Brazilian Journal of Pulmonology

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


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Year 2006 - Volume 32  - Number 5  (September/October)

Original Article

3 - Asthma management in a public referral center in Porto Alegre in comparison with the guidelines established in the III Brazilian Consensus on Asthma Management

Estudo comparativo entre o manejo da asma em uma unidade de referência da rede pública de Porto Alegre (RS) e as proposições do III Consenso Brasileiro no Manejo da Asma

Waldo Mattos, Luciano Bauer Grohs, Fabíola Roque, Maurício Ferreira, Gabriela Mânica, Ernesto Soares

J Bras Pneumol.2006;32(5):385-390

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether the guidelines put forth in the III Brazilian Consensus on Asthma Management are being applied in a population of asthma patients treated at a public hospital that is a referral center for asthma in the city of Porto Alegre, Brazil. Methods: All adult asthma patients who began their treatment between 1999 and 2002 were evaluated. The treatment given was classified as consistent or inconsistent with the Consensus guidelines. The clinical features of asthma and the frequency of treatment provided by a specialist were compared between the two groups (those receiving guideline-consistent treatment and those receiving guideline-inconsistent treatment). Results: The charts of 357 patients were evaluated. The study sample consisted of 106 males (29.9%) and 251 females (70.3%). The mean age was 41 years, and 33 (9.2%) of the patients were smokers. The treatment was considered inconsistent with the Consensus guidelines in 246 cases (70%). Of those 246, 174 (71%) had presented persistent asthma and were not treated with an inhaled corticosteroid. Normal forced expiratory volume in one second, being from 12 to 18 years of age, and having intermittent asthma were more frequently observed among the patients receiving guideline-consistent treatment (p < 0.01). No correlations were found between guideline-inconsistent treatment and being treated by a pulmonologist, severity of persistent asthma or number of emergency room visits. Conclusion: Most of the asthma patients treated at the public referral center in Porto Alegre did not receive treatment that was consistent with the Consensus guidelines. Undertreatment with inhaled corticosteroids was the principal source of that inconsistency.


Keywords: Asthma/therapy; Guidelines; Comparative study


4 - Risk factors for multiple hospital admissions among children and adolescents with asthma

Fatores de risco para readmissão hospitalar de crianças e adolescentes asmáticos

Laura Maria de Lima Belizario Facury Lasmar, Paulo Augusto Moreira Camargos, Eugênio Marcos Andrade Goulart, Emília Sakurai

J Bras Pneumol.2006;32(5):391-399

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the influence that hospital admission of suckling infants with asthma has on their risk for future admissions for the same cause. Methods: A retrospective study was conducted, in which the charts of 202 patients, all less than fifteen years of age, were evaluated. All of the patients had been treated as outpatients in a pediatric pulmonology clinic and had been admitted to the hospital on one or more occasions. A multivariate analysis was conducted in order to evaluate the risk factors associated with multiple hospitalizations. Results: Virtually all of the patients evaluated were hospitalized a second time within 18 months of the first hospitalization. Among the patients first hospitalized at = 12 months of age, the second admission occurred sooner than did that recorded for those first hospitalized at > 12 months of age (p = 0.001). The risk factors found to be associated with multiple hospital admissions were as follows: age at first admission = 12 months (odds ratio: 2.55; 95% confidence interval: 1.18-5.48); age at first admission between 13 and 24 months (odds ratio: 3.54; 95% confidence interval: 1.31-9.63); and severity of asthma symptoms (odds ratio: 3.86; 95% confidence interval: 2.02-7.40). Conclusion: After the first hospitalization, children with asthma should be closely monitored, since the risk of subsequent admissions is elevated in the first months following discharge, especially among those of less than two years of age. Health care facilities should be organized to confront this problem appropriately and should dispense prophylactic medication more freely.


