Bronquiolitis obliterante secundaria a sindrome de stevens-johnson. Presentacion de 2 casos y revision de la literatura / Obliterans bronchiolitis secondary to stevens-johnson syndrome: case reports

Stevens-Johnson syndrome corresponds to a hypersensitivity reaction produced by various etiologies, for example exposure to drugs, microbial agents, or by an idiopathic cause. It is marked by an acute vesicular-bullous eruption, which affects the skin and mucous membranes, with systemic manifestations of variable severity, and it may present a fatal evolution. Stevens-Johnson syndrome can occasionally present chronic pulmonary complications, such as bronchiolitis obliterans; however, other etiologies are more frequent in our environment, for example severe pneumonia due to adenovirus. Our objective is to present two cases of bronchiolitis obliterans post Stevens-Johnson syndrome and to make a literature review.

El síndrome de Stevens-Johnson corresponde a una respuesta de hipersensibilidad producida por diversas etiologías, que incluyen exposición a drogas, agentes microbianos o idiopática. Se manifiesta por una erupción vesículo-bulosa aguda, que afecta la piel y las mucosas, con manifestaciones sistémicas de severidad variable, pudiendo presentar una evolución fatal. El síndrome de Stevens-Johnson puede presentar ocasionalmente complicaciones pulmonares crónicas, como bronquiolitis obliterante, siendo en nuestro medio más frecuente otras etiologías, como la observada luego de una neumonía grave por adenovirus. El objetivo es presentar dos casos de bronquiolitis obliterante post síndrome de Stevens-Johnson y hacer una revisión de la literatura.

Evaluación de los músculos respiratorios en la parálisis diafragmática bilateral / Assessment of respiratory muscle strength in bilateral diaphragmatic paralysis

Measurement of respiratory muscle strength is useful in order to detect respiratory muscle weakness and to quantify its severity. Apropos of a patient with bilateral diaphragmatic paralysis, we review the clinical manifestations and methods for assessing the strength of the respiratory muscles. In patients with severe respiratory muscle weakness, vital capacity and total lung capacity are reduced but are a non-specific and relatively insensitive measure. Conventionally, inspiratory and expiratory muscle strength has been assessed by maximal inspiratory and expiratory mouth pressures sustained for one second (PIMax and PEMax). The sniffmanoeuvre is natural and probably easier to perform. Sniff pressures are more reproducible and useful measure of diaphragmatic strength. However, the PIMax-PEMax and sniff manoeuvres are volition dependent, and submaximal efforts are most likely to occur in patients who are ill or breathless. Non-volitional tests include measurements of twitch esophageal, gastric and transdiaphragmatic pressure during bilateral electrical and magnetic phrenic nerve stimulation. Electrical phrenic nerve stimulation is technically difficult and is also uncomfortable and painful. Magnetic phrenic nerve stimulation is less painful and transdiaphragmatic pressure is reproducible in normal subjects. Systematic clinical evaluation and additional laboratory tests allow the diagnosis in most patients with respiratory muscle weakness.

La evaluación de la fuerza de los músculos respiratorios permite diagnosticar y cuantificar la gravedad de la debilidad muscular en diferentes enfermedades. A propósito de un paciente con parálisis diafragmática bilateral, hemos revisado el cuadro clínico y los procedimientos diagnósticos para evaluar la fuerza de los músculos respiratorios. En los pacientes con debilidad muscular respiratoria severa, disminuye la capacidad vital y la capacidad pulmonar total, pero es una medida inespecífica y relativamente insensible. Tradicionalmente, la fuerza muscular respiratoria es evaluada midiendo la presión inspiratoria y espiratoria máximas en la boca sostenidas durante un segundo (PIMax y PEMax). La medición de la presión inspiratoria máxima en la nariz (SNIP) es una maniobra natural, más simple de medir y más reproducible, siendo útil en la evaluación de la fuerza diafragmática. Sin embargo, estas técnicas no invasivas son operador dependiente, por lo tanto, esfuerzos submáximos es más probable que ocurran en pacientes graves o con disnea. Las mediciones de las presiones esofágica, gástrica y transdiafragmática mediante estimulación eléctrica o magnética del nervio frénico no son dependientes de la voluntad y son más confiables. Sin embargo, la estimulación eléctrica del nervio frénico es técnicamente difícil y puede ser incómoda y dolorosa. La estimulación magnética del nervio frénico es menos dolorosa y la medición de la presión transdiafragmática es reproducible en sujetos normales. La evaluación clínica sistemática y los exámenes de laboratorio complementarios permiten establecer el diagnóstico en la mayoría de los pacientes con debilidad de los músculos respiratorios.

