Brazilian Journal of Pulmonology

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


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Year 2009 - Volume 35  - Number 6  (/June)

Original Article

2 - Obstructive sleep apnea syndrome in truck drivers

Síndrome da apneia obstrutiva do sono em motoristas de caminhão

Lucia Castro Lemos, Elaine Cristina Marqueze, Fernanda Sachi, Geraldo Lorenzi-Filho, Claudia Roberta de Castro Moreno

J Bras Pneumol.2009;35(6):500-506

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the prevalence of obstructive sleep apnea syndrome (OSAS), as well as to identify factors associated with a greater risk of developing OSAS, among truck drivers. Methods: The study population comprised 209 truck drivers (mean age, 38.8 years; 98.5% males) at two branches of a transportation company. The mean body mass index was 26.5 ± 4.4 kg/m2. The participants completed questionnaires regarding sociodemographic data, physical activity and OSAS. The prevalence of OSAS was estimated using the Berlin Questionnaire, associations between OSAS and the factors studied being assessed through univariate and multivariate regression analysis. Results: The prevalence of OSAS in the population was 11.5%. Of the 209 truck drivers, 72 (34.5%) reported having fallen asleep while driving and 81 (38.7%) reported snoring. The following variables were found to present statistically significant associations with OSAS: informal employment (OR = 0.27; p = 0.01); body mass index ≥ 25 kg/m2 (OR = 13.64; p = 0.01); and poor sleep quality (OR = 3.00; p = 0.02). Conclusions: The prevalence of OSAS in this study was lower than that reported in other studies of truck drivers and yet higher that that observed for the general population. In addition, our results suggest that work characteristics, such as employment status, are associated with OSAS. These data show the relevance of considering work activity in studies of factors associated with OSAS.


Keywords: Sleep apnea, obstructive; Sleep disorders; Questionnaires.


3 - Dimensions of sleepiness and their correlations with sleep-disordered breathing in mild sleep apnea

Dimensões da sonolência e suas correlações com os transtornos respiratórios do sono na apneia do sono leve

Denis Martinez, Magali Santos Lumertz, Maria do Carmo Sfreddo Lenz

J Bras Pneumol.2009;35(6):507-514

Abstract PDF PT PDF EN Portuguese Text

Objective: There are many ways of assessing sleepiness, which has many dimensions. In patients presenting a borderline apnea-hypopnea index (AHI, expressed as events/hour of sleep), the mechanisms of excessive daytime sleepiness (EDS) remain only partially understood. In the initial stages of sleep-disordered breathing, the AHI might be related to as-yet-unexplored EDS dimensions. Methods: We reviewed the polysomnography results of 331 patients (52% males). The mean age was 40 ± 13 years, and the mean AHI was 4 ± 2 (range, 0-9). We assessed ten potential dimensions of sleepiness based on polysomnography results and medical histories. Results: The AHI in non-rapid eye movement (NREM) stage 1 sleep (AHI-N1), in NREM stage 2 sleep (AHI-N2), and in REM sleep (AHI-REM) were, respectively, 6 ± 7, 3 ± 3 and 10 ± 4. The AHI-N2 correlated significantly with the greatest number of EDS dimensions (5/10), including the Epworth sleepiness scale score (r = 0.216, p < 0.001). Factor analysis, using Cronbach's alpha, reduced the variables to three relevant factors: QUESTIONNAIRE (α = 0.7); POLYSOMNOGRAPHY (α = 0.68); and COMPLAINTS (α = 0.55). We used these factors as dependent variables in a stepwise multiple regression analysis, adjusting for age, gender, and body mass index. The AHI-N1 correlated significantly with POLYSOMNOGRAPHY (β = −0.173, p = 0.003), and the AHI-N2 correlated significantly with COMPLAINTS (β = −0.152, p = 0.017). The AHI-REM did not correlate with any factor. Conclusions: Our results underscore the multidimensionality of EDS in mild sleep apnea.


