Brazilian Journal of Pulmonology

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


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Year 2004 - Volume 30  - Number 6  (November/December)


1 - Thirty years of the Brazilian Journal of Pulmonology: 100% growth in 2 years points to a promising future

Trinta anos de Jornal Brasileiro de Pneumologia: Crescimento de 100% em 2 anos apontam futuro promissor

Geraldo Lorenzi-Filho

J Bras Pneumol.2004;30(6):499

Abstract PDF PT PDF EN Portuguese Text

This will be my last editorial as the editor of the Jornal Brasileiro de Pneumologia (JBP, Brazilian Journal of Pulmonology).


2 - The SBPT and conflicts of interest

A SBPT e os conflitos de interesse

Carlos AC Pereira

J Bras Pneumol.2004;30(6):500

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Dados norte-americanos mostram que no ano de 2000, a indústria de medicamentos financiou mais de 314.000 eventos para médicos, desde jantares até finais de semana em lugares interessantes, ao custo de quase dois bilhões de dólares. Isto levanta a questão do conflito de interesse (COI).


Original Article

3 - Anthropometric index for quantitative assessment of pectus excavatum

Índice antropométrico para classificação quantitativa do pectus excavatum*

Eduardo B. Rebeis, Marcos N. Samano, Carlos T. Santos Dias, Ângelo Fernandez, José R. M. Campos, Fábio B. Jatene, Sérgio A. Oliveira

J Bras Pneumol.2004;30(6):501-507

Abstract PDF PT PDF EN Portuguese Text

Background: Pectus excavatum is characterized by concave growth of costal cartilage and depression of the lower sternum. Clinical means of classifying these malformations are few and difficult to apply. Objective: To devise clinical tools for quantifying the deformity and comparing preoperative and postoperative findings. Method: A total of 10 pectus excavatum patients who underwent surgery in which the modified Robicsek technique was used by the Thoracic Surgery Group of the Hospital das Clínicas of the University of São Paulo School of Medicine, were clinically and radiologically evaluated in the preoperative and postoperative periods. Ten control individuals, presenting no thoracic or radiological abnormalities, were submitted to identical evaluations. Deformities at the sternum notch level and at the point of maximum deformity were assessed using the anthropometric index and the Haller index. Results: Multivariate analysis of anthropometric index means revealed significant differences between preoperative and control values and between preoperative and postoperative values, as well as a non-significant difference between postoperative and control values. The same results were obtained when Haller index means were analyzed. A paired comparison of preoperative and postoperative means showed two distinct groups. An 86% canonical correlation was found between the anthropometric index and the Haller index. Conclusion: Patients with pectus excavatum can be quantitatively assessed in the preoperative and postoperative periods through the use of the anthropometric index, which allows objective, comparative evaluation of the results and is easily performed.


Keywords: Funnel Chest. Anthropometry/methods.


4 - Evaluation of Pulmonary Function in Class I and II Obesity

Avaliação da função pulmonar na obesidade graus I e II

Zied Rasslan, Roberto Saad Junior, Roberto Stirbulov, Renato Moraes Alves Fabbri, Carlos Alberto da Conceição Lima

J Bras Pneumol.2004;30(6):508-514

Abstract PDF PT PDF EN Portuguese Text

Background: Obesity can effect the thorax, diphragm and abdominal muscles, thereby resulting in altered respiratory function. Objective: To evaluate the effects of obesity and to determine whether body mass index (BMI) and waist circumference correlate with spirometry values in obese individuals. Method: We studied 96 non-smokers of both sexes, 48 suffering from class I and class II obesity and ranging in age rom 18 to 75. All participants presented a BMI between 30 kg/m2 and 40 kg/m2 and none had a history of morbidity. Spirometry was performed, and waist circumferences were measured. Results: No significant differences were found between the spirometric values of men with class I or II obesity and those of non-obese men. In obese women, forced vital capacity and forced expiratory volume in one second (FEV1) were significantly lower than in women who were not obese. Obese individuals of both sexes presented significantly lower expiratory reserve volume (ERV) than did non-obese individuals. Although inspiratory capacity was greater in obese men and women, the difference was significant only for the men. In obese men, there was a significant negative correlation, not seen in the women, between waist circumference and FEV1. Conclusion: Pulmonary function is altered in women suffering from class I and II obesity. In obese men, although pulmonary function is unaffected by BMI, we observed a significant negative correlation between BMI and ERV. We can conclude that pulmonary function is influenced by waist circumference in men suffering from class I and II obesity.


Keywords: Respiratory function tests. Spirometry. Body mass index. Obesity.


