Waldo Mattos

Ventilatory profile of patients undergoing CABG surgery.

OBJECTIVE To assess the ventilatory, radiological and clinical profile of patients undergoing elective CABG in a cardiology reference hospital in South Brazil. METHODS This study included 108 patients undergoing elective CABG surgery, in the period between April 2006 and February 2007 at the Cardiology Institute of Rio Grande do Sul (IC-FUC). The surgical procedure involved median sternotomy, and the saphenous vein and/or internal mammary artery were used for grafting. Lung volume and capacity, as well as the possible existence of ventilatory changes, were assessed by spirometry, and the ventilatory muscle strength was assessed using a vaccum manometer. All evaluations were performed on the preoperative period and on the sixth postoperative day. RESULTS Preoperative levels of FEV1 and FVC were significantly reduced on the 6th postoperative day (P<0.001) when compared to the preoperative levels. A significant decrease of ventilatory muscle strength, expressed as maximum inspiratory and expiratory pressures (MIP and MEP), was also observed from the pre- to the sixth postoperative day (P<0.001). Pulmonary events were more frequent on the 6th postoperative day (78%) than on the 1st postoperative day (40%). CONCLUSION Patients undergone CABG surgery present important reduction in pulmonary volume and capacity, as well as on the ventilatory muscle strength during the postoperative period.

Acurácia do exame clínico no diagnóstico da DPOC

OBJECTIVE: Simple diagnostic methods can facilitate the diagnosis of COPD, which is a major public health problem. The objective of this study was to investigate the accuracy of clinical variables in the diagnosis of COPD. METHODS: Patients with COPD and control subjects were prospectively evaluated by two investigators regarding nine clinical variables. The likelihood ratio for the diagnosis of COPD was determined using a logistic regression model. RESULTS: The study comprised 98 patients with COPD (mean age, 62.3± 12.3 years; mean FEV1, 48.3 ± 21.6%) and 102 controls. The likelihood ratios (95% CIs) for the diagnosis of COPD were as follows: 4.75 (2.29-9.82; p 0.9; 2.36 (1.22-4.58; p 4 s; and 4.78 (2.13-10.70; p 4 cm from lower costal edge. Inter-rater reliability for those same variables was, respectively, 0.57, 0.45, 0.62, 0.32, 0.53, 0.32, 0.59, 0.52 and 0.44 (p < 0.0001 for all). CONCLUSIONS: Various clinical examination findings could be used as diagnostic tests for COPD.

Estudo comparativo entre o manejo da asma em uma unidade de referência da rede pública de Porto Alegre (RS) e as proposições do III Consenso Brasileiro no Manejo da Asma

OBJECTIVE: To determine whether the guidelines put forth in the III Brazilian Consensus on Asthma Management are being applied in a population of asthma patients treated at a public hospital that is a referral center for asthma in the city of Porto Alegre, Brazil. METHODS: All adult asthma patients who began their treatment between 1999 and 2002 were evaluated. The treatment given was classified as consistent or inconsistent with the Consensus guidelines. The clinical features of asthma and the frequency of treatment provided by a specialist were compared between the two groups (those receiving guideline-consistent treatment and those receiving guideline-inconsistent treatment). RESULTS: The charts of 357 patients were evaluated. The study sample consisted of 106 males (29.9%) and 251 females (70.3%). The mean age was 41 years, and 33 (9.2%) of the patients were smokers. The treatment was considered inconsistent with the Consensus guidelines in 246 cases (70%). Of those 246, 174 (71%) had presented persistent asthma and were not treated with an inhaled corticosteroid. Normal forced expiratory volume in one second, being from 12 to 18 years of age, and having intermittent asthma were more frequently observed among the patients receiving guideline-consistent treatment (p < 0.01). No correlations were found between guideline-inconsistent treatment and being treated by a pulmonologist, severity of persistent asthma or number of emergency room visits. CONCLUSION: Most of the asthma patients treated at the public referral center in Porto Alegre did not receive treatment that was consistent with the Consensus guidelines. Undertreatment with inhaled corticosteroids was the principal source of that inconsistency.