Keywords: Disorders of excessive somnolence; Sleep apnea syndromes; Sleep, REM; Polysomnography.


4 - Surgical treatment of congenital tracheal stenoses

Tratamento cirúrgico das estenoses traqueais congênitas

Ricardo Mingarini Terra, Helio Minamoto, Lívia Caroline Barbosa Mariano, Angelo Fernandez, José Pinhata Otoch, Fabio Biscegli Jatene

J Bras Pneumol.2009;35(6):515-520

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the outcomes of patients undergoing repair of congenital tracheal stenosis. Methods: This was a retrospective review of congenital tracheal stenosis patients treated between 2001 and 2007 at the University of São Paulo School of Medicine Hospital das Clínicas in São Paulo, Brazil. Results: Six boys and one girl (age at diagnosis ranging from 28 days to 3 years) were included. Five of the patients also had cardiac or major vessel malformations. The stenosis length was short in three patients, medium in one and long in three. The techniques used were pericardial patch tracheoplasty in three patients, resection and anastomosis in two, slide tracheoplasty in one and vascular ring correction in one. One patient died during surgery due to hypoxia and hemodynamic instability, and one died from septic shock on postoperative day 11. Other complications included pneumonia, arrhythmia, stenosis at the anastomosis level, residual stenosis, granuloma formation and malacia. The mean follow-up period was 31 months; four patients were cured, and one required the use of a T-tube to maintain airway patency. Conclusions: Congenital tracheal stenosis is a curable disease. However, its repair is complex and is associated with high rates of morbidity and mortality.


Keywords: Tracheal stenosis/congenital; Tracheal diseases; Surgical procedures, operative.


5 - Assessment of pulmonary function and quality of life in patients submitted to pulmonary resection for cancer

Avaliação da função pulmonar e da qualidade de vida em pacientes submetidos à ressecção pulmonar por neoplasia

Luciana Nunes Titton Lima, Rodrigo Afonso da Silva, Jefferson Luiz Gross, Daniel Deheinzelin, Elnara Márcia Negri

J Bras Pneumol.2009;35(6):521-528

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the effects that pulmonary resection has on pulmonary function and quality of life (QoL) in patients with primary or metastatic lung cancer. Methods: This was a prospective cohort study involving all patients submitted to pulmonary resection for cancer between September of 2006 and March of 2007 at the A. C. Camargo Hospital in São Paulo, Brazil. Patients underwent spirometry in the preoperative period and at six months after the surgical procedure. After a postoperative period of six months, the patients completed an overall QoL questionnaire (the Medical Outcomes Study 36-item Short-form Health Survey) and another one, specific for respiratory symptoms (the Saint George's Respiratory Questionnaire). The scores obtained in our study were compared with those previously obtained for a general population and for a population of patients with COPD. Results: We included 33 patients (14 males and 19 females), ranging in age from 39 to 79 years. All of the patients, smokers and nonsmokers alike, presented significant worsening of pulmonary function. The mean scores on the overall QoL questionnaire were approximately 5% lower than those obtained for the general population. The scores of various domains of the symptom-specific QoL questionnaire were 50-60% lower than those obtained for the general population and approximately 20% higher than those obtained for the population with COPD. Conclusions: Pulmonary resection has a direct negative impact on pulmonary function and QoL, especially on the QoL related to aspects directly linked to pulmonary function. We highlight the importance of preoperative assessment of pulmonary function in patients undergoing pulmonary resection, in order to predict their postoperative evolution.


Keywords: Thoracic surgery; Lung neoplasms/surgery; Spirometry; Quality of life; Questionnaires.


