Showing papers in "Jornal Brasileiro De Pneumologia in 2009"

Portuguese-language version of the Epworth sleepiness scale: validation for use in Brazil

Abstract: Objective: The aim of this study was to develop a Portuguese-language version of the Epworth sleepiness scale (ESS) for use in Brazil. Methods: The steps involved in creating the ESS in Brazilian Portuguese (ESS-BR) were as follows: translation; back-translation; comparison (by a committee) between the translation and the back-translation; and testing in bilingual individuals. The ESS-BR was applied to a group of patients who were submitted to overnight polysomnography in order to identify obstructive sleep apnea-hypopnea syndrome (OSAHS), insomnia and primary snoring. A control group was composed of subjects with a history of normal sleep habits, without reported snoring. Results: A total of 114 patients and 21 controls were included. The 8-item scores of the ESS-BR had an overall reliability coefficient of 0.83. The study group was composed of 59 patients with OSAHS, 34 patients with primary snoring and 21 patients with insomnia. One-way ANOVA demonstrated significant differences in ESS-BR scores among the four diagnostic groups (p 0.05). The ESS-BR scores were significantly higher for OSAHS patients and for primary snorers than for controls (p < 0.05). In addition, the scores for OSAHS patients were significantly higher than were those for primary snorers (p < 0.05). Conclusions: The results of the present study demonstrate that the ESS-BR is a valid and reliable instrument for the assessment of daytime sleepiness, equivalent to its original version when applied to individuals who speak Brazilian Portuguese.

III Brazilian Thoracic Association Guidelines on tuberculosis.

Abstract: New scientific articles about tuberculosis (TB) are published daily worldwide. However, it is difficult for health care workers, overloaded with work, to stay abreast of the latest research findings and to discern which information can and should be used in their daily practice on assisting TB patients. The purpose of the III Brazilian Thoracic Association (BTA) Guidelines on TB is to critically review the most recent national and international scientific information on TB, presenting an updated text with the most current and useful tools against TB to health care workers in our country. The III BTA Guidelines on TB have been developed by the BTA Committee on TB and the TB Work Group, based on the text of the II BTA Guidelines on TB (2004). We reviewed the following databases: LILACS (SciELO) and PubMed (Medline). The level of evidence of the cited articles was determined, and 24 recommendations on TB have been evaluated, discussed by all of the members of the BTA Committee on TB and of the TB Work Group, and highlighted. The first version of the present Guidelines was posted on the BTA website and was available for public consultation for three weeks. Comments and critiques were evaluated. The level of scientific evidence of each reference was evaluated before its acceptance for use in the final text.

Psychometric properties of the Fagerström Test for Nicotine Dependence

Abstract: OBJECTIVE: The Fagerstrom Test for Nicotine Dependence (FTND) is a screening instrument for physical nicotine dependence and is extensively used in various countries. The objective of the present report was to review articles related to the psychometric properties of the FTND. METHODS: A systematic search for articles published up through December of 2007 was carried out in various electronic databases. The following search terms were used: "Fagerstrom Test for Nicotine Dependence"; "FTND"; "psychometric"; "validity"; "reliability"; "feasibility"; and "factors". We included articles published in English, Spanish or Portuguese and in which the psychometric properties of the FTND were evaluated. RESULTS: Twenty-six studies related to the psychometric properties of the FTND were identified in the indexed literature. Analysis of the studies confirmed the reliability of the FTND for the assessment of nicotine dependence in different settings and populations. CONCLUSIONS: Further validation studies using previously validated instruments as a comparative measure are needed before the extensive use of the FTND can be justified on the basis of its psychometric qualities.

Perfil do nível de atividade física na vida diária de pacientes portadores de DPOC no Brasil

Abstract: OBJECTIVE: To evaluate characteristics of physical activities in daily life in COPD patients in Brazil, correlating those characteristics with physiological variables. METHODS: Physical activities in daily life were evaluated in 40 COPD patients (18 males; 66 ± 8 years of age; FEV1 = 46 ± 16 % of predicted; body mass index = 27 ± 6 kg/m2) and 30 healthy age- and gender-matched subjects, using a multiaxial accelerometer-based sensor for 12 h/day on two consecutive days. We also assessed maximal and functional exercise capacity, using the incremental exercise test and the six-minute walk test (6MWT), respectively; MIP and MEP; peripheral muscle force, using the one-repetition maximum test and the handgrip test; quality of life, using the Saint George's Respiratory Questionnaire (SGRQ); functional status, using the London Chest Activity of Daily Living questionnaire; and dyspnea sensation, using the Medical Research Council (MRC) scale. RESULTS: Mean walking time/day was shorter for COPD patients than for the controls (55 ± 33 vs. 80 ± 28 min/day; p = 0.001), as movement intensity was lower (1.9 ± 0.4 vs. 2.3 ± 0.6 m/s2; p = 0.004). The COPD patients also tended to spend more time seated (294 ± 114 vs. 246 ± 122 min/day, p = 0.08). Walking time/day correlated with the 6MWT (r = 0.42; p = 0.007) and maximal workload (r = 0.41; p = 0.009), as well as with age, MRC scale score and SGRQ activity domain score (-0.31 < r < -0.43; p < 0.05 for all). CONCLUSIONS: This sample of Brazilian patients with COPD, although more active than those evaluated in studies conducted in Europe, were less active than were the controls. Walking time/day correlated only moderately with maximal and functional exercise capacity.