Incidência de complicações pulmonares na cirurgia de revascularização do miocárdio

BACKGROUND despite the increasingly careful attempts to reduce perioperative risks, pulmonary complications following surgery are still very common, leading to longer length of hospital stays or death. OBJECTIVE to describe the incidence of pulmonary complications and identify their association with duration of extracorporeal circulation (ECC), surgery and ischemia, number of bypass grafts performed, location of drains and length of drainage following myocardial revascularization (MRV). METHODS this contemporaneous cohort consisted of 202 patients undergoing elective myocardial revascularization (MRV) with saphenous vein graft and internal mammary artery graft and ECC, at a referral university cardiology hospital in Southern Brazil, from April 2006 to November 2007. The following outcomes were analyzed: duration of mechanical ventilation; pneumonia onset; atelectasis; pleural effusion; location of drains and time of removal; and length of hospital stay. RESULTS of the 202 patients, 90 developed some sort of pulmonary complication. The incidence of pleural effusion was 84%, whereas atelectasis was 65%. The following variables were associated with pulmonary complications: duration of ECC (p = 0.003), surgery (p = 0.040) and ischemia (p = 0.001); length of drainage (p = 0.050) and location of pleural drains (p = 0.033); age (p = 0.001); ejection fraction (p = 0.010); diagnosis of asthma (p = 0.047) and preoperative abnormal chest X-ray findings (p = 0.029). CONCLUSION variables related to the complexity of the surgery and preexisting comorbidities are associated with a high incidence of postoperative pulmonary complications. These data reinforce the importance of having patients undergo perioperative clinical assessment to detect early respiratory complications after MRV.FUNDAMENTO: No periodo do peri-operatorio, os cuidados tem sido cada vez mais criteriosos, entretanto, as complicacoes pulmonares apos a abordagem cirurgica ainda sao frequentes, predispondo o paciente a um maior tempo de internacao ou ao obito. OBJETIVO: Descrever a incidencia de complicacoes pulmonares e identificar a sua associacao com tempos de circulacao extracorporea (CEC); cirurgia e isquemia; numero de enxertos; localizacao e tempo de drenos apos cirurgia de revascularizacao do miocardio (CRM). METODOS: Nesta coorte contemporânea, foram estudados 202 pacientes em hospital universitario de referencia para cardiologia no sul do Brasil, submetidos a CRM eletiva com ponte safena e arteria mamaria interna com CEC, no periodo de abril/2006 a novembro/2007. Os desfechos considerados foram: tempo de ventilacao mecânica; surgimento de pneumonia; atelectasia; derrame pleural; hora da retirada e localizacao dos drenos; e tempo de internacao. RESULTADOS: Observou-se algum tipo de complicacao pulmonar em 90 dos 202 pacientes. A frequencia de derrame pleural foi de 84% e a de atelectasia foi de 65%. Apresentaram associacao com complicacoes pulmonares os tempos de CEC (p = 0,003), cirurgico (p = 0,040) e isquemia (p = 0,001); o tempo de permanencia de drenos (p = 0,050) e a localizacao pleural dos drenos (p = 0,033), alem de idade (p = 0,001), fracao de ejecao (p = 0,010), diagnostico de asma (p = 0,047) e exame radiologico de torax pre-operatorio anormal (p = 0,029). CONCLUSAO: Variaveis relacionadas a complexidade do ato cirurgico e comorbidades pre-existentes estao associadas a uma alta incidencia de complicacoes pulmonares no pos-operatorio. Esses dados reforcam a importância da avaliacao clinica peri-operatoria para deteccao precoce de complicacao respiratoria apos CRM.

