 2.69%, p = 0.072), healthcare insurance status (annual change without healthcare insurance: 2.18%, p < 0.001; with healthcare insurance: 1.84%, p = 0.014), and geographic regions (annual change North: 4.68%, p < 0.001; Northeast: 4.14%, p < 0.001; and Southeast: 1.84%, p = 0.025). Female gender, obesity, living in urban areas and depression were associated with asthma diagnosed prevalence. Discussion: PNAD and PNS surveys allow for a very large, representative community-based sample of the Brazilian adults to investigate the asthma prevalence. From 2003 to 2013, the prevalence of self-reported physician diagnosis of asthma increased, especially in the North and Northeast regions. Gender, region of residence, household location (urban/rural), obesity, and depression diagnosis seem to play significant roles in the epidemiology of asthma in Brazil.


Keywords: Adults; Asthma; Logistic models; Prevalence; Risk factors.


11 - Genetic and phenotypic traits of children and adolescents with cystic fibrosis in Southern Brazil

Características genéticas e fenotípicas de crianças e adolescentes com fibrose cística no Sul do Brasil

Katiana Murieli da Rosa1,a, Eliandra da Silveira de Lima2,b, Camila Correia Machado3,c, Thaiane Rispoli4,d, Victória d'Azevedo Silveira3,e, Renata Ongaratto2,f, Talitha Comaru2,g, Leonardo Araújo Pinto5,h

J Bras Pneumol.2018;44(6):498-504

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Objectives: To characterize the main identified mutations on cystic fibrosis transmembrane conductance regulator (CFTR) in a group of children and adolescents at a cystic fibrosis center and its association with the clinical and laboratorial characteristics. Method: Descriptive cross-sectional study including patients with cystic fibrosis who had two alleles identified with CFTR mutation. Clinical, anthropometrical, laboratorial and pulmonary function (spirometry) data were collected from patients' records in charts and described with the results of the sample genotyping. Results: 42 patients with cystic fibrosis were included in the study. The most frequent mutation was F508del, covering 60 alleles (71.4%). The second most common mutation was G542X (six alleles, 7.1%), followed by N1303K and R1162X mutations (both with four alleles each). Three patients (7.14%) presented type III and IV mutations, and 22 patients (52.38%) presented homozygous mutation for F508del. Thirty three patients (78.6%) suffered of pancreatic insufficiency, 26.2% presented meconium ileus, and 16.7%, nutritional deficit. Of the patients in the study, 59.52% would be potential candidates for the use of CFTR-modulating drugs. Conclusions: The mutations of CFTR identified more frequently were F508del and G542X. These are type II and I mutations, respectively. Along with type III, they present a more severe cystic fibrosis phenotype. More than half of the sample (52.38%) presented homozygous mutation for F508del, that is, patients who could be treated with Lumacaftor/Ivacaftor. Approximately 7% of the patients (7.14%) presented type III and IV mutations, therefore becoming candidates for the treatment with Ivacaftor.


Keywords: Cystic fibrosis; Mutations; Genetics; Phenotype; Child


12 - Proportional weight loss in six months as a risk factor for mortality in stage IV nonsmall cell lung cancer

Perda de peso proporcional em seis meses como fator de risco para mortalidade no câncer de pulmão de células não pequenas estádio IV

Guilherme Watte1,2,5,a, Claudia Helena de Abreu Nunes1,b, Luzielio Alves Sidney-Filho3,c, Matheus Zanon2,4,d, Stephan Philip Leonhardt Altmayer4,5,e, Gabriel Sartori Pacini4,f, Marcelo Barros5,g, Ana Luiza Schneider Moreira4,h, Rafael José Vargas Alves1,i, Alice de Medeiros Zelmanowicz4,j, Bashir Mnene Matata2,k, Jose da Silva Moreira1,l