6 - Esclerose sistêmica e pneumonia intersticial idiopática: diferenças histomorfométricas em biópsias pulmonares

Esclerose sistêmica e pneumonia intersticial idiopática: diferenças histomorfométricas em biópsias pulmonares

Edwin Roger Parra, Leandro Hideki Otani, Erika Franco de Carvalho, Alexandre Ab'Saber, Vera Luiza Capelozzi

J Bras Pneumol.2009;35(6):529-540

Abstract PDF PT PDF EN Portuguese Text

Objective: The aim of this study was to examine the parenchymal and extracellular matrix remodeling process in two histologic patterns-nonspecific interstitial pneumonia (NSIP) and usual interstitial pneumonia (UIP)-in cases of idiopathic and sclerosis/systemic sclerosis (SSc)-associated interstitial pneumonia. Methods: We examined 15 cases of idiopathic NSIP, 10 cases of idiopathic UIP, 5 cases of SSc-UIP and 9 cases of SSc-NSIP. In the lung parenchyma, epithelial cells, endothelial cells and myofibroblasts were evaluated by immunohistochemical staining, whereas histochemical staining was used in order to evaluate collagen/elastic fibers in the extracellular matrix. Results: The percentage of surfactant protein A-positive epithelial cells was significantly greater in idiopathic NSIP than in SSc-NSIP, as well as being greater in idiopathic UIP than in SSc-UIP. Idiopathic NSIP and idiopathic UIP presented significantly higher immunoexpression of alpha smooth muscle actin in myofibroblasts than did SSc-NSIP and SSc-UIP. The percentage of CD34 endothelial cells in the pulmonary microvasculature was significant lower in idiopathic UIP than in SSc-UIP. The density of collagen fibers was significantly greater in idiopathic NSIP and idiopathic UIP than in SSc-NSIP and UIP. In contrast, the elastic fiber density was significantly lower in idiopathic UIP than in SSc-UIP. Conclusions: Increased collagen synthesis, destruction of elastic fibers, high myofibroblast proliferation and poor microvascularization might represent a remodeling process found in idiopathic interstitial pneumonia, whereas the reverse might represent a repair process in SSc-associated interstitial pneumonia.


Keywords: Epithelial cells; Neovascularization, pathologic; Collagen; Elastin; Idiopathic interstitial pneumonias; Scleroderma, systemic.


7 - Evaluation of the diagnostic performance and cut-off value for the rapid shallow breathing index in predicting extubation failure

Avaliação do desempenho diagnóstico e do valor de corte para o índice de respiração rápida e superficial na predição do insucesso da extubação

Aline Roberta Danaga, Ana Lúcia Gut, Letícia Cláudia de Oliveira Antunes, Ana Lúcia dos Anjos Ferreira, Fábio Akio Yamaguti, José Carlos Christovan, Ubirajara Teixeira, Cristina Aparecida Veloso Guedes, Ana Beatriz Sasseron, Luis Cuadrado Martin

J Bras Pneumol.2009;35(6):541-547

Abstract PDF PT PDF EN Portuguese Text

Objective: To evaluate the diagnostic performance of the rapid shallow breathing index (RSBI) in predicting extubation failure among adult patients in the intensive care unit and to determine the appropriateness of the classical RSBI cut-off value. Methods: This was a prospective study conducted in the adult intensive care unit of the Botucatu School of Medicine Hospital das Clínicas. The RSBI was evaluated in 73 consecutive patients considered clinically ready for extubation. Results: The classical RSBI cut-off value (105 breaths/min/L) presented a sensitivity of 20% and a specificity of 95% (sum = 115%). Analysis of the receiver operator characteristic (ROC) curve revealed a better cut-off value (76.5 breaths/min/L), which presented a sensitivity of 66% and a specificity of 74% (sum = 140%). The area under the ROC curve for the RSBI was 0.78. Conclusions: The classical RSBI cut-off value proved inappropriate, predicting only 20% of the cases of extubation failure in our sample. The new cut-off value provided substantial improvement in sensitivity, with an acceptable loss of specificity. The area under the ROC curve indicated that the discriminative power of the RSBI is satisfactory, which justifies the validation of this index for use.


Keywords: Adult; Intensive care; ROC curve; Ventilator weaning; Diagnosis; Respiration, artificial.


