Estudio de sobrevida a largo plazo en pacientes adultos con enfermedades respiratorias crónicas atendidos por infección respiratoria aguda por coronavirus SARS-CoV-2 / Study of long-term survival in adult patients with chronic respiratory diseases treated for acute respiratory infection by coronavirus SARS-CoV-2

La enfermedad respiratoria aguda por coronavirus SARS-CoV-2 (COVID-19) se ha convertido en un grave problema de salud pública a nivel mundial. Objetivos: Examinar el uso de recursos sanitarios, riesgo de complicaciones y muerte en pacientes adultos con enfermedades respiratorias crónicas atendidos por COVID-19. Métodos: Estudio clínico descriptivo prospectivo realizado en pacientes adultos atendidos por COVID-19 en la Red de Salud UC Christus entre el 1 de abril y 31 de diciembre de 2020. Resultados: Se evaluaron 2.160 pacientes adultos, edad: 47 ± 17 años (rango: 18-100), 51,3% sexo masculino, 43,8% tenía comorbilidades, especialmente hipertensión (23,2%), diabetes (11,7%) y enfermedades respiratorias crónicas: asma (5%), EPOC (1,4%) y enfermedad pulmonar difusa (EPD: 0,8%). Los pacientes adultos con enfermedades respiratorias crónicas tuvieron mayor riesgo de hospitalización y uso de oxígeno suplementario; sin embargo, la evolución de los pacientes asmáticos y la sobrevida a los doce meses fue similar a los pacientes sin comorbilidades atendidos por COVID-19, mientras que en los pacientes con EPOC y EPD la admisión a la unidad de paciente crítico y riesgo de muerte fueron más elevados. En el análisis multivariado, los principales predictores clínicos asociados al riesgo de muerte en el seguimiento a doce meses en pacientes adultos con COVID-19 fueron la edad y admisión al hospital, mientras que el asma fue un factor protector. Conclusión: Los pacientes asmáticos tuvieron bajo riesgo de complicaciones y muerte asociados a COVID-19; mientras que los pacientes con EPOC y EPD tuvieron mayor riesgo de complicaciones y muerte en el seguimiento a largo plazo.

The acute respiratory disease associated to coronavirus SARS-CoV-2 (COVID-19) has become a serious public health problem worldwide. Objectives: To examine the use of healthcare resources, risk of complications and death in adult patients with chronic respiratory diseases treated for COVID-19. Methods: Prospective descriptive clinical study conducted in adult patients treated for COVID-19 in the UC Christus Healthcare Network between April 1 and December 31, 2020. Results: 2,160 adult patients were evaluated, age: 47 ± 17 years-old (range: 18-100), 51.3% male, 43.8% had comorbidities, especially hypertension (23.2%), diabetes (11.7%), and chronic respiratory diseases: asthma (5%), COPD (1,4%) and interstitial lung disease (ILD: 0.8%). Adult patients with chronic respiratory diseases were at higher risk for hospitalization and use of supplemental oxygen; however, the evolution of asthmatic patients and survival at twelve months was similar to that of adult patients without comorbidities treated for COVID-19, while in patients with COPD and ILD admission to the critical care unit and risk of death were higher. In the multivariate analysis, the main clinical predictors associated to 12-month mortality risk in adult patients with COVID-19 were age and hospital admission, while asthma was a protective factor. Conclusion: Asthmatic patients had minor risk of complications and mortality associated with COVID-19; while patients with COPD and ILD had a significant higher risk of complications and 12-month mortality.

Neumonitis intersticial descamativa en el paciente pediátrico / Desquamative interstitial penumonitis in a pediatric patient

