Protocolos de encaminhamento da Atenção Básica para a Atenção Especializada: cirurgia torácica e pneumologia / Routing protocols of primary care to specialized care: thoracic surgery and pulmonology

Este material tem como objetivo orientar as equipes que atuam na AB, qualificando o processo de referenciamento de usuários para outros serviços especializados. É uma ferramenta, ao mesmo tempo, de gestão e de cuidado, pois tanto guiam as decisões dos profissionais solicitantes quanto se constitui como referência que modula as avaliações apresentadas pelos médicos reguladores.

Dor torácica na sala de emergência: avaliação inicial / Pain in the emergency room: initial evaluation

Nessa revisão, abordaremos o quadro clínico e a investigação complementar das condições e doenças que se manifestam com esse sintoma. Entre elas, o enfoque será sobre as que apresentam maior morbimortalidade e exigem conduta mais rápida e precisa.

In this review, we will discuss the clinical features and the ancillary studies of the conditions and diseases that present with this symptom. Among them, the focus will be those that have a higher morbi-mortality and require faster and accurate management.

Ressonância magnética do tórax: aplicações tradicionais e novas, com ênfase em pneumologia / Magnetic resonance imaging of the chest: current and new applications, with an emphasis on pulmonology

O objetivo deste estudo de revisão foi apresentar as principais aplicações da ressonância magnética (RM) no estudo do tórax, incluindo a descrição de novas técnicas. Na ultima década, esse método teve grande evolução, com novos equipamentos, incluindo a interconexão simultânea de bobinas e a movimentação da mesa simultaneamente à aquisição das imagens, além do advento de novas técnicas rápidas de aquisição de imagem, tais como imagem paralela e aquisição parcial de dados, com ou sem utilização de apneia, somando-se ainda a introdução de novos agentes de contraste. Todos esses avanços fizeram com que a RM tenha ganhado espaço no estudo de diferentes patologias do tórax, incluindo as doenças pulmonares. Atualmente, a RM pode ser considerada a modalidade de escolha para a avaliação das lesões mediastinais, da parede torácica e dos tumores do sulco superior, mas também pode auxiliar no diagnóstico de doenças pulmonares, pleurais, cardíacas e da vasculatura pulmonar. A angiografia pulmonar por RM pode ser utilizada na avaliação de várias doenças vasculares pulmonares, e seu papel no estudo do tromboembolismo vem crescendo. A RM cardíaca, devido à possibilidade de avaliação morfológica e funcional em um mesmo exame, também já faz parte da rotina clínica na investigação de muitas patologias cardíacas. Por fim, o papel da RM vem sendo ampliado para a identificação e caracterização de nódulos pulmonares, avaliação das doenças das vias aéreas e caracterização dos derrames pleurais.

The objective of the present review study was to present the principal applications of magnetic resonance imaging (MRI) of the chest, including the description of new techniques. Over the past decade, this method has evolved considerably because of the development of new equipment, including the simultaneous interconnection of phased-array multiple radiofrequency receiver coils and remote control of the table movement, in addition to faster techniques of image acquisition, such as parallel imaging and partial Fourier acquisitions, as well as the introduction of new contrast agents. All of these advances have allowed MRI to gain ground in the study of various pathologies of the chest, including lung diseases. Currently, MRI is considered the modality of choice for the evaluation of lesions in the mediastinum and in the chest wall, as well as of superior sulcus tumors. However, it can also facilitate the diagnosis of lung, pleural, and cardiac diseases, as well as of those related to the pulmonary vasculature. Pulmonary MRI angiography can be used in order to evaluate various pulmonary vascular diseases, and it has played an ever greater role in the study of thromboembolism. Because cardiac MRI allows morphological and functional assessment in the same test, it has also become part of the clinical routine in the evaluation of various cardiac diseases. Finally, the role of MRI has been extended to the identification and characterization of pulmonary nodules, the evaluation of airway diseases, and the characterization of pleural effusion.