8 - Epidemiological aspects of pleural tuberculosis in the state of São Paulo, Brazil (1998-2005)

Aspectos epidemiológicos da tuberculose pleural no estado de São Paulo (1998-2005)

Márcia Seiscento, Francisco Suso Vargas, Maria Josefa Penon Rujula, Sidney Bombarda, David Everson Uip, Vera Maria Nedes Galesi

J Bras Pneumol.2009;35(6):548-554

Abstract PDF PT PDF EN Portuguese Text

Objective: To analyze the epidemiological characteristics of and trends regarding the incidence of pleural TB. Methods: This was a retrospective descriptive study of TB cases reported between 1998 and 2005 and compiled from the Epidemiological Surveillance Tuberculosis System (Epi-TB database). Results: A total of 144,347 new cases of TB were reported during the period studied. Pulmonary TB was the predominant form (118,575 cases; 82.2%). Among the extrapulmonary forms (25,773 cases; 17.8%), pleural TB was the form most often reported (12,545 cases; 48.7%). For all forms, the incidence (per 100,000 population) decreased (from 49.7 in 1998 to 44.6 in 2005; R2 = 0.898; p < 0.001), whereas the incidence of pleural TB remained stable (4.1 in 1998 and 3.8 in 2005; R2 = 0.433; p = 0.076). The highest incidence of pleural TB was found among males (2:1) aged from 30 to 59 years. Of the 12,545 patients with pleural TB, 4,018 (32.0%) presented comorbidities: alcoholism (9.5%); HIV (8.0%); diabetes (3.3%); and mental illness (1.2%). The diagnosis was based on bacteriological (14.2%) and histological (30.2%) methods, as well as on unspecified methods (55.6%). Conclusions: Pleural TB was the predominant extrapulmonary form of TB in the state of São Paulo, with a stable incidence between 1998 and 2005, although there was a trend toward a decrease in the incidence of the pulmonary forms. The diagnosis of pleural TB was confirmed through histology and bacteriology in 44.4% of the cases.


Keywords: Pleural effusion; Tuberculosis, pleural; HIV.


9 - Prevalence of drug-resistant Mycobacterium tuberculosis in patients under intermittent or daily treatment

Prevalência de Mycobacterium tuberculosis resistente em pacientes sob tratamento parcialmente intermitente ou sob tratamento diário

Tomás Aiza Alvarez, Marcelo Palmeira Rodrigues, Carlos Alberto de Assis Viegas

J Bras Pneumol.2009;35(6):555-560

Abstract PDF PT PDF EN Portuguese Text

Objective: To compare the prevalence rates of drug-resistant Mycobacterium tuberculosis in patients under intermittent treatment with those observed in patients under daily treatment. Methods: We used World Health Organization data regarding 5,138 patients with active pulmonary TB in Brazil, separated into two groups: patients in the Federal District of Brasília, treated with a one-month daily regimen followed by an intermittent thrice-weekly regimen; and patients in other parts of Brazil, treated with a daily regimen only. The resistance pattern was categorized as primary or acquired, based on the history of previous treatment. Multidrug resistance was defined as resistance to at least isoniazid and rifampin, whereas monoresistance was defined as resistance to only one drug. Results: The prevalence of primary resistance in the Federal District of Brasília and in the other parts of Brazil, respectively, was as follows: overall, 9.2% and 9.3% (p = 0.94); monoresistance, 6.6% and 6.9% (p = 0.89); and multidrug resistance, 1.0% and 1.2% (p = 0.85). The prevalence of acquired resistance in the Federal District of Brasília and in the other parts of Brazil, respectively, was as follows: overall, 15.8% and 26.8% (p = 0.39); monoresistance, 5.3% and 13.7% (p = 0.33); and multidrug resistance, 0.0% and 10.2% (p = 0.16). Conclusions: No significant differences were found between patients treated with an intermittent regimen and those treated with a daily regimen in term of resistance rates.