Introducción: la neumonitis intersticial descamativa es una entidad caracterizada en la clínica por mostrar tos, disnea, cianosis e hipercapnia, con un patrón restrictivo de las pruebas funcionales respiratorias, debido a la presencia de fibrosis pulmonar, cuya frecuencia es inusual en Pediatría. Presentación del caso: adolescente que fue remitida al Hospital Docente Pediátrico del Cerro por sospecha de dengue, al referir fiebre de 38 °C de 3 días de evolución, acompañada de dolores musculares en miembros inferiores, escalofríos y cefalea, por lo cual fue internada en la sala de misceláneas. Durante su evolución mostró dificultad respiratoria, tos seca, taquipnea, taquicardia y disminución del murmullo vesicular en la base del pulmón izquierdo. Se observó en la radiografía de tórax una opacidad en dicha zona y fue tratada con antibióticos. En etapa posterior se trasladó a la Unidad de Cuidados Intensivos por ocurrir un incremento de las lesiones pulmonares e insuficiencia respiratoria; por ello, se indicó ventilación mecánica, variedad presión controlada. Posteriormente se aisló en hemocultivo y secreciones bronquiales, Pseudomona Stutzeri, evento considerado como una sepsis asociada a cuidados sanitarios. Se planteó un distrés respiratorio del adulto en niños que no involucionó, y falleció en un cuadro de insuficiencia respiratoria a los 19 días de estadía. Conclusiones: esta paciente mostró síntomas y signos sugestivos de una infección pulmonar bacteriana de evolución tórpida. Los hallazgos necrópsicos describen la presencia de una bronconeumonía bacteriana como causa directa, y una neumonitis intersticial descamativa, como entidad básica del fallecimiento(AU)

Introduction: desquamative interstitial pneumonitis is a characterized condition in the clinical field since it shows cough, dysnea, cyanosis and hypercapnia, with a restrictive pattern of the functional respiratory tests due to the presence of pulmonary fibrosis that is unusual in pediatrics. Case presentation: a female adolescent was referred to the pediatric teaching hospital of Cerro on suspicion of dengue since she presented with 38 °C for three days, accompanied with muscle aches in lower limbs, chills and headache. She was admitted to a general ward. During her progression, she showed respiratory distress, unproductive cough, tachypnea, tachycardia and reduction of vesicular murmur in the left lung basis. The thoracic X ray showed opacity in the area and was treated with antibiotics. In a later phase, she was moced to the intensive care unit due to increase in pulmonary lesions and respiratory failure. She was also under mechanical ventilation with controlled pressure. Later, Pseudomona Stutzeri was isolated in blood culture and bronchial secretions, an event considered to be health care-associated sepsis. It was stated that this case was a respiratory distress of adult in a child that evolved and finally the adolescent died of respiratory failure 19 days after her hospitalization. Conclusions: this patient showed symptoms and signs suggestive of bacterial pulmonary infection of torpid progression. The necropsis finding describe the presence of bacterial bronchopneumonia as a direct cause and desquamative interstitial pneumonitis as the basic condition for death(AU)

Enfermedad pulmonar difusa en esclerodermia: diagnóstico y tratamiento / Intetstitial lung disease in scleroderma: diagnosis and treatment

Scleroderma is among the connective tissue diseases (CTD) with more pulmonary involvement. More than half of scleroderma patients have some kind of interstitial lung disease (ILD), and this is currently the leading cause of death due to the disease itself. The main risk factor for ILD is the autoantibodie profile, and the period of greatest risk of developing ILD is among the first 3-5 years of disease. The most common histopathological form is NSIP, but the histopathological subtype has no influence on prognosis or response to treatment. Given the fact that some ILD patients will remain stable and because of the lack of a really effective and risk free treatment, immunosuppressive therapy is generally reserved for patients with extensive and / or progressive disease. The main risk factors for progressive disease are pulmonary extent and functional impairment. With currently available therapies the more realistic goal is stabilization of lung disease. The most widely used immunosuppressive induction therapy is Cyclophosphamide (CYC), but there is enough evidence to support the use of Mycophenolate Mofetil (MMF). As maintenance therapy, options are MMF and Azathioprine. Periodic clinical and functional reassessment is of vital importance, to monitor functional progression and/or the response to immunosuppressive therapy...

