Eanes Delgado Barros Pereira

Prospective assessment of the risk of postoperative pulmonary complications in patients submitted to upper abdominal surgery.

OBJECTIVE To investigate associations between preoperative variables and postoperative pulmonary complications (PPC) in elective upper abdominal surgery. DESIGN Prospective clinical trial. SETTING A tertiary university hospital. PATIENTS 408 patients were prospectively analyzed during the preoperative period and followed up postoperatively for pulmonary complications. MEASUREMENTS Patient characteristics, with clinical and physical evaluation, related diseases, smoking habits, and duration of surgery. Preoperative pulmonary function tests (PFT) were performed on 247 patients. RESULTS The postoperative pulmonary complication rate was 14 percent. The significant predictors in univariate analyses of postoperative pulmonary complications were: age >50, smoking habits, presence of chronic pulmonary disease or respiratory symptoms at the time of evaluation, duration of surgery >210 minutes and comorbidity (p <0.04). In a logistic regression analysis, the statistically significant predictors were: presence of chronic pulmonary disease, surgery lasting >210 and comorbidity (p <0.009). CONCLUSIONS There were three major clinical risk factors for pulmonary complications following upper abdominal surgery: chronic pulmonary disease, comorbidity, and surgery lasting more than 210 minutes. Those patients with three risk factors were three times more likely to develop a PPC compared to patients without any of these risk factors (p <0.001). PFT is indicated when there are uncertainties regarding the patients pulmonary status.

Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial

OBJECTIVE To evaluate the effect of 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection. DESIGN Randomized single-blinded study. SETTING A teaching hospital. PARTICIPANTS Patients undergoing lung cancer resection (N=24). INTERVENTIONS Patients were randomly assigned to receive PR (strength and endurance training) versus CPT (breathing exercises for lung expansion). Both groups received educational classes. MAIN OUTCOME MEASURES Functional parameters assessed before and after 4 weeks of PR or CPT (phase 1), and pulmonary complications assessed after lung cancer resection (phase 2). RESULTS Twelve patients were randomly assigned to the PR arm and 12 to the CPT arm. Three patients in the CPT arm were not submitted to lung resection because of inoperable cancer. During phase 1 evaluation, most functional parameters in the PR group improved from baseline to 1 month: forced vital capacity (FVC) (1.47L [1.27-2.33L] vs 1.71L [1.65-2.80L], respectively; P=.02); percentage of predicted FVC (FVC%; 62.5% [49%-71%] vs 76% [65%-79.7%], respectively; P<.05); 6-minute walk test (425.5±85.3m vs 475±86.5m, respectively; P<.05); maximal inspiratory pressure (90±45.9cmH(2)O vs 117.5±36.5cmH(2)O, respectively; P<.05); and maximal expiratory pressure (79.7±17.1cmH(2)O vs 92.9±21.4cmH(2)O, respectively; P<.05). During phase 2 evaluation, the PR group had a lower incidence of postoperative respiratory morbidity (P=.01), a shorter length of postoperative stay (12.2±3.6d vs 7.8±4.8d, respectively; P=.04), and required a chest tube for fewer days (7.4±2.6d vs 4.5±2.9d, respectively; P=.03) compared with the CPT arm. CONCLUSIONS These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity.

Influência das máscaras facial total, facial e nasal nos efeitos adversos agudos durante ventilação não-invasiva

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.

Effect of melatonin administration on subjective sleep quality in chronic obstructive pulmonary disease

Disturbed sleep is common in chronic obstructive pulmonary disease (COPD). Conventional hypnotics worsen nocturnal hypoxemia and, in severe cases, can lead to respiratory failure. Exogenous melatonin has somnogenic properties in normal subjects and can improve sleep in several clinical conditions. This randomized, double-blind, placebo-controlled study was carried out to determine the effects of melatonin on sleep in COPD. Thirty consecutive patients with moderate to very severe COPD were initially recruited for the study. None of the participants had a history of disease exacerbation 4 weeks prior to the study, obstructive sleep apnea, mental disorders, current use of oral steroids, methylxanthines or hypnotic-sedative medication, nocturnal oxygen therapy, and shift work. Patients received 3 mg melatonin (N = 12) or placebo (N = 13), orally in a single dose, 1 h before bedtime for 21 consecutive days. Sleep quality was assessed by the Pittsburgh Sleep Quality Index (PSQI) and daytime sleepiness was measured by the Epworth Sleepiness Scale. Pulmonary function and functional exercise level were assessed by spirometry and the 6-min walk test, respectively. Twenty-five patients completed the study protocol and were included in the final analysis. Melatonin treatment significantly improved global PSQI scores (P = 0.012), particularly sleep latency (P = 0.008) and sleep duration (P = 0.046). No differences in daytime sleepiness, lung function and functional exercise level were observed. We conclude that melatonin can improve sleep in COPD. Further long-term studies involving larger number of patients are needed before melatonin can be safely recommended for the management of sleep disturbances in these patients.