Presentación inusual de microcarcinoma papilar tiroideo: insuficiencia respiratoria por metástasis pulmonares / Unusual presentation of micro carcinoma of thyroid: pulmonary metastases and respiratory distress

El micro carcinoma papilar de la glándula tiroidea son lesiones de 1 cm o menos, siendo su incidencia hasta en un 35% en series de autopsias en población general, y comúnmente son de buen pronóstico. Las metástasis distantes en el carcinoma diferenciado de tiroides son bien infrecuentes y su prevalencia puede variar entre un 5% al 23% de los casos, pero son extremadamente inusuales en el micro carcinoma tiroideo. Se relata un caso clínico de una paciente de 38 años de edad; quien consultó por insuficiencia respiratoria aguda realizando el diagnóstico de micro carcinoma papilar con metástasis pulmonares y se describe su manejo, encontrándose actualmente eutiroidea, controlada su enfermedad, con tratamiento hormonal supresivo y con niveles de tiroglobulinas y anticuerpos antitiroglobulinas normales

The papillary micro carcinoma thyroid gland is injuries of 1 cm or less, with incidence until 35% in series of autopsies in general population, and is commonly considered as a good prognosis. The distant metastases in the differentiated thyroid carcinoma are infrequent and its prevalence varies from 5% to 23% of all cases, but is extremely unusual in the thyroid micro carcinoma. We describe a clinical case of a female patient of 38 years old; who consulted us by acute respiratory failure, we are making the diagnosis of a papillary micro carcinoma with lung metastases and describes its handling, and finding currently normal thyroid hormone value and controlled her disease, the suppression hormonal treatment, tyro globulin and anti- tyro globulins antibody normal levels

Postmortem diagnosis of acute myocardial infarction in patients with acute respiratory failure: demographics, etiologic and pulmonary histologic analysis

OBJECTIVES: Acute respiratory failure is present in 5% of patients with acute myocardial infarction and is responsible for 20% to 30% of the fatal post-acute myocardial infarction. The role of inflammation associated with pulmonary edema as a cause of acute respiratory failure post-acute myocardial infarction remains to be determined. We aimed to describe the demographics, etiologic data and histological pulmonary findings obtained through autopsies of patients who died during the period from 1990 to 2008 due to acute respiratory failure with no diagnosis of acute myocardial infarction during life. METHODS: This study considers 4,223 autopsies of patients who died of acute respiratory failure that was not preceded by any particular diagnosis while they were alive. The diagnosis of acute myocardial infarction was given in 218 (4.63%) patients. The age, sex and major associated diseases were recorded for each patient. Pulmonary histopathology was categorized as follows: diffuse alveolar damage, pulmonary edema, alveolar hemorrhage and lymphoplasmacytic interstitial pneumonia. The odds ratio of acute myocardial infarction associated with specific histopathology was determined by logistic regression. RESULTS: In total, 147 men were included in the study. The mean age at the time of death was 64 years. Pulmonary histopathology revealed pulmonary edema as well as the presence of diffuse alveolar damage in 72.9% of patients. Bacterial bronchopneumonia was present in 11.9% of patients, systemic arterial hypertension in 10.1% and dilated cardiomyopathy in 6.9%. A multivariate analysis demonstrated a significant positive association between acute myocardial infarction with diffuse alveolar damage and pulmonary edema. CONCLUSIONS: For the first time, we demonstrated that in autopsies of patients with acute respiratory failure as the cause of death, 5% were diagnosed with acute myocardial infarction. Pulmonary histology revealed a significant inflammatory response, which has not previously been reported.