Keywords: Asthma; Child, hospitalized; Patient readmission; Risk factors


5 - Pulmonary auscultation terminology employed in Brazilian medical journals between January of 1980 and December of 2003

Terminologia da ausculta pulmonar utilizada em publicações médicas brasileiras, no período de janeiro de 1980 a dezembro de 2003

Kamila Fernanda Staszko, Carla Lincho, Vivian da Cas Engelke, Nádia Spada Fiori, Karina Cirino Silva, Elisa Iribarren Nunes, Linjie Zhang

J Bras Pneumol.2006;32(5):400-404

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the appropriateness of the use of auscultation terminology in Brazilian respiratory disease-related medical journals published between January of 1980 and December of 2003. Methods: A descriptive study was conducted, evaluating three medical journals: the Jornal de Pneumologia (Journal of Pulmonology), Jornal de Pediatria (Journal of Pediatrics) and Revista Brasileira de Medicina (Brazilian Journal of Medicine). Original articles and case reports about respiratory diseases were selected, and auscultation terminology was extracted from these articles. The appropriateness of terms used to describe adventitious sounds was assessed. Results: We found that the inappropriate use of terms was more frequent when intermittent sounds were described than when continuous sounds were described (87.7% versus 44.0%; p = 0.0000). No significant difference was observed between the inappropriate use of terms by pulmonologists and that observed for other specialists (56.5% versus 62.0%; p = 0.26). In addition, there were no significant differences among the various regions of the country or between the periods prior to and after the dissemination of international nomenclature. Conclusion: Inappropriate use of pulmonary auscultation terms describing adventitious sounds remains common and widespread in Brazilian medical publications.


Keywords: Auscultation; Lung/physiopathology; Lung diseases/diagnosis; Respiratory sounds; Terminology


6 - Rhodococcus equi infection in acquired immunodeficiency syndrome. Computed tomography aspects

Infecção pulmonar pelo Rhodococcus equi na síndrome da imunodeficiência adquirida. Aspectos na tomografia computadorizada

Edson Marchiori, Renato Gonçalves de Mendonça, Domenico Capone, Elza Maria de Cerqueira, Arthur Soares Souza Júnior, Gláucia Zanetti, Dante Escuissato, Emerson Gasparetto

J Bras Pneumol.2006;32(5):405-409

Abstract PDF PT PDF EN Portuguese Text

Objective: To present the computed tomography aspects of Rhodococcus equi pneumonia in seven patients with acquired immunodeficiency syndrome. Methods: A retrospective study of the computed tomography scans of seven patients with acquired immunodeficiency syndrome and Rhodococcus equi infection. Results: The most common findings were consolidation (n = 7), consolidation with cavitation (n = 6), ground glass opacities (n = 6), peribronchial nodules (n = 4) and centrilobular nodules presenting a "tree-in-bud" pattern (n = 3). Conclusion: The most common finding in patients with Rhodococcus equi pulmonary infection and acquired immunodeficiency syndrome was consolidation with cavitation.


Keywords: Acquired immunodeficiency syndrome; Rhodococcus equi; Actimomycetales infections; Lung diseases, fungal; Tomography, emission-computed


7 - Outpatient smoking cessation program in the state of Ceará, Brazil: patient profiles and factors associated with treatment success

Ambulatório de apoio ao tabagista no Ceará: perfil dos pacientes e fatores associados ao sucesso terapêutico

Maria Penha Uchoa Sales, Mara Rúbia Fernandes de Figueiredo, Maria Irenilza de Oliveira, Helano Neiva de Castro

J Bras Pneumol.2006;32(5):410-417

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate patient profiles and factors associated with successful treatment. Methods: A retrospective study of patients enrolled in the smoking cessation program at the Hospital de Messejana, located in the state of Ceará, Brazil, from October of 2002 to April of 2005. The treatment was evaluated based on patient profile, type of medication prescribed and time on that medication. Results: Of the 320 patients enrolled, 65.5% were women. The mean age at the outset of treatment was 48 years, and the mean duration of the smoking habit was 33 years. More than 90% of the patients had started smoking before the age of 20. Of the 258 individuals who had enrolled in the program at least one year prior, 50.8% had achieved treatment success; 17.8% had relapsed, and 31.4% had not quit smoking. On average, partial success was achieved in the fifth week of the treatment, and relapse occurred predominantly in the fourth month. Approximately 60% of the patients were treated with medication. Conclusion: Quitting smoking was significantly associated with the use of medication, regardless of the profile of the smoker evaluated. In the second year of the program, quitting smoking was more strongly associated with the use of bupropion and nicotine replacement, resulting in a higher success rate and a trend toward a reduction in the relapse rate.


