Telma Antunes

Interaction between intra-abdominal pressure and positive-end expiratory pressure

OBJECTIVE: The aim of this study was to quantify the interaction between increased intra-abdominal pressure and Positive-End Expiratory Pressure. METHODS: In 30 mechanically ventilated ICU patients with a fixed tidal volume, respiratory system plateau and abdominal pressure were measured at a Positive-End Expiratory Pressure level of zero and 10 cm H2O. The measurements were repeated after placing a 5 kg weight on the patients’ belly. RESULTS: After the addition of 5 kg to the patients’ belly at zero Positive-End Expiratory Pressure, both intra-abdominal pressure (p<0.001) and plateau pressures (p=0.005) increased significantly. Increasing the Positive-End Expiratory Pressure levels from zero to 10 cm H2O without weight on the belly did not result in any increase in intrazxabdominal pressure (p=0.165). However, plateau pressures increased significantly (p< 0.001). Increasing Positive-End Expiratory Pressure from zero to 10 cm H2O and adding 5 kg to the belly increased intra-abdominal pressure from 8.7 to 16.8 (p<0.001) and plateau pressure from 18.26 to 27.2 (p<0.001). Maintaining Positive-End Expiratory Pressure at 10 cmH2O and placing 5 kg on the belly increased intra-abdominal pressure from 12.3 +/− 1.7 to 16.8 +/− 1.7 (p<0.001) but did not increase plateau pressure (26.6+/−1.2 to 27.2 +/−1.1 −p=0.83). CONCLUSIONS: The addition of a 5kg weight onto the abdomen significantly increased both IAP and the airway plateau pressure, confirming that intra-abdominal hypertension elevates the plateau pressure. However, plateau pressure alone cannot be considered a good indicator for the detection of elevated intra-abdominal pressure in patients under mechanical ventilation using PEEP. In these patients, the intra-abdominal pressure must also be measured.

Granulomatose de Wegener

Wegeners granulomatosis is characterized by granulomatous necrotizing vasculitis that primarily affects the airways (upper and lower) and the kidneys. The diagnosis is made by analyzing the clinical and radiological manifestations (multiple pulmonary cavitations), together with the pathological findings and results of the test for cytoplasmic-pattern antineutrophil cytoplasmic antibodies. Treatment consists of corticosteroids and cyclophosphamide and leads to remission of the disease within one year in 90% of cases.

Acometimento pulmonar na doença de Behçet: uma boa experiência com o uso de imunossupressores

OBJECTIVE Behcets syndrome, or Behcets disease (BD), is a multisystem pathology, and survival is related to pulmonary involvement. However, it appears that different treatments correlate with different prognoses. The aim of this study was to evaluate clinical and tomographic evolution, as well as the survival, of patients with BD-related pulmonary involvement. METHODS A retrospective review of our experience with pulmonary manifestations in patients with BD treated at our institution between January 1, 1988 and April 30, 2006. The clinical, radiological, treatment and survival data were obtained from medical charts. RESULTS We identified 9 patients with BD-related pulmonary involvement. The mean age was 34 +/- 11.5 years, and 7 of the patients were male. The radiological findings were as follows: pulmonary artery aneurysm (PAA) in 8 patients; pulmonary embolism in 3 (translating to an incidence of 5.11 cases/100 patient-years); alveolar hemorrhage in one; and pulmonary hypertension in one. The treatment consisted of immunosuppression with prednisone plus chlorambucil (or cyclophosphamide or mycophenolate mofetil) in all patients, with partial or complete resolution of the PAAs. One patient with a PAA and pulmonary hypertension also received sildenafil and warfarin, with good clinical and tomographic response (the first report in the English literature). In our sample, the mean duration of the follow-up period was 6.52 years. The three-year survival rate was 88.8%, as was the five-year survival rate. CONCLUSIONS Patients with BD-related pulmonary involvement can present good survival with immunosuppressive therapy, and BD should be borne in mind as a possible cause of pulmonary hypertension and alveolar hemorrhage.

Frequência de sintomas de asma e de redução da função pulmonar entre crianças e adolescentes nadadores amadores

OBJECTIVE To investigate the incidence of asthma symptoms in young amateur swimmers, and to describe the clinical treatment of the children with asthma in a private sports club in the city of São Paulo, Brazil. METHODS The study included 171 amateur swimmers, ranging from 6 to14 years of age. All of the participants or their legal guardians were asked to complete the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire, and 119 were submitted to pulmonary function testing at rest. RESULTS The overall incidence of asthma symptoms (ISAAC score > 6) among the swimmers was 16.8%. Of the 119 swimmers submitted to spirometry, 39 (32.7%) presented spirometric alterations (FEV1/FVC < 0.75). Among those with an ISAAC score > 6, there were 10 (31.2%) who stated that they were receiving no asthma treatment. Of those who reported receiving pharmacological treatment, 24% made use of bronchodilators but not of corticosteroids. CONCLUSIONS The incidence of asthma symptoms and pulmonary function alterations among amateur swimmers within the 6-14 age bracket was high. In addition, a relevant proportion of these athletes were receiving no treatment.

