Brazilian Journal of Pulmonology

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


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Year 2012 - Volume 38  - Number 3  (May/June)


1 - Guidelines: what for?

Diretrizes: para quê?

José Antônio Baddini Martinez

J Bras Pneumol.2012;38(3):

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Special Article

2 - Highlights of the Brazilian Thoracic Association Guidelines for Interstitial Lung Diseases

Destaques das Diretrizes de Doenças Pulmonares Intersticiais da Sociedade Brasileira de Pneumologia e Tisiologia

Bruno Guedes Baldi, Carlos Alberto de Castro Pereira, Adalberto Sperb Rubin, Alfredo Nicodemos da Cruz Santana, André Nathan Costa, Carlos Roberto Ribeiro Carvalho, Eduardo Algranti, Eduardo Mello de Capitani, Eduardo Pamplona Bethlem, Ester Nei Aparecida Martins Coletta, Jaquelina Sonoe Ota Arakaki, José Antônio Baddini Martinez, Jozélio Freire de Carvalho, Leila John Marques Steidle, Marcelo Jorge Jacó Rocha, Mariana Silva Lima, Maria Raquel Soares, Marlova Luzzi Caramori, Miguel Abidon Aidé, Rimarcs Gomes Ferreira, Ronaldo Adib Kairalla, Rudolf Krawczenko Feitoza de Oliveira, Sérgio Jezler, Sílvia Carla Sousa Rodrigues, Suzana Pinheiro Pimenta

J Bras Pneumol.2012;38(3):282-291

Abstract PDF PT PDF EN Portuguese Text

Interstitial lung diseases (ILDs) are heterogeneous disorders, involving a large number of conditions, the approach to which continues to pose an enormous challenge for pulmonologists. The 2012 Brazilian Thoracic Association ILD Guidelines were established in order to provide Brazilian pulmonologists with an instrument that can facilitate the management of patients with ILDs, standardizing the criteria used for the diagnosis of different conditions and offering guidance on the best treatment in various situations. The objective of this article was to briefly describe the highlights of those guidelines.


Keywords: Lung diseases, interstitial; Guidelines as topic; Brazil.


Original Article

3 - Exercise-induced bronchoconstriction in elite long-distance runners in Brazil

Broncoespasmo induzido por exercício em corredores brasileiros de longa distância de elite

Renata Nakata Teixeira, Luzimar Raimundo Teixeira, Luiz Augusto Riani Costa, Milton Arruda Martins, Timothy Derick Mickleborough, Celso Ricardo Fernandes Carvalho

J Bras Pneumol.2012;38(3):292-298

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of exercise-induced bronchoconstriction among elite long-distance runners in Brazil and whether there is a difference in the training loads among athletes with and without exercise-induced bronchoconstriction. Methods: This was a cross-sectional study involving elite long-distance runners with neither current asthma symptoms nor a diagnosis of exercise-induced bronchoconstriction. All of the participants underwent eucapnic voluntary hyperpnea challenge and maximal cardiopulmonary exercise tests, as well as completing questionnaires regarding asthma symptoms and physical activity, in order to monitor their weekly training load. Results: Among the 86 male athletes recruited, participation in the study was agreed to by 20, of whom 5 (25%) were subsequently diagnosed with exercise-induced bronchoconstriction. There were no differences between the athletes with and without exercise-induced bronchoconstriction regarding anthropometric characteristics, peak oxygen consumption, baseline pulmonary function values, or reported asthma symptoms. The weekly training load was significantly lower among those with exercise-induced bronchoconstriction than among those without. Conclusions: In this sample of long-distance runners in Brazil, the prevalence of exercise-induced bronchoconstriction was high.


Keywords: Athletes; Asthma, exercise-induced; Exercise test.