La esclerodermia está entre las enfermedades del tejido conectivo (ETC) que con mayor frecuencia presentan enfermedad pulmonar difusa (EPD), y se encuentra en más de la mitad de los pacientes. Actualmente la EPD representa la principal causa de muerte atribuible a la propia enfermedad. El principal factor de riesgo es el perfil de autoanticuerpos, y el período de mayor riesgo de desarrollar EPD son los primeros tres a cinco años de enfermedad. La forma histopatológica más frecuente es neumonía intersticial no específica (NINE), pero el subtipo histopatológico no tiene mayor influencia en el pronóstico ni en la respuesta al tratamiento. Dada la existencia de pacientes con EPD intrínsecamente estable y a la ausencia de una terapia realmente efectiva y exenta de riesgos, la inmunosupresión se reserva en general para pacientes con enfermedad extensa y/o progresiva. Lo parámetros que mejor se han correlacionado con el riesgo de progresión son la extensión radiológica y el compromiso de la función pulmonar. Con las terapias actualmente disponibles, el objetivo más realista es la estabilización del compromiso pulmonar. El Inmunosupresor más utilizado para la terapia de inducción es ciclofosfamida (CYC), pero existe evidencia suficiente que avala el uso de micofenolato mofetil (MMF). Como terapia de mantención las principales opciones son azatioprina y MMF. La reevaluación clínica y funcional periódica es fundamental, para monitorizar la progresión y/o la respuesta al tratamiento inmunosupresor...

Enfermedad pulmonar intersticial en la niñez. Ocho años de experiencia / Childhood interstitial lung disease. Eight years experience

Se presenta la casuística de 8 años (2005-2013) de 27 enfermos con cuadros intersticiales en seguimiento efectivo. No fueron incluidas las displasias bronco-pulmonares, el daño pulmonar crónico por virus, la fibrosis quística y la aspiración recurrente. Método. Revisión de Historias Clínicas; tomografías computadas y biopsias pulmonares en actividad multidisciplinaria coordinada. Se modificaron las técnicas quirúrgicas de biopsia, radiología (tomografía computada) y se consultó a centros extranjeros con mayor experiencia en 14 casos. Resultados. Se presentan resultados de tomografías y de la clínica. La patología diagnosticada más frecuente fue la hemorragia pulmonar con 4 hemosiderosis pulmonares idiopáticas y 2 de otro origen (sangrado por celiaquía y hemorragia pulmonar del lactante). La segunda frecuencia, 4 casos, correspondió a posibles defectos del surfactante con genética incluida. Está representado casi todo el espectro de la patología intersticial. Los cuadros intersticiales pulmonares en la infancia seguramente son más frecuentes que lo supuesto hasta la fecha. Deben ser diagnosticados y tratados por equipos multidisciplinarios con énfasis especial en la técnica de biopsia, la tomografía computada y el futuro desarrollo de estudios genéticos avanzados...

Twenty-seven cases of interstitial lung disease in children with complete follow-up are presented. Bronchopulmonary dysplasia, viral chronic lung damage, cystic fibrosis and recurrent aspiration were not included. Methods. Detailed revision of 27 clinical records during the period 2005-2013. Results. computerized tomography, clinical symptoms, lung biopsies and diagnosis are shown. Coordinated multidisciplinary organization is underlined as necessary. Foreign Centers with larger experience were consulted in 14 cases; biopsy technique as well as computed tomography were accordingly modified. Most frequent finding was pulmonary hemorrhage of different origin: 4 idiopathic pulmonary hemosiderosis cases; one bleeding due to celiac disease and one acute pulmonary hemorrhage of infancy. Four cases of possible surfactant deficiencies were suspected (genetic studies included). Almost the whole spectrum of interstitial lung disease was found and surely it shall be found to be more frequent as long as a coordinated multidisciplinary effort is undertaken...

Morphometric evaluation of nitric oxide synthase isoforms and their cytokine regulators predict pulmonary dysfunction and survival in systemic sclerosis

