José da Silva Moreira

Abscesso pulmonar de aspiração: análise de 252 casos consecutivos estudados de 1968 a 2004

OBJECTIVE: To relate the experience of the staff at a health care facility specializing in the management of patients with aspiration lung abscess. METHODS: Diagnostic aspects and therapeutic results of 252 consecutive cases of lung abscess seen in patients hospitalized between 1968 and 2004. RESULTS: Of the 252 patients, 209 were male, and 43 were female. The mean age was 41.4 years, and 70.2% were alcoholic. Cough, expectoration, fever and overall poor health were seen over 97% of patients. Chest pain was reported by 64%, 30.2% presented digital clubbing, 82.5% had dental disease, 78.6% reported having lost consciousness at least once, and 67.5% presented foul smelling sputum. In 85.3% of the patients, the lung lesions were located either in the posterior segments of the upper lobe or in the superior segments of the lower lobe, and 96.8% were unilateral. Concomitant pleural empyema was seen in 24 (9.5%) of the patients. Mixed flora was identified in the bronchopulmonary or pleural secretions of 182 patients (72.2%). All patients were initially treated with antibiotics (mainly penicillin or clindamycin), and postural drainage was performed in 98.4% of cases. Surgical procedures were performed in 52 (20.6%) of the patients (drainage of empyema in 24, pulmonary resection in 22 and drainage of the abscess in 6). Cure was obtained in 242 patients (96.0%), and 10 (4.0%) died. CONCLUSION: Lung abscess occurred predominantly in male adults presenting dental disease and having a history of loss of consciousness (especially as a result of alcohol abuse). Most of the patients were treated clinically with antibiotics and postural drainage, although some surgical procedure was required in one-fifth of the study sample.

CT Quantification of Emphysema in Young Subjects with No Recognizable Chest Disease

OBJECTIVE The purpose of this prospective study was to evaluate volumetric CT emphysema quantification (CT densitovolumetry) in a young population with no recognizable lung disease. SUBJECTS AND METHODS A cohort of 30 nonsmoking patients with no recognizable lung disease (16 men, 14 women; age range, 19-41 years) underwent inspiratory and expiratory CT, after which the data were postprocessed for volumetric quantification of emphysema (threshold, -950 HU). Correlation was tested for age, weight, height, sex, body surface area (BSA), and physical activity. Normal limits were established by mean +/- 1.96 SD. RESULTS No correlation was found between the measured volumes and age or physical activity. Correlation was found between BSA and normal lung volume in inspiration (r = 0.69, p = 0.000), shrink volume (i.e., difference in total lung volume in inspiration and in expiration) (r = 0.66, p = 0.000), and percentage of shrink volume (r = 0.35, p = 0.05). For an alpha error of 5%, the limits of normality based on this sample are percentage of emphysema in inspiration, 0.35%; percentage of emphysema in expiration, 0.12%; and maximum lung volume in expiration, 3.6 L. The maximum predicted percentage of shrink volume can be calculated as %SV = 29.43% + 16.97% x BSA (+/- 1.96 x 7.61%). CONCLUSION Young healthy nonsmokers with no recognizable lung disease can also show a small proportion of emphysematous-like changes on CT densitovolumetry when a threshold of -950 HU is used. Reference values should be considered when applying the technique for early detection or grading of emphysema and when studying aging lungs.

Surgical treatment of bronchial carcinoid tumors: a single-center experience.

BACKGROUND Bronchial carcinoid is an infrequent neoplasm with a neuroendocrine differentiation. Surgical treatment is the gold standard therapy, with procedures varying from sublobar resections to complex lung sparing broncoplastic procedures. This study evaluates the results of surgical treatment of bronchial carcinoids and its prognostic factors. PATIENTS AND METHODS Retrospective review of 126 consecutive patients who underwent surgical treatment for bronchial carcinoid tumors between December 1974 and July 2007. RESULTS There were 70 females (55%) and the mean age was 46 years, ranging from 17 to 81 years. Upon clinical presentation, 38 patients (30%) have had recurrent respiratory tract infection, 31 (24%) cough, 16 (12%) chest pain and 25 (20%) were asymptomatic. Preoperative bronchoscopic diagnosis was obtained in 74 cases (58.7%). The procedures performed were: 19 sublobar resections (14,9%), 58 lobectomies (46%), 8 bilobectomies (6.3%), 6 pneumonectomies (4.7%), 2 sleeve segmentectomies (1.5%), 26 sleeve lobectomies (20.6%) and 9 bronchoplastic procedures without lung resection (7.1%). Operative mortality was 1.5% (n = 2) and morbidity was 25.8% (n=32), including 12 respiratory tract infections and 4 reinterventions due to bleeding (3) and pleural empyema (1). Among the 112 patients available for follow-up, the overall survival at 3, 5 and 10 years was 89.2%, 85.5% and 79.8%, respectively. Five and 10-year survival for typical and atypical carcinoids were 91, 89% and 56, 47%, respectively. Overall disease-free survival at 5 years was 91.9% Statistical analysis showed that overall disease-free survival correlated with histology--typical vs. atypical--(p = 0.04) and stage (p = 0.02). CONCLUSION Surgery provides safe and adequate treatment to bronchial carcinoid tumors. Histology and stage were the main prognostic factors.