4 - Comparison between two methods of asthma control evaluation based on individual perception

Comparação entre dois métodos de avaliação do controle da asma baseados na percepção individual

Paula Cristina Andrade Almeida, Adelmir Souza-Machado, Mylene dos Santos Leite, Lourdes Alzimar Mendes de Castro, Ana Carla Carvalho Coelho, Constança Sampaio Cruz, Álvaro Augusto Cruz

J Bras Pneumol.2012;38(3):299-307

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the subjective perception of asthma control reported by the patient with that measured by the score obtained on the Asthma Control Questionnaire 6-item version (ACQ-6) in patients with severe asthma and to determine whether asthma control is associated with the number of emergency room visits in the previous month. Methods: This was a cross-sectional study involving 528 patients treated at the Bahia State Asthma and Allergic Rhinitis Control Program Central Referral Clinic between August of 2008 and March of 2010, in the city of Salvador, Brazil. The patients completed the ACQ-6 and answered a specific additional question in order to evaluate their own perception of asthma control in the previous week. Results: We evaluated 423 patients who met the inclusion criteria. The sample was predominantly female (81.3%), and 64.3% had an income lower than two times the national minimum wage. The mean age was 49.85 ± 13.71 years, and the duration of asthma symptoms was 32.11 ± 16.35 years. The patients had been regularly treated via the program for 36.65 ± 18.10 months. Based on the subjective perception of asthma control, only 8% of the patients considered their asthma to be uncontrolled, whereas 38.8% had an ACQ-6 score  1.5, which indicates poor control. The kappa statistic revealed poor concordance between the two methods. There was a direct association between uncontrolled asthma and the number of emergency room visits in the previous month (p < 0.001). Conclusions: In this sample of patients, the subjective perception of asthma control differed from that measured by the ACQ-6 score, and the patients overestimated their own level of asthma control, which puts them at risk of being undertreated.


Keywords: Asthma; Health services; Questionnaires.


5 - Respiratory muscle strength in children and adolescents with asthma: similar to that of healthy subjects

Força dos músculos respiratórios em crianças e adolescentes com asma: similar à de indivíduos saudáveis?

Cilmery Marly Gabriel de Oliveira, Fernanda de Cordoba Lanza, Dirceu Solé

J Bras Pneumol.2012;38(3):308-314

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare children/adolescents with mild or moderate asthma and healthy subjects in terms of respiratory muscle strength, correlating it with spirometric variables in the former group. Methods: This was a cross-sectional study involving individuals 6-16 years of age and clinically diagnosed with mild/moderate asthma, together with a group of healthy, age- and gender-matched subjects. We determined spirometric values, as well as MIP and MEP, and we selected three reproducible measurements (variation < 10%). Results: We evaluated 75 patients with asthma and 90 controls. The mean age was 10.0 ± 2.6 years. There were no statistically significant differences between the controls and the asthma group regarding MIP (−89.7 ± 26.7 cmH2O vs. −92.2 ± 26.3 cmH2O; p = 0.541) or MEP (79.2 ± 22.9 cmH2O vs. 86.4 ± 24.0 cmH2O; p = 0.256). The groups were subdivided by age (children and adolescents: 6-12 and 13-16 years of age, respectively). Within the asthma group, there was a significant difference between the child and adolescent subgroups in terms of MEP (74.1 ± 24.1 cmH2O vs. 92.1 ± 21.9 cmH2O; p < 0.001) but not MIP (p = 0.285). Within the control group, there were significant differences between the child and adolescent subgroups in terms of MIP (−79.1 ± 17.7 cmH2O vs. −100.9 ± 28.1 cmH2O; p < 0.001) and MEP (73.9 ± 18.7 cmH2O vs. 90.9 ± 28.1cmH2O; p < 0.001). In the asthma group, spirometric variables did not correlate with MIP or MEP. Conclusions: In our sample, asthma was found to have no significant effect on respiratory muscle strength.


Palavras-chave: Asma; Músculos respiratórios; Testes de função respiratória.


6 - Flexible bronchoscopy as the first-choice method of removing foreign bodies from the airways of adults

Broncoscopia flexível como primeira opção para a remoção de corpo estranho das vias aéreas em adultos

Ascedio José Rodrigues, Eduardo Quintino Oliveira, Paulo Rogério Scordamaglio, Marcelo Gervilla Gregório, Márcia Jacomelli, Viviane Rossi Figueiredo

