Alexandra Catarino

Silicose – Breve revisão e experiência de um serviço de pneumologia

Resumo A silicose e uma doenca pulmonar, fibronodular intersticial difusa, causada pela inalacao de silica cristalina. A proposito desta patologia procedeu-se a uma breve revisao do tema, focando os aspectos mais importantes e, posteriormente, a analise retrospectiva dos processos de 84 doentes internados no Servico de Pneumologia dos Hospitais da Universidade de Coimbra (HUC), num periodo de 10 anos, cujo diagnostico principal ou secundario foi silicose. Apresentam-se os aspectos clinicos mais relevantes, bem como as conclusoes retiradas desta revisao. Os autores destacam a historia ocupacional dos doentes, as alteracoes do estudo funcional ventilatorio, os achados imagiologicos e as complicacoes associadas. Rev Port Pneumol 2010; XVI (1): 99-115

Pneumonia aguda fibrinosa e organizante

Resumo O padrão histológico de Pneumonia Aguda Fibrinosa e Organizante (AFOP – Acute Fibrinous And Organizing Pneumonia), descrito por Beasley em 2002, caracteriza-se pela existência de fibrina intra-alveolar sob a forma de bolas de fibrina e pneumonia organizativa difusa. A apresentação clínica desta doença intersticial pulmonar pode ser aguda ou subaguda, diferindo no entanto dos outros padrões histológicos habitualmente associados a lesão pulmonar aguda – Lesão Alveolar Difusa (DAD), Pneumonia Organizativa (OP) e Pneumonia Eosinofílica (EP). A propósito deste tema, os autores fazem uma revisão da literatura e descrevem o caso clínico de um doente de 44 anos, com aspectos imagiológicos e evolução pouco habituais. Abstract The histologic pattern of Acute Fibrinous and Organizing Pneumonia (AFOP), described by Beasley in 2002, is characterized by the existence of intra alveolar fibrin in the form of fibrin “balls” and diffuse organizing pneumonia. Presenting symptoms of this interstitial pulmonary disease can be acute or subacute. However, it differs from the well-recognized histologic patterns of acute pulmonary lesion – Diffuse Alveolar Damage (DAD), Organizing Pneumonia (OP) and Eosinophilic Pneumonia (EP). The authors carry out a review of the literature concerning this topic and describe the clinical case of a 44-year-old patient with unusual imaging features and outcome.

Pneumonia eosinofílica crónica idiopática: A propósito de um caso clínico

The eosinophilic pneumonias are a heterogeneous group of pulmonary disorders, which may compromise only the air ways, the pulmonary parenchyma, or both, characterised by alveolar eosinophils and infiltration of pulmonary tissue, with or without peripheral blood eosinophilia1. Idiopathic Chronic Eosinophilic Pneumonia (ICEP), detailed description was by Carrington5 in 1969, is a rare eosinophilic lung disease, of unknown aetiology, characterised by peripheral blood eosinophilia, chest radiograph infiltrates and prompt response to corticosteroid therapy. ICEP most commonly affects women of middle age and usual symptoms are cough, dyspnea, fever and weight loss2. The authors present a case of ICEP in a young woman, 21 years old, non-smoker and previously healthy. Rev Port Pneumol 2008; XIV (4): 551-559

Positional sleep apnea: An issue of therapeutic adherence

Cartwright in 1984 defined positional obstructive sleep apnea (OSA) patients as those in whom the apnea-hypopnea index (AHI) was at least twice as high while sleeping in the supine as in the non-supine position. Several authors intended, since then, to propose better classification systems, but the first (and simplest) is still used nowadays. In general, the prevalence of positional variant is higher in mild to moderate OSA, where it can reach 65--69%, but varies from 9 to 69%. It is inversely correlated to OSA severity, body mass index (BMI) and age. This classification intended to better identify whose patients did not require ventilatory support and could be treated with positional therapy (PT), a more economical and practical treatment. Traditionally, it has been used a tennis ball inside a pocket sewed in the back of a nightshirt as the positional ‘‘device’’. Nevertheless, ineffectiveness, backache, discomfort and no improvement in sleep quality or daytime alertness have been responsible for poor compliance and subsequent disappointing long-term results of positional therapy. With this in mind, we carried out a study to determine the effectiveness of usual conservative measures and PT with tennis ball technique (TBT) and to verify the compliance to this therapy in our population. A total of 93 positional OSA patients were retrospectively identified after a cardiorespiratory sleep study with 7 channels in our center, in which the supine AHI was at least twice as high as in a non-supine position. Booklets were provided to patients with information on hygiene, dietary and sleep rules, snoring and TBT. These patients were reassessed in a follow-up visit in average in 3--6 months, and a follow-up sleep study was then performed, under positional therapy with TBT. Sleep related parameters, subject’s characteristics and Epworth Sleepiness Scale (ESS) were evaluated. Forty six (49.5%) patients performed the follow-up night study with the TBT. There were 36 men (78.3%), with average age of 54,8 years and mean BMI of 29.3 kg/m. Of these 46 patients, only 26 (56.5%) said to correctly use the tennis ball every or almost every night, considered as high adherence patients group. We found differences between the two groups of patients (high and low adherence). They did not significantly differ in parameters such as age, gender, or BMI, however, the low adherence patients had more comorbidities: higher prevalence of diabetes mellitus and ischemic vascular disease (Table 1). Results of the followup study showed an improvement in all parameters, with mean total AHI decrease from 15.0/h to 9.3/h and mean supine AHI from 34.2/h to 24.3/h. Time spent in supine position fell from 40% to 17.1%, oxygen desaturation index (ODI) from 14.8/h to 8.8/h and minimum SpO2 increased from 82.2% to 85.6% (Table 2). More than half of the noncompliant patients (n = 11; 55%) needed other therapeutic options, mainly continuous positive airway pressure (CPAP) (n = 10). Only 2 compliant patients needed other therapies (1 CPAP and 1 mandibular advancement device). In our results, PT and other conservative measures were effective, with good clinical outcomes when enforced. There was a significant decrease in sleepiness accessed by ESS, and improvement in the overall sleep respiratory parameters. However, there is a high level of noncompliance with 20 patients (43.5%) reporting low adherence. Nevertheless, these results (56.5% of compliance) seem better than other studies. Oksenberg et al., reported only 38% of compliance with TBT at six months. The compliant patients in that study were older, and the main reason for stopping was discomfort. Our results showed no differences in age, but we found non-compliant patients to have more comorbidities and more severe illnesses, as oncologic and cardiovascular diseases. These patients may underestimate the burden of OSA, considering it as a minor health problem. Just half of the low adherent patients accepted CPAP therapy. Results in long-term tend to be even worse, as demonstrated by Bignold et al., with only 6% of patients still using the TBT after 2.5 years. As so, currently, several new devices to replace the TBT are becoming available on the international market. However the efficacy of these modalities has not been studied in clinical trials on long-term or been patented. Our study has some limitations. Data on TBT compliance and patients division in adherence groups was accessed only in a subjective way (interview in follow-up visit). Validated questionnaires on these topics could have been used in a prospective study. Unfortunately, we could not infer why 47 patients did not attend the follow-up study, however most of them attended to the follow-up visit reporting good results with the recommended measures. We can speculate they

