Calcificaciones pulmonares metastásicas, 3 casos clínicos / Metastatic pulmonary calcifications: three clinical cases

Las calcificaciones pulmonares metastásicas, hacen referencia a una enfermedad metabólica, caracterizada por depósitos de calcio en tejido pulmonar sano. La etiología es amplia e incluye enfermedades malignas y benignas, siendo la falla renal la causa más frecuente. Es una condición, que, a pesar de ser frecuente, suele ser subdiagnosticada, por presentar pocos o ningún síntoma. Presentamos tres casos clínicos asociados a enfermedad renal crónica, pre y post trasplante.

Metastatic pulmonary calcifications refer to a metabolic disease, characterized by calcium deposits in healthy lung tissue. The etiology is broad and includes malignant and benign diseases, the kidney failure being the most frequent cause. It is a condition, which, despite being frequent, is usually underdiagnosed, because it presents few or no symptoms. We present three clinical cases associated with pre- and post-transplant kidney disease.

Associação entre comprometimento pulmonar, fatores de risco e desfechos em pacientes com covid-19 atendidos em hospital de referência na Paraíba / Association between lung involvement, risk factors and outcomes in COVID-19 patients treated at a reference hospital in Paraíba

Objetivo: Avaliar a associação entre o grau de comprometimento pulmonar (CP) na TC de tórax dos pacientes com COVID-19 com fatores de risco e desfechos. Métodos: Estudo observacional e retrospectivo com 284 pacientes com COVID-19. Avaliou-se idade, sexo, quadro clínico, saturação na admissão, fatores de risco, tempo de sinto-mas, porcentagem de CP, tempo de internação em enfermaria, UTI e de IOT, e óbito. Foram divididos três grupos conforme o grau de CP. Resultados: 167 pacientes possuíam comprometimento <25%; 80, 25-50%; e 37, >50%. O grupo com maior comprometimento pulmonar possuía maior idade, mais homens e maior presença de tosse, dispneia e alguma comorbidade. Também apresentou menor saturação à admissão, maior necessidade de IOT, in-ternação em enfermaria ou UTI e maior mortalidade. O CP, IOT e idade foram fatores preditores de mortalidade.Conclusões: O grau de CP aparenta estar significativamente associado a alguns parâmetros clínicos, necessidade de internação, intubação e óbito (AU)

Objective: To assess the association between the degree of lung involvement (LI) on chest CT scans of COVID-19 patients, risk factors and outcomes. Methods: Observational and retrospective study of 284 COVID-19 patients. Age, sex, clinical presentation, oxygen saturation on admission, risk factors, time after symptom onset, percentage of LI, length of stay in ward and ICU, duration of ETI, and death were assessed. 3 groups were created according to the LI. Results: 167 patients had an involvement of <25%; 80, 25-50%; and 37, >50%. The group with gre-ater LI was older, had more males and a higher incidence of cough, dyspnea and some comorbidity. Moreover, the group with greater LI had lower saturation on admission, more ETI, more admissions to the ward or ICU, and higher mortality. LI, ETI and age were predictors of mortality. Conclusion: The degree of LI appears to be significantly associated with some clinical parameters, need for hospitalization, intubation, and death (AU)

Utilidad de los estudios de función pulmonar en el niño / Utility of lung function tests in children

Pulmonary function testing in children includes a large number of methods and aspects. Children constitute a very heterogeneous group of individuals, among which are non-collaborative infants and preschoolers who represent a challenge in the development of new methods that do not require collaboration or coordination. This review attempts to achieve a comprehensive approach to pulmonary function tests in children that allow the physician working in pediatrics to get to know: their pathophysiological bases; the reasons for a request for a pulmonary function test taking into account the underlying pathophysiological process that is suspected; the study procedures; the possible clinical findings and their interpretation; the advantages and limitations of several of the tests. Information related to spirometry is developed more specifically, since it is the most widespread, accessible and widely validated methods.

El estudio de la función pulmonar (FP) en niños abarca un gran número de métodos y aspectos. La edad pediátrica en sí constituye un grupo muy heterogéneo de individuos, entre los que se encuentran los de edades más tempranas que son no colaborativos y que representan un desafío en el desarrollo de nuevos métodos que no requieran colaboración ni coordinación. En esta revisión se describirá un enfoque integral de los estudios de FP más utilizados en niños. Se mencionan sus bases fisiopatológicas; los motivos de un pedido de estudio de FP teniendo en cuenta el proceso fisiopatológico subyacente que se sospecha; los posibles hallazgos clínicos y su interpretación y las ventajas y limitaciones de varios de los test.

Fisioterapia aquática em indivíduos com distrofia muscular: uma revisão sistemática do tipo escopo / Fisioterapia acuática en individuos con distrofia muscular: una revisión sistemática de alcance / Aquatic physical therapy in individuals with muscular dystrophy: systematic scoping review

RESUMO O objetivo deste estudo foi mapear o uso da fisioterapia aquática em indivíduos com distrofias musculares, de forma a caracterizar as intervenções no meio aquático e identificar componentes mensurados (variáveis estudadas e instrumentos utilizados nos estudos). A revisão sistemática do tipo de escopo incluiu estudos experimentais, descritivos e observacionais (em inglês, português e espanhol). As buscas foram realizadas nas plataformas Medline (PubMed), CINAHL, Embase, PEDro, Lilacs, ERIC, Scopus, Web of Science e Google Scholar. Os dados extraídos foram alocados em três categorias: (1) caracterização dos registros, (2) informações referentes a fisioterapia aquática e (3) componentes mensurados. Foram encontrados 556 registros e, destes, selecionados 20. As amostras dos estudos selecionados incluíram, na maioria, indivíduos com distrofia muscular de Duchenne, com idade entre 5 e 22 anos, que fizeram fisioterapia aquática com duração média de 45 minutos uma ou duas vezes por semana, por 21 semanas. Essas características corroboram estudos feitos em diferentes populações. A maioria dos estudos investigou alterações pulmonares e controle postural/desempenho funcional, poucos avaliaram os efeitos no sistema cardíaco. Recomenda-se usar a Egen Klassifikation, a North Star Ambulatory Assessment e fazer o teste de caminhada de seis minutos.

