Brazilian Journal of Pulmonology

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


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Year 2020 - Volume 46  - Number 1  (January/February)


4 - Upper limbs: how physically limited is your patient?

Membros superiores: quão limitado fisicamente o seu paciente está?

Karina Couto Furlanetto1,2, Natielly Soares Correia1, Simone Dal Corso2

J Bras Pneumol.2020;46(1):e20190430

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Continuing Education: Imaging

5 - Peripheral consolidation/ground-glass opacities

Consolidações/opacidades em vidro fosco periféricas

Edson Marchiori1, Bruno Hochhegger2, Gláucia Zanetti1

J Bras Pneumol.2020;46(1):e20190384

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Original Article

6 - Tumor-node-metastasis staging and treatment patterns of 73,167 patients with lung cancer in Brazil

Estadiamento tumor-nódulo-metástase e padrão de tratamento oncológico de 73.167 pacientes com câncer de pulmão no Brasil

Guilherme Jorge Costa1,2, Maria Júlia Gonçalves de Mello3, Anke Bergmann4, Carlos Gil Ferreira5, Luiz Claudio Santos Thuler4,6

J Bras Pneumol.2020;46(1):e20180251

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Objective: To characterize the clinical and histological profile, as well as treatment patterns, of patients with early-stage, locally advanced (LA), or advanced/metastatic (AM) lung cancer, diagnosed between 2000 and 2014, in Brazil. Methods: This was an analytical cross-sectional epidemiological study employing data obtained for the 2000-2014 period from the hospital cancer registries of two institutions in Brazil: the José Alencar Gomes da Silva National Cancer Institute, in the city of Rio de Janeiro; and the São Paulo Cancer Center Foundation, in the city of São Paulo. Results: We reviewed the data related to 73,167 patients with lung cancer. The proportions of patients with early-stage, LA, and AM lung cancer were 13.3%, 33.2%, and 53.4%, respectively. The patients with early-stage lung cancer were older and were most likely to receive a histological diagnosis of adenocarcinoma; the proportion of patients with early-stage lung cancer remained stable throughout the study period. In those with LA lung cancer, squamous cell carcinoma predominated, and the proportion of patients with LA lung cancer decreased significantly over the period analyzed. Those with AM lung cancer were younger and were most likely to have adenocarcinoma; the proportion of patients with AM lung cancer increased significantly during the study period. Small cell carcinoma accounted for 9.2% of all cases. In our patient sample, the main treatment modality was chemotherapy. Conclusions: It is noteworthy that the frequency of AM lung cancer increased significantly during the study period, whereas that of LA lung cancer decreased significantly and that of early-stage lung cancer remained stable. Cancer treatment patterns, by stage, were in accordance with international guidelines.


Keywords: Lung neoplasms/epidemiology; Lung neoplasms/therapy; Neoplasm staging; Brazil.


7 - Robotic thoracic surgery for resection of thymoma and tumors of the thymus: technical development and initial experience

Cirurgia torácica robótica para ressecção de timoma e tumores tímicos: desenvolvimento técnico e experiência inicial

Ricardo Mingarini Terra1,a, José Ribas Milanez-de-Campos1,b, Rui Haddad2,c, Juliana Rocha Mol Trindade3,d, Leticia Leone Lauricella3,e, Benoit Jacques Bibas3,f, Paulo Manuel Pêgo-Fernandes1,g

J Bras Pneumol.2020;46(1):e20180315

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Objective: To evaluate the results of resection of tumors of the thymus by robotic thoracic surgery, analyzing the extent of resection, postoperative complications, time of surgery, and length of stay. Methods: Retrospective study from a database involving patients diagnosed with a tumor of the thymus and undergoing robotic thoracic surgery at one of seven hospitals in Brazil between October of 2015 and June of 2018. Results: During the study period, there were 18 cases of resection of tumors of the thymus: thymoma, in 12; carcinoma, in 2; and carcinoid tumor, in 1; high-grade sarcoma, in 1; teratoma, in 1; and thymolipoma, in 1. The mean lesion size was 60.1 ± 32.0 mm. Tumors of the thymus were resected with tumor-free margins in 17 cases. The median (interquartile range) for pleural drain time and hospital stay, in days, was 1 (1-3) and 2 (2-4), respectively. There was no need for surgical conversion, and there were no major complications. Conclusions: Robotic thoracic surgery for resection of tumors of the thymus has been shown to be feasible and safe, with a low risk of complications and with postoperativeymoma; Thymus neoplasms; Thymectomy; Thoracic surgery; R outcomes comparable to those of other techniques.