Knowledge of and technique for using inhalation devices among asthma patients and COPD patients

Abstract: OBJETIVO: Avaliar a compreensao e a tecnica de uso dos dispositivos inalatorios prescritos de pacientes com asma ou DPOC atendidos em um hospital-escola terciario. METODOS: Os pacientes foram avaliados na sala de pos-consulta sem que o medico soubesse do estudo. Foi solicitado que o paciente demonstrasse como utiliza a medicacao inalatoria e, em seguida, esse foi entrevistado sobre a compreensao dos dispositivos inalatorios, controle da doenca e orientacoes recebidas durante as consultas. RESULTADOS: Foram avaliados 120 voluntarios: 60 asmaticos e 60 com DPOC. Todos os asmaticos e 98,3% do grupo DPOC relataram saber utilizar os medicamentos inalatorios. Na amostra como um todo, 113 pacientes (94,2%) cometeram pelo menos um erro ao utilizar o dispositivo inalatorio. Os pacientes cometeram mais erros ao utilizar aerossol dosimetrado do que ao utilizar os inaladores de po seco Aerolizer® (p < 0,001) ou Pulvinal® (p < 0,001), assim como mais erros ao utilizar Aerolizer® do que ao utilizar Pulvinal® (p < 0,05). O grupo DPOC cometeu significativamente mais erros que o grupo asma ao utilizar o aerossol dosimetrado (p = 0,0023), Pulvinal® (p = 0,0065) e Aerolizer® (p = 0,012). CONCLUSOES: Embora a maioria dos pacientes relatasse saber a tecnica adequada de utilizacao dos dispositivos inalatorios, 94,2% cometeu pelo menos um erro na utilizacao dos dispositivos, demonstrando tecnica insatisfatoria e discrepância entre a compreensao e a pratica. Portanto, apenas questionar os pacientes sobre o uso dos dispositivos inalatorios nao e suficiente. Medidas praticas devem ser tomadas a fim de diminuir os erros e otimizar a terapeutica.

Pneumonia nosocomial: importância do microambiente oral

Abstract: Nosocomial pneumonia, especially ventilator-associated pneumonia, is a common infection in ICUs. The main etiologic factors involve colonizing and opportunistic bacteria from the oral cavity. Oral hygiene measures, including the use of oral antiseptic agents, such as chlorhexidine, have proven useful in reducing its incidence. The objective of this article was to review the literature on the importance of the oral environment in the development of nosocomial pneumonia.

Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation

Abstract: OBJECTIVE: Failure of noninvasive ventilation (NIV) has been associated with short-term adverse effects related to the use of masks. The aim of this study was to compare the incidence, type and intensity of adverse effects, as well as the comfort, of total face masks (TFMs), facial masks (FMs) and nasal masks (NMs) during NIV. METHODS: This was a randomized crossover trial involving 24 healthy volunteers submitted to six sessions of NIV in bilevel positive airway pressure mode using the TFM, FM and NM masks at low and moderate-to-high pressure levels. A written questionnaire was applied in order to evaluate eleven specific adverse effects related to the use of the masks. Comfort was assessed using a visual analog scale. The CO2 exhaled into the ventilator circuit was measured between the mask and the exhalation port. RESULTS: The performance of the TFM was similar to that of the NM and FM in terms of comfort scores. Higher pressure levels reduced comfort and increased adverse effects, regardless of the mask type. When the TFM was used, there were fewer air leaks and less pain at the nose bridge, although there was greater oronasal dryness and claustrophobia. Air leaks were most pronounced when the FM was used. The partial pressure of exhaled CO2 entering the ventilator circuit was zero for the TFM. CONCLUSIONS: The short-term adverse effects caused by NIV interfaces are related to mask type and pressure settings. The TFM is a reliable alternative to the NM and FM. Rebreathing of CO2 from the circuit is less likely to occur when a TFM is used.

