Vicente Forte

Tratamento operatório de 60 pacientes com malformações pulmonares: o que aprendemos?

OBJECTIVE To retrospectively analyze the medical charts of patients with pulmonary malformations submitted to surgical treatment and to investigate the clinical evolution prior to the definitive diagnosis. METHODS We analyzed the medical charts of patients with pulmonary malformations operated on at the São Paulo Hospital-Federal University of São Paulo/Paulista School of Medicine-from 1969 to 2004. Each medical chart was analyzed as to the following aspects: clinical profile; diagnosis; previous treatment; surgical treatment; and nosocomial complications. The inclusion criteria were having received a diagnosis of pulmonary malformation, having undergone pulmonary resection, and chart data being complete. RESULTS The analysis of the medical charts revealed that 60 patients diagnosed with pulmonary malformations-27 cases of bronchogenic cyst, 14 cases of congenital lobar emphysema, 10 cases of pulmonary sequestration, and 9 cases of cystic adenomatoid malformation-underwent surgery. Ages ranged from 4 days to 62 years (mean, 17.9 years). There was a predominance of males (55%). Ninety-two percent of the patients presented symptoms (mean duration: 15.37 months). Of the 60 patients undergoing surgery, 27 (45%) received preoperative home or hospital treatment with antibiotics. Regarding complications, we observed that morbidity was 23%, and mortality was 3.3%. Surgical times ranged from 1 to 8 h (mean, 3.2 h). CONCLUSIONS Misdiagnosis or delayed diagnosis of pulmonary malformations resulted in unnecessary treatments and hospitalizations, as well as in frequent, recurrent infectious complications. We believe that the definitive treatment is surgery, which is curative and has low morbidity and mortality rates.

Traqueostomia na UTI: vale a pena realizá-la?

OBJETIVO: Analisar a viabilidade, as complicacoes e a mortalidade da traqueostomia realizada em ambiente de unidade de terapia intensiva (UTI). METODOS: Analise retrospectiva dos prontuarios medicos dos 73 pacientes que foram submetidos a traqueostomia nos leitos das UTIs do Hospital Sao Paulo da Universidade Federal de Sao Paulo no periodo de janeiro a novembro de 2003. Os procedimentos foram realizados sempre por um residente de cirurgia, sob a orientacao de um cirurgiao toracico, utilizando a tecnica aberta sistematizada no servico. RESULTADOS: A idade media dos pacientes foi de 55,2 anos, sendo que 47 eram do sexo masculino (64,4%) e 26 eram do sexo feminino (35,6%). A indicacao mais frequente foi a intubacao orotraqueal prolongada (76,7%). Nao houve mortalidade relacionada ao procedimento, e em todos os pacientes o procedimento pode ser realizado na UTI. As complicacoes imediatas ocorreram em 2 pacientes (2,7%), nos quais houve sangramento local aumentado que cessou com compressao local. A complicacao tardia foi a infeccao ao redor da ferida operatoria, a qual ocorreu em 2 pacientes (2,7%) e foi tratada com curativos locais, sem maiores repercussoes clinicas. CONCLUSOES: Com base nos resultados de nossa analise, os quais sao comparaveis aos resultados sobre traqueostomias realizadas no centro cirurgico encontrados na literatura, concluimos que a traqueostomia na UTI e viavel e apresenta baixo indice de complicacoes, mesmo quando realizada em pacientes graves por cirurgioes em treinamento. Portanto, a nosso ver, e possivel afirmar que vale a pena realizar a traqueostomia na UTI.

Desenvolvimento e avaliação de um programa multimídia de computador para ensino de drenagem pleural

OBJECTIVE: To develop a multimedia educational computer program designed to teach pleural drainage techniques to health professionals, as well as to evaluate its efficacy. METHODS: We planned and developed a program, which was evaluated by 35 medical students, randomized into two groups. Group 1 comprised 18 students who studied using the program, and group 2 comprised 17 students who attended a traditional theoretical class given by an experienced teacher. Group 1 students were submitted to two subjective evaluations using questionnaires, and both groups took an objective theoretical test with multiple choice questions and descriptive questions. The results of the theoretical test were compared using the Mann-Whitney test. RESULTS: The subjective evaluation of the technological aspects and content of the program ranged from excellent to very good and good. The software was considered highly instructive by 16 students (88.9%), and 17 students (94.4%) thought it might partially substitute for traditional classes. Between the two groups, there was no significant difference in the multiple choice test results, although there was such a difference in the descriptive question results (p < 0.001), group 1 students scoring higher than did those in group 2. CONCLUSIONS: The computer program developed at the Federal University of Sao Paulo Paulista School of Medicine proved to be a feasible means of teaching pleural drainage techniques. The subjective evaluation of this new teaching method revealed a high level of student satisfaction, and the objective evaluation showed that the program was as efficacious as is traditional instruction.