Vía aérea difícil / Difficult airway

Difficult airway is a life-threatening situation which compromises the permeability of the upper airway and thus adequate ventilation and oxygenation. Multiple factors, acute and chronic such as: infectious, neoplastic and trauma have been associated with critical airway. Morbidity and mortality related to a difficult airway management remains as a significant problem in children, so is essential for the pediatric health team to be trained to recognize and anticipate situations that in clinical practice might determine a critical airway. The aim of this review is to provide concepts and guidance to assess patients with potentially difficult airway.

Una vía aérea difícil condiciona una situación con riesgo vital, ya que pone en peligro la permeabilidad de la vía aérea superior y con esto la capacidad de mantener una adecuada ventilación y oxigenación. Múltiples factores, tanto agudos como crónicos, entre ellos factores anatómicos propios del niño/a, complicaciones infecciosas, neoplásicas y/o traumáticas se han asociado con una vía aérea crítica. La morbilidad y mortalidad asociada al manejo inadecuado de esta condición continua siendo un problema significativo en la edad pediátrica; siendo fundamental que el equipo de salud se encuentre entrenado en reconocer y anticipar situaciones que en la práctica clínica podrían asociarse con una vía aérea difícil o crítica. El objetivo de la presente revisión es otorgar conceptos y una orientación en el enfrentamiento de los pacientes con una vía aérea potencialmente difícil.

Demographic, etiological, and histological pulmonary analysis of patients with acute respiratory failure: a study of 19 years of autopsies

INTRODUCTION: Acute respiratory failure has been one of the most important causes of death in intensive care units, and certain aspects of its pulmonary pathology are currently unknown. OBJECTIVES: The objective was to describe the demographic data, etiology, and pulmonary histopathological findings of different diseases in the autopsies of patients with acute respiratory failure. METHOD: Autopsies of 4,710 patients with acute respiratory failure from 1990 to 2008 were reviewed, and the following data were obtained: age, sex, and major associated diseases. The pulmonary histopathology was categorized as diffuse alveolar damage, pulmonary edema, alveolar hemorrhage, and lymphoplasmacytic interstitial pneumonia. The odds ratio of the concordance between the major associated diseases and specific autopsy findings was calculated using logistic regression. RESULTS: Bacterial bronchopneumonia was present in 33.9 percent of the cases and cancer in 28.1 percent. The pulmonary histopathology showed diffuse alveolar damage in 40.7 percent (1,917) of the cases. A multivariate analysis showed a significant and powerful association between diffuse alveolar damage and bronchopneumonia, HIV/AIDS, sepsis, and septic shock, between liver cirrhosis and pulmonary embolism, between pulmonary edema and acute myocardial infarction, between dilated cardiomyopathy and cancer, between alveolar hemorrhage and bronchopneumonia and pulmonary embolism, and between lymphoplasmacytic interstitial pneumonia and HIV/ AIDS and liver cirrhosis. CONCLUSIONS: Bronchopneumonia was the most common diagnosis in these cases. The most prevalent pulmonary histopathological pattern was diffuse alveolar damage, which was associated with different inflammatory conditions. Further studies are necessary to elucidate the complete pathophysiological mechanisms involved with each disease and the development of acute respiratory failure.