J Bras Pneumol.2012;38(3):315-320

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the success rate of flexible bronchoscopy as the first-choice method of removing foreign bodies from the airways of adults. Methods: This was a retrospective study of all adult patients (over 18 years of age) with foreign body aspiration submitted to bronchoscopy between January of 2009 and January of 2011 at the University of São Paulo School of Medicine Hospital das Clínicas, located in São Paulo, Brazil. Results: The study sample comprised 40 adult patients, with a mean age of 52 years (range, 18-88 years). The median time of permanence of the foreign body in the airway was 15 days (range, 12 h to 10 years). All of the patients first underwent diagnostic flexible bronchoscopy. Foreign bodies were successfully removed with flexible bronchoscopy in 33 (82.5%) of the patients. In 1 patient, a metal object lodged in the distal bronchial tree required the use of fluoroscopy. Six patients (15%) required rigid bronchoscopy due to tracheal foreign body-induced dyspnea, in 2, and because the foreign body was too large for the flexible forceps, in 4. Bronchoscopy failed in 1 patient, who therefore required surgical bronchotomy. Conclusions: Although rigid bronchoscopy is considered the gold standard for the removal of foreign bodies from the airways, our experience showed that flexible bronchoscopy can be safely and effectively used in the diagnosis and treatment of stable adult patients.


Keywords: Bronchoscopy; Foreign bodies; Airway obstruction; Airway management.


7 - Immunophenotyping and extracellular matrix remodeling in pulmonary and extrapulmonary sarcoidosis

Imunofenotipagem e remodelamento da matriz extracelular na sarcoidose pulmonar e extrapulmonar

Pedro Henrique Ramos Quintino da Silva, Edwin Roger Parra, William Sanches Zocolaro, Ivy Narde, Fabíola Rodrigues, Ronaldo Adib Kairalla, Carlos Roberto Ribeiro de Carvalho, Vera Luiza Capelozzi

J Bras Pneumol.2012;38(3):321-330

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the significance of cellular immune markers, as well as that of collagen and elastic components of the extracellular matrix, within granulomatous structures in biopsies of patients with pulmonary or extrapulmonary sarcoidosis. Methods: We carried out qualitative and quantitative evaluations of inflammatory cells, collagen fibers, and elastic fibers in granulomatous structures in surgical biopsies of 40 patients with pulmonary and extrapulmonary sarcoidosis using histomorphometry, immunohistochemistry, picrosirius red staining, and Weigert's resorcin-fuchsin staining. Results: The extrapulmonary tissue biopsies presented significantly higher densities of lymphocytes, macrophages, and neutrophils than did the lung tissue biopsies. Pulmonary granulomas showed a significantly higher number of collagen fibers and a lower density of elastic fibers than did extrapulmonary granulomas. The amount of macrophages in the lung samples correlated with FVC (p < 0.05), whereas the amount of CD3+, CD4+, and CD8+ lymphocytes correlated with the FEV1/FVC ratio and VC. There were inverse correlations between TLC and the CD1a+ cell count (p < 0.05), as well as between DLCO and collagen/elastic fiber density (r = −0.90; p = 0.04). Conclusions: Immunophenotyping and remodeling both showed differences between pulmonary and extrapulmonary sarcoidosis in terms of the characteristics of the biopsy samples. These differences correlated with the clinical and spirometric data obtained for the patients, suggesting that two different pathways are involved in the mechanism of antigen clearance, which was more effective in the lungs and lymph nodes.


Keywords: Sarcoidosis; Granulomatous disease, chronic; Extracellular matrix; Immunophenotyping; Respiratory function tests.


8 - Influence that sociodemographic variables, clinical characteristics, and level of dependence have on quality of life in COPD patients on long-term home oxygen therapy

Influência das características sociodemográficas e clínicas e do nível de dependência na qualidade de vida de pacientes com DPOC em oxigenoterapia domiciliar prolongada

Simone Cedano, Angélica Gonçalves Silva Belasco, Fabiana Traldi, Maria Christina Lombardi Oliveira Machado, Ana Rita de Cássia Bettencourt

J Bras Pneumol.2012;38(3):331-338

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate and correlate the quality of life (QoL) of COPD patients on long-term home oxygen therapy (LTOT) with their sociodemographic/clinical characteristics and level of dependence. Methods: This was a cross-sectional analytical study involving COPD patients on LTOT followed at the Oxygen Therapy Outpatient Clinic of the Federal University of São Paulo Hospital São Paulo, in the city of São Paulo, Brazil. Sociodemographic, clinical, and biochemical data were collected. We assessed QoL and level of dependence using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Katz index, respectively. Multiple linear regression models were constructed in order to determine the influence of these variables on QoL. Results: We included 80 patients in the study. The mean age was 69.6 ± 9.1 years, and 51.3% were female. The lowest SF-36 scores were for the physical functioning and role-physical domains. All sociodemographic characteristics (except gender) were found to correlate significantly with the SF-36 domains mental health, vitality, role-physical, and social functioning. We also found that body mass index, PaO2, post-bronchodilator FEV1, hemoglobin, and Katz index correlated significantly with the physical functioning, mental health, role-physical, and bodily pain domains. In addition, oxygen flows were found to correlate negatively with the physical functioning, mental health, vitality, and role-emotional domains. Conclusions: Low scores for SF-36 domains, as well as the variables that negatively influence them, should be considered and analyzed during the development and implementation of strategies for improving the QoL of COPD patients on LTOT.