Keywords: Thymoma; Thymus neoplasms; Thymectomy; Thoracic surgery; Robotic surgical procedures.


8 - Robotic thoracic surgery for non-small cell lung cancer: initial experience in Brazil

Cirurgia torácica robótica no tratamento do câncer de pulmão de células não pequenas: experiência inicial no Brasil

Ricardo Mingarini Terra1,2,3,4,a, Benoit Jacques Bibas1,3,4,b, Rui Haddad5,6,c, José Ribas Milanez-de-Campos1,3,d, Pedro Henrique Xavier Nabuco-de-Araujo1,2,4,e, Carlos Eduardo Teixeira-Lima5,6,f, Felipe Braga dos Santos5,6,g, Leticia Leone Lauricella1,2,4,h, Paulo Manuel Pêgo-Fernandes1,2,3,i

J Bras Pneumol.2020;46(1):e20190003

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Objective: To describe the morbidity, mortality, and rate of complete resection associated with robotic surgery for the treatment of non-small cell lung cancer in Brazil, as well as to report the rates of overall survival and disease-free survival in patients so treated. Methods: This was a retrospective study of patients diagnosed with non-small cell lung carcinoma and undergoing resection by robotic surgery at one of six hospitals in Brazil between February of 2015 and July of 2018. Data were collected retrospectively from the electronic medical records. Results: A total of 154 patients were included. The mean age was 65 ± 9.5 years (range, 30-85 years). The main histological diagnosis was adenocarcinoma, which was identified in 128 patients (81.5%), followed by epidermoid carcinoma, identified in 14 (9.0%). Lobectomy was performed in 133 patients (86.3%), and segmentectomy was performed in 21 (13.7%). The mean operative time was 209 ± 80 min. Postoperative complications occurred in 32 patients (20.4%). The main complication was air leak, which occurred in 15 patients (9.5%). The median (interquartile range) values for hospital stay and drainage time were 4 days (3-6 days) and 2 days (2-4 days), respectively. There was one death in the immediate postoperative period (30-day mortality rate, 0.5%). The mean follow-up period was 326 ± 274 days (range, 3-1,110 days). Complete resection was achieved in 97.4% of the cases. Overall mortality was 1.5% (3 deaths), and overall survival was 97.5%. Conclusions: Robotic pulmonary resection proved to be a safe treatment for lung cancer. Longer follow-up periods are required in order to assess long-term survival.


Keywords: Lung neoplasms/surgery; Lung neoplasms/mortality; Robotic surgical procedures.


9 - Reference values for the Unsupported Upper Limb Exercise test in healthy adults in Brazil

Valores normativos para o teste Unsupported Upper Limb Exercise para adultos saudáveis no Brasil

Vanessa Pereira Lima1,2 , Marcelo Velloso3,4 , Bruno Porto Pessoa3,4 , Fabiana Damasceno Almeida3,4 , Giane Amorim Ribeiro-Samora3,4 , Tania Janaudis-Ferreira5,6

J Bras Pneumol.2020;46(1):e20180267

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Objective: To establish reference values for the Unsupported Upper Limb EXercise (UULEX) test, which measures peak arm exercise capacity, in healthy adults in Brazil. Methods: This was a cross-sectional study, involving presumably healthy individuals ≥ 30 years of age who completed questionnaires and underwent spirometry. All of the individuals underwent two UULEX tests 30-min apart. The outcome measure was the maximum time (in min) to completion of the test. Results: We included 100 individuals between 30 and 80 years of age. The mean test completion time was 11.99 ± 1.90 min among the women and 12.89 ± 2.15 min among the men (p = 0.03). The test completion time showed statistically significant correlations with age (r = −0.48; p < 0.001), gender (r = 0.28; p = 0.004), body mass index (BMI, r = −0.20; p = 0.05), and height (r = 0.28; p = 0.005). Linear regression analysis showed that the predictors of UULEX completion time were age (p = 0.000), BMI (p = 0.003), and gender (p = 0.019), which collectively explained 30% of the total variability. The mean UULEX completion time was 6% lower for the women than for the men. Conclusions: The present study was able to establish reference values for the UULEX test in healthy adults in Brazil. The values were influenced by age, gender, and BMI.