Keywords: Smoking/therapy; Tobacco use cessation; Bupropion; Nicotine


8 - Impact of open lung biopsy on refractory acute respiratory failure

Impacto de biópsia pulmonar a céu aberto na insuficiência respiratória aguda refratária

Carmen Silvia Valente Barbas, Vera Luiza Capelozzi, Cristiane Hoelz, Ricardo Borges Magaldi, Rogério de Souza, Maria Laura Sandeville, José Ribas Milanez de Campos, Eduardo Werebe, Laerte O. Andrade Filho, Elias Knobel

J Bras Pneumol.2006;32(5):418-423

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the impact that open lung biopsy findings have on decisions regarding changes in the treatment strategies employed for critically ill patients presenting diffuse pulmonary infiltrates and suffering from refractory acute respiratory failure, as well as on their clinical improvement. Methods: This study involved 12 mechanically ventilated patients with acute respiratory failure who were subjected to open lung biopsy (by thoracotomy) after not presenting a clinical response to standard treatment. Results: The single most common cause of the acute respiratory failure was viral infection, which was identified in 5 patients (40%). The pre-operative evaluation of the cause of respiratory failure was modified in 11 patients (91.6%), and a specific diagnosis was made in 100% of the cases. Regardless of changes in treatment regimen, the mortality rate was 50%. Six patients (50%) survived to be discharged from the hospital. All of the discharged patients survived for at least one year after the open lung biopsy, for an overall one-year survival rate of 50% among the 12 patients studied. For the patients who died in the hospital, the time of survival after open lung biopsy was 14 + 10.8 days. Conclusion: We conclude that open lung biopsy is a useful tool in the management of acute respiratory failure when there is no clinical improvement after standard treatment, since it can lead to a specific diagnosis that requires distinct treatment, which probably lowers the mortality rate among such patients.


Keywords: Respiratory distress syndrome, adult; Lung/pathology; Biposy; Acute respiratory syndrome


9 - Co-infection with Mycobacterium tuberculosis and human immunodeficiency virus: an epidemiological analysis in the city of Taubaté, Brazil

Co-infecção por Mycobacterium tuberculosis e vírus da imunodeficiência humana: uma análise epidemiológica em Taubaté (SP)

Luiz Gustavo Miranda de Carvalho, Anabelli Zanchetta Buani, Maria Stella Amorim da Costa Zöllner, Alexandre Prado Scherma

J Bras Pneumol.2006;32(5):424-429

Abstract PDF PT PDF EN Portuguese Text

Objective: To discuss the main aspects of co-infection with Mycobacterium tuberculosis and human immunodeficiency virus in the city of Taubaté (located in the state of São Paulo, Brazil) in 2001 and 2002. Methods: This study presents epidemiological data on tuberculosis cases occurring in Taubaté in 2001 and 2002. Results: Of the 250 cases of tuberculosis analyzed, 70 (28%) presented human immunodeficiency virus seropositivity, 95 (38%) presented human immunodeficiency virus seronegativity, and 85 (34%) were patients who had not been submitted to serological testing. In the first group (tuberculosis and human immunodeficiency virus seropositivity), males from 30 to 40 years of age predominated, the most common clinical presentation of tuberculosis was pulmonary (65.71%), and the cure rate was 59.38%. In the group of tuberculosis patients presenting human immunodeficiency virus seronegativity, males from 30 to 40 years of age also predominated, the most common clinical presentation of tuberculosis was also pulmonary (70.55%), and the cure rate was 81.63%. Conclusion: We conclude that the human immunodeficiency virus plays an important role in the epidemiology of tuberculosis. Therefore, serological testing for human immunodeficiency virus should be carried out when a diagnosis of tuberculosis is made.