Keywords: Pulmonary disease, chronic obstructive; Quality of life; Oxygen inhalation therapy.


9 - Cultural adaptation and reproducibility of the Breathing Problems Questionnaire for use in patients with COPD in Brazil

Adaptação cultural e reprodutibilidade do Questionário para Problemas Respiratórios em pacientes portadores de DPOC no Brasil

Patrícia Nobre Calheiros da Silva, José Roberto Jardim, George Márcio da Costa e Souza, Michael E Hyland, Oliver Augusto Nascimento

J Bras Pneumol.2012;38(3):339-345

Abstract PDF PT PDF EN Portuguese Text

Objective: To translate the Breathing Problems Questionnaire (BPQ) into Portuguese and adapt it to the Brazilian culture, as well as to evaluate its reproducibility in patients with COPD. Methods: After the BPQ had been translated and adapted to the Brazilian culture, it was administered to a subgroup of 8 patients in order to identify their uncertainties and difficulties. The questionnaire was reviewed by an expert committee, and its final version was arrived at. A second translator back-translated the final version into English, which was sent to the original author in order to verify that the original meaning of the questionnaire had been maintained. After the approval of the original author, the final Portuguese-language version of the questionnaire was administered to 50 patients with COPD, in order to evaluate its reproducibility. Results: The mean response time was 9.5 min. Of the 50 patients, 21 were female and 29 were male. The mean age was 65.8 ± 7.5 years. Most of the patients were classified as having moderate COPD (29.16%) or severe COPD (52%). The intraclass correlation coefficient (ICC) for the total score was 0.94. The ICCs for the eleven BPQ domains and its two subscales were also above 0.70. Moderate correlations were found between the BPQ domains and subscales. Conclusions: The translation and cultural adaptation of the BPQ for use in Brazil was deemed appropriate, because the patients could easily understand and answer the questions. In addition, the Brazilian version of the BPQ questionnaire was found to be reliable, showing good reproducibility.


Keywords: Pulmonary disease; chronic obstructive; Quality of life; Reproducibility of results.


10 - Six-minute walk distance is not related to quality of life in patients with non-cystic fibrosis bronchiectasis

Distância percorrida no teste de caminhada de seis minutos não se relaciona com qualidade de vida em pacientes com bronquiectasias não fibrocísticas

Patrícia Santos Jacques, Marcelo Basso Gazzana, Dora Veronisi Palombini, Sérgio Saldanha Menna Barreto, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2012;38(3):346-355

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate physical performance on the six-minute walk test (6MWT) in patients with non-cystic fibrosis bronchiectasis and to investigate its relationship with quality of life (QoL). To identify predictors of exercise performance, we also investigated whether six-minute walk distance (6MWD) is associated with clinical and spirometric findings. Methods: This was a cross-sectional study involving patients with non-cystic fibrosis bronchiectasis (age,  18 years), with at least one respiratory symptom for  2 years and an FEV1  70% of predicted. Patients underwent clinical evaluation, pulmonary function tests, the 6MWT, and QoL assessment with the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). Results: We included 70 patients (48 females). Mean age was 54.5 ± 17.7 years, and mean FEV1 was 44.9 ± 14.5% of predicted. The patients were divided into two groups: 6MWD-low (6MWD below the predicted lower limit; n = 23); and 6MWD-norm (normal 6MWD; n = 47). The following variables were significantly lower in the 6MWD-low group than in the 6MWD-norm group: age; age at diagnosis of bronchiectasis; proportion of former smokers; body mass index (BMI); FEV1% of predicted; and MEP% of predicted. There were no significant differences in the SF-36 scores between the groups. In the logistic regression model, lower age and lower BMI were significantly associated with lower 6MWD. Conclusions: In this sample, there was a high proportion of patients who had a lower than expected 6MWD. Although 6MWD was not related to QoL, it was associated with age and BMI.