RESUMEN El presente estudio tuvo el objetivo de mapear la práctica de fisioterapia acuática por individuos con distrofias musculares, para caracterizar las intervenciones en el medio acuático e identificar los componentes medidos (variables estudiadas e instrumentos utilizados en los estudios). La revisión sistemática de alcance incluyó estudios experimentales, descriptivos y observacionales (en inglés, portugués y español). Se llevaron a cabo las búsquedas en Medline (PubMed), CINAHL, Embase, PEDro, Lilacs, ERIC, Scopus, Web of Science y Google Scholar. Los datos obtenidos se asignaron en tres categorías: (1) caracterización de registros; (2) informaciones sobre fisioterapia acuática; y (3) componentes medidos. Se encontraron 556 registros, de los cuales se seleccionaron 20. Las muestras de los estudios seleccionados incluyeron mayoritariamente a individuos con distrofia muscular de Duchenne, con edades entre 5 y 22 años, y que se habían sometido a sesiones de fisioterapia acuática con un promedio de duración de 45 minutos, una o dos veces por semana, durante 21 semanas. Estas características confirman estudios realizados con diferentes poblaciones. La mayoría de los estudios han investigado las alteraciones pulmonares y el control postural/rendimiento funcional, pero pocos han evaluado los efectos sobre el sistema cardíaco. Se recomienda emplear la Egen Klassifikation, la North Star Ambulatory Assessment y aplicar la prueba de caminata de seis minutos.

ABSTRACT The aim of this study is to map the use of aquatic physical therapy in individuals with muscular dystrophy, to characterize aquatic physical therapy intervention and identify measured components (variables and measurement instruments used) by the studies. A systematic scoping review included experimental, descriptive and observational studies (in English, Portuguese and Spanish languages). The searches were carried out on MEDLINE (PubMed), CINAHL, Embase, PEDro, Lilacs, ERIC, Scopus, Web of Science, Google Scholar. The extracted data were characterized into three categories: (1) characterization of the records, (2) information referring to aquatic physical therapy, and (3) measured components. There were 556 studies records and 20 records were selected. The studies samples included mostly individuals with Duchenne muscular dystrophy, aged between 5 and 22 years old. Aquatic physical therapy sessions lasted about 45 minutes, and one or two sessions per week were carried out for 21 weeks. That corroborates studies conducted in different populations. Most of the studies investigated pulmonary system and postural control/ functional ability, and a few studies evaluated cardiac system. Egen Klassifikation and North Star Ambulatory Assessment are recommended, and also to perform 6-minute walk test.

Spirometry results after treatment for pulmonary tuberculosis: comparison between patients with and without previous lung disease: a multicenter study / Comparação entre os resultados de espirometria após tratamento para tuberculose pulmonar em pacientes com e sem doença pulmonar prévia: um estudo multicêntrico

ABSTRACT Objective: To compare patients with and without previous lung disease, in terms of the spirometry results after they had been treated for pulmonary tuberculosis (PTB) and cured, as well as to analyze risk factors related to functional severity. Methods: This was a cross-sectional, multicenter study conducted at four referral centers in Brazil. Patients were divided into two groups: those with a history of lung disease or smoking (LDS+ group); and those with no such history (LDS− group). Patients underwent spirometry (at least six months after being cured). Sociodemographic and clinical data were collected. Results: A total of 378 patients were included: 174 (46.1%) in the LDS+ group and 204 (53.9%) in the LDS− group. In the sample as a whole, 238 patients (62.7%) had spirometric changes. In the LDS+ group, there was a predominance of obstructive lung disease (in 33.3%), whereas restrictive lung disease predominated in the LDS− group (in 24.7%). Radiological changes were less common in the LDS− group than in the LDS+ group (p < 0.01), as were functional changes (p < 0.05). However, of the 140 (79.1%) LDS− group patients with a normal or minimally altered chest X-ray, 76 (54%) had functional changes (p < 0.01). The risk factors associated with functional severity in the LDS− group were degree of dyspnea (p = 0.03) and moderate or severe radiological changes (p = 0.01). Conclusions: Impaired pulmonary function is common after treatment for PTB, regardless of the history of lung disease or smoking. Spirometry should be suggested for patients who develop moderate/severe dyspnea or relevant radiological changes after treatment for PTB.

RESUMO Objetivo: Comparar os resultados da espirometria de pacientes tratados e curados para tuberculose pulmonar (TBP) com e sem doença pulmonar prévia e analisar os fatores de risco relacionados à gravidade funcional. Métodos: Estudo transversal, multicêntrico, em quatro centros de referência no Brasil. Os pacientes foram classificados em dois grupos: grupo com doença pulmonar prévia ou história de tabagismo (grupo DPT+) e grupo sem doença pulmonar prévia e sem tabagismo (grupo DPT−). Os pacientes realizaram espirometria (pelo menos seis meses após a cura), e foram coletados dados sociodemográficos e clínicos. Resultados: Foram incluídos 378 pacientes: 174 (46,1%) no grupo DPT+ e 204 (53,9%) no grupo DPT−. Na amostra total, 238 pacientes (62,7%) apresentaram alguma alteração espirométrica. No grupo DPT+ houve predominância de distúrbio ventilatório obstrutivo (em 33,3%), e distúrbio ventilatório restritivo predominou no grupo DPT− (em 24,7%). Quando comparados com o grupo DPT+, os pacientes do grupo DPT− apresentaram menos frequentemente alteração radiológica (p < 0,01) e funcional (p < 0,05). Porém, dos 140 (79,1%) do grupo DPT− com radiografia de tórax normal ou minimamente alterada, 76 (54%) apresentaram alguma alteração funcional (p < 0,01). Os fatores de risco relacionados com a gravidade funcional no grupo DPT− foram grau de dispneia (p = 0,03) e alterações radiológicas moderadas ou acentuadas. Conclusões: O comprometimento da função pulmonar é frequente após o tratamento da TBP independentemente do histórico de tabagismo ou doença pulmonar prévia. A espirometria deve ser sugerida para esses pacientes que evoluem com grau moderado/grave de dispneia e/ou alteração radiológica relevante após o tratamento da TBP.