J Bras Pneumol.2018;44(6):505-509

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Objective: To evaluate different weight loss (WL) cut-off points as prognostic markers of 3-month survival after diagnosis of stage IV non-small cell lung cancer (NSCLC). Methods: This was a prospective study involving 104 patients with metastatic (stage IV) NSCLC who were admitted to a cancer treatment center in southern Brazil between January of 2014 and November of 2016. We evaluated total WL and WL per month, as well as WL and WL per month in the 6 months preceding the diagnosis. The patients were followed for 3 months after diagnosis. A Cox proportional hazards regression model and Kaplan-Meier curves were used in order to evaluate 3-month survival. Results: The median WL in the 6 months preceding the diagnosis was 6% (interquartile range, 0.0- 12.9%). Patients with WL ≥ 5% had a median survival of 78 days, compared with 85 days for those with WL < 5% (p = 0.047). Survival at 3 months was 72% for the patients with WL ≥ 5% (p = 0.047), 61% for those with WL ≥ 10% (p < 0.001), and 45% for those with WL ≥ 15% (p < 0.001). In the multivariate analysis, the hazard ratio for risk of death was 4.51 (95% CI: 1.32-15.39) for the patients with WL ≥ 5%, 6.34 (95% CI: 2.31-17.40) for those with WL ≥ 10%, and 14.17 (95% CI: 5.06-39.65) for those with WL ≥ 15%. Conclusions: WL in the 6 months preceding the diagnosis of NSCLC is a relevant prognostic factor and appears to be directly proportional to the rate of survival at 3 months.


Keywords: Weight loss; Carcinoma, non-small-cell lung; Prognosis.


Review Article

13 - Obesity hypoventilation syndrome: a current review

Síndrome de obesidade-hipoventilação: uma revisão atual

Rodolfo Augusto Bacelar de Athayde1,2,a, José Ricardo Bandeira de Oliveira Filho1,b, Geraldo Lorenzi Filho2,c, Pedro Rodrigues Genta2,d

J Bras Pneumol.2018;44(6):510-518

Abstract Portuguese Text

Obesity hypoventilation syndrome (OHS) is defined as the presence of obesity (body mass index ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg) in the absence of other causes of hypoventilation. OHS is often overlooked and confused with other conditions associated with hypoventilation, particularly COPD. The recognition of OHS is important because of its high prevalence and the fact that, if left untreated, it is associated with high morbidity and mortality. In the present review, we address recent advances in the pathophysiology and management of OHS, the usefulness of determination of venous bicarbonate in screening for OHS, and diagnostic criteria for OHS that eliminate the need for polysomnography. In addition, we review advances in the treatment of OHS, including behavioral measures, and recent studies comparing the efficacy of continuous positive airway pressure with that of noninvasive ventilation.


Keywords: Obesity; Obesity hypoventilation syndrome; Noninvasive ventilation.


Letters to the Editor

16 - Pulmonary involvement in Crohn's disease

Comprometimento pulmonar na doença de Crohn

Rodolfo Augusto Bacelar de Athayde1,a, Felipe Marques da Costa1,b, Ellen Caroline Toledo do Nascimento2,c, Roberta Karla Barbosa de Sales1,d, Andre Nathan Costa1,e

J Bras Pneumol.2018;44(6):519-521

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17 - Eosinophilic pneumonia: remember topical drugs as a potential etiology

Pneumonia eosinofílica: lembre-se de medicamentos tópicos como possível etiologia

Olívia Meira Dias1,a, Ellen Caroline Toledo do Nascimento2,b, Rodrigo Caruso Chate3,c, Ronaldo Adib Kairalla1,d, Bruno Guedes Baldi1,e

J Bras Pneumol.2018;44(6):522-524

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18 - Near-fatal pulmonary embolism: capnographic perspective

Embolia pulmonar quase fatal: perspectiva capnográfica

Marcos Mello Moreira1,2,a, Luiz Claudio Martins3,b, Konradin Metze4,c, Marcus Vinicius Pereira2,d, Ilma Aparecida Paschoal1,e

J Bras Pneumol.2018;44(6):525-528

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