Because histopathological changes in the lungs of patients with systemic sclerosis (SSc) are consistent with alveolar and vessel cell damage, we presume that this interaction can be characterized by analyzing the expression of proteins regulating nitric oxide (NO) and plasminogen activator inhibitor-1 (PAI-1) synthesis. To validate the importance of alveolar-vascular interactions and to explore the quantitative relationship between these factors and other clinical data, we studied these markers in 23 cases of SSc nonspecific interstitial pneumonia (SSc-NSIP). We used immunohistochemistry and morphometry to evaluate the amount of cells in alveolar septa and vessels staining for NO synthase (NOS) and PAI-1, and the outcomes of our study were cellular and fibrotic NSIP, pulmonary function tests, and survival time until death. General linear model analysis demonstrated that staining for septal inducible NOS (iNOS) related significantly to staining of septal cells for interleukin (IL)-4 and to septal IL-13. In univariate analysis, higher levels of septal and vascular cells staining for iNOS were associated with a smaller percentage of septal and vascular cells expressing fibroblast growth factor and myofibroblast proliferation, respectively. Multivariate Cox model analysis demonstrated that, after controlling for SSc-NSIP histological patterns, just three variables were significantly associated with survival time: septal iNOS (P=0.04), septal IL-13 (P=0.03), and septal basic fibroblast growth factor (bFGF; P=0.02). Augmented NOS, IL-13, and bFGF in SSc-NSIP histological patterns suggest a possible functional role for iNOS in SSc. In addition, the extent of iNOS, PAI-1, and IL-4 staining in alveolar septa and vessels provides a possible independent diagnostic measure for the degree of pulmonary dysfunction and fibrosis with an impact on the survival of patients with SSc.

Tobacco smoking related interstitial lung diseases.

Smoking is a leading cause of death worldwide and is the important proximate cause of the most common noncommunicable respiratory disease, chronic obstructive pulmonary disease (COPD). Smoking is causally related to the development of certain forms of interstitial lung diseases (ILDs) including desquamative interstitial pneumonia (DIP), respiratory bronchiolitis associated interstitial lung disease (RB-ILD), pulmonary Langerhans’ cell histiocytosis (LCH), idiopathic pulmonary fibrosis (IPF) and acute eosinophilic pneumonia (AEP), among others. It is important to understand this causal relationship, as well as the natural history and prognosis of these diseases. The response to treatment of ILDs in general is quite dismal. For most of the ILDs, the only definitive treatment measure remains oxygen therapy and lung transplantation. As lung transplantation is still in its infancy and is unaffordable for a majority of patients with ILD in India, most of these patients can only hope to receive palliative supportive care. However, patients with tobacco smoking related ILDs have better outcomes, and progression of these disease ceases with smoking cessation. We review here, the varied clinical, radiological, pathological features, and the progression and outcome in this group of ILDs. Better understanding of these diseases, including making “smoking cessation” a central goal of management will improve overall outcomes.

Lymphatic fluctuation in the parenchymal remodeling stage of acute interstitial pneumonia, organizing pneumonia, nonspecific interstitial pneumonia and idiopathic pulmonary fibrosis

Because the superficial lymphatics in the lungs are distributed in the subpleural, interlobular and peribroncovascular interstitium, lymphatic impairment may occur in the lungs of patients with idiopathic interstitial pneumonias (IIPs) and increase their severity. We investigated the distribution of lymphatics in different remodeling stages of IIPs by immunohistochemistry using the D2-40 antibody. Pulmonary tissue was obtained from 69 patients with acute interstitial pneumonia/diffuse alveolar damage (AIP/DAD, N = 24), cryptogenic organizing pneumonia/organizing pneumonia (COP/OP, N = 6), nonspecific interstitial pneumonia (NSIP/NSIP, N = 20), and idiopathic pulmonary fibrosis/usual interstitial pneumonia (IPF/UIP, N = 19). D2-40+ lymphatic in the lesions was quantitatively determined and associated with remodeling stage score. We observed an increase in the D2-40+ percent from DAD (6.66 ± 1.11) to UIP (23.45 ± 5.24, P = 0.008) with the advanced process of remodeling stage of the lesions. Kaplan-Meier survival curves showed a better survival for patients with higher lymphatic D2-40+ expression than 9.3%. Lymphatic impairment occurs in the lungs of IIPs and its severity increases according to remodeling stage. The results suggest that disruption of the superficial lymphatics may impair alveolar clearance, delay organ repair and cause severe disease progress mainly in patients with AIP/DAD. Therefore, lymphatic distribution may serve as a surrogate marker for the identification of patients at greatest risk for death due to IIPs.