Chapter 6: Paracoccidioidomycosis

Abstract: Paracoccidioidomycosis is a systemic mycosis caused by the dimorphic fungus Paracoccidioides brasiliensis. The disease is restricted to Latin America. It is the principal systemic mycosis in Brazil, with higher incidences in the southern, southeastern and central regions. The disease is acquired by inhaling fungal propagules. In endemic areas, the primary infection occurs during childhood and involves the immune system. The most common chronic form of paracoccidioidomycosis in adults is the multifocal form, in which there is dissemination to the lungs, lymph nodes, skin and mucosae. This form of the disease has a chronic progression, and the diagnosis is typically delayed. Cough, dyspnea and weight loss due to cutaneous and mucosal lesions are evident and are the principal complaints reported by paracoccidioidomycosis patients. Chest X-rays reveal diffuse reticulonodular infiltrates, which are more evident in the upper lobes. The etiologic diagnosis is based on the identification of P. brasiliensis in clinical specimens, such as lymph node aspirates or BAL fluid, by direct microscopy and culture. Histopathological testing of tissue samples reveals the thick birefringent cell wall of the fungus and the typical pattern of multiple budding around the mother cell. Double agar gel immunodiffusion is useful for the diagnosis when the fungus cannot be detected through mycological tests. Although paracoccidioidomycosis is most often treated with the sulfamethoxazole-trimethoprim combination, itraconazole is preferable. Amphotericin B is used in severe cases.

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

Abstract: 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 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.

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

Abstract: 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.

Air stacking and chest compression increase peak cough flow in patients with Duchenne muscular dystrophy

Abstract: OBJETIVO: Avaliar a eficiencia da tosse atraves do uso de duas manobras manuais de auxilio a tosse. METODOS: Foram selecionados 28 pacientes portadores de distrofia muscular de Duchenne em uso de ventilacao mecânica nao-invasiva noturna e CVF < 60% do previsto. O pico de fluxo da tosse (PFT) foi medido, com o paciente sentado, em quatro momentos: com esforco expiratorio maximo (EEM) de forma espontânea (basal), EEM associado a compressao toracica, EEM apos empilhamento de ar com bolsa de ventilacao e EEM com o uso dessas duas tecnicas (tecnica combinada). As tres ultimas medicoes foram realizadas em ordem aleatoria. Os resultados foram comparados usando o teste de correlacao de Pearson e ANOVA para medidas repetidas, seguido do teste post hoc de Tukey (p < 0,05). RESULTADOS: A idade media dos pacientes foi de 20 ± 4 anos, e a CVF media foi de 29 ± 12%. A media de PFT basal, com compressao toracica, com empilhamento de ar e com o uso da tecnica combinada foi 171 ± 67, 231 ± 81, 225 ± 80, e 292 ±86 L/min, respectivamente. Os resultados com o uso da tecnica combinada foram maiores que aqueles com o uso das duas tecnicas separadamente [F(3,69) = 67,07; p < 0,001]. CONCLUSOES: As tecnicas de compressao toracica e de empilhamento de ar foram eficientes para aumentar o PFT. No entanto, a combinacao dessas manobras teve um efeito aditivo significativo (p < 0,0001).

Prevalence of gastroesophageal reflux disease in patients with idiopathic pulmonary fibrosis.

Abstract: OBJECTIVE: To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate its clinical presentation, as well as the esophageal function profile in patients with idiopathic pulmonary fibrosis (IPF). METHODS: In this prospective study, 28 consecutive patients with IPF underwent stationary esophageal manometry, 24-h esophageal pH-metry and pulmonary function tests. All patients also completed a symptom and quality of life in GERD questionnaire. RESULTS: In the study sample, the prevalence of GERD was 35.7%. The patients were then divided into two groups: GERD+ (abnormal pH-metry; n = 10) and GERD- (normal pH-metry; n = 18). In the GERD+ group, 77.7% of the patients presented at least one typical GERD symptom. The pH-metry results showed that 8 (80%) of the GERD+ group patients had abnormal supine reflux, and that the reflux was exclusively in the supine position in 5 (50%). In the GERD+ and GERD- groups, respectively, 5 (50.0%) and 7 (38.8%) of the patients presented a hypotensive lower esophageal sphincter, 7 (70.0%) and 10 (55.5%), respectively, presenting lower esophageal dysmotility. There were no significant differences between the groups regarding demographic characteristics, pulmonary function, clinical presentation or manometric findings. CONCLUSIONS: The prevalence of GERD in the patients with IPF was high. However, the clinical and functional characteristics did not differ between the patients with GERD and those without.

Obstructive sleep apnea syndrome in truck drivers.

Abstract: 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.