Keywords: Tuberculosis/epidemiology; HIV infections; HIV; Prevalence


10 - Multidrug-resistant Mycobacterium tuberculosis at a referral center for infectious diseases in the state of Minas Gerais, Brazil: sensitivity profile and related risk factors

Perfil de sensibilidade e fatores de risco associados à resistência do Mycobacterium tuberculosis, em centro de referência de doenças infecto-contagiosas de Minas Gerais

Márcia Beatriz de Souza, Carlos Maurício de Figueiredo Antunes, Guilherme Freire Garcia

J Bras Pneumol.2006;32(5):430-437

Abstract PDF PT PDF EN Portuguese Text

Objective: To assess the determining factors for Mycobacterium tuberculosis multidrug resistance at a referral center for infectious diseases in the state of Minas Gerais, Brazil. Methods: A retrospective case-control study was conducted using data collected from September of 2000 to January of 2004. During this period, 473 cultures presenting growth of M. tuberculosis, corresponding to 313 patients, were submitted to susceptibility tests at the Central Laboratory of Minas Gerais. Cases presenting resistance to at least rifampin and isoniazid were classified as cases of multidrug resistance and were selected for study. These cases were paired to control group cases of drug-susceptible tuberculosis at a ratio of 1:3. Clinical and demographic data were analyzed using univariate and multivariate analyses. Results: During the study period, 12 (3.83%) cases of multidrug-resistant tuberculosis were identified. In the univariate analysis, multidrug-resistant tuberculosis was found to be more common among male patients, as well as among those testing positive in the sputum smear microscopy, those with cavitations larger than 4 cm in diameter and those having been previously treated for tuberculosis (p = 0.10 for all). After the multivariate analysis, only previous treatment for tuberculosis remained statistically significant (p = 0.0374), with an odds ratio of 14.36 (1.96-176.46). Conclusion: In the present study, previous treatment for tuberculosis was found to be an independent risk factor for multidrug-resistant tuberculosis.


Keywords: Mycobacterium tuberculosis; Tuberculosis, multidrug-resistant; Tuberculosis; Microbial sensitivity tests; Risk factors


11 - Tuberculin testing of individuals infected with the human immunodeficiency virus: relationship with peripheral T-cell counts and active tuberculosis

Teste tuberculínico em indivíduos com infecção pelo vírus da imunodeficiência humana: relação com número de linfócitos T periféricos e atividade tuberculosa

Lenice do Rosário de Souza, Marli Therezinha Gimenez Galvão, Jussara Marcondes Machado, Domingos Alves Meira, Karlla Cunhas

J Bras Pneumol.2006;32(5):438-443

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate tuberculin test results and relate them to the presence or absence of active tuberculosis, as well as to CD4+ and CD8+ T-lymphocyte counts. Method: The charts of 802 patients with acquired immunodeficiency syndrome treated between August of 1985 and March of 2003 were reviewed. Of the 185 patients submitted to tuberculin tests (23.1%), 107 (57.8%) were male, and 78 (42.2%) were female. Patients were divided into two study groups: tuberculin test reactors (n = 28); and tuberculin test non-reactors (n = 157). Among the reactors, the mean age was 30.60 years, with a standard deviation of 6.62 years, compared with 34.45 years, with a standard deviation of 10.32 years, among the non-reactors. Results: Most of the individuals tested presented only a mild response to the tuberculin test. We found that, at the time of the test, the percentage of individuals with active tuberculosis was greater in the reactor group than in the non-reactor group. During the test period, 10 reactor group patients and 11 non-reactor group patients presented some clinical form of active tuberculosis. In addition, CD4+ T-lymphocyte counts were lower than 200 cells/mm3 in 6 reactor group patients and in 8 non-reactor group patients. Conclusion: Indurations greater than 5 mm were unrelated to higher absolute CD4+ T-cell counts.