Pronóstico de pacientes ingresados a Unidad de Cuidados Intensivos por falla respiratoria asociada a presencia de infiltrados pulmonares / Prognosis of patients with acute respiratory failure and pulmonary infiltrates admitted to intensive care unit

En la unidad de cuidados intensivos (UCI), la insuficiencia respiratoria aguda (IRA) asociada a infiltrados pulmonares de causa desconocida se relaciona con alta morbilidad y mortalidad. El objetivo principal de este trabajo fue conocer el pronóstico de pacientes con IRA, infiltrados pulmonares y necesidad de ventilación mecánica (VM) ingresados a UCI. Como objetivo secundario se planteó evaluar la utilidad de medios diagnósticos de uso habitual en este grupo de pacientes en relación al pronóstico y la conducta terapéutica. Se realizó un estudio observacional retrospectivo que incluyó todos los pacientes ingresados a la UCI del Hospital Naval Almirante Nef por IRA de causa desconocida asociada a infiltrados pulmonares en radiografía de tórax y que tengan necesidad de VM entre los años 2006 y 2010. Se incluyeron 90 pacientes de los cuales 45,6 por ciento fueron de sexo masculino. La edad promedio fue 66 años (DS 17,1). El puntaje promedio de score APACHE II fue 20,6 (DS 7,7). La mortalidad fue 52,2 por ciento y el tiempo promedio de estadía en UCI fueron 14 días (DS 14,4). La principal causa de IRA fue síndrome de distress respiratorio agudo (32 por ciento).Otras causas fueron neumonía adquirida en la comunidad (28,2 por ciento), neumonía aspirativa (12,2 por ciento), neumonía nosocomial (7,8 por ciento) y neumonía criptogénica organizada (6,7 por ciento). La realización de tomografía computarizada de tórax, lavado broncoalveolar y biopsia pulmonar determinó cambio de conducta terapéutica en 31 por ciento, 58 por ciento y 88 por ciento de los casos, respectivamente. En conclusión, los pacientes con IRA tienen alta mortalidad. La causa más frecuente fue el síndrome de distress respiratorio agudo. El uso de procedimientos diagnósticos pueden cambiar las medidas terapéuticas empleadas, en especial la biopsia pulmonar.

In the intensive care unit (ICU), acute respiratory failure (ARF) associated with unexplained pulmonary infiltrates is associated with high morbidity and mortality. The main objective of this study was to determine the prognosis of patients with ARF and pulmonary infiltrates admitted to ICU. The secondary objective was proposed to evaluate the usefulness of diagnostic methods frequently used in this patient group and correlated them with prognosis and therapeutic management. We performed a retrospective observational study that included all patients admitted to ICU of Almirante Nef Naval Hospital with ARF of unknown cause associated with pulmonary infiltrates on chest radiography during the years 2006-2010. We included 90 patients of which 45 percent were male. The average age was 66 years. The average APACHE II score was 20.6. Mortality was 52.2 percent and the average length of stay in the ICU was 14 days (SD 14.4). The main cause of ARF was acute respiratory distress syndrome (32 percent). Other causes were community-acquired pneumonia (28.2 percent), aspiration pneumonia (12.2 percent), nosocomial pneumonia (7.8 percent) and cryptogenic organized pneumonia (6.7 percent. The performance of chest computed tomography, bronchoalveolar lavage and lung biopsy determined therapeutic behavior change in 31 percent 58 percent and 88 percent of cases, respectively. In conclusion, patients with ARF have high mortality. The most common cause was acute respiratory distress syndrome. The use of diagnostic procedures may change the therapeutic measures used, particularly lung biopsy.

Pathological and ultrastructural analysis of surgical lung biopsies in patients with swine-origin influenza type A/H1N1 and acute respiratory failure

BACKGROUND: Cases of H1N1 and other pulmonary infections evolve to acute respiratory failure and death when co-infections or lung injury predominate over the immune response, thus requiring early diagnosis to improve treatment. OBJECTIVE: To perform a detailed histopathological analysis of the open lung biopsy specimens from five patients with ARDS with confirmed H1N1. METHODS: Lung specimens underwent microbiologic analysis, and examination by optical and electron microscopy. Immunophenotyping was used to characterize macrophages, natural killer, T and B cells, and expression of cytokines and iNOS. RESULTS: The pathological features observed were necrotizing bronchiolitis, diffuse alveolar damage, alveolar hemorrhage and abnormal immune response. Ultrastructural analysis showed viral-like particles in all cases. CONCLUSIONS: Viral-like particles can be successfully demonstrated in lung tissue by ultrastructural examination, without confirmation of the virus by RT-PCR on nasopharyngeal aspirates. Bronchioles and epithelium, rather than endothelium, are probably the primary target of infection, and diffuse alveolar damage the consequence of the effect of airways obliteration and dysfunction on innate immunity, suggesting that treatment should be focused on epithelial repair.