Prevalence of active and latent TB among inmates in a prison hospital in Bahia, Brazil

Abstract: OBJECTIVE: To determine the prevalence of latent and active TB among detainees in a prison hospital in Bahia, Brazil. METHODS: A cross-sectional study with prospective data collection was carried out comprising 237 inmates in the Bahia State Prison Hospital between July 2003 and April 2004. A standardized questionnaire was applied and completed by medical students. The detainees were systematically submitted to the following tests: tuberculin skin test, chest X-ray (anteroposterior), sputum smear microscopy and culture for mycobacteria. The events of interest were active TB and latent TB. RESULTS: The mean age of the participants was 36.6 years, and 89.9% were male. Smoking and alcohol consumption were reported by 70.0% and 43.9% of the inmates, respectively. A history of treatment for TB was reported by 11.3% of the inmates. Of the inmates evaluated, 36.3% reported cough and 31.4% reported expectoration. Other less common symptoms were asthenia (in 26.2%), weight loss (in 23.1%), loss of appetite (in 17.7%), fever (in 11.3%) and hemoptysis (in 6.7%). Of the 86 inmates tested, none presented positive HIV serology. The prevalence of latent TB was 61.5% (96 of the 156 inmates submitted to tuberculin skin tests), whereas that of active TB was 2.5% (6 of the 237 inmates evaluated). The presence of cough was a determinant of active TB (prevalence ratio = 8.8; 95% CI: 1.04-73.9; p = 0.025). CONCLUSIONS: Active and latent TB are highly prevalent among inmates hospitalized in the Bahia State Prison Hospital. Our findings justify the need to implement public policies specifically directed towards the control of TB in this population.

Prevalence of obstructive sleep apnea in children and adolescents with sickle cell anemia.

Abstract: OBJECTIVE: To estimate the prevalence of obstructive sleep apnea syndrome (OSAS) in children and adolescents with sickle cell anemia (SCA); to investigate the possible correlation between mean annual hemoglobin level and total sleep time with SpO2 1 was considered indicative of a diagnosis of OSAS. RESULTS: The prevalence of OSAS was 10.6%. We found a negative correlation between mean annual hemoglobin level and total sleep time with SpO2 < 90% (r = µ0.343; p = 0.002), as well as between mean annual hemoglobin level and total sleep time with SpO2 < 80% (r = µ0.270; p = 0.016). There was no association between AHI and painful crisis. CONCLUSIONS: The prevalence of OSAS in this population was high (10.6%). Therefore, it is important to identify signs of OSAS as soon as possible and to determine the mean annual hemoglobin level because of the inverse correlation between that level and the total sleep time with SpO2 < 90% or < 80%.

Prevalence of pectus carinatum and pectus excavatum in students in the city of Manaus, Brazil

Abstract: OBJECTIVE: To determine the prevalence of congenital anterior chest wall deformities in 11- to 14-year-old students. METHODS: Students participating in the study were recruited from public schools in the city of Manaus, Brazil. The statistically significant sample (precision, 1%; 95% CI) comprised 1,332 students. Pectus deformities were identified by physical examination of the chest, and the individuals with one of these deformities completed a questionnaire regarding heredity and symptoms resulting from the chest abnormality. RESULTS: The mean age of the participants was 11.7 years. The prevalence of pectus abnormalities was 1.95% (pectus excavatum: 1.275%; pectus carinatum: 0.675%). Of the 26 students with a pectus deformity, 17 (65.4%) had pectus excavatum, and 18 (69.2%) were male. Concomitant scoliosis was observed in 3 cases (11.5%). A family history of pectus was reported by 17 students (65.4%), and 17 (65.4%) reported chest pain, dyspnea or palpitations. CONCLUSIONS: In this study, the prevalence of pectus deformities (1.95%) was lower than that reported in other studies conducted in Brazil (3.6-4.9%) but was higher than that reported in the literature (mean, 1%).

Viral pneumonia: epidemiological, clinical, pathophysiological and therapeutic aspects

Abstract: In humans, the most common types of infection are respiratory tract infections, among which viral infections predominate. Viruses can also infect the low respiratory tract, causing bronchiolitis, bronchitis and pneumonia. The objective of this review article was to show epidemiological, pathophysiological, clinical and therapeutic aspects of viral community-acquired pneumonia. These types of pneumonia are commonly caused by influenza A and B; parainfluenza 1, 2 and 3; respiratory syncytial virus; or adenovirus. We also address the types of pneumonia caused by hantaviruses, metapneumoviruses and rhinoviruses.