5 - Maximal respiratory pressures and vital capacity: comparison mouthpiece and face-mask evaluation methods

Pressões respiratórias máximas e capacidade vital: comparação entre avaliações através de bocal e de máscara facial

Julio Flavio Fiore Junior, Denise de Morais Paisani, Juliana Franceschini, Luciana Dias Chiavegato, Sonia Maria Faresin

J Bras Pneumol.2004;30(6):515-520

Abstract PDF PT PDF EN Portuguese Text

Background: Measurement of maximal respiratory pressures and vital capacity are essential in evaluating respiratory function. However, methodological variations may interfere with the interpretation of results. Objective: To compare values obtained using mouthpiece and face-mask evaluation methods in the measurement of maximal respiratory pressures and vital capacity. Method: We studied 30 patients (16 male), with a mean age of 55.9 ± 15.7, in the preoperative phase of abdominal surgery. Maximal inspiratory pressure and maximal expiratory pressure, as well as vital capacity, were evaluated using either a rigid flanged mouthpiece or a face mask, in randomized order. Results: Evaluation with a face mask did not significantly alter vital capacity and maximal inspiratory pressure values, although maximal expiratory pressure values were significantly lower than when measured using a rigid mouthpiece. During measurement of maximal expiratory pressure, air leakage from around the mask was observed in 60% of cases. When maximal expiratory pressure measurements in which there was no such leakage were considered in isolation, face-mask values were higher than those obtained with the moutpiece. Conclusion: With a face mask, maximal inspiratory pressure and vital capacity can be accurately evaluated. Maximal expiratory pressure can also be adequately evaluated using a face mask, provided that air leakage from the mask edges can be avoided. However, such leakage and the consequent reduction in the values obtained are common and limit the use of this method of evaluation.


Keywords: Respiratory function tests. Maximal voluntary ventilation. Respiratory muscles.


6 - Polymerase chain reaction used to detect Streptococcus pneumoniae resistance to penicillin

A reação em cadeia da polimerase na detecção da resistência à penicilina em Streptococcus pneumoniae

Eduardo Walker Zettler, Rosane M. Scheibe, Cícero A.G. Dias, Patricia Santafé, José da Silva Moreira, Diógenes S. Santos, Carlos Cezar Fritscher

J Bras Pneumol.2004;30(6):521-527

Abstract PDF PT PDF EN Portuguese Text

Background: Streptococcus pneumoniae is the most common etiologic agent of community-acquired respiratory infections. In recent years, S. pneumoniae resistance to antimicrobial agents has increased. Minimum inhibitory concentration (MIC) is routinely used to determine resistance. Polymerase chain reaction (PCR) detects the genes responsible for Streptococcus pneumoniae resistance to penicillin within approximately 8 hours. Objective: To compare the PCR and MIC methods in determining Streptococcus pneumoniae resistance to penicillin. Method: A total of 153 Streptococcus pneumoniae samples, isolated from various anatomical sites, were evaluated in order to detect mutations in the genes encoding pbp1a, pbp2a and pbp2x, which are responsible for Streptococcus pneumoniae penicillin resistance. A correlation was found between mutations and penicillin MIP, as determined by the agar diffusion method. Results: Overal Streptococcus pneumoniae resistance to penicillin was 22.8% (16.3% intermediate resistance and 6.5% high resistance). In a statistically significant finding, we observed no mutations in the penicillin-sensitive samples and only one mutation, typically in the gene encoding pbp2x, among the samples with intermediate resistance, whereas mutations in all three genes studied were observed in the high-resistance samples. Conclusion: For determining Streptococcus pneumoniae resistance to penicillin, PCR is a rapid method of detection that could well be used in clinical practice.


Keywords: Streptococcus pneumoniae. Penicillin resistance. Polymerase chain reaction/methods.


7 - Chronic Dyspnea and Altered Respiratory Function in Former Workers with Asbestosis Evaluated to Determine Benefits

Dispnéia crônica e alterações funcionais respiratórias em ex-trabalhadores com asbestose avaliados para concessão de benefício

Lara M. Nápolis, Andréa Ap. Sette, Ericson Bagatin, Mário Terra Filho, Reynaldo T. Rodrigues, Jorge Issamu Kavakama, José Alberto Neder, Luiz Eduardo Nery