Pulmonary histopathological alterations in patients with acute respiratory failure: an autopsy study / Alterações histopatológicas pulmonares em pacientes com insuficiência respiratória aguda: um estudo em autopsias

OBJETIVOS: Apresentar alterações histopatológicas pulmonares encontradas em autopsias de pacientes falecidos por insuficiência respiratória aguda (IRA) e verificar se doenças de base e específicos fatores de risco associados aumentam a incidência dessas alterações. MÉTODOS: Foram revisados laudos finais de autopsias e selecionadas 3.030 autopsias de pacientes > 1 ano de idade, com infiltrado pulmonar radiológico, portadores de doença de base e fatores de risco associados, que morreram por alterações pulmonares decorrentes de IRA. RESULTADOS: As principais alterações histopatológicas pulmonares causadoras de morte imediata foram: dano alveolar difuso (DAD); edema pulmonar; pneumonia intersticial linfocítica (PIL) e hemorragia alveolar. As principais doenças de base encontradas foram: AIDS; broncopneumonia; sepse; cirrose hepática; tromboembolismo pulmonar; infarto agudo do miocárdio (IAM); acidente vascular cerebral; tuberculose; câncer; insuficiência renal crônica e leucemia. Os principais fatores de risco associados foram: idade > 50 anos; hipertensão arterial; insuficiência cardíaca congestiva; doença pulmonar obstrutiva crônica e diabetes mellitus. Pacientes com esses fatores de risco e AIDS apresentaram alta probabilidade de desenvolver PIL; pacientes com esses mesmos fatores, de desenvolver DAD, se portadores de sepse ou cirrose hepática; pacientes com tromboembolismo e os mesmos fatores de risco, de desenvolver hemorragia alveolar; pacientes com esses fatores de risco e IAM, de desenvolver edema pulmonar. CONCLUSÕES: Os achados pulmonares em pacientes com óbito por IRA apresentaram quatro padrões histopatológicos: DAD, edema pulmonar, PIL e hemorragia alveolar. Doenças de base e específicos fatores de risco associados correlacionaram-se positivamente com determinados padrões histopatológicos detectados à autópsia.

OBJECTIVE: To present the pulmonary histopathological alterations found in the autopsies of patients with acute respiratory failure (ARF) and determine whether underlying diseases and certain associated risk factors increase the incidence of these histopathological patterns. METHODS: Final autopsy reports were reviewed, and 3030 autopsies of patients > 1 year of age with an underlying disease and associated risk factors were selected. All had developed diffuse infiltrates and died of ARF-related pulmonary alterations. RESULTS: The principal pulmonary histopathological alterations resulting in immediate death were diffuse alveolar damage (DAD), pulmonary edema, lymphocytic interstitial pneumonia (LIP) and alveolar hemorrhage. The principal underlying diseases were AIDS, bronchopneumonia, sepsis, liver cirrhosis, pulmonary thromboembolism, acute myocardial infarction (AMI), cerebrovascular accident, tuberculosis, cancer, chronic kidney failure and leukemia. The principal associated risk factors were as follows: age > 50 years; arterial hypertension; congestive heart failure; chronic obstructive pulmonary disease; and diabetes mellitus. These risk factors and AIDS correlated with a high risk of developing LIP; these same risk factors, if concomitant with sepsis or liver cirrhosis, correlated with a risk of developing DAD; thromboembolism and these risk factors correlated with a risk of developing alveolar hemorrhage; these risk factors and AMI correlated with a risk of developing pulmonary edema. CONCLUSION: Pulmonary findings in patients who died of ARF presented four histopathological patterns: DAD, pulmonary edema, LIP and alveolar hemorrhage. Underlying diseases and certain associated risk factors correlated positively with specific histopathological findings on autopsy.