Keywords: Tuberculosis, pulmonary; Drug resistance; Drug administration schedule; Tuberculosis, multidrug-resistant.


Review Article

10 - Pulmonary eosinophilia

Eosinofilia pulmonar

Luiz Eduardo Mendes Campos, Luiz Fernando Ferreira Pereira

J Bras Pneumol.2009;35(6):561-573

Abstract PDF PT PDF EN Portuguese Text

Pulmonary eosinophilia comprises a heterogeneous group of diseases defined by eosinophilia in pulmonary infiltrates (bronchoalveolar lavage fluid) or in tissue (lung biopsy specimens). Although the inflammatory infiltrate is composed of macrophages, lymphocytes, neutrophils and eosinophils, eosinophilia is an important marker for the diagnosis and treatment. Clinical and radiological presentations can include simple pulmonary eosinophilia, chronic eosinophilic pneumonia, acute eosinophilic pneumonia, allergic bronchopulmonary aspergillosis and pulmonary eosinophilia associated with a systemic disease, such as in Churg-Strauss syndrome and hypereosinophilic syndrome. Asthma is frequently concomitant and can be a prerequisite, as in allergic bronchopulmonary aspergillosis and Churg-Strauss syndrome. In diseases with systemic involvement, the skin, the heart and the nervous system are the most affected organs. The radiological presentation can be typical, or at least suggestive, of one of three types of pulmonary eosinophilia: chronic eosinophilic pneumonia, acute eosinophilic pneumonia and allergic bronchopulmonary aspergillosis. The etiology of pulmonary eosinophilia can be either primary (idiopathic) or secondary, due to known causes, such as drugs, parasites, fungal infection, mycobacterial infection, irradiation and toxins. Pulmonary eosinophilia can be also associated with diffuse lung diseases, connective tissue diseases and neoplasia.


Keywords: Pulmonary eosinophilia; Hypereosinophilic syndrome; Aspergillosis, allergic bronchopulmonary; Churg-Strauss syndrome.


Guidelines SBPT

11 - Brazilian guidelines for community-acquired pneumonia in immunocompetent adults - 2009

Diretrizes brasileiras para pneumonia adquirida na comunidade em adultos imunocompetentes - 2009

Ricardo de Amorim Corrêa, Fernando Luiz Cavalcanti Lundgren, Jorge Luiz Pereira-Silva, Rodney Luiz Frare e Silva (editores); Grupo de Trabalho da Diretriz

J Bras Pneumol.2009;35(6):574-601

Abstract PDF PT PDF EN Portuguese Text

Community-acquired pneumonia continues to be the acute infectious disease that has the greatest medical and social impact regarding morbidity and treatment costs. Children and the elderly are more susceptible to severe complications, thereby justifying the fact that the prevention measures adopted have focused on these age brackets. Despite the advances in the knowledge of etiology and physiopathology, as well as the improvement in preliminary clinical and therapeutic methods, various questions merit further investigation. This is due to the clinical, social, demographical and structural diversity, which cannot be fully predicted. Consequently, guidelines are published in order to compile the most recent knowledge in a systematic way and to promote the rational use of that knowledge in medical practice. Therefore, guidelines are not a rigid set of rules that must be followed, but first and foremost a tool to be used in a critical way, bearing in mind the variability of biological and human responses within their individual and social contexts. This document represents the conclusion of a detailed discussion among the members of the Scientific Board and Respiratory Infection Committee of the Brazilian Thoracic Association. The objective of the work group was to present relevant topics in order to update the previous guidelines. We attempted to avoid the repetition of consensual concepts. The principal objective of creating this document was to present a compilation of the recent advances published in the literature and, consequently, to contribute to improving the quality of the medical care provided to immunocompetent adult patients with community-acquired pneumonia.


Keywords: Pneumonia; Diagnosis; Epidemiology; Practice guideline; Primary prevention.