Escalas de risco de Torrington e Henderson e de Epstein: aplicabilidade e efetividade nas ressecções pulmonares

OBJECTIVE: To compare the incidences of pulmonary and cardiopulmonary postoperative complications estimated using, respectively, the scoring systems devised by Torrington and Henderson and by Epstein in a populational sample undergoing lung resection for the treatment of lung cancer. METHODS: Prospective data from patients submitted to resection of one or more pulmonary lobes were selected from the databases of two tertiary-care hospitals. The outcome measures were pulmonary complications, cardiac complications and mortality rates. Fishers exact test was used to evaluate the concordance between the predicted and observed complications. RESULTS: The Torrington and Henderson scoring system was applied to 50 patients, in which the risk was found to be mild in 12, moderate in 32, and high in 6. Although accurately identifying patients at high risk, the Torrington and Henderson scale underestimated the rate of postoperative cardiopulmonary complications in the mild and moderate risk categories (p = 0.0003 and p = 0.0006, respectively). The Epstein scoring system was applied to 38 patients, 4 of which were found to be at high risk, and 34 of which were found to be at mild risk. The Epstein scale also underestimated the risk in the patients (the majority) that were classified as being at mild risk (p < 0.0001) and yet, like the Torrington and Henderson scale, accurately identified those at high risk. CONCLUSION: Neither of the two scoring systems analyzed were found to be appropriate for predicting the risk of pulmonary and cardiopulmonary complications in most cases.OBJETIVO: Comparar a incidencia de complicacoes pulmonares e cardiopulmonares estimadas, respectivamente, pelas escalas de Torrington e Henderson e de Epstein, em amostra populacional submetida a resseccao pulmonar para tratamento de câncer de pulmao. METODOS: Dados de doentes submetidos a resseccao de um lobo pulmonar ou mais foram retirados de dois bancos de dados montados de forma prospectiva, oriundos de dois hospitais terciarios. As medidas de desfecho analisadas foram complicacoes pulmonares, cardiacas e obito. Teste exato de Fisher foi usado para avaliar a concordância das taxas de complicacoes obtidas com as estimadas previamente. RESULTADOS: A escala de Torrington e Henderson foi aplicada em 50 doentes (12 apresentaram risco leve, 32 moderado e 6 grave) e subestimou a taxa de complicacoes pulmonares nas categorias leve e moderado (p = 0,0003 e p = 0,0006, respectivamente), porem foi capaz de reconhecer os pacientes com alto risco de desenvolver complicacoes. A escala de Epstein foi aplicada em 38 doentes (4 apresentaram risco alto e 34 baixo) e tambem subestimou a taxa de complicacoes cardiopulmonares pos-operatorias da categoria de risco leve, que continha a maioria dos doentes (p < 0,0001), mas reconheceu, tambem, os pacientes com chance alta de complicar. CONCLUSAO: As duas escalas nao foram adequadas para estimar ocorrencia de complicacoes pulmonares e cardiopulmonares na maioria dos doentes.

Reoperação de tromboendarterectomia pulmonar em recidiva de tromboembolismo pulmonar crônico hipertensivo

Pulmonary thromboendarterectomy has been established as the standard method for the treatment of chronic thromboembolic pulmonary hypertension, with excellent results. However, repeat pulmonary thromboendarterectomy due to recurrence of pulmonary embolism has never been reported in the Brazilian literature. Its safety and effectiveness remain obscure. We report the case of a patient presenting recurrence of chronic thromboembolic pulmonary hypertension five years after the first pulmonary thromboendarterectomy and requiring a second operation for resolution of the symptoms.