Post-mortem histological pulmonary analysis in patients with HIV/AIDS

OBJECTIVES: Certain aspects of pulmonary pathology observed in autopsies of HIV/AIDS patients are still unknown. This study considers 250 autopsies of HIV/AIDS patients who died of acute respiratory failure and describes the demographic data, etiology, and histological pulmonary findings of the various pathologies. METHODS: The following data were obtained: age, sex, and major associated diseases (found at the autopsy). Pulmonary histopathology was categorized as: diffuse alveolar damage; pulmonary edema; alveolar hemorrhage; and acute interstitial pneumonia. Odds ratio of the HIV/AIDS-associated diseases developing a specific histopathological pattern was determined by logistic regression. RESULTS: A total of 197 men and 53 women were studied. The mean age was 36 years. Bacterial bronchopneumonia was present in 36 percent (91 cases) and Pneumocystis jiroveci pneumonia in 27 percent (68) of patients. Pulmonary histopathology showed acute interstitial pneumonia in 40 percent (99), diffuse alveolar damage in 36 percent (89), pulmonary edema in 13 percent (33), and alveolar hemorrhage in 12 percent (29) of patients. Multivariate analysis showed a significant and positive association between Pneumocystis jiroveci pneumonia and acute interstitial pneumonia (Odds ratio, 4.51; 95 percent CI, 2.46 - 8.24; p < 0.001), severe sepsis and/or septic shock and diffuse alveolar damage (Odds ratio, 3.60; 95 percent CI, 1.78 -7.27; p < 0.001), and cytomegalovirus and acute interstitial pneumonia (Odds ratio, 2.22; 95 percent CI, 1.01 - 4.93; p = 0.05). CONCLUSIONS: This report is the first autopsy study to include demographic data, etiologic diagnosis, and respective histopathological findings in patients with HIV/AIDS and acute respiratory failure. Further studies are necessary to elucidate the complete pulmonary physiopathological mechanism involved with each HIV/AIDS-associated disease.

Relación entre las maloclusiones y la respiración bucal en pacientes que asistieron al Servicio de Otorrinolaringología del Hospital Pediátrico San Juan de Dios; junio de 2005 / Relationship between malocclusions and mouth breathing in patients who attended the ORL Service of the Juan de Dios Pediatric Hospital, June 2005

La Insuficiencia Respiratoria Nasal es una condición patológica que se presenta con relativa frecuencia en los pacientes que acuden a consulta odontológica y de otorrinolaringología. Estos pacientes adquieren una postura adaptativa de las estructuras de la cabeza y la región del cuello, que afectan la relación de los maxilares y el desarrollo normal de la oclusión. El propósito del presente estudio fue demostrar si existe relación entre los pacientes con Insuficiencia Respiratoria Nasal y un tipo específico de maloclusión dentaria utilizando la clasificación de Angle. Así mismo se planteó como propósito interrelacionar el área de odontología con la de otorrinolaringología, con el fin de establecer un sistema de referencias de un área a otra para brindar una atención integral. El estudio se realizó, en 39 niños que asistieron al servicio de otorrinolaringología del Hospital San Juan de Dios en el mes de Junio de 2005, de edades comprendidas entre 6 y 12 años, de ambos sexos y que presentaban problemas otorrinos que causaran respiración bucal. A estos pacientes se les realizó el examen clínico bucal para determinar las maloclusiones presentes. Los resultados no evidenciaron relación entre la Insuficiencia Respiratoria Nasal y una maloclusión específica. Hubo una marcada presencia de apiñamiento anteroinferior, de mordidas abiertas y de características propias de la fascie adenoidea. El tipo de maloclusión predominante fue la Clase I y el principal problema de otorrinolaringología causante de insuficiencia respiratoria nasal fue la Hipertrofia Adenotonsilar.