CYP1A1, CYP2E1, GSTM1, GSTT1, GSTP1, and TP53 polymorphisms : do they indicate susceptibility to chronic obstructive pulmonary disease and non-small-cell lung cancer?

Gene polymorphisms of phase I (CYP1A1 and CYP2E of cytochrome P,) and phase II (GSTM1, GSTT1 and GSTP1 of glutathione-S-transferase,) enzymes and the TP53 tumor suppressor gene were studied as markers in a sample of 262 Brazilians of European descent, the sample consisting of 97 patients with non-small-cell lung cancer (NSCLC), 75 patients with chronic obstructive pulmonary disease (COPD) and 90 control individuals. For NSCLC, we found no significant relationship between any of the markers studied and susceptibility to this disease. With respect to COPD, although the distribution of the CYP1A1, GSTM1, GSTP1, GSTT1 and TP53 genotypes was similar to that of the controls the frequency of the CYP2E1*1A/*5B heterozygote was about 6 times higher in COPD patients than in controls (OR= 6.3; CI = 1.1-35.5 for p = 0.04). Individuals who presented the GSTT1 null phenotype and GSTP1 Ile/Val genotype had a risk about four times higher (OR= 4.0; CI = 1.2–14.6 for p = 0.02) of having COPD than individuals without these genotypes, the same being true for individuals having the GSTT1 null phenotype and CYP1A1*1A/*2A genotype (OR= 3.7; 1.1–14.6 for p = 0.04).These results suggest that the CYP2E1 and GSTT1 + GSTP or GSTT1 + CYP1A1 polymorphisms may be predictive of susceptibility to COPD, at least in this population of European ancestry.

Prevalência da doença do refluxo gastroesofágico em pacientes com fibrose pulmonar idiopática

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.

Pneumonia associada à ventilação mecânica: impacto da multirresistência bacteriana na morbidade e mortalidade

INTRODUCAO: A pneumonia associada a ventilacao mecânica e a infeccao hospitalar mais comum nas unidades de terapia intensiva. OBJETIVO: Determinar o impacto da multirresistencia dos microorganismos na morbidade e mortalidade dos pacientes com pneumonia associada a ventilacao mecânica. METODO: Estudo de coorte retrospectivo. Em 40 meses consecutivos, 91 pacientes sob ventilacao mecânica tiveram o diagnostico de pneumonia. Os casos foram divididos entre causados por microorganismo multirresistente e causados por microorganismo sensivel a antibioticoterapia. RESULTADOS: Pneumonia foi causada por microorganismo multirresistente em 75 casos (82,4%) e por microorganismo sensivel 16 (17,6%) deles. As caracteristicas clinicas e epidemiologicas nao foram estatisticamente diferentes entre os grupos. O Staphylococcus aureus foi responsavel por 27,5% dos episodios de pneumonia associada a ventilacao mecânica e a Pseudomonas aeruginosa por 17,6%. A doenca foi de inicio recente em 33 pacientes (36,3%) e de inicio tardio em 58 deles (63,7%). Os tempos de ventilacao mecânica, de internacao em unidade de terapia intensiva e de internacao hospitalar total nao diferiram. O tratamento empirico foi considerado inadequado em 42 pacientes com pneumonia por microorganismo multirresistente (56%) e em 4 com pneumonia por microorganismo sensivel (25%) (p = 0,02). Obito ocorreu em 46 pacientes com a pneumonia por microorganismo multirresistente (61,3%), e em 4 daqueles com pneumonia por microorganismo sensivel (25%) (p = 0,008). CONCLUSAO: A multirresistencia bacteriana nao determinou nenhum impacto na morbidade, mas esteve associada a maior mortalidade.