Estudo das pressões no interior dos balonetes de tubos traqueais

BACKGROUND AND OBJECTIVES Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigators external acoustic meatus positioned 10-20 cm apart from patients mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively. After the maneuver, standard deviation decreased from 56.3 to 8.2 in group I, and from 48 to 6.7 in group II. Maneuver has decreased cuff volume and pressure in 100% of group I patients, and in 97.3% of group II patients. CONCLUSIONS Both groups had intra-cuff pressures higher than necessary to keep ventilator cycling with no tidal volume leakage. Maneuver to keep intra-cuff pressure below 30 cmH2O was simple and cheap.JUSTIFICATIVA Y OBJETIVOS: Como no es de rutina el control de la presion en el interior de los balones de tubos traqueales, y como tambien no hay descripcion detallada en la literatura de como mantenerla abajo de los 30 cmH2O sin utilizacion de manometro, se decidio confirmar las presiones en el interior de los balones de tubos traqueales en pacientes bajo intubacion traqueal en la unidad de terapia intensiva y en el centro quirurgico, ensayando maniobras para mantener la presion en el balon abajo de 30 cmH2O, mas en niveles minimos necesarios para el ciclo del ventilador sin perdida del volumen corriente. METODO: Se estudiaron las presiones en el interior de balones de tubos traqueales de 50 pacientes bajo intubacion traqueal en la unidad de terapia intensiva (Grupo I) y 72 pacientes bajo intubacion traqueal en el centro quirurgico (Grupo II). Se experimento una maniobra para obtener la presion minima en el interior del balon del tubo traqueal, necesaria para una adecuada ventilacion, sin vaciamiento de aire. Se registro la presion inicial (P1) en el interior de los balones de los tubos traqueales utilizandose un manometro digital graduado en centimetros de agua, acoplado a una jeringa de 15 ml. Fue aspirada secrecion de la orofaringe. Con el meato acustico externo del examinador proximo de la boca del paciente entre 10 y 20 cm, se conecto el manometro al balon, que fue vaciado lentamente, hasta escucharse ruido en soplo, por el vaciamiento del volumen corriente en el periodo inspiratorio de la ventilacion artificial. En este momento, se lleno lentamente el balon hasta el desaparecimiento del ruido. Se anoto la presion final (P2) del balon y el volumen de aire que quedo en la jeringa del manometro (V). RESULTADOS: Las medias de las presiones P1 en los grupos I y II fueron 85,3 y 56,2 cmH2O, respectivamente. Las medias de presiones P2 en los grupos I y II fueron 26,7 y 15,5 cmH2O respectivamente. Despues de la maniobra hecha, el desvio patron bajo de 56,3 para 8,2 en el grupo I, y de 48 para 6,7 en el grupo II. En el grupo I, la maniobra redujo el volumen y la presion del balon en 100% de los pacientes y en el grupo II, en 97,3 %. CONCLUSIONES: Los dos grupos presentaron presiones en el interior de los balones en niveles arriba de lo necesario para el ciclo del ventilador sin perdida del volumen corriente. La maniobra para mantener la presion en el interior del balon en niveles inferiores a 30 cmH2O fue simples y de pequeno costo.

Study of tracheal tube intra-cuff pressure

BACKGROUND AND OBJECTIVES Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigators external acoustic meatus positioned 10-20 cm apart from patients mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively. After the maneuver, standard deviation decreased from 56.3 to 8.2 in group I, and from 48 to 6.7 in group II. Maneuver has decreased cuff volume and pressure in 100% of group I patients, and in 97.3% of group II patients. CONCLUSIONS Both groups had intra-cuff pressures higher than necessary to keep ventilator cycling with no tidal volume leakage. Maneuver to keep intra-cuff pressure below 30 cmH2O was simple and cheap.JUSTIFICATIVA Y OBJETIVOS: Como no es de rutina el control de la presion en el interior de los balones de tubos traqueales, y como tambien no hay descripcion detallada en la literatura de como mantenerla abajo de los 30 cmH2O sin utilizacion de manometro, se decidio confirmar las presiones en el interior de los balones de tubos traqueales en pacientes bajo intubacion traqueal en la unidad de terapia intensiva y en el centro quirurgico, ensayando maniobras para mantener la presion en el balon abajo de 30 cmH2O, mas en niveles minimos necesarios para el ciclo del ventilador sin perdida del volumen corriente. METODO: Se estudiaron las presiones en el interior de balones de tubos traqueales de 50 pacientes bajo intubacion traqueal en la unidad de terapia intensiva (Grupo I) y 72 pacientes bajo intubacion traqueal en el centro quirurgico (Grupo II). Se experimento una maniobra para obtener la presion minima en el interior del balon del tubo traqueal, necesaria para una adecuada ventilacion, sin vaciamiento de aire. Se registro la presion inicial (P1) en el interior de los balones de los tubos traqueales utilizandose un manometro digital graduado en centimetros de agua, acoplado a una jeringa de 15 ml. Fue aspirada secrecion de la orofaringe. Con el meato acustico externo del examinador proximo de la boca del paciente entre 10 y 20 cm, se conecto el manometro al balon, que fue vaciado lentamente, hasta escucharse ruido en soplo, por el vaciamiento del volumen corriente en el periodo inspiratorio de la ventilacion artificial. En este momento, se lleno lentamente el balon hasta el desaparecimiento del ruido. Se anoto la presion final (P2) del balon y el volumen de aire que quedo en la jeringa del manometro (V). RESULTADOS: Las medias de las presiones P1 en los grupos I y II fueron 85,3 y 56,2 cmH2O, respectivamente. Las medias de presiones P2 en los grupos I y II fueron 26,7 y 15,5 cmH2O respectivamente. Despues de la maniobra hecha, el desvio patron bajo de 56,3 para 8,2 en el grupo I, y de 48 para 6,7 en el grupo II. En el grupo I, la maniobra redujo el volumen y la presion del balon en 100% de los pacientes y en el grupo II, en 97,3 %. CONCLUSIONES: Los dos grupos presentaron presiones en el interior de los balones en niveles arriba de lo necesario para el ciclo del ventilador sin perdida del volumen corriente. La maniobra para mantener la presion en el interior del balon en niveles inferiores a 30 cmH2O fue simples y de pequeno costo.