Expresión de la neumopatía intersticial en pacientes cubanos con esclerosis sistémica / Expression of interstitial pneumopathy in Cuban patients with systemic sclerosis

La neumopatía intersticial (NI) se presenta frecuentemente en pacientes con esclerosis sistémica (ES) y ocasiona morbilidad y mortalidad significativas. Se realizó un estudio descriptivo, prospectivo con 46 pacientes, que cumplieron criterios del Colegio Americano de Reumatología, para identificar las formas de expresión y detección de la NI. Se estimó porcentajes, análisis univariable para medidas de centralización, dispersión y pruebas de significación estadística chi cuadrado (X2). Se halló una edad media de 50,4 años, predominio femenino (88 por ciento), color de piel blanco (66 por ciento), tuvieron neumopatía intersticial 20 pacientes (43,4 por ciento); disnea de esfuerzo, el 100 por ciento de los casos, lo cual fue estadísticamente significativo (p=0,02). La función respiratoria estuvo afectada en el 75 por ciento de los enfermos. Según tomografía computadorizada de alta resolución (TC) de pulmón, 50 por ciento tuvo patrón en vidrio esmerilado y 50 por ciento, patrón en panal de abejas, 66 por ciento de los pacientes con NI tuvieron lavado broncoalveolar activo y de ellos, 88 por ciento correspondió a los que tenían patrón en vidrio esmerilado. Se concluyó que la neumopatía intersticial se expresó en un alto porcentaje de pacientes, la disnea de esfuerzo fue el síntoma más frecuente, predominó el patrón restrictivo. La TC y el estudio citológico del lavado broncoalveolar constituyeron herramientas clave para el diagnóstico precoz de NI.

Interstitial pneumopathy (IP) usually appears in patients with systemic sclerosis (SS) and causes significant morbidity and mortality. A descriptive and prospective study was conducted among 46 patients that fulfilled the criteria of the American Rheumatology College to identify the forms of expression and detection of IP. Percentages were estimated, and the univariable analysis for centralization and dispersion measurements and the chi square tests (X2) of statistical significance were used. A mean age of 50.4 years old was found. A prevalence of females (88 percent) and of white individuals (66 percent) was observed. 20 patients (43.4percent) had interstitial pneumopathy, whereas 100 percent of the cases presented effort dyspnea, which was statistically significant (p=0.02). The respiratory function was affected in 75 percent of the sick. According to high resolution computerized tomography of the lung, 50 percent had ground glass pattern and 50 percent honeycomb pattern, 66 percent of the patients with IP had active bronchoalveolar lavage and of them, 88 percent corresponded to those with ground glass pattern. It was concluded that interstitial pneumopathy was expressed in a high percentage of patients. Effort dyspnea was the most frequent symptom and the restrictive pattern predominated. CAT and the cytological study of bronchoalveolar lavage were key tools for the early diagnosis of IP.

Biopsia en enfermedad intersticial pulmonar / Lung biopsy for the diagnosis of interstitial lung disease

El objetivo del presente estudio fue determinar el rédito diagnóstico y los factores asociados a mayor morbimortalidad en la biopsia quirúrgica de pulmón en pacientes con enfermedad intersticial difusa. Se analizaron en forma retrospectiva los registros clínicos de 71 pacientes. Se registraron complicaciones en 16 pacientes (22.5%). La mortalidad operatoria fue 11.2%. Los pacientes en quienes la biopsia se realizó por videotoracoscopia (n = 52) y por toracotomía (n = 17) tuvieron la misma duración de estadía en terapia intensiva y de estadía hospitalaria. La tasa de complicaciones (22.2% vs. 21.0%, p = 1.0000) y la mortalidad (9.2 vs. 15.7%, p = 0.2738) no fueron diferentes. Ocho pacientes murieron dentro de los 30 días. La prevalencia de inmunosupresión (4/8 vs. 9/63, p = 0.0325) fue significativamente superior en el grupo de pacientes fallecidos. Estos pacientes tuvieron valores preoperatorios más elevados de urea (50 ± 20.1 mg/dl vs. 31.2 ± 10.3 mg/ dl, p = 0.0013) y menores valores de saturación de O2: 82.7 ± 14.8% vs. 92.8 ± 3.4%, p = 0.0009. En los 11 pacientes con iniciación aguda la mortalidad fue significativamente más elevada (36.3% vs. 7.1%, p = 0.0223). La biopsia aportó un diagnóstico específico en 100% de los pacientes y cambió la estrategia terapéutica en 66.7%. En conclusión, la biopsia de pulmón por vía toracoscópica es un procedimiento útil y seguro en los pacientes con enfermedad intersticial difusa del pulmón. Sin embargo, en el grupo de pacientes inmunocomprometidos, con cuadros de presentación aguda y con insuficiencia respiratoria preoperatoria, la mortalidad es elevada y deben balancearse muy críticamente los riesgos contra los beneficios en ese grupo de enfermos.