Keywords: Reference values; Exercise test; Upper extremity


10 - Assessment of religious coping in patients with COPD

Avaliação do coping religioso em pacientes com DPOC

Francisco Alessandro Braga do Nascimento1,2,a, Guilherme Pinheiro Ferreira da Silva1,3,b, Geisyani Francisca Gomes Prudente1,c, Rafael Mesquita1,d, Eanes Delgado Barros Pereira1,2,e

J Bras Pneumol.2020;46(1):e20180150

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Objective: To compare religious coping (RC) in patients with COPD and healthy individuals, as well as to determine whether RC is associated with demographic characteristics, quality of life, depression, and disease severity in the patients with COPD. Methods: This was a cross-sectional study conducted between 2014 and 2016, involving outpatients with moderate to severe COPD seen at one of two hospitals in Fortaleza, Brazil, as well as gender- and age-matched healthy controls. The Brief RCOPE scale assessed RC in all of the participants. We also evaluated the COPD group patients regarding symptoms, quality of life, and depression, as well as submitting them to spirometry and a six-minute walk test. Results: A total of 100 patients were evaluated. The mean age was 67.3 ± 6.8 years, and 54% were men. In the COPD group, the mean positive RC score was significantly higher than was the mean negative RC score (27.17 ± 1.60 vs. 8.21 ± 2.12; p = 0.001). The mean positive RC score was significantly higher in women than in men (27.5 ± 1.1 vs. 26.8 ± 2.8; p = 0.02). Negative RC scores were significantly higher in the COPD group than in the control group (p = 0.01). Negative RC showed an inverse association with six-minute walk distance (6MWD; r = −0.3; p < 0.05) and a direct association with depressive symptoms (r = 0.2; p < 0.03). Positive RC correlated with none of the variables studied. Multiple regression analysis showed that negative RC was associated with 6MWD (coefficient = −0.009; 95% CI: −0.01 to −0.003). 6MWD explained the variance in negative RC in a linear fashion. Conclusions: Patients with COPD employ negative RC more often than do healthy individuals. Exercise capacity and depressive symptoms are associated with negative RC.


Keywords: Religion; Spirituality; Adaptation, psychological; Quality of life; Pulmonary disease, chronic obstructive.


11 - Clinical and functional correlations of the difference between slow vital capacity and FVC

Correlação clínica e funcional da diferença entre capacidade vital lenta e CVF

Jonathan Jerias Fernandez1,2, Maria Vera Cruz de Oliveira Castellano3, Flavia de Almeida Filardo Vianna3, Sérgio Roberto Nacif1, Roberto Rodrigues Junior4, Sílvia Carla Sousa Rodrigues1,5

J Bras Pneumol.2020;46(1):e20180328

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Objective: To evaluate the relationship that the difference between slow vital capacity (SVC) and FVC (ΔSVC-FVC) has with demographic, clinical, and pulmonary function data. Methods: This was an analytical cross-sectional study in which participants completed a respiratory health questionnaire, as well as undergoing spirometry and plethysmography. The sample was divided into two groups: ΔSVC-FVC ≥ 200 mL and ΔSVC-FVC < 200 mL. The intergroup correlations were analyzed, and binomial logistic regression analysis was performed. Results: The sample comprised 187 individuals. In the sample as a whole, the mean ΔSVC-FVC was 0.17 ± 0.14 L, and 61 individuals (32.62%) had a ΔSVC-FVC ≥ 200 mL. The use of an SVC maneuver reduced the prevalence of nonspecific lung disease and of normal spirometry results by revealing obstructive lung disease (OLD). In the final logistic regression model (adjusted for weight and body mass index > 30 kg/m2), OLD and findings of air trapping (high functional residual capacity and a low inspiratory capacity/TLC ratio) were predictors of a ΔSVC-FVC ≥ 200 mL. The chance of a bronchodilator response was found to be greater in the ΔSVC-FVC ≥ 200 mL group: for FEV1 (OR = 4.38; 95% CI: 1.45-13.26); and for FVC (OR = 3.83; 95% CI: 1.26-11.71). Conclusions: The use of an SVC maneuver appears to decrease the prevalence of nonspecific lung disease and of normal spirometry results. Individuals with a ΔSVC-FVC ≥ 200 mL, which is probably the result of OLD and air trapping, are apparently more likely to respond to bronchodilator administration.