Exame do escarro no manejo clínico dos pacientes com pneumonia adquirida na comunidade Sputum examination in the clinical management of community-acquired pneumonia

OBJECTIVE To evaluate the frequency of the use of sputum examination in the clinical management of community-acquired pneumonia (CAP) in a general hospital and to determine whether its use has an impact on mortality. METHODS The medical records of CAP patients treated as inpatients between May and November of 2004 at the Nossa Senhora da Conceição Hospital, located in Porto Alegre, Brazil, were reviewed regarding the following aspects: age; gender; severity of pneumonia (Fine score); presence of sputum; sputum bacteriology; treatment history; change in treatment; and mortality. RESULTS A total of 274 CAP patients (134 males and 140 females) were evaluated. Using the Fine score to quantify severity, we classified 79 (28.8%) of those 274 patients as class II, 45 (16.4%) as class III, 97 (35.4%) as class IV, and 53 (19.3%) as class V. Sputum examination was carried out in 92 patients (33.6%). A valid sample was obtained in 37 cases (13.5%), and an etiological diagnosis was obtained in 26 (9.5%), resulting in a change of treatment in only 9 cases (3.3%). Overall mortality was 18.6%. Advanced age (above 65), CAP severity, and dry cough were associated with an increase in the mortality rate. Sputum examination did not alter any clinical outcome or have any influence on mortality. CONCLUSION Sputum examination was used in a minority of patients and was not associated with any noticeable benefit in the clinical management of patients with CAP treated in a hospital setting.

Avaliação da eficácia clínica, aceitabilidade e preferência de dois sistemas inalatórios de beclometasona no tratamento da asma: Pulvinal® versus Aeroliser®

BACKGROUND: Approximately half of all asthmatic patients adhere to their prescribed treatment regimen, which makes noncompliance with treatment one of the main problems associated with the disease. It is possible that inhalation devices combining technological advances with comfort and simplicity of use could increase treatment compliance. OBJECTIVE: To compare the acceptability of and preference for two inhalation devices (Pulvinal and Aerolizer), as well as to evaluate the efficacy of and tolerance for beclomethasone dipropionate when delivered by these two systems. METHOD: A multicenter, randomized, crossover parallel study was carried out involving 83 patients with stable asthma. Patients received 500-1000 mg/day of beclomethasone dipropionate. After a 2-week run in, the patients were randomized to begin a 4-week crossover treatment period with equivalent doses of Clenil Pulvinal (CP) or Miflasona Aerolizer (MA). RESULTS: Both groups showed improvement in dyspnea and FEV1, and acceptability was considered good or excellent in both groups. Of the patients studied, 50.6% preferred CP, and 39% preferred MA. In their future treatment regimes, 54.5% would choose the CP and 37.7% the MA. CONCLUSION: Clinical efficacy and acceptability were comparable between CP and MA.