Evolução da pneumonia lipoide exógena em crianças: aspectos clínicos e radiológicos e o papel da lavagem broncoalveolar

OBJECTIVE To present aspects of the evolution of lipoid pneumonia in children, based on clinical, radiological and bronchoalveolar lavage fluid findings, emphasizing the importance of bronchoalveolar lavage for the diagnosis and treatment. METHODS We included 28 children, with a mean age of 20 months (range, 1-108 months), diagnosed with chronic pneumonia refractory to antimicrobial therapy, with TB or with a combination of the two. Most of the children had at least one risk factor for aspiration, and all of them had a history of mineral oil ingestion for intestinal constipation (23/28) or complicated ascaridiasis (5/28). Clinical evaluations, tomographic evaluations and analyses of bronchoalveolar lavage fluid were carried out at the beginning of treatment and throughout a follow-up period of 24 months. RESULTS Tachypnea and cough were the most common symptoms. The most common radiological alterations were areas of consolidation (23/28), perihilar infiltrates (13/28) and hyperinflation (11/28). Chest CT scans showed areas of consolidation with air bronchogram (24/28), decreased attenuation in the areas of consolidation (16/28), ground-glass opacities (3/28) and crazy-paving pattern (1/28). In the analysis of the bronchoalveolar lavage fluid, Sudan staining revealed foamy macrophages, confirming the diagnosis of lipoid pneumonia. After treatment with multiple bronchoalveolar lavages (mean = 9.6), 20 children became asymptomatic, 18 of those presenting normal tomographic images. CONCLUSIONS A diagnosis of lipoid pneumonia should be considered in patients with chronic refractory pneumonia or TB, especially if there is a history of mineral oil ingestion. Bronchoscopy with multiple bronchoalveolar lavages was an efficient treatment for the clearance of mineral oil from the lung parenchyma and the prevention of fibrosis. This strategy contributed to reducing the morbidity of lipoid pneumonia, which remains a rare diagnosis.

A Comparison Between Ventilation Modes: How Does Activity Level Affect Energy Expenditure Estimates?

BACKGROUND An appropriate diet is essential to avoid complications of overfeeding or underfeeding in mechanically ventilated intensive care unit (ICU) patients. The paucity of consistent comparative data on energy expenditure for each ventilation mode complicates diet prescription. This study evaluates caloric requirements by comparing estimated and measured energy expenditure values for 2 ventilation modes. METHODS The energy expenditure of 100 ICU patients on assisted or controlled mechanical ventilation was measured by indirect calorimetry for 20 minutes. Values were calculated for a 24-hour period and compared with Harris-Benedict estimates multiplied by an injury factor and either multiplied or not by a 10% activity factor. RESULTS The mean Harris-Benedict estimate was 1858.87 +/- 488.67 kcal/24 h when multiplied by an injury factor and a 10% activity factor. The mean energy expenditure values measured by indirect calorimetry were 1712.76 +/- 491.95 kcal/24 h for controlled and 1867.33 +/- 542.67 kcal/24 h for assisted ventilation. The mean total energy expenditure for assisted ventilation was 10.71% greater than the mean for controlled ventilation (P < .001). For controlled ventilation, Harris-Benedict results overestimated indirect calorimetry values by 141.10 +/- 10 kcal/24 h (8.2%, P = .012) when multiplied by injury and activity factors, and underestimated values by 44.28 +/- 28 kcal/24 h (2.6%, P = .399) when the equation was calculated without the activity factor. For assisted ventilation, Harris-Benedict results underestimated indirect calorimetry values by 198.84 +/- 84 kcal/24 h (10.7%, P = .001) when not multiplied by the activity factor and by 13.46 kcal/24 h (0.75%) when the activity factor was used, but differences were not statistically significant (P = .829). CONCLUSIONS Results suggest that a 10% activity factor should be adopted only for assisted ventilation because multiplication by an activity factor may lead to overfeeding of patients on controlled ventilation.

Magnetic resonance imaging findings in acute pulmonary embolism

Pulmonary embolism (PE) is the third most common acute cardiovascular disease after myocardial infarction and stroke, and results in thousands of deaths each year. Improvements in MRI accuracy are ongoing with the use of parallel imaging for angiography techniques and pulmonary perfusion. This, associated with other potential advantages of MRI (e.g. a radiation free method and better safety profile of MR contrast media), reinforces its use. The aim of this paper is to perform a pictorial review of the principal findings of MRI in acute PE. Acute PE can manifest itself as complete arterial occlusion and the affected artery may be enlarged. We report the main vascular and parenchymal signs, and an overview of current literature regarding accuracy, limitations and technical aspects is provided.

Complicações relacionadas à lobectomia em doadores de transplante pulmonar intervivos

OBJECTIVE To evaluate post-operative complications in living lobar lung transplant donors. METHODS Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of postoperative complications and alterations in pulmonary function after lobectomy. RESULTS Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values. CONCLUSIONS Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.