J Bras Pneumol.2004;30(6):528-534

Abstract PDF PT PDF EN Portuguese Text

Background: Dyspnea is a symptom that is difficult to evaluate, especially in occupational diseases. Objective: To evaluate the relationship between chronic dyspnea, in its varying degrees of severity, and the functional repercussions for dysfunction or incapacitation in former workers with asbestosis. Method: A total of 40 former workers diagnosed with asbestosis were evaluated. Dyspnea scores were determined using the modified Medical Research Council scale, the 1984 and 1993 American Medical Association scales, and the Baseline Dyspnea Index. Spirometry, measurement of diffusion capacity for carbon monoxide and cardiopulmonary exercise tests (incremental and submaximal) were also performed. Results: Based on scores obtained using the Medical Research Council and 1984 American Medical Association scales, respectively, 72.5% and 67.5% of the subjects were classified as dyspneic, compared with 37.5% and 31.6%, respectively, using the 1993 American Medical Association and Baseline Dyspnea Index scales. There was greater concordance between the Medical Research Council and 1993 American Medical Association scales, as well as between the 1984 and 1993 American Medical Association scales, when the categories of "absent" and "mild" were grouped. No significant relation was found between dyspnea, as determined by each of the scales, and functional abnormalities - either at rest or during exercise. Conclusion: In individuals with asbestosis, the degree of concordance among the available dyspnea scales varies significantly. There is a real need for dyspnea indices that evaluate respiratory dysfunction at rest and during exercise.


Keywords: Asbestosis/diagnosis. Dyspnea/physiopathology. Spirometry/methods.


8 - Effects of continuos positive airway pressure on nasal and pharyngeal symptoms in patients with obstructive sleep apnea

Efeitos da pressão positiva contínua em vias aéreas sobre os sintomas nasofaríngeos em pacientes com a síndrome da apnéia obstrutiva do sono

Adelaide Cristina de Figueiredo, Maria Cecília Lorenzi, Simone Prezzoti, Marília Montenegro Cabral, Luiz Ubirajara Sennes, Geraldo Lorenzi-Filho

J Bras Pneumol.2004;30(6):535-539

Abstract PDF PT PDF EN Portuguese Text

Background: Nasal and pharyngeal symptoms are common in patients with obstructive sleep apnoea (OSA) treated with nasal continuous positive airway pressure (CPAP). However, these symptoms are common in OSA patients even before the treatment. Objectives: Determine the impact of nasal CPAP on nasal and pharyngeal symptoms in OSA patients. Method: Thirty-five adult patients (28 males), age 54±10 years old, with OSA diagnosed by polissonography. All patients answered to a questionnaire about the presence and quantification of sneezing, rhinorrhea, nasal pruritus, obstruction and bleeding, nasal and pharyngeal dryness. The questionnaire was answered before and after at least three months of CPAP therapy. Results: The apnea-hypopnea index was 50±25 events per hour. Twenty six patients (74%) presented at least one naso-pharingeal symptom before treatment. Nasal obstruction was the most common symptom, being referred by 18 patients (51%). Among the patients that were initially assymptomatic (n=9), 78% developed adverse nasal reactions to CPAP. In contrast, among the patients that presented nasal symptoms before treatment, there was a significant reduction in nasal obstruction, nasal and throat dryness scores as well as nasal bleeding after CPAP therapy. Conclusions: Nasal na pharyngeal symptoms are frequent in OSAS patients. CPAP therapy may originate nasal symptoms in patients previously assymptomatic, as well as reduce the intensity of these symptoms in patients that are previously symptomatic.


Keywords: Obstructive sleep apnea syndrome. Nasal obstruction. Continuous positive airway pressure, compliance.


9 - Ventilator-associated pneumonia: impact of bacterial multidrug-resistance on morbidity and mortality

Pneumonia associada à ventilação mecânica: impacto da multirresistência bacteriana na morbidade e mortalidade

Paulo José Zimermann Teixeira, Felipe Teixeira Hertz, Dennis Baroni Cruz, Fernanda Caraver, Ronaldo Campos Hallal, José da Silva Moreira