Tratamiento de la discinecia ciliar primaria / Treatmen of ciliary primary discinesia

At present, there is no specific treatment for primary ciliary dyskinesia, nor controlled and randomized clinical trials to determine how the management and monitoring of these patients should be considered. The therapeutic options are extrapolated from other diseases, such as cystic fibrosis, or non-cystic fibrosis bronchiectasis. However, the implementation of specific groups of experts, both in the USA (PDC-foundation) and in Europe (BESTCILIA or BEAT-PD), are helping to increase knowledge of the disease, opening research channels and seeking new treatments. Until we have therapies capable of correcting the basic defect of the disease, the pillars of treatment are the daily cleansing of the airways and aggressive antibiotherapy against respiratory infections. Multidisciplinary care in specialized centers where pulmonary function is monitored and the infection is prevented and treated will improve, as in cystic fibrosis, the results of patients.

En la actualidad no existe un tratamiento específico para la discinesia ciliar primaria, ni se cuenta con ensayos clínicos controlados y randomizados que permitan determinar cómo debe plantearse el manejo y seguimiento de estos pacientes. Las opciones terapéuticas son extrapoladas de otras enfermedades, como la fibrosis quística, o las bronquiectasias no fibrosis quística. Sin embargo, la puesta en marcha de grupos específicos de expertos, tanto en USA (PDC-foundation) como en Europa (BESTCILIA o BEAT-PD), están permitiendo incrementar el conocimiento de la enfermedad, abriendo vías de investigación y buscando nuevos tratamientos. Hasta contar con terapias capaces de corregir el defecto básico de la enfermedad, los pilares del tratamiento son la limpieza diaria de las vías aéreas y la antibioterapia agresiva frente a las infecciones respiratorias. La atención multidisciplinar en centros especializados donde se monitorice la función pulmonar y se prevengan y traten las infecciones mejorará, como en la fibrosis quística, los resultados de los pacientes.

Actualización en espirometría en el preescolar / Preeschools spirometry update

Spirometry is better pulmonary function test for evaluating preschoolers with chronic lung disease and recurrent wheeze. It is useful, accessible and very good performance. For a correct interpretation it must be under the conditions specially controlled for this age group. In this review, product of the work done during the year 2018, by the Committee on pulmonary function in pediatric pulmonology Chilean society, will be showcased aspects for the realization and interpretation of spirometry in preschool children, with emphasis on the differences in the criteria typically described for older children and adults.

La espirometría es la prueba de función pulmonar más adecuada para evaluar a preescolares con enfermedades pulmonares crónicas y sibilancias recurrentes. Es útil, accesible y de buen rendimiento. Para una correcta interpretación debe realizarse bajo las condiciones especialmente normadas para este grupo etario. En esta revisión, producto del trabajo realizado durante el año 2018, por la comisión de función pulmonar de la sociedad Chilena de Neumología Pediátrica, se expondrán los aspectos actualizados para la realización e interpretación de la espirometría en preescolares, con énfasis en las diferencias de los criterios clásicamente descritos para niños mayores y adultos.

Mecanismos de los efectos nocivos para la salud de la contaminación atmosférica proveniente de incendios forestales / Mechanisms of noxious effects of wildfire air pollution over human health

Los incendios forestales representan un problema creciente de la salud pública a nivel mundial, especialmente para la población más vulnerable (niños, ancianos, embarazadas y portadores de enfermedades cardiovasculares o respiratorias crónicas) expuesta al humo y a otros contaminantes aéreos. A diferencia de la contaminación atmosférica habitual de grandes urbes, aquella derivada de los incendios forestales tiene una composición diferente y su ocurrencia es esporádica y difícil de prever. La exposición a contaminantes atmosféricos derivados de incendios forestales se asocia a aumento de la morbilidad respiratoria y cardiovascular, mediada por una respuesta inflamatoria pulmonar y sistémica, estrés oxidativo y disfunción endotelial. En sujetos expuestos a humo de incendios forestales se ha observado un aumento en la producción de citoquinas pro-inflamatorias, activación endotelial y disfunción del sistema nervioso autónomo, que produce daño tisular, aumento de los mecanismos protrombóticos, aumento de la presión arterial y cambios en el ritmo cardiaco. Esta revisión analiza los mecanismos que han sido involucrados en generar efectos nocivos para la salud de seres humanos expuestos a material particulado y gases emanados de incendios forestales.

Wildfires represent a growing global public health issue, especially to the most vulnerable segment of the population (children, old people, pregnant women, patients with cardiovascular or respiratory diseases) exposed to smoke and other air borne contaminants generated from these events. In contrast to great cities ' usual atmospheric pollution, that derives from forest fires differ in composition and its occurrence is sporadic and usually unpredictable. Exposure to atmospheric pollutants derived from forest fires has been associated to increased respiratory and cardiovascular morbidity, mediated by an inflammatory systemic response, oxidative stress and endothelial dysfunction. In people exposed to forest fire smoke an increased production of pro-inflammatory cytokines, endothelial activation and autonomic nervous system dysfunction has been observed, that leads to tissue injury, increased prothrombotic response, increased blood pressure and changes in heart rhythm. This review analyzes the mechanisms that have been involved in generating harmful health effects in humans exposed to inhaled particulate matter and gases steaming from wildfires.