Transplante isolado de pulmão: experiência da Escola Paulista de Medicina

Two cases of left single lung transplantation for pulmonary fibrosis are reported, one of a 50 years old white male who is alive and well 8 months after the transplantation and the other of a 36 years old female weighing 45 kg who received an upper lobe transplantation from a 85 kg donor. This patient died of multiple organ failure in the 8th postoperative day due to complications related to an unexplained cardiac tamponade and also possible rejection but was able to maintain good ventilatory and hemodynamic conditions in the first 3 days following transplantation; radiographic studies showed adequate expansion of the transplanted lobe. Autopsy revealed no problems in the anastomotic sites and signs of difuse bronchopneumonia. In the two cases a flap of pericardial fat was utilized instead of omental flap to protect the bronchial anastomosis and in the first case a telescoping anastomotic technique was done. Both patients received corticoids since the begining and the immunossupression protocol consisted of cyclosporin, prednisone and azathioprine and had no airways complications. In spite of being an initial experience, the authors express their hope in single lung and lobe transplantation for selected terminal lung diseases and in the near future also as an alternative in the surgical treatment of complex congenital cardiac anomalies.

Fatores de risco nas lobectomias realizadas para tratar o carcinoma brônquico

Determining which patients will suffercomplications or die when submitted to pulmonaryresection remains the greatest concern ofpulmonologists and thoracic surgeons. Due to theincreasing incidence of lung cancer cases, thefollowing types of pulmonary resection are beingemployed with ever greater frequency:segmentectomy; lobectomy (with or withoutsurgical reconstruction of the bronchus); andpneumonectomy. They can be associated withthoracoplasty, the resection of the superior venacava, aorta or carina.The complexity of the resections depends onchanges in the patterns of patients, who are of anadvanced age, smoke (or used to smoke) heavilyand have one or more of the following comorbidities:varying degrees of emphysema; arterial hypertension;heart disease; diabetes; and vascular diseases(peripheral, renal, hepatic or cerebral).Despite these risks, we cannot counsel againstpulmonary resection, since total resection of thetumor, evaluated in isolation, still offers the bestresults in terms of five-year survival rates. To decreasethese risks, we need to know, with the greatestpossible degree of accuracy, what will occur in theintra-operative and post-operative periods.If we have no notion of what will occur post-operatively, performing a pulmonary resection cancure the cancer and yet, if the resection is tooextensive, leave the patient a pulmonary invalid.In addition, some types of pulmonary resectionsin some patients will certainly create complications,thereby increasing the suffering of the patient, whowill spend more time in the hospital, while reducingthe number of available beds and increasing hospitalcosts. Nor is it acceptable that patients with stageIA lung cancer, whose chances for cure are 80%,suffer complications or die because one or morerisk factors were neglected before surgery, and theappropriate prophylaxis was not performed. In