Keywords: Bronchiectasis; Quality of life; Respiratory function tests; Exercise tolerance.


11 - Smoking and abdominal fat in blood donors

Tabagismo e obesidade abdominal em doadores de sangue

Cássia da Silva Faria, Clovis Botelho, Regina Maria Veras Gonçalves da Silva, Márcia Gonçalves Ferreira

J Bras Pneumol.2012;38(3):356-363

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the association between smoking and abdominal fat among male blood donors. Methods: This was a cross-sectional study involving 1,235 adult male blood donors (age, 20-59 years) in the city of Cuiabá, Brazil. Socioeconomic, demographic, and anthropometric data, as well as information on the lifestyle of the participants, were collected. In this study, waist circumference and waist-to-hip ratio were used as markers of abdominal fat. The association between these two markers and smoking was analyzed by multiple linear regression in separate models, adjusted for potential confounders. Results: Of the 1,235 respondents, 273 (22.1%) reported being smokers, and, of those, 99 (36.3%) reported smoking more than 15 cigarettes per day. The average body mass index was lower among smokers than among nonsmokers (p < 0.001). In the multiple linear regression analyses, smoking was associated with waist circumference and waist-to-hip ratio for smokers of 6-10 cigarettes/day and of ≥ 11 cigarettes/day. Conclusions: In our sample, smoking was positively associated with indicators of abdominal fat, regardless of potential confounding factors, including the consumption of alcoholic beverages.


Keywords: Smoking; Obesity; Abdominal fat.


12 - Impact of a mechanical ventilation weaning protocol on the extubation failure rate in difficult-to-wean patients

Impacto de um protocolo de desmame de ventilação mecânica na taxa de falha de extubação em pacientes de difícil desmame

Cassiano Teixeira, Juçara Gasparetto Maccari, Silvia Regina Rios Vieira, Roselaine Pinheiro Oliveira, Augusto Savi, André Sant'Ana Machado, Túlio Frederico Tonietto, Ricardo Viegas Cremonese, Ricardo Wickert, Kamile Borba Pinto, Fernanda Callefe, Fernanda Gehm, Luis Guilherme Borges, Eubrando Silvestre Oliveira

J Bras Pneumol.2012;38(3):364-371

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether the predictive accuracy of clinical judgment alone can be improved by supplementing it with an objective weaning protocol as a decision support tool. Methods: This was a multicenter prospective cohort study carried out at three medical/surgical ICUs. The study involved all consecutive difficult-to-wean ICU patients (failure in the first spontaneous breathing trial [SBT]), on mechanical ventilation (MV) for more than 48 h, admitted between January of 2002 and December of 2005. The patients in the protocol group (PG) were extubated after a T-piece weaning trial and were compared with patients who were otherwise extubated (non-protocol group, NPG). The primary outcome measure was reintubation within 48 h after extubation. Results: We included 731 patients-533 (72.9%) and 198 (27.1%) in the PG and NPG, respectively. The overall reintubation rate was 17.9%. The extubation success rates in the PG and NPG were 86.7% and 69.6%, respectively (p < 0.001). There were no significant differences between the groups in terms of age, gender, severity score, or pre-inclusion time on MV. However, COPD was more common in the NPG than in the PG (44.4% vs. 17.6%; p < 0.001), whereas sepsis and being a post-operative patient were more common in the PG (23.8% vs. 11.6% and 42.4% vs. 26.4%, respectively; p < 0.001 for both). The time on MV after the failure in the first SBT was higher in the PG than in the NPG (9 ± 5 days vs. 7 ± 2 days; p < 0.001). Conclusions: In this sample of difficult-to-wean patients, the use of a weaning protocol improved the decision-making process, decreasing the possibility of extubation failure.


Keywords: Ventilator weaning; Ventilation; Ventilators, mechanical.