The objective of this study was to determine the morbidity, mortality and diagnostic yield of video assisted thoracoscopy (VATS) and thoracotomy lung biopsy in interstitial lung disease (ILD). Clinical records of 71 patients were retrospectively analyzed. There was no difference in mean hospital stay, intensive care unit stay and duration of chest tube drainage in patients with VATS (n = 52) compared with those undergoing open thoracotomy (n = 17). Complications rate (22.2% vs. 21.0%, p = 1.0000) and operating mortality (9.2 vs. 15.7%, p = 0.2738) were also similar. Overall, complications occurred in 16 patients (22.5%). Thirty-day mortality rate was 11.2% (n = 8). Prevalence of immunosupression (4/8 vs. 9/63, p = 0.0325) was significantly higher in the group of patients who died. No surviving patients had higher values of plasmatic urea (50 ± 20.1 mg/dl vs. 31.2 ± 10.3 mg/dl, p = 0.0013) or lower values of preoperative oxygen saturation (SaO2): 82.7 ± 14.8% vs. 92.8 ± 3.4%, (p = 0.0009). Eleven patients had an acute illness. Those patients did not show a higher complication rate (4/11 vs. 10/45, p = 0.4390) but mortality was significantly higher (4/11, 36.3% vs. 3/45, 7.1%, p = 0.0223). Biopsy allowed a specific histologic diagnosis in 100% of patients and changed therapy in 66.7%. We conclude that surgical lung biopsy is a safe and useful procedure in patients with ILD. However the higher mortality rate in patients with acute symptoms, immunocompromise, or in respiratory failure must be balanced against potential benefits of altering treatment decisions.

Autopsy-proven causes of death in lungs of patients immunocompromised by secondary interstitial pneumonia

PURPOSE: To present the more frequent associations found in autopsies of immunocompromised patients who developed secondary interstitial pneumonia as well as the risk of death (odds ratio) in having specific secondary interstitial pneumonia according to the cause of immunocompromise. METHOD: From January 1994 to March 2004, 17,000 autopsies were performed at Hospital das Clínicas, São Paulo University Medical School. After examining the pathology report review, we selected 558 of these autopsies (3.28 percent) from patients aged 15 years or more with primary underlying diseases who developed radiologically diffuse infiltrates of the lung during their hospital course and died after secondary interstitial pneumonia (bronchopneumonia, lobar pneumonia, interstitial pneumonia, diffuse alveolar damage, pulmonary recurrence of underlying disease, drug-induced lung disease, cardiogenic pulmonary edema, or pulmonary embolism). Histology slides were reviewed by experienced pathologists to confirm or not the presence of secondary interstitial pneumonia. Statistical analysis included the Fisher exact test to verify any association between histopathology and the cause of immunocompromise; a logistic regression was used to predict the risk of death for specific histological findings for each of the independent variables in the model. RESULTS: Secondary interstitial pneumonia was histologically represented by diffuse interstitial pneumonitis ranging from mild nonspecific findings (n = 213) to a pattern of diffuse alveolar damage (n = 273). The principal causes of immunocompromise in patients with diffuse alveolar damage were sepsis (136 cases), neoplasia (113 cases), diabetes mellitus (37 cases), and transplantation (48 cases). A high risk of death by pulmonary edema was found for patients with carcinoma of colon. Similarly, in patients with lung cancer or cachexia, A high risk of death by bronchopneumonia (OR = 3.6; OR = 2.6, respectively) was found. Pulmonary...