Incidence of pulmonary complications in myocardial revascularization

BACKGROUND despite the increasingly careful attempts to reduce perioperative risks, pulmonary complications following surgery are still very common, leading to longer length of hospital stays or death. OBJECTIVE to describe the incidence of pulmonary complications and identify their association with duration of extracorporeal circulation (ECC), surgery and ischemia, number of bypass grafts performed, location of drains and length of drainage following myocardial revascularization (MRV). METHODS this contemporaneous cohort consisted of 202 patients undergoing elective myocardial revascularization (MRV) with saphenous vein graft and internal mammary artery graft and ECC, at a referral university cardiology hospital in Southern Brazil, from April 2006 to November 2007. The following outcomes were analyzed: duration of mechanical ventilation; pneumonia onset; atelectasis; pleural effusion; location of drains and time of removal; and length of hospital stay. RESULTS of the 202 patients, 90 developed some sort of pulmonary complication. The incidence of pleural effusion was 84%, whereas atelectasis was 65%. The following variables were associated with pulmonary complications: duration of ECC (p = 0.003), surgery (p = 0.040) and ischemia (p = 0.001); length of drainage (p = 0.050) and location of pleural drains (p = 0.033); age (p = 0.001); ejection fraction (p = 0.010); diagnosis of asthma (p = 0.047) and preoperative abnormal chest X-ray findings (p = 0.029). CONCLUSION variables related to the complexity of the surgery and preexisting comorbidities are associated with a high incidence of postoperative pulmonary complications. These data reinforce the importance of having patients undergo perioperative clinical assessment to detect early respiratory complications after MRV.FUNDAMENTO: No periodo do peri-operatorio, os cuidados tem sido cada vez mais criteriosos, entretanto, as complicacoes pulmonares apos a abordagem cirurgica ainda sao frequentes, predispondo o paciente a um maior tempo de internacao ou ao obito. OBJETIVO: Descrever a incidencia de complicacoes pulmonares e identificar a sua associacao com tempos de circulacao extracorporea (CEC); cirurgia e isquemia; numero de enxertos; localizacao e tempo de drenos apos cirurgia de revascularizacao do miocardio (CRM). METODOS: Nesta coorte contemporânea, foram estudados 202 pacientes em hospital universitario de referencia para cardiologia no sul do Brasil, submetidos a CRM eletiva com ponte safena e arteria mamaria interna com CEC, no periodo de abril/2006 a novembro/2007. Os desfechos considerados foram: tempo de ventilacao mecânica; surgimento de pneumonia; atelectasia; derrame pleural; hora da retirada e localizacao dos drenos; e tempo de internacao. RESULTADOS: Observou-se algum tipo de complicacao pulmonar em 90 dos 202 pacientes. A frequencia de derrame pleural foi de 84% e a de atelectasia foi de 65%. Apresentaram associacao com complicacoes pulmonares os tempos de CEC (p = 0,003), cirurgico (p = 0,040) e isquemia (p = 0,001); o tempo de permanencia de drenos (p = 0,050) e a localizacao pleural dos drenos (p = 0,033), alem de idade (p = 0,001), fracao de ejecao (p = 0,010), diagnostico de asma (p = 0,047) e exame radiologico de torax pre-operatorio anormal (p = 0,029). CONCLUSAO: Variaveis relacionadas a complexidade do ato cirurgico e comorbidades pre-existentes estao associadas a uma alta incidencia de complicacoes pulmonares no pos-operatorio. Esses dados reforcam a importância da avaliacao clinica peri-operatoria para deteccao precoce de complicacao respiratoria apos CRM.

Intravenous azithromycin plus ceftriaxone followed by oral azithromycin for the treatment of inpatients with community-acquired pneumonia: an open-label, non-comparative multicenter trial

Community-Acquired Pneumonia (CAP) is a major public health problem. In Brazil it has been estimated that 2,000,000 people are affected by CAP every year. Of those, 780,000 are admitted to hospital, and 30,000 have death as the outcome. This is an open-label, non-comparative study with the purpose of evaluating efficacy, safety, and tolerability levels of IV azithromycin (IVA) and IV ceftriaxone (IVC), followed by oral azithromycin (OA) for the treatment of inpatients with mild to severe CAP. Eighty-six patients (mean age 56.6 +/- 19.8) were administered IVA (500 mg/day) and IVC (1g/day) for 2 to 5 days, followed by AO (500 mg/day) to complete a total of 10 days. At the end of treatment (EOT) and after 30 days (End of Study--EOS) the medication was evaluated clinically, microbiologically and for tolerability levels. Out of the total 86-patient population, 62 (72.1%) completed the study. At the end of treatment, 95.2% (CI95: 88.9% - 100%) reported cure or clinical improvement; at the end of the study, that figure was 88.9% (CI95: 74.1% - 91.7%). Out of the 86 patients enrolled in the study, 15 were microbiologically evaluable for bacteriological response. Of those, 6 reported pathogen eradication at the end of therapy (40%), and 8 reported presumed eradication (53.3%). At end of study evaluation, 9 patients showed pathogen eradication (50%), and 7 showed presumed eradication (38.89%). Therefore, negative cultures were obtained from 93.3% of the patients at EOT, and from 88.9% at the end of the study. One patient (6.67% of patient population) reported presumed microbiological resistance. At study end, 2 patients (11.11%) still reported undetermined culture. Uncontrollable vomiting and worsening pneumonia condition were reported by 2.3% of patients. Discussion and Conclusion Treatment based on the administration of IV azithromycin associated to ceftriaxone and followed by oral azithromycin proved to be efficacious and well-tolerated in the treatment of Brazilian inpatients with CAP.