13 - Thirty years of prophylactic cranial irradiation in patients with small cell lung cancer: a meta-analysis of randomized clinical trials

Trinta anos de irradiação craniana profilática em pacientes com câncer de pulmão de pequenas células: uma meta-análise de ensaios clínicos randomizados

Gustavo Arruda Viani, André Campiolo Boin, Veridiana Yuri Ikeda, Bruno Silveira Vianna, Rondinelli Salvador Silva, Fernando Santanella

J Bras Pneumol.2012;38(3):372-381

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the role of prophylactic cranial irradiation (PCI) in patients with small cell lung cancer (SCLC). Methods: We searched various databases, selecting randomized clinical trials published in journals or conference proceedings within the last 30 years and investigating the role of PCI in the mortality of patients with SCLC, submitted to PCI or not. Results: Sixteen randomized clinical trials, collectively involving 1,983 patients, were considered eligible for inclusion. Of those 1,983 patients, 1,021 were submitted to PCI and 962 were not. Overall mortality was 4.4% lower in the patients submitted to PCI than in those who were not (OR = 0.73; 95% CI: 0.57-0.97; p = 0.01), especially among the patients showing a complete response after induction chemotherapy (OR = 0.68; 95% CI: 0.50-0.93; p = 0.02) and in those submitted to PCI after that treatment (OR = 0.68; 95% CI: 0.49-0.94; p = 0.03). That decrease did not correlate with the stage of the disease: limited disease (OR = 0.73; 95% CI: 0.55-0.97; p = 0.03); and extensive disease (OR = 0.48; 95% CI: 0.26-0.87; p = 0.02). Conclusions: Our findings suggest that PCI decreases mortality in patients with SCLC, especially in those showing a complete response after induction chemotherapy and in those submitted to PCI after that treatment, regardless of the stage of the disease.


Keywords: Small cell lung carcinoma; Radiotherapy; Survival analysis.


Brief Communication

14 - Prevalence of HIV infection in tuberculosis patients treated at primary health care clinics in the city of Fortaleza, Brazil

Prevalência da infecção pelo HIV em pacientes com tuberculose na atenção básica em Fortaleza, Ceará

Helder Oliveira e Silva, Marcelo Luiz Carvalho Gonçalves

J Bras Pneumol.2012;38(3):382-385

Abstract PDF PT PDF EN Portuguese Text

The objective of this study was to determine the prevalence of HIV infection among individuals ≥ 15 years of age with a confirmed diagnosis of tuberculosis and treated at family health care clinics in the city of Fortaleza, Brazil. We evaluated a random sample of 110 patients with tuberculosis, treated at a total of 26 family health care clinics between January and May of 2009. All of the participants completed a questionnaire regarding sociodemographic and clinical data, and all underwent HIV testing. In this sample, the prevalence of tuberculosis/HIV co-infection was 3.6% (95% CI: 0.2-7.0).


Keywords: Tuberculosis; HIV seroprevalence; Primary health care.


Review Article

15 - Severe tuberculosis requiring ICU admission

Tuberculose grave com necessidade de internação em UTI

Denise Rossato Silva, Marcelo Basso Gazzana, Paulo de Tarso Roth Dalcin

J Bras Pneumol.2012;38(3):386-394

Abstract PDF PT PDF EN Portuguese Text

Tuberculosis is a curable disease that can evolve to severe forms, requiring the treatment of the patients in an ICU, especially if there is a delay in the diagnosis or if it affects elderly patients, those on dialysis, or those with HIV infection or other states of immunosuppression, as well as in cases of multidrug resistant disease. Knowledge of the radiological presentation of the cases can help diagnose these severe forms, as can the introduction of new tests, such as the early detection of the etiological agent by PCR and chest CT, which favors the early initiation of treatment. In addition, the use of regimens without isoniazid and rifampin, as well as uncertain enteral absorption and low serum concentrations of antituberculosis drugs, can reduce the efficacy of treatment. For such patients, the prognosis is generally poor and mortality rates are high.


Keywords: Tuberculosis; Respiratory insufficiency; Respiration, artificial; Hospitalization.


Case Series

16 - Bronchiolitis associated with exposure to artificial butter flavoring in workers at a cookie factory in Brazil

Bronquiolite associada à exposição a aroma artificial de manteiga em trabalhadores de uma fábrica de biscoitos no Brasil

Zaida do Rego Cavalcanti, Alfredo Pereira Leite de Albuquerque Filho, Carlos Alberto de Castro Pereira, Ester Nei Aparecida Martins Coletta

J Bras Pneumol.2012;38(3):395-399

Abstract PDF PT PDF EN Portuguese Text

Objective: To report the cases of four patients with bronchiolitis caused by exposure to artificial butter flavoring at a cookie factory in Brazil. Methods: We described the clinical, tomographic, and spirometric findings in the four patients, as well as the lung biopsy findings in one of the patients. Results: All four patients were young male nonsmokers and developed persistent airflow obstruction (reduced FEV1/FVC ratio and FEV1 at 25-44% of predicted) after 1-3 years of exposure to diacetyl, without the use of personal protective equipment, at a cookie factory. The HRCT findings were indicative of bronchiolitis. In one patient, the surgical lung biopsy revealed bronchiolitis obliterans accompanied by giant cells. Conclusions: Bronchiolitis resulting from exposure to artificial flavoring agents should be included in the differential diagnosis of airflow obstruction in workers in Brazil.