O papel do estresse oxidativo na DPOC: conceitos atuais e perspectivas

Abstract: Worldwide, COPD is a major cause of morbidity and mortality. The clinical and functional manifestations of COPD result from lung injury occurring through various mechanisms, including oxidative stress, inflammation, protease-antiprotease imbalance and apoptosis. Oxidative stress is central to the pathogenesis of COPD, since it can directly damage lung structures and exacerbate the other mechanisms involved. The cellular and molecular events involved in such lung injury are believed to occur long before the clinical and functional expression of COPD. Although the use of bronchodilators is currently the principal treatment for COPD, bronchodilators have little or no effect on disease progression. A better understanding of the pathogenesis of COPD, together with renewed efforts in basic and clinical research, will allow the diagnosis of COPD at a pre-clinical stage and provide more appropriate monitoring of disease activity, as well as leading to the development of novel therapeutic agents that will effectively prevent the progression of the disease.

Prevalence of developmental defects of enamel in children and adolescents with asthma

Abstract: OBJECTIVE: This study aimed to evaluate the prevalence of developmental defects of enamel (DDEs) in relation to asthma severity, symptom onset and pharmacological treatment in pediatric asthma patients. METHODS: Children and adolescents (68 asthma patients and 68 controls), 5-15 years of age and residents of the city of Londrina, Brazil, were enrolled in the study. Medical and dental histories were collected through the use of a structured questionnaire. Each participant underwent a dental examination in which the examiner employed the DDE index. RESULTS: Of the 68 asthma group subjects, 61 (89.7%) presented dental enamel defects, compared with only 26 (38.2%) of those in the control group. Using multivariate logistic regression analysis, we estimated the risk of DDEs in permanent dentition to be 11 times higher in pediatric subjects with asthma than in those without (OR = 11.88, p = 0.0001). The occurrence of dental enamel defects correlated with greater asthma severity (p = 0.0001) and earlier symptom onset (p = 0.0001). However, dental enamel defects did not correlate with the initiation of treatment (p = 0.08) or the frequency of medication use (p = 0.93). CONCLUSIONS: Pediatric patients with severe, early-onset asthma are at increased risk of dental enamel defects and therefore require priority dental care.

Evaluation of criteria for the diagnosis of asthma using an epidemiological questionnaire

Abstract: OBJETIVO: Avaliar criterios para o diagnostico de asma em um estudo epidemiologico. METODOS: Adolescentes (13-14 anos) e responsaveis por escolares (6-7 anos) do municipio de Santo Andre, Sao Paulo, responderam o questionario escrito padrao do International Study of Asthma and Allergies in Childhood (ISAAC). Respostas afirmativas quanto a ter sibilos nos ultimos 12 meses, ter asma ou ter bronquite (pergunta adicionada ao final do questionario), assim como o escore global do ISAAC acima dos pontos de corte pre-definidos, foram consideradas como indicativo de asma. RESULTADOS: Os questionarios foram adequadamente preenchidos por 2.180 responsaveis por escolares e 3.231 adolescentes. Dependendo do criterio empregado, a prevalencia de asma variou de 4,9% a 26,8% para os escolares, e de 8,9% a 27,9% para os adolescentes. Os criterios com as menores e maiores prevalencias foram, respectivamente, diagnostico medico de asma e diagnostico medico de bronquite. A analise comparativa entre o diagnostico medico de bronquite e os demais criterios mostrou niveis de concordância entre 71,9% e 79,4%, valores preditivos positivos entre 0,16 e 0,63 e concordância fraca (kappa: 0,21-0,46). Indices elevados de concordância foram observados entre sibilos nos ultimos 12 meses e o escore global do ISAAC (kappa: 0,82 e 0,98). CONCLUSOES: A prevalencia de asma variou significantemente, de acordo com o criterio diagnostico adotado, e houve baixa concordância entre os criterios. Sibilos nos ultimos 12 meses e o escore global do ISAAC sao os criterios mais recomendados para se diagnosticar asma, ao passo que a pergunta "bronquite alguma vez" nao demonstrou melhorar o questionario. Modificacoes nesse instrumento devem ser cuidadosamente avaliadas e podem dificultar comparacoes.

Compensatory sweating after thoracoscopic sympathectomy: characteristics, prevalence and influence on patient satisfaction

Abstract: OBJECTIVE: This prospective study aimed at investigating predictive factors for compensatory sweating after thoracoscopic sympathectomy METHODS: From 2000 to 2002, 80 patients (53 females and 27 males) underwent thoracoscopic sympathectomy to treat hyperhidrosis Patient ages ranged from 12 to 56 years, and the mean post-operative follow-up period was 4251 ± 598 months Patient satisfaction with the results was evaluated through the use of a rating scale The procedure was performed bilaterally: at the T2 level for facial hyperhidrosis; at the T3-T4 level for axillary hyperhidrosis; and at the T3 level for palmar hyperhidrosis RESULTS: Post-operatively, 68 patients (850%) presented compensatory sweating, which was classified as mild in 23 (338%), moderate in 23 (338%) and severe in 22 (324%) Considering the final surgical results, 70 patients (875%) were satisfied with the outcome of the operation, whereas 10 patients (125%) were dissatisfied The level of patient satisfaction varied according to gender, age, body mass index (BMI) and extent of denervation The compensatory sweating was more severe on the abdomen and back than on the legs CONCLUSIONS: Although compensatory sweating, which is a common adverse effect of sympathectomy, occurred in the majority of cases, the level of patient satisfaction was high The best candidates for thoracoscopic sympathectomy are young adult women with a BMI < 249 kg/m2