J Bras Pneumol.2004;30(6):540-548

Abstract PDF PT PDF EN Portuguese Text

Background: Ventilator-associated pneumonia is the most common nosocomial infection occurring in intensive care units. Objective: To determinate the impact of multidrug-resistant bacteria on morbidity and mortality in patients with ventilator-associated pneumonia. Method: Retrospective cohort study. Over 40 consecutive months, 91 patients on mechanical ventilation developed pneumonia. Cases were grouped into those caused by multidrug-resistant microorganisms and those caused by drug-sensitive microorganisms. Results: Multidrug-resistant bacteria were isolated in 75 cases (82.4%) and drug-sensitive bacteria in 16 (17.6%). Clinical and epidemiological characteristics were not statistically different between the groups. Staphylococcus aureus was responsible for 27.5% of ventilator-associated pneumonia episodes and Pseudomonas aeruginosa for 17.6%. Early-onset ventilator-associated pneumonia occurred in 33 patients (36.3%) and late-onset in 58 (63.7%). Time on mechanical ventilation, length of intensive care unit stay and overall length of hospital stay were not statistically different between groups. Empirical treatment was considered inadequate in 42 patients with pneumonia caused by multidrug-resistant microorganisms (56%) and in 4 with pneumonia caused by drug-sensitive microorganisms (25%) (p = 0.02). Death occurred in 46 patients with pneumonia caused by multidrug-resistant microorganisms (61.3%) and in 4 with pneumonia caused by drug-sensitive microorganisms (25%) (p = 0.008). Conclusion: Bacterial multidrug-resistance had no impact on morbidity but was associated with higher mortality.


Keywords: Pneumonia bacterial/etiology. Respiration artificial/complications. Indicators of morbidity and mortality.


10 - Pleural fluid adenosine deaminase detection for the diagnosis of pleural tuberculosis

Dosagem da atividade da adenosina deaminase no líquido pleural para o diagnóstico da tuberculose pleural

Morrys Casagrande Kaisemann, Afrânio Lineu Kritski, Maria de Fátima C Pereira, Anete Trajman

J Bras Pneumol.2004;30(6):549-556

Abstract PDF PT PDF EN Portuguese Text

Background: The diagnosis of pleural tuberculosis continues to be a challenge due to the low sensitivity of traditional diagnostic methods. Histopathological examination of pleural tissue is the most accurate method, with a sensitivity of up to 80%. Determination of adenosine deaminase levels is a recently introduced method, although its usefulness in the diagnosis of pleural tuberculosis in Brazil has yet to better elucidated. Objective: To verify the sensitivity and specificity of an experimental method of measuring adenosine deaminase activity in pleural fluid in a series of patients with pleural effusion patients evaluated between August 1998 and November 2002 in Rio de Janeiro (RJ). Results: Out of 137 cases, 111 pleural fluid samples were available. Of those, 83 were from pleural tuberculosis patients. Among the 67 pleural tuberculosis patients tested, 10 (14.9%) presented human immunodeficiency virus. The adenosine deaminase cutoff value of 35U/L was determined by a receiver operator characteristic curve. The sensitivity, specificity and likelihood ratios (positive and negative) were 92.8%, 93.3%, 25.8 and 13.9, respectively. Mean adenosine deaminase in the pleural tuberculosis group was 84.7 ± 43.1 U/L, versus 15.9 ± 11.1 U/L in the group with other diseases. There was no significant difference in adenosine deaminase activity between patients with and without human immunodeficiency virus co-infection. Conclusions: Adenosine deaminase measurement in pleural fluid is a sensitive and specific method for the diagnosis of pleural tuberculosis and its use can preclude the need for pleural biopsy in the initial workup of pleural effusion patients. An adenosine deaminase cutoff value of 35U/L is recommended.


Keywords: Pleural fluid. Adenosine deaminase. Diagnosis. Tuberculosis. HIV


Review Article

11 - Smoke inhalation injury

Lesão por inalação de fumaça

Rogério Souza, Carlos Jardim, João Marcos Salge, Carlos Roberto Ribeiro Carvalho

J Bras Pneumol.2004;30(6):557-565

Abstract PDF PT PDF EN Portuguese Text

Inhalation injury is the main cause of death in burn patients and has therefore, understandably, been the subject of numerous published studies. The pathogenesis of inhalation injury involves both local and systemic mechanisms, thereby increasing the repercussions of the injury. The search for tools that would allow earlier diagnosis of inhalation injury and for treatment strategies to lessen its deleterious effects is ongoing. In this review, we describe the physiopathological mechanisms of inhalation injury, as well as the current diagnostic tools and treatment strategies used in patients suffering from inhalation injury. We also attempt to put experimental therapeutic approaches into perspective.


Keywords: Smoke inhalation injury/diagnosis. Smoke inhalation injury/pathophysiology. Smoke inhalation injury/ complications. Burns, inhalation/therapy. Review literature. Carbon monoxide. Poisoning/complications.