Keywords: Diacetyl; Flavoring agents; Bronchiolitis.


Case Report

17 - Pleural effusion following ovarian hyperstimulation

Derrame pleural secundário à hiperestimulação ovariana

Jader Joel Machado Junqueira, Ricardo Helbert Bammann, Ricardo Mingarini Terra, Ana Cristina Pugliesi de Castro, Augusto Ishy, Angelo Fernandez

J Bras Pneumol.2012;38(3):400-403

Abstract PDF PT PDF EN Portuguese Text

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication that occurs in the luteal phase of an induced hormonal cycle. In most cases, the symptoms are self-limited and spontaneous regression occurs. However, severe cases are typically accompanied by acute respiratory distress. The objective of the present study was to describe the clinical presentation, treatment, and outcome of pleural effusion associated with OHSS in three patients undergoing in vitro fertilization. The patients ranged in age from 27 to 33 years. The onset of symptomatic pleural effusion (bilateral in all cases) occurred, on average, 43 days (range, 27-60 days) after initiation of hormone therapy for ovulation induction. All three patients required hospitalization for massive fluid resuscitation, and two required noninvasive mechanical ventilation. Although all three patients initially underwent thoracentesis, early recurrence of symptoms and pleural effusion prompted the use of drainage with a pigtail catheter. Despite the high output from the pleural drain (mean, 1,000 mL/day in the first week) and prolonged drainage (for 9-22 days), the outcomes were excellent: all three patients were discharged from hospital. Although pleural effusion secondary to OHSS is probably underdiagnosed, the associated morbidity should not be underestimated, especially because it affects potentially pregnant patients. In this study, early diagnosis and appropriate supportive measures yielded favorable results, limiting the surgical approach to adequate pleural drainage.


Keywords: Fertilization in vitro; Ovarian hyperstimulation syndrome; Pleural effusion.


Letters to the Editor

18 - Spontaneous pneumomediastinum (Hamman's syndrome)

Pneumomediastino espontâneo (síndrome de Hamman)

Giordano Rafael Tronco Alves, Régis Vinícius de Andrade Silva, José Roberto Missel Corrêa, Cassiano Minussi Colpo, Helen Minussi Cezimbra, Carlos Jesus Pereira Haygert

J Bras Pneumol.2012;38(3):404-407

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19 - Report of two cases of ARDS patients treated with pumpless extracorporeal interventional lung assist

Relato de dois casos de pacientes com SARA tratados com membrana extracorpórea de troca gasosa sem bomba

Alexandre Peixoto Coscia, Haroldo Falcão Ramos da Cunha, Alessandra Gouvea Longo, Enio Gustavo Schoeder Martins, Felipe Saddy, Andre Miguel Japiassu412

J Bras Pneumol.2012;38(3):408-411

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20 - Pulmonary hemosiderosis associated with celiac disease: improvement after a gluten-free diet

Hemossiderose pulmonar associada à doença celíaca: melhora após dieta livre de glúten

José Wellington Alves dos Santos, Abdias Baptista de Mello Neto, Roseane Cardoso Marchiori, Gustavo Trindade Michel, Ariovaldo Leal Fagundes, Leonardo Gonçalves Marques Tagliari, Tiago Cancian

J Bras Pneumol.2012;38(3):412-414

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21 - Pregnancy as a risk factor for hospitalization due to pandemic influenza A (H1N1) 2009

Gestação como fator de risco para internação hospitalar na influenza pandêmica A (H1N1) 2009

Lessandra Michelim Rodriguez Nunes Vieira, Juliano Fracasso, Viviane Raquel Buffon, Mariana Menegotto, Thaiana Pezzi

J Bras Pneumol.2012;38(3):415-416

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