Nasal Respiratory Insufficiency is a frequent disease in patients suffering from odontological and ORL conditions. These patients acquire an adaptive posture of the head and neck structures affecting the relationship between the maxilla, the mandible and the occlusion normal development. The purpose of this study was to demonstrate the existence of a relationship between Nasal Respiratory Insufficiency and a specific type of dental malocclusion using Angle's classification. Another purpose was to integrate the Dental and ORL fields in order to establish a reference system between both specialties. The study included 39 children of either sex, 6 to 12 years-old. They were treated during June 2005 at the ORL Department of the San Juan de Dios Hospital. They presented ORL conditions which also caused oral respiration. They were studied to determine the existence of dental malocclusion. The results did not show any relationship between Nasal Respiratory Insufficiency and malocclusion. The predominant malocclusion type was Class I and the main ORL pathology causing Nasal Respiratory Insufficiency was Adenotonsilar Hypertrophy.

Impacto de biópsia pulmonar a céu aberto na insuficiência respiratória aguda refratária / Impact of open lung biopsy on refractory acute respiratory failure

OBJETIVO: Verificar o impacto dos resultados da biópsia pulmonar a céu aberto nas decisões que determinem mudanças nas estratégias de tratamento de pacientes críticos, com infiltrados pulmonares difusos e insuficiência respiratória aguda refratária, bem como na melhora de seu quadro clínico. MÉTODOS: Foram avaliados 12 pacientes com insuficiência respiratória aguda e sob ventilação mecânica, que foram submetidos à biópsia pulmonar a céu aberto (por toracotomia) após a ausência de resposta clínica ao tratamento padrão. RESULTADOS: A maior causa isolada de insuficiência respiratória aguda foi a infecção viral, identificada em 5 pacientes (40 por cento). A avaliação pré-operatória da causa da insuficiência respiratória foi modificada em 11 pacientes (91,6 por cento), e um diagnóstico específico foi feito em 100 por cento dos casos. A taxa de mortalidade foi de 50 por cento, a despeito das mudanças no regime terapêutico. Seis pacientes (50 por cento) sobreviveram e obtiveram alta hospitalar. Todos os pacientes que obtiveram alta sobreviveram por pelo menos um ano após a biópsia pulmonar a céu aberto, totalizando uma taxa de sobrevida em um ano de 50 por cento dentre os 12 pacientes estudados. Quanto aos pacientes que faleceram no hospital, o tempo de sobrevida após a biópsia pulmonar a céu aberto foi de 14 + 10,8 dias. CONCLUSÃO: Concluímos que a biópsia pulmonar a céu aberto é uma ferramenta útil no controle da insuficiência respiratória aguda quando não se observa melhora clínica após o tratamento padrão, já que pode resultar em um diagnóstico específico que requeira tratamento distinto, provavelmente diminuindo a taxa de mortalidade desses pacientes.

OBJECTIVE: To determine the impact that open lung biopsy findings have on decisions regarding changes in the treatment strategies employed for critically ill patients presenting diffuse pulmonary infiltrates and suffering from refractory acute respiratory failure, as well as on their clinical improvement. METHODS: This study involved 12 mechanically ventilated patients with acute respiratory failure who were subjected to open lung biopsy (by thoracotomy) after not presenting a clinical response to standard treatment. RESULTS: The single most common cause of the acute respiratory failure was viral infection, which was identified in 5 patients (40 percent). The pre-operative evaluation of the cause of respiratory failure was modified in 11 patients (91.6 percent), and a specific diagnosis was made in 100 percent of the cases. Regardless of changes in treatment regimen, the mortality rate was 50 percent. Six patients (50 percent) survived to be discharged from the hospital. All of the discharged patients survived for at least one year after the open lung biopsy, for an overall one-year survival rate of 50 percent among the 12 patients studied. For the patients who died in the hospital, the time of survival after open lung biopsy was 14 + 10.8 days. CONCLUSION: We conclude that open lung biopsy is a useful tool in the management of acute respiratory failure when there is no clinical improvement after standard treatment, since it can lead to a specific diagnosis that requires distinct treatment, which probably lowers the mortality rate among such patients.