OBJETIVO: Apresentar as associações mais freqüentes encontradas em autópsias de pacientes imunossuprimidos que desenvolveram pneumonia intersticial secundária bem como o risco de óbito (Odds Ratio) de desenvolver PIS associada à causa da imunossupressão. MÉTODO: De janeiro de 1994 a março de 2004, 17000 autópsias foram realizadas no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. A partir da revisão dos laudos patológicos foram selecionados 558 destas autópsias (3,28 por cento) de pacientes com 15 anos de idade ou mais, com alguma doença de base que desenvolveu um infiltrado pulmonar radiologicamente difuso durante o curso da hospitalização e que depois foi para óbito com pneumonia intersticial secundária (broncopneumonia, pneumonia lobar, pneumonia intersticial, dano alveolar difuso, doença pulmonar recorrente, doença pulmonar induzida por drogas, edema pulmonar cardiogênico e embolismo pulmonar). As lâminas histológicas foram revisadas por patologistas experientes para confirmar ou não a presença de pneumonia intersticial secundária. A análise estatística incluiu o "Teste exato de Fisher" para verificar associação entre a histolopatologia e causa de imunocomprometimento; e regressão logística para predizer o risco de óbito por achados histológicos específicos para cada variável independente do modelo. RESULTADOS: A pneumonia intersticial secundária foi representada histológicamente por pneumonite intersticial difusa variando de características não especificas leves (n=213) ao padrão histológico de dano alveolar difuso (n=273). A principal causa de imunossupressão nos pacientes com dano alveolar difuso foi sepse (136 casos), neoplasia (113 casos), diabetes melito (37 casos) e transplantados (37 casos). O maior risco de morte por edema pulmonar foi encontrado nos pacientes com carcinoma de cólon. Da mesma forma, nos pacientes com câncer pulmonar ou cachexia ocorreu um alto risco de morte (OR=3.6; OR=2.6, respectivamente)...

Correlation between surgical lung biopsy and autopsy findings and clinical data in patients with diffuse pulmonary infiltrates and acute respiratory failure

INTRODUCTION: Surgical lung biopsy is an invasive procedure performed when other procedures have failed to provide an urgent and specific diagnosis, but there may be reluctance to perform it in critically ill patients with diffuse pulmonary infiltrates. PURPOSE: To evaluate the diagnostic accuracy, the changes in therapy and survival of patients with diffuse lung infiltrates, mostly presenting acute respiratory failure, who underwent surgical biopsy. METHODS: We retrospectively examined medical records and surgical lung biopsies from 1982 to 2003 of 63 patients older than 18 years with diffuse infiltrates. Clinical diagnoses were compared to histopathological ones, from biopsies and autopsies. Laboratory and epidemiological data were evaluated, and their relationship to hospital survival was analyzed. RESULTS: All histological specimens exhibited abnormalities, mostly presenting benign/inflammatory etiologies. Fifteen patients had an etiologic factor determined in biopsy, most commonly Mycobacterium tuberculosis. The preoperative diagnosis was rectified in 37 patients. Autopsies were obtained in 25 patients and confirmed biopsy results in 72 percent of cases. Therapy was changed for 65 percent of patients based on biopsy results. Forty-nine percent of patients survived to be discharged from the hospital. Characteristics that differed significantly between survivors and nonsurvivors included sex (P = 0.05), presence of comorbidity (P = 0.05), SpO2 (P = 0.05), and presence of diffuse alveolar damage in the biopsy (P = 0.004). CONCLUSION: Surgical lung biopsy provided a specific, accurate etiologic diagnosis in many patients with diffuse pulmonary infiltrates when clinical improvement did not occur after standard treatment. Surgical lung biopsy may reveal a specific diagnosis that requires distinct treatment, and it would probably have an impact in lowering the mortality of these patients.