Controle da asma e qualidade de vida em pacientes com asma moderada ou grave

OBJECTIVE To evaluate the association between degree of asthma control and health-related quality of life in patients with moderate or severe asthma. METHODS This was a descriptive observational study involving 59 outpatients with moderate or severe asthma under treatment at the Asthma Outpatient Clinic of the Federal University of Ceará Walter Cantídio University Hospital, in the city of Fortaleza, Brazil. The patients were evaluated regarding sociodemographic and clinical characteristics, as well as spirometric parameters. The asthma control status was assessed using the asthma control test (ACT), and quality of life was assessed using the Saint Georges Respiratory Questionnaire (SGRQ). RESULTS The mean age of the patients was 55.0 ± 12.4 years, and 76.3% were female. The ACT score showed statistically significant negative correlations with all SGRQ scores: total (r = -0.72); symptoms (r = -0.78); activity (r = -0.67); and impact (r = -0.68). Multiple regression analysis showed that the most robust predictive variables for SGRQ total score were ACT score (coefficient = -3.18; 95% CI: -4.14 to -2.23) and duration of disease (coefficient = -0.29; 95% CI: -0.54 to -0.03). The ACT score also explained the linear variation of the SGRQ domains: symptoms (coefficient = -3.41; 95% CI: -4.45 to -2.37); activity (coefficient = -3.07; 95% CI: -4.57 to -1.57); and impact (coefficient = -2.68; 95% CI: -3.71 to -1.65). CONCLUSIONS The degree of asthma control appears to have a significant impact on health-related quality of life.

Melatonin reduces lung oxidative stress in patients with chronic obstructive pulmonary disease: a randomized, double-blind, placebo-controlled study.

Abstract:  Chronic obstructive pulmonary disease (COPD), a major cause of death and disability, is attributed to an abnormal inflammatory response by the lungs to noxious substances, primarily from cigarette smoke. Although oxidative stress is regarded as central to the pathogenesis of COPD, very few studies have examined the effects of antioxidants in this condition. This was a randomized, double‐blind, placebo‐controlled study on the effects of melatonin in COPD. Thirty‐six consecutive patients with clinically stable moderate to very severe COPD (30 men; mean ± S.D. = 66.6 ± 7.8 yr) were randomized to receive 3 mg melatonin (N = 18) or placebo for 3 months. Oxidative stress was evaluated by 8‐isoprostane levels in exhaled breath condensate at baseline (T0) and after one (T1), two (T2), and three months (T3) of treatment. Additionally, exhaled breath condensate levels of IL‐8, dyspnea severity (Medical Research Council scale), lung function (spirometry), and functional exercise capacity (six min walk test) were compared at baseline and after treatment. Patients receiving melatonin showed a decrease in 8‐isoprostane (T0: mean ± S.E.M. = 20.41 ± 2.92 pg/mL; T1: 18.56 ± 2.68 pg/mL; T2: 12.68 ± 2.04 pg/mL; T3: 12.70 ± 2.18 pg/mL; P = 0.04; repeated measures ANOVA) with significant differences from baseline after 2 (P = 0.03) and 3 months (P = 0.01). Dyspnea was improved by melatonin (P = 0.01), despite no significant changes in lung function or exercise capacity. Placebo‐treated patients, but not those who were given melatonin, showed an increase in IL‐8 (P = 0.03). In summary, melatonin administration reduced oxidative stress and improved dyspnea in COPD. Further studies are necessary to determine the potential role for melatonin in the long‐term management of these patients.

Influência dos parâmetros funcionais respiratórios na qualidade de vida de pacientes com DPOC Influence of respiratory function parameters on the quality of life of COPD patients

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 Georges 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.