Treatment of ANCA-Associated Vasculitis

To the Editor: Dr Bosch and colleagues conducted a systematic review of treatment of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis, including Wegener granulomatosis. However, their article did not discuss the increased incidence of thromboembolic events in patients with Wegener granulomatosis and the possible role of anticoagulation in these patients. The incidence of thromboembolic events in Wegener granulomatosis is as high as in patients with previous idiopathic venous thromboembolism (7.0 cases/ 100 patient-years vs 7.2 cases/100 patient-years, respectively). Considering that prophylactic use of warfarin is an effective method of preventing thromboembolic events in patients with previous idiopathic venous thromboembolism, it is possible that prophylactic anticoagulation may also have a role in patients with Wegener granulomatosis who have no contraindications to warfarin. This may be especially important during disease activity because 81% of thromboembolic events in persons with active Wegener granulomatosis occur during this phase. However, this would need to be addressed by a randomized clinical trial.

Síndrome de Churg-Strauss

A sindrome de Churg Strauss e uma doenca auto-imune e de etiologia indeterminada. Seu diagnostico e dificil, nao somente pela raridade, mas tambem pela sobreposicao clinica e anatomopatologica que pode haver entre diferentes vasculites, podendo, por este motivo, ter sua prevalencia subestimada. Descrita primeiramente em 1951 por Churg e Strauss, foi definida como angeite granulomatosa, determinada por tres criterios maiores: presenca de vasculite necrotizante, infiltracao tecidual eosinofilica e de granulomas extravasculares.(1) Em 1990, o American College of Rheumatology revisou tais criterios, sendo que pelo menos quatro dos seis criterios diagnosticos seguintes devem estar presentes para o diagnostico da sindrome de ChurgStrauss: asma grave a moderada, eosinofilia periferica (>10% ou 1,5 x 109/L), mono ou polineuropatia, infiltrados pulmonares transitorios, comprometimento dos seios paranasais e exame anatomopatologico obtido de biopsia demonstrando vasos sanguineos com eosinofilos extravasculares.(2-3) A etiologia da doenca ainda nao esta totalmente esclarecida, mas parece haver um importante componente alergico e imune-mediado, ja que ha forte relacao de pacientes com eosinofilia persistente (> 6 meses) e asma, alem de titulos elevados de IgE serica em alguns casos. O papel dos eosinofilos pode ser tanto protetor, por sua capacidade de fagocitose, como tambem lesivo ao epitelio, por acao direta.(1-3) A historia natural da sindrome divide-se em tres fases: a primeira, mais longa, prodromica, cursa com asma e sinais e sintomas previos de rinite e sinusite; a fase eosinofilica, que se pode manifestar em anos, sendo marcada por eosinofilia periferica e infiltrados eosinofilicos teciduais semelhantes a sindrome de Loffler ou pneumonia eosinofilica cronica; e a fase vasculitica, que pode ser grave, e aumentar muito a morbi-mortalidade dos pacientes.(2-3) Embora seja reconhecida como doenca sistemica, ha preferencia pelos sistemas nervoso e respiratorio, e pele. As manifestacoes extrapulmo-nares incluem perda de peso, mialgia e artralgia (37,5%). Apos os pulmoes, o coracao e o local mais acometido, contribuindo com 48% dos obitos, principalmente por infarto agudo do miocardio, pericardite aguda ou constritiva. O tratamento deve ser Resumo A sindrome de Churg-Strauss caracteriza-se por asma, eosinofilia e graus variados de vasculite sistemica. As formas mais graves com acometimento cardiaco, gastrintestinal, sistema nervoso central e renal requerem ciclofosfamida para seu tratamento. Abstract Churg-Strauss syndrome is characterized by asthma, eosinophilia and various degrees of systemic vasculitis. The most severe forms of the disease, presenting cardiac, gastrointestinal, central nervous system and renal involvement, require cyclophosphamide therapy.Churg-Strauss syndrome is characterized by asthma, eosinophilia and various degrees of systemic vasculitis. The most severe forms of the disease, presenting cardiac, gastrointestinal, central nervous system and renal involvement, require cyclophosphamide therapy.

Vasculites pulmonares: quando suspeitar e como fazer o diagnóstico

As vasculites pulmonares primarias sao caracterizadas por processo inflamatorio na parede dos vasos pulmonares que leva a isquemia e hemorragia pulmonar com as consequentes expressoes clinicas e radiologicas. As vasculites pulmonares primarias sao acompanhadas de expressao sistemicas cutâneas, em nervos perifericos, rins, seios da face, olhos e ouvidos, alem do trato gastrintestinal, e sistemas cardiaco e nervoso central. O diagnostico e feito atraves da associacao das informacoes clinicas, radiologicas e anatomopatologicas. O tratamento com corticosteroides e imunossupressores deve ser instituido precocemente e apresenta altas taxas de remissao.