Keywords: Vital capacity; Plethysmography; Airway obstruction.


12 - The Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living questionnaire: construct validity, reliability, and measurement error.

Versão em português do Brasil do questionário Manchester Respiratory Activities of Daily Living: validade de construto, confiabilidade e erro de medida.

Fernanda Rodrigues Fonseca1,2,a, Roberta Rodolfo Mazzali Biscaro1,b, Alexânia de Rê1,2,c, Maíra Junkes-Cunha3,d, Cardine Martins dos Reis1,e, Marina Mônica Bahl1,f, Abebaw Mengistu Yohannes4,g, Rosemeri Maurici1,2,5,h

J Bras Pneumol.2020;46(1):e20180397

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Objective: To test the construct validity, reliability, and measurement error of the Brazilian Portuguese-language version of the Manchester Respiratory Activities of Daily Living (MRADL) questionnaire in patients with COPD. Methods: We evaluated 50 patients with COPD, among whom 30 were men, the mean age was 64 ± 8 years, and the median FEV1 as a percentage of the predicted value (FEV1%predicted) was 38.4% (interquartile range, 29.1-57.4%). Pulmonary function and limitations in activities of daily living (ADLs) were assessed by spirometry and by face-to-face application of the MRADL, respectively. For the construct validity analysis, we tested the hypothesis that the total MRADL score would show moderate correlations with spirometric parameters. We analyzed inter-rater reliability, test-retest reliability, inter-rater measurement error, and test-retest measurement error. Results: The total MRADL score showed moderate correlations with the FEV1/FVC ratio, FEV1 in liters, FEV1%predicted, and FVC%predicted, all of the correlations being statistically significant (r = 0.34, r = 0.31, r = 0.42, and r = 0.38, respectively; p < 0.05 for all). For the reliability and measurement error of the total MRADL score, we obtained the following inter-rater and test-retest values, respectively: two-way mixed-effects model intraclass correlation coefficient for single measures, 0.92 (95% CI: 0.87-0.96) and 0.89 (95% CI: 0.81-0.93); agreement standard error of measurement, 1.03 and 0.97; smallest detectable change at the individual level, 2.86 and 2.69; smallest detectable change at the group level, 0.40 and 0.38; and limits of agreement, −2.24 to 1.96 and −2.65 to 2.69. Conclusions: In patients with COPD in Brazil, this version of the MRADL shows satisfactory construct validity, satisfactory inter-rater/test-retest reliability, and indeterminate inter-rater/test-retest measurement erro


Keywords: Pulmonary disease, chronic obstructive; Activities of daily living; Disability evaluation; Patient reported outcome measures; Validation studies.


Original Article > Asthma

13 - Body mass index, asthma, and respiratory symptoms: a population-based study

Índice de massa corpórea, asma e sintomas respiratórios: um estudo de base populacional

Elaine Cristina Caon de Souza1,2,a, Marcia Margaret Menezes Pizzichini1,2,b, Mirella Dias1,2,c, Maíra Junkes Cunha1,2,d, Darlan Lauricio Matte1,2,e, Manuela Karloh1,2,f, Rosemeri Maurici1,2,g, Emilio Pizzichini1,2,h