Frecuencia, tipo y predictores de complicaciones pleuropulmonares en los primeros treinta días del postoperatorio de pacientes pediátricos intervenidos de cirugía cardiovascular sin apoyo de circulación extracorpórea / Frequency and type of pleuropulmonary complications and their predictors during the first thirty days after cardiopulmonary bypass surgery in children

Resumen Objetivo: Determinar la frecuencia, tipo y predictores de complicaciones pleuropulmonares en los primeros 30 días de postoperatorio de pacientes intervenidos de cirugía cardiovascular sin apoyo de circulación extracorpórea. Métodos: Se realizó un estudio de cohorte retrospectivo durante el periodo comprendido del 1 de enero de 2013 al 31 de diciembre 2014. Incluyó a todos los pacientes portadores de cardiopatías congénitas intervenidos de cirugía cardiaca con abordaje esternal o torácico, sin soporte de circulación extracorpórea con ingreso registrado a Unidad de Cuidados Intensivos del Hospital de Pediatría del Centro Médico Nacional Siglo XXI, IMSS. Se cuantificó la frecuencia de eventos de las complicaciones pleuropulmonares y se realizó un análisis multivariado de regresión logística para identificar los factores de riesgo asociados a complicaciones pleuropulmonares, calculándose odds ratio (OR) e intervalos de confianza al 95% (IC 95%). Resultados: Se incluyeron un total de 139 pacientes, en los cuales la frecuencia de complicaciones pleuropulmonares fue del 42.4% (n = 59), y los tipos más frecuentes fueron atelectasia (28 eventos), neumonía asociada a ventilador (24 eventos), neumotórax (20 eventos), pudiéndose encontrar más de una complicación por paciente. Los predictores más significativos de complicaciones pleuropulmonares fueron las cardiopatías congénitas cianógenas (OR = 3.58; IC 95%: 1.10-7.50; p = 0.001), el abordaje por toracotomía (OR = 1.46; IC 95%: 1.18-1.12; p = 0.008) y el evento quirúrgico realizado de urgencia (OR = 3.46; IC 95%: 1.51-7.95; p = 0.002). Conclusiones: La principal complicación pleuropulmonar fue la atelectasia lo cual concuerda con lo reportado en la literatura internacional. Los pacientes que presenten alguno de los predictores identificados en el presente estudio deben ser monitorizados de manera especial para prevenir, detectar y/o tratar oportunamente las complicaciones pleuropulmonares tras cirugía cardiaca.

Abstract Objective: To determine the frequency and type of pleuropulmonary complications and their predictors in the first thirty postoperative days of patients undergoing surgery without cardiopulmonary bypass. Methods: A retrospective cohort study was carried out between January 2013 and December 2014. It included all patients with congenital heart disease who underwent cardiac surgery using a sternal or thoracic approach, without cardiopulmonary bypass with a registered admission to a Neonatal or Paediatric Intensive Care. The frequency of events of pleuropulmonary complications and logistic regression analysis was performed, and the adjusted odds ratio (OR) and confidence intervals at 95% (95% CI) were calculated. Results: A total of 139 patients were included. The frequency of pleuropulmonary complications was 42.4% (N = 59), and the most frequent types were atelectasis (28 events), ventilator-associated pneumonia (24 events), pneumothorax (20 events), with more than one complication per patient occasionally being found. Significant risk factors were cyanogenic congenital heart disease (OR = 3.58, 95% CI: 1.10-7.50, P =.001), thoracotomy approach (OR = 1.46, 95% CI: 1.18-1.12, P = .008), and an emergency surgical event (OR = 3.46, 95% CI: 1.51-7.95, P = .002). Conclusions: The main pleuropulmonary complication was atelectasis, which is consistent with that reported in the international literature. Patients with any of the predictors identified in the present study should be closely monitored in order to prevent, detect and/or treat pleuropulmonary complications in a timely manner after cardiac surgery.

O papel do gradiente pressórico transdiafragmático na fisiopatologia da doença do refluxo gastroesofágico / The role of the transdiaphragmatic pressure gradient in the pathophysiology of gastroesophageal reflux disease

ABSTRACT Gastroesophageal reflux disease (GERD) is the most common disease of the upper gastrointestinal tract in the Western world. GERD pathophysiology is multifactorial. Different mechanisms may contribute to GERD including an increase in the transdiaphragmatic pressure gradient (TPG). The pathophysiology of GERD linked to TPG is not entirely understood. This review shows that TPG is an important contributor to GERD even when an intact esophagogastric barrier is present in the setting of obesity and pulmonary diseases.

RESUMO A doença do refluxo gastroesofágico (DRGE) é a enfermidade mais comum do trato digestivo alto no mundo ocidental. A fisiopatologia da DRGE é multifatorial. Diferentes mecanismos podem contribuir para um aumento do gradiente pressórico transdiafragmático (GPT). A fisiopatologia da DRGE associada ao GPT não é totalmente compreendida. Esta revisão enfoca que o GPT é um importante contribuinte para DRGE mesmo na presença de uma barreira gastroesofágica intacta como na obesidade e doenças pulmonares crônicas.

Use of cardiopulmonary exercise testing to assess early ventilatory changes related to occupational particulate matter

Spirometry has been used as the main strategy for assessing ventilatory changes related to occupational exposure to particulate matter (OEPM). However, in some cases, as one of its limitations, it may not be sensitive enough to show abnormalities before extensive damage, as seen in restrictive lung diseases. Therefore, we hypothesized that cardiopulmonary exercise testing (CPET) may be better than spirometry to detect early ventilatory impairment caused by OEPM. We selected 135 male workers with at least one year of exposure. After collection of self-reported socioeconomic status, educational level, and cardiovascular risk data, participants underwent spirometry, CPET, body composition assessment (bioelectrical impedance), and triaxial accelerometry (for level of physical activity in daily life). CPET was performed using a ramp protocol on a treadmill. Metabolic, cardiovascular, ventilatory, and submaximal relationships were measured. We compared 52 exposed to 83 non-exposed workers. Multiple linear regressions were developed using spirometry and CPET variables as outcomes and OEPM as the main predictor, and adjusted by the main covariates. Our results showed that OEPM was associated with significant reductions in peak minute ventilation, peak tidal volume, and breathing reserve index. Exposed participants presented shallower slope of ΔVT/ΔlnV̇E (breathing pattern), i.e., increased tachypneic breathing pattern. The OEPM explained 7.4% of the ΔVT/ΔlnV̇E variability. We found no significant influence of spirometric indices after multiple linear regressions. We conclude that CPET might be a more sensitive feature of assessing early pulmonary impairment related to OEPM. Our cross-sectional results suggested that CPET is a promising tool for the screening of asymptomatic male workers.