The impact of smoking cessation on patient quality of life

OBJECTIVE To evaluate changes in health-related quality of life (HRQoL) after twelve months of smoking cessation. METHODS This was a prospective study to evaluate the effectiveness of a smoking cessation program on the quality of life of 60 self-referred subjects, at a public hospital, during the period of August 2006 to December 2007. The program consisted of 2-h group sessions once a week during the first month and then every 15 days over six months, followed by monthly phone contacts for another six months. The treatment was based on behavior modification and the use of bupropion in combination with nicotinic replacement therapy. Abstinence was verified by exhaled CO measurements. Patient HRQoL was quantified using the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) questionnaire. Differences in quality of life scores between quitters and non-quitters at twelve months after the initial intervention were evaluated using analysis of covariance with baseline characteristics as covariates. RESULTS Self-reported quality of life scores were significantly higher among the 40 quitters than among the 20 non-quitters. The following SF-36 domains were most affected: role-emotional (p = 0.008); general health (p = 0.006); vitality (p < 0.001); and mental health (p = 0.002). At twelve months after the smoking cessation intervention, the SF-36 mental component and physical component summary scores were higher among quitters than among non-quitters (p = 0.004 and p = 0.001, respectively). CONCLUSIONS Our findings illustrate that smoking abstinence is related to better HRQoL, especially in aspects of mental health.

Portuguese-language version of the COPD Assessment Test: validation for use in Brazil.

OBJECTIVE: To validate a Portuguese-language version of the COPD assessment test (CAT) for use in Brazil and to assess the reproducibility of this version. METHODS: This was multicenter study involving patients with stable COPD at two teaching hospitals in the city of Fortaleza, Brazil. Two independent observers (twice in one day) administered the Portuguese-language version of the CAT to 50 patients with COPD. One of those observers again administered the scale to the same patients one week later. At baseline, the patients were submitted to pulmonary function testing and the six-minute walk test (6MWT), as well as completing the previously validated Portuguese-language versions of the Saint Georges Respiratory Questionnaire (SGRQ), modified Medical Research Council (MMRC) dyspnea scale, and hospital anxiety and depression scale (HADS). RESULTS: Inter-rater and intra-rater reliability was excellent (intraclass correlation coefficient [ICC] = 0.96; 95% CI: 0.93-0.97; p < 0.001; and ICC = 0.98; 95% CI: 0.96-0.98; p < 0.001, respectively). Bland Altman plots showed good test-retest reliability. The CAT total score correlated significantly with spirometry results, 6MWT distance, SGRQ scores, MMRC dyspnea scale scores, and HADS-depression scores. CONCLUSIONS: The Portuguese-language version of the CAT is a valid, reproducible, and reliable instrument for evaluating patients with COPD in Brazil.

Restless legs syndrome, sleep impairment, and fatigue in chronic obstructive pulmonary disease

OBJECTIVE To investigate the frequency of factors associated with restless legs syndrome (RLS) in patients with chronic obstructive pulmonary disease (COPD). METHODS RLS diagnosis was investigated (International RLS Study Group, IRLSSG) and severity was assessed (IRLS rating scale) in 104 consecutive COPD patients (age 69.1±8). Other measures were dyspnea severity (Modified Medical Research Council, MMRC), sleep quality (Pittsburgh Sleep Quality Index, PSQI), daytime somnolence (Epworth Sleepiness Scale, ESS), depressive symptoms (Beck Depression Inventory, BDI-II), and fatigue (Fatigue Severity Scale, FSS). Laboratory values included hemoglobin, ferritin, creatinine, and fibrinogen. RESULTS Thirty-two patients (30.8%) were diagnosed with RLS (65.6% women), which was moderate/severe (IRLS >11) in 26 (81.3%). RLS symptoms started after age 40 in most patients (93.3%). RLS patients had poorer sleep quality (PSQI >5=59.6%; p=0.002), worse fatigue (FSS >27=51%; p=0.005), and more depressive symptoms (BDI-II >10=14.4%; p=0.005). Patients with RLS also presented more severe dyspnea (p=0.009) and lower creatinine levels (p=0.005). Overall, fatigue severity was correlated with older age (p=0.001); level of dyspnea was positively correlated with PSQI and FSS (p<0.005) and negatively correlated with ferritin (p=0.03) and creatinine (p=0.005), and PSQI scores correlated positively with FSS (p<0.005) and negatively with ferritin (p=0.005) and creatinine (p=0.02). Quality of sleep was independently predicted by dyspnea severity and creatinine and fatigue by age and depression. CONCLUSION RLS is common in COPD. Patients with RLS have low creatinine, poorer quality of sleep, and more fatigue and depressive symptoms. RLS symptom severity is correlated to lower ferritin and severity of dyspnea.