Keywords: Tuberculin test; Acquired immunodeficiency syndrome; Tuberculosis; CD4-positive T-lymphocytes; CD8-positive T-lymphocytes


12 - Tuberculosis as a disease defining acquired immunodeficiency syndrome: ten years of surveillance in Rio de Janeiro, Brazil

Tuberculose como doença definidora de síndrome da imunodeficiência adquirida: dez anos de evolução na Cidade do Rio de Janeiro

Elizabeth Cristina Coelho Soares, Valéria Saraceni, Lilian de Mello Lauria, Antonio Guilherme Pacheco, Betina Durovni, Solange Cesar Cavalcante

J Bras Pneumol.2006;32(5):444-448

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the frequency of tuberculosis and of the other principal opportunistic infections defining acquired immunodeficiency syndrome at the time such cases were reported in the city of Rio de Janeiro, Brazil. Methods: Analysis of the data compiled in the Rio de Janeiro Municipal Program for the Surveillance of Sexually Transmitted Diseases and Acquired Immunodeficiency Syndrome database from 1993 to 2002. Results: The expanded definition of a case of acquired immunodeficiency syndrome, implemented in 1998, resulted in a substantial increase in the number of reported cases of acquired immunodeficiency syndrome, especially of those defined by immunologic criteria. Among the cases of acquired immunodeficiency syndrome defined only by disease, esophageal candidiasis, in its various forms, remained the most common opportunistic infection present at the time the cases of acquired immunodeficiency syndrome were reported. Although Pneumocystis carinii pneumonia was the second leading opportunistic infection in most of the years evaluated, it was surpassed by tuberculosis in 2001. Conclusion: Despite the decreased numbers of cases of acquired immunodeficiency syndrome defined by disease, tuberculosis remains a significant acquired immunodeficiency syndrome-defining event, currently more common than P. carinii pneumonia and toxoplasmosis. This is probably due to the high rate of tuberculosis prevalence in the city.


Keywords: Tuberculosis; Acquired immunodeficiency syndrome; AIDS-related opportunistic infections


Review Article

13 - An update on the use of antifungal agents

Atualização no uso de agentes antifúngicos

Roberto Martinez

J Bras Pneumol.2006;32(5):449-460

Abstract PDF PT PDF EN Portuguese Text

We summarize here data regarding the spectrum of action, the pharmacological aspects, the toxicological aspects and the clinical efficacy of liposomal amphotericin B, amphotericin B in colloidal dispersion, amphotericin B lipid complex, voriconazole and caspofungin. We discuss the use of these more recently introduced antifungal agents in terms of their safety, efficiency and cost. We also offer suggestions for the clinical use of these drugs in pulmonary and systemic infections, with an emphasis on the lower toxicity of the lipid formulations of amphotericin B in comparison with conventional medications. In addition, we explore the possibility of using voriconazole as the primary treatment for invasive infections such as aspergillosis, as well as those caused by Scedosporium spp. and Fusarium spp., together with that of using caspofungin to treat disseminated candidiasis and invasive aspergillosis.


Keywords: Aspergillosis; Lung diseases, fungal/drug therapy; Amphotericin b/administration & dosage;


14 - Nutrition therapy for chronic obstructive pulmonary disease and related nutritional complications

Terapia nutricional na doença pulmonar obstrutiva crônica e suas complicações nutricionais

Amanda Carla Fernandes, Olívia Maria de Paula Alves Bezerra

J Bras Pneumol.2006;32(5):461-471

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Chronic obstructive pulmonary disease is characterized by progressive and partially reversible airway obstruction. The innumerable complications that occur during the progression of the disease can affect the nutritional state of patients suffering from this illness. The objective of this study was to present a brief review of the literature regarding the nutrition therapy used in the treatment of chronic obstructive pulmonary disease. To that end, we performed a bibliographic search for related articles published within the last 18 years and indexed for the Literatura Latinoamericana y del Caribe en Ciencias de la Salud (LILACS, Latin American and Caribbean Health Sciences Literature) and Medline databases. Malnutrition is associated with a poor prognosis for patients with chronic obstructive pulmonary disease, since it predisposes such patients to infections, as well as reducing respiratory muscle force, exercise tolerance and quality of life. Despite the fact that such malnutrition is extremely common in chronic obstructive pulmonary disease patients, it should be recognized as an independent risk factor, since it can be modified through appropriate and efficacious diet therapy and monitoring. For patients with chronic obstructive pulmonary disease, nutrition therapy is initiated after the evaluation of the nutritional state of the patient, which identifies nutritional risk, thereby allowing the proper level of treatment to be established. In this evaluation, anthropometric and biochemical markers, as well as indicators of dietary consumption and body composition, should be used. The prescribed diet should contain appropriate proportions of macronutrients, micronutrients and immunonutrients in order to regain or maintain the proper nutritional state and to avoid complications. The physical characteristics of the diet should be tailored to the individual needs and tolerances of each patient. In the treatment of patients with chronic obstructive pulmonary disease, individualized nutrition therapy is extremely important and has been shown to be fundamental to improving quality of life.