A study of pulmonary function in end-stage renal disease patients on hemodialysis: a cross-sectional study

ABSTRACT BACKGROUND: The aim here was to study acute effects of hemodialysis among end-stage renal disease (ESRD) patients. DESIGN AND SETTING: Prospective study in tertiary-level care center. METHODS: Fifty ESRD patients undergoing hemodialysis were studied. Spirometric pulmonary function tests were performed before and after four-hour hemodialysis sessions. RESULTS: The patients' average age was 45.8 ± 10.0 years; 64% were males and 64% had normal body mass index. Anemia (94%) and hypoalbuminemia (72%) were common. Diabetes mellitus (68%), hypertension (34%) and coronary artery disease (18%) were major comorbidities. Forty-five patients (90%) had been on hemodialysis for six months to three years. The patients' pre-dialysis mean forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) were below normal: 45.8 ± 24.9% and 43.5 ± 25.9% of predicted, respectively. After hemodialysis, these increased significantly, to 51.1 ± 23.4% and 49.3 ± 25.5% of predicted, respectively (P < 0.01). The increase in mean FEV1/FVC, from 97.8 ± 20.8% to 99.3 ± 20.1% of predicted, was not significant (P > 0.05). The pre-dialysis mean forced expiratory flow 25-75% was 50.1 ± 31% and increased significantly, to 56.3 ± 31.6% of predicted (P < 0.05). The mean peak expiratory flow was below normal (43.8 ± 30.7%) and increased significantly, to 49.1 ± 29.9% of predicted (P < 0.05). Males and females showed similar directions of change after hemodialysis. CONCLUSIONS: Pulmonary function abnormalities are common among ESRD patients. Comparison of pre and post-hemodialysis parameters showed significant improvements, but normal predicted values were still not achieved.

Cardiopulmonary Exercise Test: Background, Applicability and Interpretation / Teste Cardiopulmonar de Exercício: Fundamentos, Aplicabilidade e Interpretação

ABSTRACT Cardiopulmonary exercise test (CPET) has been gaining importance as a method of functional assessment in Brazil and worldwide. In its most frequent applications, CPET consists in applying a gradually increasing intensity exercise until exhaustion or until the appearance of limiting symptoms and/or signs. The following parameters are measured: ventilation; oxygen consumption (VO2); carbon dioxide production (VCO2); and the other variables of conventional exercise testing. In addition, in specific situations, pulse oximetry and flow-volume loops during and after exertion are measured. The CPET provides joint data analysis that allows complete assessment of the cardiovascular, respiratory, muscular and metabolic systems during exertion, being considered gold standard for cardiorespiratory functional assessment.1-6 The CPET allows defining mechanisms related to low functional capacity that can cause symptoms, such as dyspnea, and correlate them with changes in the cardiovascular, pulmonary and skeletal muscle systems. Furthermore, it can be used to provide the prognostic assessment of patients with heart or lung diseases, and in the preoperative period, in addition to aiding in a more careful exercise prescription to healthy subjects, athletes and patients with heart or lung diseases. Similarly to CPET clinical use, its research also increases, with the publication of several scientific contributions from Brazilian researchers in high-impact journals. Therefore, this study aimed at providing a comprehensive review on the applicability of CPET to different clinical situations, in addition to serving as a practical guide for the interpretation of that test.

RESUMO O teste cardiopulmonar de exercício (TCPE) vem ganhando importância crescente como método de avaliação funcional tanto no Brasil quanto no Mundo. Nas suas aplicações mais frequentes, o teste consiste em submeter o indivíduo a um exercício de intensidade gradativamente crescente até a exaustão ou o surgimento de sintomas e/ou sinais limitantes. Neste exame se mensura a ventilação (VE), o consumo de oxigênio (VO2), a produção de gás carbônico (VCO2) e as demais variáveis de um teste de exercício convencional. Adicionalmente, podem ser verificadas, em situações específicas, a oximetria de pulso e as alças fluxo-volume antes, durante e após o esforço. A análise integrada dos dados permite a completa avaliação dos sistemas cardiovascular, respiratório, muscular e metabólico no esforço, sendo considerado padrão-ouro na avaliação funcional cardiorrespiratória.1-6 O TCPE permite definir mecanismos relacionados à baixa capacidade funcional, os quais podem ser causadores de sintomas como a dispneia, correlacionando-os com alterações dos sistemas cardiovascular, pulmonar e musculoesquelético. Também pode ser de grande aplicabilidade na avaliação prognóstica em cardiopatas, pneumopatas e em pré-operatório, além de auxiliar na prescrição mais criteriosa do exercício em sujeitos normais, em atletas, em cardiopatas e em pneumopatas. Assim como ocorre com o uso clínico, a pesquisa nesse campo também cresce e várias contribuições científicas de pesquisadores nacionais são publicadas em periódicos de alto fator de impacto. Sendo assim, o objetivo deste documento é fornecer uma revisão ampla da aplicabilidade do TCPE nas diferentes situações clínicas, bem como servir como guia prático na interpretação desse teste propedêutico.