Estudio de las presiones en el interior de los balones de tubos traquéales

BACKGROUND AND OBJECTIVES Since controlling tracheal tube cuffs internal pressure is unusual and there is no detailed description in the literature on how to maintain it below 30 cmH2O without manometer, this study aimed at checking tracheal tube intra-cuff pressures in intensive care unit and operating room patients. A maneuver was tested to keep intra-cuff pressure below 30 cmH2O, but at minimum levels needed for ventilator cycling with no tidal volume leakage. METHODS Tracheal tube intra-cuff pressures were evaluated in 50 intensive care unit intubated patients (Group I) and 72 intubated patients in the operating room (Group II). A maneuver was tested to obtain the minimum tracheal tube intra-cuff pressure to maintain adequate ventilation with no air leakage. Initial tracheal tube intra-cuff pressure (P1) was recorded using a gaged digital manometer (cmH2O) coupled to a 15-ml syringe. Oropharynx secretion was aspirated. With the investigators external acoustic meatus positioned 10-20 cm apart from patients mouth and cuff connected to the manometer, cuff was slowly deflated until a murmur sound was heard, determined by tidal volume leakage during the inspiratory period of artificial ventilation. At this moment, cuff was slowly inflated until murmur disappearance. Final intra-cuff pressure (P2) and the remaining air volume in the manometer syringe (V) were recorded. RESULTS Mean P1 values in groups I and II were 85.3 and 56.2 cmH2O, respectively. Mean P2 values in groups I and II were 26.7 and 15.5 cmH2O, respectively. After the maneuver, standard deviation decreased from 56.3 to 8.2 in group I, and from 48 to 6.7 in group II. Maneuver has decreased cuff volume and pressure in 100% of group I patients, and in 97.3% of group II patients. CONCLUSIONS Both groups had intra-cuff pressures higher than necessary to keep ventilator cycling with no tidal volume leakage. Maneuver to keep intra-cuff pressure below 30 cmH2O was simple and cheap.JUSTIFICATIVA Y OBJETIVOS: Como no es de rutina el control de la presion en el interior de los balones de tubos traqueales, y como tambien no hay descripcion detallada en la literatura de como mantenerla abajo de los 30 cmH2O sin utilizacion de manometro, se decidio confirmar las presiones en el interior de los balones de tubos traqueales en pacientes bajo intubacion traqueal en la unidad de terapia intensiva y en el centro quirurgico, ensayando maniobras para mantener la presion en el balon abajo de 30 cmH2O, mas en niveles minimos necesarios para el ciclo del ventilador sin perdida del volumen corriente. METODO: Se estudiaron las presiones en el interior de balones de tubos traqueales de 50 pacientes bajo intubacion traqueal en la unidad de terapia intensiva (Grupo I) y 72 pacientes bajo intubacion traqueal en el centro quirurgico (Grupo II). Se experimento una maniobra para obtener la presion minima en el interior del balon del tubo traqueal, necesaria para una adecuada ventilacion, sin vaciamiento de aire. Se registro la presion inicial (P1) en el interior de los balones de los tubos traqueales utilizandose un manometro digital graduado en centimetros de agua, acoplado a una jeringa de 15 ml. Fue aspirada secrecion de la orofaringe. Con el meato acustico externo del examinador proximo de la boca del paciente entre 10 y 20 cm, se conecto el manometro al balon, que fue vaciado lentamente, hasta escucharse ruido en soplo, por el vaciamiento del volumen corriente en el periodo inspiratorio de la ventilacion artificial. En este momento, se lleno lentamente el balon hasta el desaparecimiento del ruido. Se anoto la presion final (P2) del balon y el volumen de aire que quedo en la jeringa del manometro (V). RESULTADOS: Las medias de las presiones P1 en los grupos I y II fueron 85,3 y 56,2 cmH2O, respectivamente. Las medias de presiones P2 en los grupos I y II fueron 26,7 y 15,5 cmH2O respectivamente. Despues de la maniobra hecha, el desvio patron bajo de 56,3 para 8,2 en el grupo I, y de 48 para 6,7 en el grupo II. En el grupo I, la maniobra redujo el volumen y la presion del balon en 100% de los pacientes y en el grupo II, en 97,3 %. CONCLUSIONES: Los dos grupos presentaron presiones en el interior de los balones en niveles arriba de lo necesario para el ciclo del ventilador sin perdida del volumen corriente. La maniobra para mantener la presion en el interior del balon en niveles inferiores a 30 cmH2O fue simples y de pequeno costo.