Eficácia e tolerabilidade de próteses na via aérea

Resumo As proteses na via aerea tem a funcao de manter as estruturas tubulares abertas e estaveis. A sua colocacao esta indicada essencialmente na obstrucao intrinseca ou compressao extrinseca da via aerea, fistulas ou traqueobroncomalacia. Com este estudo pretendeu-se determinar a tolerabilidade a eficacia de proteses na via aerea nas situacoes em que a sua colocacao era imprescindivel. Procedeu-se ao estudo retrospectivo dos processos clinicos de 23 doentes em que se tinha procedido a colocacao de proteses traqueobronquicas atraves de broncoscopia rigida, durante dois anos consecutivos (2006–2007), na Unidade Funcional de Tecnicas de Diagnostico e Terapeutica, tendo sido avaliadas a indi- cacao, a eficacia, a tolerabilidade, as complicacoes e a localizacao exacta da sua insercao, tendo em conta a informacao imagiologica fornecida por TC do torax. Em todas as situacoes foram utilizadas proteses flexiveis de silicone tipo Dumon (Tracheobronxane®), sendo previamente avaliada, atraves de broncoscopia flexivel, a necessidade de tecnicas complementares, nomeadamente laserterapia e dilatacao mecânica. O estudo efectuado permitiu concluir que a insercao de proteses nao apresentou complicacoes, demonstrando boa tolerabilidade, tendo em conta a maioria das situacoes, de natureza neoplasica em estadio avancado, apenas com indicacao terapeutica paliativa.

Linfangioleiomiomatose – A propósito de três casos clínicos

Resumo A linfangioleiomiomatose (LAM) e uma doenca rara, de etiologia desconhecida, caracterizada pela proliferacao anormal de celulas musculares lisas nas regioes perilinfatica, perivascular e peribronquica. A LAM pode ocorrer esporadicamente ou associada ao complexo esclerose tuberosa (CET) e hamartose hereditaria multiorgânica 1 . Em ambas as situacoes a LAM afecta principalmente mulheres jovens em idade fertil, sendo que aproximadamente 1/3 das mulheres com CET tem LAM 2 . A proposito desta patologia, os autores elaboram uma revisao da literatura e descrevem os casos clinicos de tres doentes do sexo feminino com o diagnostico de LAM com base nos achados clinicos e imagiologicos. Rev Port Pneumol 2010; XVI (1): 187-196

Avaliação funcional respiratória pré-operatória

Preoperative pulmonary function has much progressed over the years. Many ventilatory parameters have been used and it was Markos in 1993 that decreed that surgical risk must be established based on the predictable postoperative pulmonary function and not the preoperative. In addition to classical parameters (FEV1 and DLCO), regional functional evaluation with radioisotopes and ergometry have an important role in predicting postoperative status and assessing surgical risk. In what concerns the surgical threshold there is no consensus as to the minimum rates required to perform surgery though various recommendations have been made. Some studies even suggest that absolute contraindication for surgery may be extremely relative. The concept of predictable postoperative status has been a source of growing interest, initially related to FEV1 and more recently DLCO; acceptable minimum FEV1 volumes of 700-1000 ml or 30% theoretical value and 40% of DLCO. Stress tests allowed a new outlook in preoperative evaluation and surgical risk assessment. Currently the most highly recommended protocol is the maximum incremental test limited by symptoms; it has a high degree of predictability for postoperative mortality and morbidity. Various algorithms have been suggested by different International Societies and renowned authors in this area but the one most used is Gilberth and Weisman (1994). Lung volume reduction surgery (LVRS) requires a careful selection of candidates with objective criteria recommended by the National Emphysema Therapy Trial (NETT).