Hemorragia alveolar difusa, desafío diagnóstico y terapéutico / Diffuse alveolar hemorrhage: a diagnostic and therapeutic challenge

Diffuse alveolar hemorrhage is a syndrome causing catastrophic respiratory failure, secondary to pathophysiological processes within the natural history of a variety of diseases and clinical conditions. Should be considered a medical emergency due to the significant morbidity and mortality associated. It represents a diagnostic challenge because symptoms and signs are often nonspecific. It requires a highlevel of suspicion to early recognition, essential step towards the establishment of supportive measures and specific therapy for survival.

La hemorragia alveolar difusa es un síndrome causante de falla respiratoria catastrófica, secundario a los procesos fisiopatológicos presentes en la historia natural de varias enfermedades y condiciones clínicas. Debe considerarse como una emergencia médica debido a la significativa morbi-mortalidad asociada. Representa un desafío diagnóstico ya que a menudo los síntomas y signos son inespecíficos, requiere un alto nivel de sospecha para el reconocimiento precoz, paso esencial para la instauración de medidas de soporte vital y terapia específica requerida para la sobrevida.

Índice de aclaramiento pulmonar en pediatría / Lung clearance index

The rate of lung clearance is a measure of the ventilation inhomogeneity determined during multiple breath washout (MBW). Higher values of lung clearance index (LCI) indicate greater ventilation inhomogeneity. The test is performed during tidal breathing, needs little cooperation and coordination, and can be done in all age groups. Different tracer gases can be used; the most common are gas nitrogen as resident gas and sulfohexafluoride (SF6) as an exogenous gas.LCI has been used in various pediatric diseases, such as asthma, bronchopulmonary dysplasia and especially in patients with cystic fibrosis (CF), where high LCI values had been a more sensitive tool that spirometry to detect the early disease and bronchiectasis. It has also been used to monitor the progression of early lung disease, since the value of LCI in preschoolers predicted FEV1 in children of school age. Finally, in patients older than 6 years LCI has proven to be a useful tool to assess response to interventions in patients with normal lung function test. In conclusion the use of LCI is very promising in CF patients with early stages of the disease, and in the clinical monitoring of patients with CF. Its role in other respiratory diseases such as asthma, is still to be determined.

El índice de aclaramiento de pulmón (LCI) es una medida de la falta de homogeneidad de ventilación determinado durante el lavado pulmonar de múltiples respiraciones (MBW). Los valores más altos de LCI indican mayor inhomogeneidad de ventilación. La prueba se realiza durante respiración corriente y necesita poca cooperación y coordinación, por lo que se puede realizar en todos los grupos de edad. Pueden utilizarse diferentes gases trazadores; los más comunes son el nitrógeno como gas residente y sulfohexafluoride (SF6) como gas exógeno.LCI ha sido utilizado en diferentes enfermedades en pediatría, tales como asma, displasia broncopulmonar y especialmente fibrosis quística (FQ). En esta última los valores elevados de LCI son una herramienta más sensible quela espirometría para la detección de la enfermedad pulmonar precoz y bronquiectasias. También ha sido utilizado para monitorizar la progresión de la enfermedad pulmonar, ya que el valor de LCI en los niños en edad preescolar predice el VEF1 en edad escolar. Finalmente en pacientes mayores de 6 años LCI ha demostrado ser una herramienta útil para evaluarla respuesta a intervenciones en pacientes con función pulmonar normal. En conclusión el uso de LCI es muy prometedor en pacientes con FQ en etapa precoz de la enfermedad, su rolen el monitoreo clínico de los pacientes con FQ. En otras enfermedades de las vías respiratorias, como el asma, esto aún está por definirse.

Cánula nasal de alto flujo en lactantes: experiencia en una unidad de paciente crítico / High flow nasal cannula in infants: Experience in a critical patient unit

Introducción: La cánula nasal de alto flujo (CNAF) es un método de soporte respiratorio cada vez más utilizado en pediatría por sus resultados y seguridad. Objetivo: Determinar la efectividad de la CNAF, evaluar factores asociados a fracaso y complicaciones relacionadas con su uso en lactantes. Pacientes y método: Se analizaron los datos demográficos, clínicos, gasométricos, radiológicos y complicaciones de los pacientes conectados a CNAF en una unidad crítica entre junio de 2012 y septiembre de 2014. Se compararon los pacientes que fracasaron con los respondedores a CNAF, considerándose fracaso la necesidad de un mayor soporte respiratorio durante las primeras 48 h de conexión. Se utilizó test de Kolmogorov Smirnov, U de Mann-Whitney, Chi cuadrado, test exacto de Fisher, correlaciones y Modelo de regresión logística binaria para p ≤ 0,05. Resultados: Un total de 109 pacientes. Mediana de edad y peso: 1 mes (0,2-20 meses) y 3,7 kg (2-10 kg); percentil 95: 3,7 meses y 5,7 kg respectivamente. El diagnóstico y patrón radiológico más frecuente fue bronquiolitis (53,2%) e infiltrado intersticial (56%). Un 70,6% respondió. Hubo diferencia significativa entre fracaso y respuesta en el diagnóstico (p = 0,013), radiografía (p = 0,018), contexto de conexión (p < 0,0001), pCO2 (mediana 40,7 mm Hg [15,4-67 mm Hg] versus 47,3 mm Hg [28,6-71,3 mm Hg], p = 0,004) y horas de CNAF (mediana 60,75 h [5-621,5 h] versus 10,5 h [1-29 h], p < 0,0001). El OR de PCO2 ≥ 55 mm Hg para fracaso fue 2,97 (IC 95%: 1,08-8,17; p = 0,035). Ningún paciente falleció ni registró complicaciones. Conclusión: El porcentaje de éxito observado fue similar a lo publicado. En esta muestra el fracaso de CNAF solo se asoció a una pCO2 inicial ≥ 55 mm Hg. Su uso se consideró seguro al no reportarse complicaciones relacionadas a su utilización. Se requiere de un estudio multicéntrico, aleatorizado y controlado para contrastar estos resultados.