Incidencia de complicaciones pulmonares en la cirugía de revascularización del miocardio

BACKGROUND despite the increasingly careful attempts to reduce perioperative risks, pulmonary complications following surgery are still very common, leading to longer length of hospital stays or death. OBJECTIVE to describe the incidence of pulmonary complications and identify their association with duration of extracorporeal circulation (ECC), surgery and ischemia, number of bypass grafts performed, location of drains and length of drainage following myocardial revascularization (MRV). METHODS this contemporaneous cohort consisted of 202 patients undergoing elective myocardial revascularization (MRV) with saphenous vein graft and internal mammary artery graft and ECC, at a referral university cardiology hospital in Southern Brazil, from April 2006 to November 2007. The following outcomes were analyzed: duration of mechanical ventilation; pneumonia onset; atelectasis; pleural effusion; location of drains and time of removal; and length of hospital stay. RESULTS of the 202 patients, 90 developed some sort of pulmonary complication. The incidence of pleural effusion was 84%, whereas atelectasis was 65%. The following variables were associated with pulmonary complications: duration of ECC (p = 0.003), surgery (p = 0.040) and ischemia (p = 0.001); length of drainage (p = 0.050) and location of pleural drains (p = 0.033); age (p = 0.001); ejection fraction (p = 0.010); diagnosis of asthma (p = 0.047) and preoperative abnormal chest X-ray findings (p = 0.029). CONCLUSION variables related to the complexity of the surgery and preexisting comorbidities are associated with a high incidence of postoperative pulmonary complications. These data reinforce the importance of having patients undergo perioperative clinical assessment to detect early respiratory complications after MRV.FUNDAMENTO: No periodo do peri-operatorio, os cuidados tem sido cada vez mais criteriosos, entretanto, as complicacoes pulmonares apos a abordagem cirurgica ainda sao frequentes, predispondo o paciente a um maior tempo de internacao ou ao obito. OBJETIVO: Descrever a incidencia de complicacoes pulmonares e identificar a sua associacao com tempos de circulacao extracorporea (CEC); cirurgia e isquemia; numero de enxertos; localizacao e tempo de drenos apos cirurgia de revascularizacao do miocardio (CRM). METODOS: Nesta coorte contemporânea, foram estudados 202 pacientes em hospital universitario de referencia para cardiologia no sul do Brasil, submetidos a CRM eletiva com ponte safena e arteria mamaria interna com CEC, no periodo de abril/2006 a novembro/2007. Os desfechos considerados foram: tempo de ventilacao mecânica; surgimento de pneumonia; atelectasia; derrame pleural; hora da retirada e localizacao dos drenos; e tempo de internacao. RESULTADOS: Observou-se algum tipo de complicacao pulmonar em 90 dos 202 pacientes. A frequencia de derrame pleural foi de 84% e a de atelectasia foi de 65%. Apresentaram associacao com complicacoes pulmonares os tempos de CEC (p = 0,003), cirurgico (p = 0,040) e isquemia (p = 0,001); o tempo de permanencia de drenos (p = 0,050) e a localizacao pleural dos drenos (p = 0,033), alem de idade (p = 0,001), fracao de ejecao (p = 0,010), diagnostico de asma (p = 0,047) e exame radiologico de torax pre-operatorio anormal (p = 0,029). CONCLUSAO: Variaveis relacionadas a complexidade do ato cirurgico e comorbidades pre-existentes estao associadas a uma alta incidencia de complicacoes pulmonares no pos-operatorio. Esses dados reforcam a importância da avaliacao clinica peri-operatoria para deteccao precoce de complicacao respiratoria apos CRM.