Keywords: Pulmonary disease, chronic obstructive; Nutrition assessment; Malnutrition; Nutrition therapy


Case Report

15 - Allergic bronchopulmonary aspergillosis presenting a glove-finger shadow in radiographic images

Aspergilose broncopulmonar alérgica com imagem radiológica em "dedo de luva"

Marta Elizabeth Kalil, Ana Luiza Godoy Fernandes, Aline Cristinane da Silva Curzel, Márcio Zamuner Cortez, Gláucia Cristina Godinho Alves Lima

J Bras Pneumol.2006;32(5):472-475

Abstract PDF PT PDF EN Portuguese Text

Allergic bronchopulmonary aspergillosis is a lung disease occurring in patients with asthma or cystic fibrosis, triggered by a hypersensitivity reaction to the presence of Aspergillus fumigatus in the airways. We report herein the case of a patient presenting a clinical profile suggestive of asthma and meeting the clinical, laboratory testing and radiological criteria for a diagnosis of allergic bronchopulmonary aspergillosis. The importance of such findings is that early diagnosis can reduce the risk of respiratory exacerbations and fibrosis.


Keywords: Asthma; Bronchiectasis; Aspergillus fumigatus; Aspergillosis, allergic bronchopulmonary


16 - Isolated pulmonary cryptococcosis in an immunocompetent patient

Criptococose pulmonar isolada em paciente imunocompetente

Ana Teresa Fernandes Barbosa, Fernando Antônio Colares, Edson da Silva Gusmão, Amanda Araújo Barros, Cristiane Gonçalves Cordeiro, Maria Cecília Tolentino Andrade

J Bras Pneumol.2006;32(5):476-480

Abstract PDF PT PDF EN Portuguese Text

In this study, we report a case of pulmonary cryptococcosis in a patient presenting respiratory symptoms and a lung mass on the chest X-ray. The patient had no concomitant diseases, was seronegative for human immunodeficiency virus and was not receiving immunosuppressive therapy of any kind. The diagnosis was confirmed through transbronchial biopsy and bronchoalveolar lavage. The patient was treated as an outpatient with fluconazole (300 mg/day for six months), evolving to clinical improvement and partial regression of the lung mass, as seen on a second chest X-ray. The current case illustrates an unusual presentation of pulmonary cryptococcosis and raises questions regarding the therapeutic approaches proposed in the literature.


Keywords: Cryptococcosis; Lung diseases, fungal; Lung/radiography; Immunocompetence


17 - Idiopathic bilateral diaphragmatic paresis

Paresia diafragmática bilateral idiopática

Mônica Corso Pereira, Rodrigo Frange Miziara Mussi, Reinaldo Alexandre de Carvalho Massucio, Ana Maria Camino, Aristóteles de Souza Barbeiro, Wander de Oliveira Villalba, Ilma Aparecida Paschoal

J Bras Pneumol.2006;32(5):481-485

Abstract PDF PT PDF EN Portuguese Text

We report the case of a patient with severe dyspnea upon reclining. Lung disease, neuromuscular disorders and heart disease were ruled out. However, during the course of the investigation, bilateral diaphragmatic paresis was discovered. A key sign leading to the diagnosis was evidence of paradoxical respiration in the dorsal decubitus position. When the patient was moved from the orthostatic position to the dorsal decubitus position, oxygenation and forced vital capacity worsened. The orthostatic fluoroscopy was normal. Maximal inspiratory pressure was severely reduced. The responses to transcutaneous electric stimulation of the diaphragm were normal. However, electric stimulation of the phrenic nerve produced no response, leading to the diagnosis of bilateral diaphragmatic paresis.


Keywords: Paresis; Respiratory insufficiency; Diaphragm; Respiration



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