Introduction: The high flow nasal cannula (HFNC) is a method of respiratory support that is increasingly being used in paediatrics due to its results and safety. Objective: To determine the efficacy of HFNC, as well as to evaluate the factors related to its failure and complications associated with its use in infants. Patients and method: An analysis was performed on the demographic, clinical, blood gas, and radiological data, as well as the complications of patients connected to a HFNC in a critical care unit between June 2012 and September 2014. A comparison was made between the patients who failed and those who responded to HFNC. A failure was considered as the need for further respiratory support during the first 48 hours of connection. The Kolmogorov Smirnov, Mann-Whitney U, chi squared and the Exact Fisher test were used, as well as correlations and a binary logistic regression model for P ≤ .05. Results: The study included 109 patients, with a median age and weight: 1 month (0.2-20 months) and 3.7 kg (2-10 kg); 95 percentile: 3.7 months and 5.7 kg, respectively. The most frequent diagnosis and radiological pattern was bronchiolitis (53.2%) and interstitial infiltration (56%). Around 70.6% responded. There was a significant difference between failure and response in the diagnosis (P = .013), radiography (P = 018), connection context (P < .0001), pCO2 (median 40.7 mmHg [15.4-67 mmHg] versus 47.3 mmHg [28.6-71.3 mmHg], P = .004) and hours on HFNC (median 60.75 hrs [5-621.5 hrs] versus 10.5 hrs [1-29 hrs], P < .0001). The OR of the PCO2 ≥ 55 mmHg for failure was 2.97 (95% CI; 1.08-8.17; P = .035). No patient died and no complications were recorded. Conclusion: The percentage success observed was similar to that published. In this sample, the failure of HFNC was only associated with an initial pCO2 ≥ 55 mmHg. On there being no complications reported as regards it use, it is considered safe, although a randomised, controlled, multicentre study is required to compare and contrast these results.

Effects of home-based respiratory muscle training in children and adolescents with chronic lung disease / Efeitos do treinamento muscular respiratório domiciliar em crianças e adolescentes com doença pulmonar crônica

OBJECTIVE: Respiratory muscle weakness is a functional repercussion of chronic lung disease (CLD). The objective of this study was to assess the effects of home-based respiratory muscle training (RMT) in children and adolescents with CLD or neuromuscular disease (NMD). METHODS: This was a quasi-experimental study involving children and adolescents with CLD or NMD. Before and after 6 months of home-based RMT, we measured respiratory muscle strength (MIP and MEP), PEF, and peak cough flow (PCF). We made statistical comparisons between the pre-RMT and post-RMT values, as well as evaluating the correlation between the duration and effect of RMT. RESULTS: The study included 29 patients, with a mean age of 12 years (range, 5-17 years), of whom 18 (62.1%) were male. The CLD group comprised 11 patients (37.9%), and the NMD group comprised 18 (62.1%). The mean duration of the RMT was 60 weeks (range, 46-90 weeks) in the CLD group and 39 weeks (range, 24-89 weeks) in the NMD group. In comparison with the pre-RMT values, the post-RMT values for MIP and MEP were significantly higher in both groups, whereas those for PEF and PCF were significantly higher only in the NMD group. We found no correlation between the duration and the effect of RMT. CONCLUSIONS: Home-based RMT appears to be an effective strategy for increasing respiratory muscle strength in children and adolescents with CLD or NMD, although it increased the ability to cough effectively only in those with NMD. .

OBJETIVO: A fraqueza muscular respiratória é uma repercussão funcional da doença pulmonar crônica (DPC). O objetivo deste estudo foi avaliar os efeitos do treinamento muscular respiratório (TMR) domiciliar em crianças e adolescentes com DPC ou doença neuromuscular (DNM). MÉTODOS: Estudo quasi-experimental com crianças e adolescentes com DPC ou DNM. Foram medidos a força muscular respiratória (PEmáx e PImáx) e o pico de fluxo da tosse (PFT) antes e depois de 6 meses de TMR domiciliar. Foram realizadas comparações estatísticas entre valores pré- e pós-TMR e foram avaliadas as correlações entre a duração e o efeito do TMR. RESULTADOS: Foram incluídos no estudo 29 pacientes, com média de idade de 12 anos (variação, 5-17 anos), dos quais 18 (62,1%) eram meninos. O grupo DPC consistiu em 11 pacientes (37,9%) e o grupo DNM, em 18 (62,1%). A média da duração do TMR foi de 60 semanas (variação, 46-90 semanas) no grupo DPC e de 39 semanas (variação, 24-89 semanas) no grupo DNM. Em comparação com os valores pré-TMR, os valores pós-TMR para PImáx e PEmáx foram significativamente maiores nos dois grupos, enquanto aqueles para PFE e PFT foram significativamente maiores apenas no grupo DNM. Não houve correlações entre a duração e o efeito do TMR. CONCLUSÕES: O TMR domiciliar parece ser uma estratégia eficaz para o aumento da força muscular respiratória em crianças e adolescentes com DPC ou DNM, embora aumente efetivamente a capacidade de tosse somente naqueles com DNM. .

Analysis of pulmonary manifestations in patient infected with plasmodium vivax / Análise das manifestações pulmonares em pacientes infectados por plasmodium vivax

Objective: To evaluate pulmonary manifestations in patients infected with Plasmodium vivax. MethOds: This was a cross- sectional, retrospective study of 50 patients diagnosed in 2006 to 2008 with vivax malaria at the Evandro Chagas Institute and referred to the University Hospital João de Barros Barreto to examine the pulmonary manifestations. Results: 72% of the patients were men, 28% were 21 to 30 years of age, 30% had parasitaemia 50 to 2000 p/mm3, 88%, 94% and 92% of the patients presented respectively with fever, chills and headache respectively, 56% of the patients had cough, 62% felt breathlessness, 28% presented dyspnea and 86% experienced chest pain. COnClusiOn: The majority of patients surveyed had parasitaemia in the range 50 to 2000 p/mm3. The classic triad fever, chills and headache was present in most patients. Among pulmonary manifestations, cough, chest pain and shortness of breath were reported by the majority of patients.(AU)