J Bras Pneumol.2020;46(1):e20190006

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Objective: To estimate the prevalence of respiratory symptoms and asthma, according to body mass index (BMI), as well as to evaluate factors associated with physician-diagnosed asthma, in individuals ≥ 40 years of age. Methods: This was a population-based cross-sectional study conducted in Florianópolis, Brazil, with probability sampling. Data were collected during home visits. Demographic data were collected, as were reports of physician-diagnosed asthma, respiratory symptoms, medications in use, and comorbidities. Anthropometric measurements were taken. Individuals also underwent spirometry before and after bronchodilator administration. Individuals were categorized as being of normal weight (BMI < 25 kg/m2), overweight (25 kg/m2 ≥ BMI < 30 kg/m2), or obese (BMI ≥ 30 kg/m2). Results: A total of 1,026 individuals were evaluated, 274 (26.7%) were of normal weight, 436 (42.5%) were overweight, and 316 (30.8%) were obese. The prevalence of physician-diagnosed asthma was 11.0%. The prevalence of obesity was higher in women (p = 0.03), as it was in respondents with ≤ 4 years of schooling (p < 0.001) or a family income of 3-10 times the national minimum wage. Physician-diagnosed asthma was more common among obese individuals than among those who were overweight and those of normal weight (16.1%, 9.9%, and 8.0%, respectively; p = 0.04), as were dyspnea (35.5%, 22.5%, and 17.9%, respectively; p < 0.001) and wheezing in the last year (25.6%, 11.9%, and 14.6%, respectively; p < 0.001). These results were independent of patient smoking status. In addition, obese individuals were three times more likely to report physician-diagnosed asthma than were those of normal weight (p = 0.005). Conclusions: A report of physician-diagnosed asthma showed a significant association with being ≥ 40 years of age and with having a BMI ≥ 30 kg/m2. Being obese tripled the chance of physician-diagnosed asthma.


Keywords: Obesity; Dyspnea; Cough; Asthma; Smoking.


14 - Smoking among industrial workers in Brazil: association with sociodemographic factors, alcohol consumption, and stress levels

Tabagismo em trabalhadores da indústria no Brasil: associação com fatores sociodemográficos, consumo de bebidas alcoólicas e nível de estresse

Pablo Magno da Silveira1, Kelly Samara da Silva1, Gabrielli Thais de Mello1, Margarethe Thaisi Garro Knebel1, Adriano Ferreti Borgatto1, Markus Vinicius Nahas1

J Bras Pneumol.2020;46(1):e20180385

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Objective: To determine the prevalence of smoking, as well as its association with sociodemographic factors, alcohol consumption, and stress levels, among industrial workers in Brazil. Methods: This was a nationwide survey, conducted in 24 capitals in Brazil through the application of a pre-tested questionnaire. The response to the question "What is your smoking status?" was the outcome variable. To determine the associations, we performed Poisson regression analyses in which the inputs were blocks of variables: block 1 (age and marital status); block 2 (level of education and gross family income); block 3 (geographic region); and block 4 (alcohol consumption and stress level). All analyses were stratified by gender. Results: The sample consisted of 47,328 workers ≥ 18 years of age, of whom 14,577 (30.8%) were women. The prevalence of smoking was 13.0% (15.2% in men and 7.9% in women). Advancing age, alcohol consumption, and a high stress level were positively associated with smoking. A lower risk of smoking was associated with being married, having a higher level of education, and living in the northeastern region of the country (versus the southern region). Conclusions: The prevalence of smoking was greater in men than in women. Alcohol consumption and high stress levels appear to promote smoking.


Keywords: Tobacco use disorder/epidemiology; Tobacco smoking; Occupational health; Industry; Brazil.


Special Article

15 - 2020 Brazilian Thoracic Association recommendations for the management of asthma

Recomendações para o manejo da asma da Sociedade Brasileira de Pneumologia e Tisiologia - 2020

Marcia Margaret Menezes Pizzichini1, Regina Maria de Carvalho-Pinto2, José Eduardo Delfini Cançado3, Adalberto Sperb Rubin,4,5, Alcindo Cerci Neto6,7, Alexandre Pinto Cardoso8, Alvaro Augusto Cruz9,10, Ana Luisa Godoy Fernandes11, Daniella Cavalet Blanco12, Elcio Oliveira Vianna13, Gediel Cordeiro Junior14,15, José Angelo Rizzo16, Leandro Genehr Fritscher12, Lilian Serrasqueiro Ballini Caetano11, Luiz Fernando Ferreira Pereira17, Marcelo Fouad Rabahi18, Maria Alenita de Oliveira19, Marina Andrade Lima20, Marina Buarque de Almeida21, Rafael Stelmach2, Paulo Márcio Pitrez22, Alberto Cukier2

J Bras Pneumol.2020;46(1):e20190307

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The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.


Keywords: Asthma/therapy; Asthma/drug therapy; Asthma/prevention & control; Practice guideline.


Letters to the Editor

16 - Pulmonary manifestations of dengue.

Manifestações pulmonares da dengue.

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

J Bras Pneumol.2020;46(1):e20190246

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