Evolução da pneumonia lipoide exógena em crianças: aspectos clínicos e radiológicos e o papel da lavagem broncoalveolar / Evolution of exogenous lipoid pneumonia in children: clinical aspects, radiological aspects and the role of bronchoalveolar lavage

OBJETIVO: Descrever os aspectos da evolução da pneumonia lipoide em crianças, com base em aspectos clínicos, radiológicos e de achados no lavado broncoalveolar, enfatizando a importância diagnóstica e terapêutica da lavagem broncoalveolar. MÉTODOS: Foram incluídas 28 crianças, com idade média de 20 meses (1-108 meses) e diagnóstico de pneumonia crônica refratária a antimicrobianos e/ou TB. A maioria apresentava um fator de risco para aspiração, e todas apresentavam história de ingestão de óleo mineral para o tratamento de constipação intestinal (23/28) ou de ascaridíase complicada (5/28). A avaliação clínica e tomográfica e análises do lavado broncoalveolar foram realizadas no início do tratamento e em até 24 meses. RESULTADOS: Os sintomas mais frequentes foram taquipneia e tosse. As principais alterações radiológicas foram consolidações (23/28), infiltrado peri-hilar (13/28) e hiperinsuflação (11/28). A TC de tórax mostrou consolidações com broncograma aéreo (24/28), diminuição de atenuação nas áreas de consolidação (16/28), opacidade em vidro fosco (3/28) e padrão em mosaico (1/28). O estudo do lavado broncoalveolar apresentava macrófagos espumosos corados por Sudan, confirmando o diagnóstico da pneumonia lipoide. Após tratamento com múltiplas lavagens broncoalveolares (média = 9,6), 20 crianças tornaram-se assintomáticas, havendo normalização tomográfica em 18. CONCLUSÕES: O diagnóstico de pneumonia lipoide deve ser considerado na pneumonia crônica ou TB refratárias ao tratamento, especialmente se houver história de ingestão de óleo mineral. A broncoscopia com múltiplas lavagens broncoalveolares mostrou-se eficiente para a depuração do óleo aspirado do parênquima pulmonar e a prevenção da fibrose, contribuindo para a redução da morbidade dessa doença, que ainda é pouco diagnosticada.

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.

Diagnostic investigation of ventilator-associated pneumonia using bronchoalveolar lavage: comparative study with a postmortem lung biopsy

The purpose of the present study was to validate the quantitative culture and cellularity of bronchoalveolar lavage (BAL) for the diagnosis of ventilator-associated pneumonia (VAP). A prospective validation test trial was carried out between 1992 and 1997 in a general adult intensive care unit of a teaching hospital. Thirty-seven patients on mechanical ventilation with suspected VAP who died at most three days after a BAL diagnostic procedure were submitted to a postmortem lung biopsy. BAL effluent was submitted to Gram staining, quantitative culture and cellularity count. Postmortem lung tissue quantitative culture and histopathological findings were considered to be the gold standard exams for VAP diagnosis. According to these criteria, 20 patients (54 percent) were diagnosed as having VAP and 17 (46 percent) as not having the condition. Quantitative culture of BAL effluent showed 90 percent sensitivity (18/20), 94.1 percent specificity (16/17), 94.7 percent positive predictive value and 88.8 percent negative predictive value. Fever and leukocytosis were useless for VAP diagnosis. Gram staining of BAL effluent was negative in 94.1 percent of the patients without VAP (16/17). Regarding the total cellularity of BAL, a cut-off point of 400,000 cells/ml showed a specificity of 94.1 percent (16/17), and a cut-off point of 50 percent of BAL neutrophils showed a sensitivity of 90 percent (19/20). In conclusion, BAL quantitative culture, Gram staining and cellularity might be useful in the diagnostic investigation of VAP

Eficacia de la optimización de la presión de perfusión cerebral durante la fibrobroncoscopía en pacientes con traumatismo encefalocraneano grave / Effectiveness of the cerebral perfusion pressure optimization during fiberoptic bronchoscopy

Objetivo: Evaluar la utilidad de la optimización de la PPC antes, durante y después de la realización de FB, analizando las diferentes variables hemodinámicas cerebrales. Material y método: Estudio prospectivo, del 01/07/96 al 31/07/97. Ingresaron todos los pacientes con TEC con Glasgow ó 8 a los que se les relizó FB tanto para lavado broncoalveolar (BAL) como para resolución de atelectasias. Todos los pacientes se encotraban intubados, sedados y relajados, con asistencia respiratoria mecánica (ARM) y monitorizados con: catéter de fibra óptica para la medición de Presión Intracraneana (PIC), oximetría cerebral (rSO2) y de pulso (SaO2), capnografía (ETCO2) y catéteres arterial y venoso central. Se calculó: PPC (TAM-PIC), contenido arterial y venoso de O2, diferencia arterio-venosa de O2 cerebral (Dav02C), índice de extracción de O2 cerebral (SaO2-rSO2), consumo metabólico de O2 cerebral (CMO2C) (PCO2xDavO2C). Previo a la FB se mantuvo una PPC = 70 mmHg, una SaO2 = 95 por ciento, una ETCO2 ó 35mmHg y una rSO2 > 55 por ciento. Todas las variables se midieron y calcularon antes de comenzar la FB, luego de la optimización, en el momento de mayor PIC y 30 minutos después de la FB. El análisis estadístico se realizó con el test de Student y el test de correlación de Pearson. Valores de p ó 0,05 o de r2 >0,5, fueron considerados significativos...