Objetivo: Analisar as manifestações pulmonares em pacien- tes infectados por Plasmodium vivax. Métodos: Estudo transversal realizado por meio da análise de 50 prontuários de pacientes diagnosticados com malária vivax entre 2006 a 2008, no Instituto Evandro Chagas, e encaminhados para o Hospital Universitário João de Barros Barreto para análise das manifes- tações pulmonares. ResultadOs: Observou-se que 72% dos pacientes eram homens, 28% possuíam de 21 a 30 anos de idade, 30% apresentaram parasitemia de 50 a 2000 p/mm3. Entre as manifestações clínicas, 88%, 94% e 92% dos pacientes apresentaram, respectivamente, febre, calafrio e cefaleia, 56% apresentaram tosse, 62% sentiram falta de ar, 28% dispneia e 86% dor torácica. COnClusãO: A maioria dos pacientes pesquisados apresentou parasitemia no intervalo de 50 a 2000 p/mm3. A tríade clássica da malária esteve presente na maioria, já dentre as manifestações pulmonares pesquisadas, a tosse, a dor torácica e a falta de ar corresponderam aos sintomas mais relatados pelos pacientes.(AU)

Dinámica y patología del barrido mucociliar como mecanismo defensivo del pulmón y alternativas farmacológicas de tratamiento / Mucociliary clearance system in lung defense

The first line of defense to maintain the sterility of the intrapulmonary airways is the mucociliary clearance system. This rapidly responding, non-specific, immune defensive system is challenged by approximately 12,000 liters of air filtered by the lungs each day, containing millions of particles like spores, environmental and eventually toxic pollutants. The main components of this system are the floating mucus "blanket", the underlying mucus propelling cilia with periciliary fluid, and the airway epithelium with secretory and ciliated type of cells. The fine and coordinated regulation of these three components is critical for an effective performance. Deregulation resulting from continuous insults, inherited ion channel disease, infections or abnormal immune response may lead to mucus alterations, goblet cell hyperplasia and metaplasia, airway obstruction, air trapping and chronic lung disease. Options for treatment are limited. Understanding this system may reveal new targets for treatment of lung disease.

El ejercicio físico aumenta el daño pulmonar inducido por la exposición aguda e intermitente a 0, 5 ppm de ozono en ratas juveniles / Physical exercise increases pulmonary damage induced by acute and intermittent exposure to 0.5 ppm of ozone in juvenile rats

El ozono (O3) troposférico es el principal oxidante del esmog fotoquímico. Como es un contaminante aéreo, sus efectos están relacionados con la dosis efectiva = [Concentración] x [tiempo de exposición] x [ventilación minuto]. Objetivo: Determinar si el ejercicio físico -que aumenta la ventilación minuto- puede aumentar el daño pulmonar inducido por la exposición a O3 en ratas en reposo. Material y Métodos: Se usó 4 series de ratas Sprague-Dawley juveniles. Dos series fueron expuestas a 0,5 ppm de O3 (4 h diarias por 2 días) en reposo (n = 13) o durante ejercicio (n = 12). Dos series control respiraron aire filtrado (AF) en reposo (n = 13) o durante sesiones de ejercicio (n = 13), en una rueda vertical giratoria (15 min de ejercicio alternados con 15 min de descanso hasta completar 4 h diarias durante 2 días). Las ratas fueron eutanasiadas y se determinó la razón peso húmedo/peso seco (PH/PS) en el pulmón izquierdo. En el lavado broncoalveolar (LBA) del pulmón derecho, se determinó recuento total de células, proteínas totales y actividad de gamma-glutamiltraspeptidasa (GGT). Resultados: la razón PH/PS y el recuento de células y las proteínas del LBA aumentaron en las ratas en reposo expuestas a O3 comparadas con las ratas en reposo que respiraron AF (p < 0,05 ANOVA & Newman-Keuls). La actividad de GGT en el LBA fue mayor en las ratas que en ejercicio respiraron AF en comparación con las ratas que respiraron AF en reposo (p < 0,05). Hubo aumento de GGT, proteínas y recuento de células en el LBA de la serie [ejercicio + O3] comparada con la serie [reposo + O3] (p < 0,05). Conclusión: El ejercicio físico aumenta el daño pulmonar inducido por la exposición aguda e intermitente a 0,5 ppm de O3 en ratas juveniles.

Tropospheric ozone (O3) is the major oxidant of photochemical smog. Being an air pollutant, its effects are related to effective dose = [Concentration] x [exposure time] x [pulmonary ventilation]. Objective: Determine whether physical exercise -that increases pulmonary ventilation- is able to augment the pulmonary damage induced by O3 exposure in resting rats. Material and Methods: Four series of juvenile Sprague-Dawley rats were used. Two series were exposed to 0.5 ppm O3 (4 hours a day for 2 days) at rest (n=13) or during exercise (n=12). Two control series breathed filtered air (FA) at rest (n=13) or during exercise sessions (n=13), in a vertical rotary wheel (15 min exercise alternated with 15 min resting until to completing 4 hours a day for 2 days). Rats were euthanized and wet weight / dry weight ratio (W/D ratio) was determined in left lung. Total cell counting, total protein content and γ-glutamyltraspeptidase (GGT) activity were determined in the right lung bronchoalveolar lavage fluid (BALF). Results: W/D weight ratio as well as total cell counting and protein content increased in BALF from resting rats exposed to O3 as compared with resting rats breathing FA (p < 0.05 ANOVA & Newman-Keuls test). GGT activity in BALF increased in rats under exercise breathing FA as compared with resting rats breathing FA (p<0.05). GGT, proteins and cells counting increased in BALFfrom series [exercise + O3] as compared to series [resting + O3] (p< 0.05). Conclusion: Physical exercise increases lung damage induced by intermittent and acute 0.5 ppm O3 exposure in juvenile rats.