Case Report

12 - Synchronous pulmonary and hepatic nodules in a patient with previous bronchogenic carcinoma: the relevance of histopathological confirmation

Nódulo sincrônico pulmonar e hepático em paciente com antecedente de carcinoma broncogênico: a importância da confirmação histopatológica

José de Jesus Peixoto Camargo, Tiago Noguchi Machuca, Spencer Marcantonio Camargo, Sadi Marcelo Schio, Rodrigo Moreira Bello

J Bras Pneumol.2009;35(6):602-605

Abstract PDF PT PDF EN Portuguese Text

The synchronous presentation of pulmonary and hepatic nodules in a patient with previously resected bronchogenic carcinoma raises suspicion of recurrence and mandates restaging. We present the case of a 71-year-old male with a history of lobectomy with pericardial resection and mediastinal lymphadenectomy (T3N0M0). At five years after the operation, he presented with a new pulmonary lesion. Restaging detected a synchronous nodule in the liver. Despite the strong suspicion of tumor recurrence, further investigation with a percutaneous liver biopsy revealed hepatocellular carcinoma. In order to investigate the etiology of the pulmonary lesion (hypotheses of recurrent bronchial cancer and of metastatic hepatocellular carcinoma), an open lung biopsy was performed, which revealed chronic inflammatory tissue with foci of anthracosis and dystrophic calcification. The patient was submitted to a non-anatomic resection of the liver lesion. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. This report highlights the relevance of the histopathological diagnosis in patients with a history of bronchogenic carcinoma and suspicion of tumor recurrence. Differential diagnoses and the treatment administered are discussed.


Keywords: Carcinoma, bronchogenic; Neoplasm metastasis; Carcinoma, hepatocellular.


13 - Uncommon pleural effusion: pleuropulmonary metastasis from primitive neuroectodermal tumor

Derrame pleural incomum: metástase pleuropulmonar de tumor neuroectodérmico primitivo

Leila Antonangelo, Adriana Gonçalves Rosa, Aline Pivetta Corá, Milena Marques Pagliarelli Acencio, Luís César Moreira, Francisco Vargas Suso

J Bras Pneumol.2009;35(6):606-609

Abstract PDF PT PDF EN Portuguese Text

Primitive neuroectodermal tumor is an invasive neoplasm with neuronal differentiation, which frequently results in metastasis in various organs. We report the case of a patient with primitive neuroectodermal tumor whose primary site was the axilla. The patient presented with metastases in the lung, pleura, bone, iliac muscle and bone marrow. We highlight the uncommon finding in the pleural fluid cytology.


Keywords: Neuroectodermal tumors, primitive; Neoplasm metastasis; Cytology; Pleural effusion.


Special Article

14 - Performance assessment questionnaire regarding TB control for use in primary health care clinics in Brazil

Questionário para avaliação de desempenho de serviços de atenção básica no controle da TB no Brasil

Tereza Cristina Scatena Villa, Antônio Ruffino-Netto

J Bras Pneumol.2009;35(6):610-612

Abstract PDF PT PDF EN Portuguese Text Appendix

The objective of this study was to provide access to and disseminate a questionnaire used as an instrument to assess the organizational elements and the performance of primary health care clinics regarding TB control in Brazil, comparing selected organizational dimensions by health care clinic, by municipality and by actor (patients, health care workers and managers). The results show that municipalities where the coverage of supervised treatment was more extensive presented more favorable indicators regarding access to TB treatment. The organizational format of the health care clinics involved in TB treatment-family health programs and referral centers with specialized teams in TB control programs (TCPs)-was not a factor that expanded access to diagnosis. The TCPs involving a smaller number of patients presented better performance regarding the health care professional-patient relationship. The majority of the patients faced economic and social difficulties, and most managers were unaware of the amount of resources allocated to TB control activities. The instrument proved to be viable and to have the potential to adequately assess the performance of health care clinics in the urban areas studied.


Keywords: Questionnaires; Patient satisfaction; Primary health care; Family health program; Tuberculosis.



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