Experimental diabetes mellitus: oxidative stress and changes in lung structure

Abstract: Diabetes mellitus is an endocrine/metabolic disorder characterized by hyperglycemia. Its impact on the respiratory system is characterized by functional changes and alterations in gas exchange. The objective of this study was to evaluate the increase in oxidative stress and the potential damages to the lung structure in an experimental model of streptozotocin-induced diabetes. We conducted histological, biochemical and blood gas analyses in the lungs of diabetic rats. We concluded that the effects of experimental diabetes mellitus include oxidative stress, structural changes in the lung tissue and altered gas exchange.

Correlation between clinical parameters and health-related quality of life in women with COPD.

Abstract: OBJETIVO: Correlacionar a qualidade de vida relacionada a saude (QVRS) de mulheres portadoras de DPOC com parâmetros clinicos e com a distância percorrida no teste de caminhada de seis minutos (TC6). METODOS: Estudo transversal com 30 mulheres portadoras de DPOC leve ou moderada, atendidas no Ambulatorio de Pneumologia do Hospital Universitario Presidente Dutra. Foi aplicado o Saint George's Respiratory Questionnaire (SGRQ), assim como foram realizadas as medidas das pressoes respiratorias, da espirometria e dos resultados do TC6. Executou-se a analise estatistica descritiva, assim como o teste t de Student para variaveis dependentes, o coeficiente linear de Pearson para correlacoes de variaveis numericas e o de Spearman para variaveis ordinais. RESULTADOS: A QVRS esteve, na grande maioria das mulheres entrevistadas, comprometida, em graus variados, de acordo com o escore total do SGRQ. Os escores totais do SGRQ da maioria das participantes estavam entre o segundo e o terceiro quartil, o que reflete baixa QVRS. As participantes apresentaram ainda baixa capacidade funcional no TC6, com distância media percorrida (317,7 m) e forca muscular inspiratoria (-53,48 cmH2O) e expiratoria (69,5 cmH2O) abaixo dos valores de normalidade. Nao houve correlacao entre a QVRS e o indice de massa corporea e a funcao pulmonar. No entanto, houve correlacao linear negativa com a idade, a PImax e o TC6 e correlacao positiva com a sensacao de dispneia e de fadiga. CONCLUSOES: A QVRS medida pelo SGRQ das pacientes com DPOC desta pesquisa esteve muito comprometida, de modo a provocar limitacoes graves na funcionalidade, no controle da respiracao e na vida pessoal.

Chapter 4--histoplasmosis.

Abstract: Histoplasmosis is systemic mycosis caused by a small fungus, Histoplasma capsulatum var. capsulatum, whose natural habitat is soil contaminated by bat or bird excrement. The incidence of histoplasmosis is worldwide. In Brazil, the disease is found in all regions; however, the state of Rio de Janeiro is responsible for most of the microepidemics described. Human infection occurs when airborne spores of H. capsulatum are inhaled. The most common clinical presentation is asymptomatic. The symptoms of acute or epidemic histoplasmosis are high fever, cough, asthenia and retrosternal pain, as well as enlargement of the cervical lymph nodes, liver and spleen. The most common radiological findings are diffuse reticulonodular infiltrates in both lungs, as well as hilar and mediastinal lymph node enlargement. In chronic pulmonary histoplasmosis, the clinical and radiological manifestations are identical to those of reinfection with pulmonary tuberculosis. Histoplasmosis is diagnosed by means of the identification or culture growth of the fungus in sputum or fiberoptic bronchoscopy specimens. Histopathological examination reveals the fungus itself within or surrounding macrophages, as well as granulomatous lesions with or without caseous necrosis. Double agar gel immunodiffusion is the most easily used and readily available serologic test for making the immunological diagnosis. Acute histoplasmosis with prolonged symptoms requires treatment, as do the disseminated or chronic pulmonary forms of the disease. The drug of choice is itraconazole.

Association between nutritional status measurements and pulmonary function in children and adolescents with cystic fibrosis.