INTRODUÇÃO: A biópsia pulmonar cirúrgica é um procedimento invasivo executado quando outros procedimentos não forneceram um diagnóstico urgente e específico; no entanto, pode haver relutância em sua execução em pacientes críticos, que apresentam infiltrados pulmonares difusos. OBJETIVO: Avaliar a acurácia diagnóstica, mudanças na terapêutica e a sobrevida de pacientes com infiltrado pulmonar difuso, em sua maior parte apresentando a insuficiência respiratória aguda, submetidos a biópsia cirúrgica. MÉTODO: Foram examinados retrospectivamente registros médicos e biópsias pulmonares cirúrgicas de 63 pacientes maiores de 18 anos de idade, com infiltrados difusos, entre 1982 a 2003. Os diagnósticos clínicos foram comparados aos histopatológicos, de biópsias e de autópsias. Dados laboratoriais e epidemiológicos foram avaliados e sua correlação com a sobrevida hospitalar analisada. RESULTADOS: Todos os espécimes histológicos exibiram alterações, em sua maior parte de natureza benigna/inflamatória. Em quinze casos o fator etiológico pôde ser determinado na biópsia, sendo o Mycobacterium tuberculosis o mais freqüente. O diagnóstico pré-operatório foi mudado em 37 pacientes. Autópsias foram realizadas em 25 pacientes e confirmaram resultados da biópsia em 72 por cento. A terapêutica foi alterada em 65 por cento dos pacientes com base nos resultados da biópsia. Quarenta e nove por cento dos pacientes sobreviveram ao final do período de hospitalização. Características que diferiram significativamente entre sobreviventes versus não sobreviventes incluíram sexo (p=0.05), a presença de comorbidade (p=0.05), a SatO2 (p=0.05), e a presença de dano alveolar difuso na biópsia (p=0.004). CONCLUSÃO: A biópsia pulmonar cirúrgica forneceu um diagnóstico etiológico específico e exato em muitos pacientes com infiltrados pulmonares difusos quando a melhora clínica não ocorreu após o tratamento padrão. A biópsia pulmonar cirúrgica pode fornecer diagnósticos que requerem tratamentos específicos, com provável impacto na redução do índice de mortalidade destes pacientes.

Usual Interstitial Pneumonia and Non-Specific Interstitial Pneumonia: Serial Thin-Section CT Findings Correlated with Pulmonary Function

OBJECTIVE: We wanted to demonstrate and compare the serial high-resolution CTs (HRCT) and the pulmonary function test (PFT) findings of the usual interstitial pneumonia (UIP) and the non-specific interstitial pneumonia (NSIP). MATERIALS AND METHODS: The serial HRCT scans and the PFT results were retrospectively analysed and compared for 35 patients having UIP without significant honeycombing (UIP-w/o hc, or = 5% of honeycombing), and 25 patients with NSIP. The mortality rates were also compared. Follow-up CT scans were available in 75 patients (29 UIP-w/o hc patients, 22 UIP-w/i hc patients and 24 NSIP patients) and the follow-up periods ranged from 150 to 2, 370 days. The initial and follow-up PFT data were available for 71 patients. RESULTS: On the initial CT, significant differences were present between the UIP-w/i hc patients and both the UIP-w/o hc patients and the NSIP patients in the overall extent, ground-glass opacity (GGO) away from the reticulation, reticulation and honeycombing (all p < 0.05). Improvement was noticed in five (17%) of 29 UIP-w/o hc patients, none of 22 UIP-w/i hc patients, and 9 (37%) of 24 NSIP patients; deterioration was noted in six (21%) UIP-w/o hc patients, two (9%) UIP-w/i hc patients and three (13%) NSIP patients (p = 0.044 between UIP-w/o and UIP-w/i hc; p = 0.637 between UIP-w/o hc and NSIP; p = 0.007 between UIP-w/i hc and NSIP). The serial changes of the pulmonary function in the NSIP patients were different from those noted for the UIP-w/i hc and UIP-w/o hc patients (p = 0.440 between UIP-w/o and UIP-w/i hc; p = 0.022 between UIP-w/o hc and NSIP; p = 0.003 between UIP-w/i hc and NSIP). Five (14%) of the 35 patients with UIP-w/o hc, 16 (46%) of the 35 patients with UIP-w/i hc and three (12%) of the 25 patients with NSIP died (p = 0.002, comparison for the three groups). CONCLUSION: On CT, NSIP and UIP-w/o hc patients have similar patterns of parenchymal abnormalities and a similar likelihood of change in the extent of disease on follow-up. Patients with UIP-w/i hc have distinctive features and a worst prognosis.

Enfermedad pulmonar intersticial difusa (EPID) en Colombia

Las EPID, aunque no muy comunes, son más frecuentes en Colombia de lo que en principio se piensa. Las condiciones locales, sin duda, influyen en su distribución y frecuencia y justifican su investigación en nuestro medio. Dadas las características de presentación y los métodos necesarios para el diagnóstico de las EPID, es necesaria la intervención del neumonologo en la mayoría de los casos. La cooperación interdisciplinaria permitirá conocer mejor el espectro de las EPID en nuestros país.