Síndrome de embolismo graso: manejo anestésico: a propósito de un caso / Fat embolism syndrome: anesthetic management: a purpose of a case

El síndrome de embolismo graso se produce por las fracturas de los huesos largos. La presentación clásica consiste en un intervalo asintomático seguido de manifestaciones pulmonares y neurológicas, combinadas con hemorragias petequiales. El síndrome sigue un curso clínico bifásico. Los síntomas iniciales son probablemente causados por un mecanismo de oclusión de múmtiples vasos sanguineos por glóbulos rojos que son de demasiado tamaño para pasar a través de los capilares. El otro acontecimiento de la embolia, es que la oclusión vascular del embolismo graso es frecuentemente temporal o incompleta, porque los globulos no obstruyen completamente el flujo de sangre de los capilares por su fluidez y deformidad. El cao que se presenta a continuación es un paciente masculino de 32 años quien posterior a accidente de tránsito presentó fractura de femur derecho, y quien durante la inducción anestésica posterior a la movilización del paciente se desarrollo el embolismo graso, el cual se diagnóstico por los antecedentes del paciente, signos clínicos y hallazgos de laboratorio.

Pulmonary fibrosis in a steel mill worker

We report a case of pulmonary fibrosis in a 32-year-old man, who had worked at a steel mill and who died of respiratory failure due to interstitial fibrosis despite vigorous treatment. He showed SLE-associated symptoms, such as pleural effusion, malar rashes, discoid rashes, arthritis, leukopenia, and positive antinuclear antibody and anti-histone antibody. However, he did not present anti-DNA antibody. A thoracoscopic lung biopsy showed interstitial fibrosis, chronic inflammation and a small non-caseating granuloma in lung tissues, which could be induced by external agents such as metals. The manganese concentration in the lung tissue was 4.64 microg/g compared to 0.42-0.7 microg/g in the controls. The levels of other metals, such as iron, nickel, cobalt and zinc in patient's lung tissue were higher than those in the controls. The patient was probably exposed to Si and various metal dusts, and the lung fibrosis was related to these exposures. Exposure to Si and metal dusts should be sought in the history of any patient with SLE, especially in a male with pulmonary signs, and if present, exposure should be stopped. In the meantime, steps should be taken to ensure that workers exposure to Si and metal dusts in all environments have adequate protection.

Síndrome de embolismo graso / Fat embolism syndrome

El síndrome de embolismo graso se presenta como complicación de fracturas en huesos largos y pelvis y, en ocasiones, posterior a procedimientos diagnósticos usados en la práctica médica. El cuadro clínico se caracteriza por insuficiencia respiratoria aguda, deterioro progresivo de sensorio, no explicable por lesiones craneoencefálicas; y rash petequial en piel y mucosas. El diagnóstico se fundamenta en los hallazgos al examen clínico y en estudios paraclínicos poco específicos. La prevención descansa en la fijación quirúrgica precoz de la fractura de los huesos largos comprometidos y el tratamiento consiste en el soporte ventilatorio y circulatorio, así como en el uso profiláctico de esteroides en individuos de alto riesgo

Neumonía intersticial descamativa en niños: presentación de 2 casos / Desquamative intersticial pneumonia in children: presentation of two cases

Se presentaron 2 casos, ambos de 8 años de edad, una hembra y un varón, quienes presentaron insuficiencia respiratoria aguda (IRA) por neumonía intersticial descamativa. Ameritan biopsia del pulmón a cielo abierto para el diagnóstico de certeza, dado por la presencia de macrofagos intra-alveolares y grado variable de fibrosis intersticial. El curso clínico fue lento y hubo respuesta muy satisfactoria al tratamiento con esteroides