Abstract: OBJETIVO: Avaliar a associacao de medidas do estado nutricional com a funcao pulmonar de criancas e adolescente com fibrose cistica. METODOS: Foi avaliado o estado nutricional pelo indice de massa corporea (IMC) e por medidas de composicao corporal-circunferencia muscular do braco (CMB) e medida da dobra cutânea triciptal (DCT)-de 48 criancas e adolescentes (6-18 anos) com fibrose cistica em um centro de referencia na cidade do Rio de Janeiro. A funcao pulmonar foi analisada por espirometria, e o parâmetro adotado para a classificacao da obstrucao das vias aereas foi VEF1. Utilizou-se o teste t de Student para a comparacao entre proporcoes e a regressao linear para associacao entre variaveis continuas. O nivel de significância adotado foi p < 0,05. RESULTADOS: A avaliacao do estado nutricional atraves do IMC encontrou menos pacientes desnutridos do que a realizada atraves da CMB (14 vs. 25, respectivamente) A maioria dos pacientes apresentou doenca pulmonar leve. A media do VEF1 foi de 82,5% do previsto. Houve associacao do IMC, da CMB e da DCT com a funcao pulmonar (p = 0,001, p = 0,001 e p = 0,03, respectivamente). Todos os pacientes com comprometimento moderado e grave pulmonar eram desnutridos pela composicao corporal (CMB). Entre os 25 pacientes considerados desnutridos atraves da composicao corporal (CMB), 19 apresentavam peso adequado quando avaliados pelo IMC. CONCLUSOES: Todas as medidas do estado nutricional apresentaram associacao direta com a funcao pulmonar das criancas e adolescentes com fibrose cistica no estudo. Entretanto, as medidas de composicao corporal revelaram, de forma mais precoce, possiveis deficiencias nutricionais.

Validation of a treadmill six-minute walk test protocol for the evaluation of patients with pulmonary arterial hypertension.

Abstract: OBJETIVO: Elaborar e validar um protocolo para teste de caminhada de seis minutos em esteira (TC6est) para a avaliacao de pacientes com hipertensao arterial pulmonar (HAP). METODOS: A populacao do estudo foi composta por 73 pacientes com HAP diagnosticados atraves de cateterismo cardiaco direito, com ou sem inalacao de NO. Todos os pacientes realizaram um TC6 em solo e tres TC6est baseados em um protocolo de incremento de velocidade pre-determinado e intercalados por um periodo de repouso. Os pacientes que haviam realizado o teste hemodinâmico com inalacao de NO realizaram o terceiro TC6est com a inalacao da mesma dose de NO utilizada durante o cateterismo. RESULTADOS: Os resultados mostraram uma correlacao da distância caminhada no TC6est com os dados hemodinâmicos, assim como com a classe funcional e com a distância caminhada no solo. Alem disso, a distância percorrida no TC6est apresentou uma correlacao significativa com a sobrevida, confirmando, portanto, sua correlacao com a gravidade da doenca. A inalacao de NO durante o TC6est levou a variacoes compativeis com as variacoes hemodinâmicas frente a mesma dose de NO, sugerindo que o protocolo em questao pode refletir o efeito de intervencoes terapeuticas. CONCLUSOES: Concluimos que a distância percorrida no TC6est e um marcador funcional e prognostico na avaliacao de rotina de pacientes com HAP.

Ventilator-associated pneumonia: epidemiology and impact on the clinical evolution of ICU patients

Abstract: OBJETIVO: Apesar de representar uma das principais causas de infeccao nosocomial, o papel da pneumonia associada a ventilacao mecânica (PAVM) no prognostico ainda permanece indefinido. O objetivo deste estudo foi avaliar o impacto dessa doenca na evolucao clinica dos pacientes. METODOS: Estabeleceu-se uma coorte prospectiva de 233 pacientes sob ventilacao mecânica (grupo PAV, n = 64; grupo controle, n = 169). Os desfechos primarios foram tempo de ventilacao mecânica (TVM), tempo de permanencia na UTI (TUTI), tempo de permanencia hospitalar (TH) e mortalidade na UTI. Os desfechos secundarios foram mortalidade hospitalar, perfil microbiologico, uso previo de antibioticos e fatores de risco para PAVM. RESULTADOS: Os desfechos dos grupos controle e PAVM foram, respectivamente, os seguintes: mediana do TVM (dias), 9 (intervalo interquartilico [II]: 5-15) e 23 (II: 15-37; p < 0,0001); mediana do TUTI (dias), 12 (II: 8-21) e 27 (II: 17-42; p < 0,0001); mediana do TH (dias), 33 (II: 18-64) e 46 (II: 25-90; p = 0,02); e mortalidade na UTI, 38% (IC95%: 31-45) e 55% (IC95%: 42-67; p = 0,02). A PAVM foi um preditor de mortalidade na UTI (OR = 3,40; IC95%: 1,54-1,78). O TVM (OR = 2,27; IC95%: 1,05-4,87) e o uso previo de antibioticos (OR = 1,07; IC95%: 1,04-1,10) foram fatores de risco para PAVM. A PAVM nao afetou a mortalidade hospitalar. Acinetobacter spp. foi o isolado mais frequente (28%). Antibioticoterapia empirica inadequada foi administrada em 48% dos casos. CONCLUSOES: No presente estudo, houve uma alta incidencia de bacterias resistentes e de antibioticoterapia inicial inadequada. TVM longo e o uso previo de antibioticos sao fatores de risco para PAVM.