12 - Physiopathology and clinical management of one-lung ventilation

Fisiopatologia e manejo clínico da ventilação seletiva

Halina Cidrini Ferreira, Walter Araújo Zin, Patrícia Rieken Macedo Rocco

J Bras Pneumol.2004;30(6):566-573

Abstract PDF PT PDF EN Portuguese Text

During one-lung ventilation, the nonventilated lung is excluded from the ventilation, with all tidal volume directed into the ventilated lung. This technique facilitates viewing of intrathoracic structures, thereby providing optimal surgical conditions. However, this procedure has been associated with reduced arterial oxygen tension, principally in patients with a previous history of lung disease, since it reduces the surface area available for gas exchange and causes a loss of normal autonomic respiratory regulation. Therefore, maintaining sufficient oxygenation and elimination of carbon dioxide is the greatest challenge in the management of the one-lung ventilation. It is recommend that the tidal volume administrated to the ventilated lung be similar to that used during conventional mechanical ventilation and that high fractions of inspired oxygen be used. However, several alternative methods have been proposed in order to minimize hypoxemia during one-lung ventilation, including the correct positioning of the double-lumen tube, the use of positive end-expiratory pressure or continuous positive airway pressure, nitric oxide administration, and alveolar recruitment. The management of one-lung ventilation continues to be a challenge in clinical practice.


Keywords: tidal volume, hypoxemia, ventilatory management, mechanical ventilation


Case Report

13 - Respiratory bronchilitis-associated interstitial lung disease

Doença pulmonar intersticial associada a bronquiolite respiratória

Silvia CS. Rodrigues, Mauri M. Rodrigues, Ester MC Colleta, Nailê S Rocha, Carlos AC Pereira

J Bras Pneumol.2004;30(6):574-580

Abstract PDF PT PDF EN Portuguese Text

Respiratory bronchiolitis-associated interstitial lung disease is one of many within the spectrum of smoking-related diffuse infiltrative lung diseases. The clinical and functional characteristics are typically subtle. Herein, we describe two cases of diagnosed through open-lung biopsy, and characterized by insidious evolution of dyspnea, digital clubbing, cystic lesions on computed tomography scans, and hipoxemia upon exertion. We emphasize that, when smokers are evaluated, it is imprtant to consider a diagnosis of respiratory bronchiolitis-associated interstitial lung disease in the context of interstitial cystitis, as well as in that of lymphangioleiomyomatosis, eosinophilic granuloma and idiophatic pulmonary fibrosis.


Keywords: Smoking. Interstitial lung diseases. Bronchiolitis.


14 - Tracheobronchial amyloidosis

Amiloidose traqueobrônquica

Luciano Müller Corrêa da Silva, Jamila Bellicanta, Renata Diniz Marques, Luiz Carlos Corrêa da Silva

J Bras Pneumol.2004;30(6):581-584

Abstract PDF PT PDF EN Portuguese Text

Amyloidosis is a disease characterized by extracellular deposition of pathologic fibrillar protein in organs and tissues. Diffuse primary tracheobronchial amyloidosis is rare. Herein, we report a case of a male patient with diffuse tracheobronchial amyloidosis, initially diagnosed as bronchial asthma.


Keywords: Asthma/pathology. Amyloidosis/diagnosis. Trachea/pathology.


15 - Infiltration of old scars: a manifestation of sarcoidosis

Lesões sobre cicatrizes, uma das manifestações da sarcoidose

Paulo Ricardo Martins Souza, Rodrigo Pereira Duquia, Gerson Vetoratto, Hiram Larangeira de Almeida Junior

J Bras Pneumol.2004;30(6):585-587

Abstract PDF PT PDF EN Portuguese Text

We report the case of a 41 year-old black woman who presented a sudden infiltration of old scars of her face. These scars were from a car accident 10 years prior. Histological analysis of a skin biopsy revealed non-caseous granulomas consistent with sarcoidosis, and computed tomography of the thorax revealed enlarged mediastinal lymph nodes. The lesions regressed spontaneously and no treatment was required.


Keywords: Sarcoidosis/complications. Cicatrix/ethiology. Granuloma/complications.


Letters to the Editor

16 - Escarro induzido, recomendações do Programa de Controle de Tuberculose do Estado do Rio de Janeiro*

Marneili Martins, Eliane Dale Sucupira, Lísia M. R. de Freitas, Lia Selig, Eduardo Pamplona Bethlem Rodrigo Siqueira Batista

J Bras Pneumol.2004;30(6):591-592

PDF PT Portuguese Text

17 - 

Miguel Lia Tedde, Fabio Biscegli Jatene

J Bras Pneumol.2004;30(6):593-594

PDF PT Portuguese Text

18 - 

Paulo de Tarso G. Muller, Liana Peres Duailibe

J Bras Pneumol.2004;30(6):595

PDF PT Portuguese Text

19 - 

Marcelo Park, Luciano C. P. Azevedo

J Bras Pneumol.2004;30(6):596

PDF PT Portuguese Text


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