Long-term repercussions of a pulmonary rehabilitation program on the indices of anxiety, depression, quality of life and physical performance in patients with COPD.

Abstract: OBJECTIVE: To assess the 24-month effects of a pulmonary rehabilitation program (PRP) on anxiety, depression, quality of life and physical performance of COPD patients. METHODS: Thirty patients with COPD (mean age, 60.8 ± 10 years; 70% males) participated in a 12-week PRP, which included 24 physical exercise sessions, 24 respiratory rehabilitation sessions, 12 psychotherapy sessions and 3 educational sessions. All patients were evaluated at baseline (pre-PRP), at the end of the treatment (post-PRP) and two years later (current) by means of four instruments: the Beck Anxiety Inventory; the Beck Depression Inventory; Saint George's Respiratory Questionnaire; and the six-minute walk test (6MWT). RESULTS: The comparison between the pre-PRP and post-PRP values revealed a significant decrease in the levels of anxiety (pre-PRP: 10.7 ± 6.3; post-PRP: 5.5 ± 4.4; p = 0.0005) and depression (pre-PRP: 11.7 ± 6.8; post-PRP: 6.0 ± 5.8; p = 0.001), as well as significant improvements in the distance covered on the 6MWT (pre-PRP: 428.6 ± 75.0 m; post-PRP: 474.9 ± 86.3 m; p = 0.03) and the quality of life index (pre-PRP: 51.0 ± 15.9; post-PRP: 34.7 ± 15.1; p = 0.0001). There were no statistically significant differences between the post-PRP and current evaluation values. CONCLUSIONS: The benefits provided by the PRP in terms of the indices of anxiety, depression and quality of life, as well as the improved 6MWT performance, persisted throughout the 24-month study period.

Influence of respiratory function parameters on the quality of life of COPD patients

Abstract: Objective: To determine the quality of life of COPD patients by using the Medical Outcomes 36-item Short-Form Survey (SF-36) and the Saint George’s Respiratory Questionnaire (SGRQ), correlating the scores with respiratory function parameters. Methods: This was a cross-sectional study involving 42 COPD patients. We used the SGRQ (a specific questionnaire) and the SF-36 (a general questionnaire), together with their component summaries, in order to determine the quality of life of these patients. The functional profile was assessed by means of spirometry, arterial blood gas analysis and the six-minute walk test. Results: Of the 42 patients, 30 (71.4%) were male and 12 (28.6%) were female. The mean age of the patients was 65.4 ± 8.0 years. The mean physical component summary and mean mental component summary scores were 37.05 ± 11.19 and 45.61 ± 15.65, respectively. The physical component summary correlated significantly with FEV 1 in L/s (r = 0.38; p = 0.012). There was a correlation between the SGRQ total score and FEV 1 (r = −0.50; p < 0.01). The SGRQ activity domain showed negative correlations with all respiratory function parameters. The multiple regression analysis showed that only FEV 1 correlated significantly with the SGRQ total score, as well as with the activity domain score (r= −0.32; p = 0.04 and r = −0.34; p = 0.03, respectively). Conclusions: In COPD patients, a decline in FEV 1 is associated with poorer quality of life, as evaluated using the SGRQ.

Methods for the assessment of peripheral muscle fatigue and its energy and metabolic determinants in COPD.

Abstract: It has been well established that, in addition to the pulmonary involvement, COPD has systemic consequences that can lead to peripheral muscle dysfunction, with greater muscle fatigue, lower exercise tolerance and lower survival in these patients. In view of the negative repercussions of early muscle fatigue in COPD, the objective of this review was to discuss the principal findings in the literature on the metabolic and bioenergy determinants of muscle fatigue, its functional repercussions, as well as the methods for its identification and quantification. The anatomical and functional substrate of higher muscle fatigue in COPD appears to include lower levels of high-energy phosphates, lower mitochondrial density, early lactacidemia, higher serum ammonia and reduced muscle perfusion. These alterations can be revealed by contraction failure, decreased firing rates of motor units and increased recruitment of motor units in a given activity, which can be functionally detected by a reduction in muscle strength, power and endurance. This review article also shows that various types of muscle contraction regimens and protocols have been used in order to detect muscle fatigue in this population. With this understanding, rehabilitation strategies can be developed in order to improve the resistance to muscle fatigue in this population.