Thoracic Splenosis: A Case Report and the Importance of Clinical History

We present a case of thoracic splenosis in a 42-yr-old man with a medical history of abdominal surgery for a penetration injury with an iron bar of the left abdomen and back. He had been in good condition, but a chest radiograph taken during a regular checkup showed a multinodular left pleura-based mass. Computed tomography (CT) showed that the mass was well-enhanced and homogeneous, indicating a sclerosing hemangioma. Following its removal by video-assisted thoracoscopic surgery, the mass appeared similar to a hemangioma, with marked adhesion to the left side diaphragmatic pleura and lung parenchyma. Frozen section showed that the lesion was a solid mass consisted with abundant lymphoid cells, suggesting a low grade lymphoma. On permanent section, however, the mass was found to be composed of white pulp, red pulp, a thick capsule and trabeculae and was diagnosed as ectopic splenic tissue, or thoracic splenosis. Review of the patient's history and chest CT at admission revealed that the patient had undergone a splenectomy for the penetration injury 20 yr previously.

O papel da ultrassonografia na avaliação de doenças torácicas em crianças / The role of ultrasonography in the valuation of thoracic diseases in children

Esta revisão tem por objetivo apresentar uma análise sobre os usos e benefícios da ultrassonografia como uma ferramenta para o diagnóstico correto de doenças torácicas em crianças. Através deste método de imagem, podemos avaliar com maior acurácia anormalidades de pulmões, pleura, parede torácica, bem como mediastimo.

Pott's disease in a young child.

A 16-month-old emaciated, immunized child presented with low-grade fever and progressive kyphosis with a right sided para-vertebral abscess for 9 months. During this period of illness the child had marked loss of appetite and progressive weight loss. There was history of contact with sputum smear positive father. A gibbus was present at thoraco-lumbar region with a cold abscess at the right side of the gibbus and signs of upper motor neuron lesion were found on lower limb examination. Diagnosis was supported by relevant investigations including MRI of dorsolumbar spine and treatment was started beforehand with anti-tubercular drugs. The paravertebral abscess was drained several times and antibiotics were used depending upon the results of microbiological study. At the same time the patient was advised to wear a modified chest brace for immobilization and the management for severe malnutrition was also started accordingly. There was significant clinical improvement observed within one month of starting treatment.

Radiographic findings of screening chest films in Priest Hospital.

OBJECTIVE: To study radiographic findings in abnormal chest films from screening programs as part of a Sustained and Holistic Health Care in Priests and Novices in Commemoration of His Majesty the King's 60 Years Accession to the Throne MATERIAL AND METHOD: A retrospective, descriptive study of chest x-ray findings in phase l of the screening of chest film program was performed between February 2006 and June 2006. RESULTS: One thousand one hundred twenty two cases participated in phase l of the screening program. Nine hundred and three cases had a chest x-ray. One hundred thirty one cases had abnormal chest film from radiographic reports. The age range was 17-92 years, with mean age of 42.69 years. The abnormalities found were classified into abnormal heart size in 34 cases (25.95%), pulmonary lesions in 80 cases (61.07%), pleural lesions in 7 cases (5.34%) and other abnormality in 10 cases (7.64%). CONCLUSION: The result of abnormality that was detected from chest films, frontal PA view, was about 14.51%. However, the authors cannot assume that the cases that have a normal chest film are the healthy group. Therefore, a physical and laboratory examinations are a useful combination to classify cases in healthy, asymptomatic, or symptomatic group. In the asymptomatic cases, the results are useful for early detection and treatment. The early diagnosis can improve the result of the treatment and quality of life. This study will be useful for other epidemiology and clinical study.

Transthoracic cutting needle biopsy: a valuable diagnostic procedure.

Intrathoracic mass lesions, especially peripherally situated masses, often present as a problem as tissue diagnosis is not always possible by cytopathological examination. Cutting needle biopsy may be the method of choice in selected cases for tissue diagnosis. Cutting needle biopsy is indicated for patients with peripherally situated mass lesions abutting chest wall, which are non-vascular and non-cystic in nature.

Displasia torácica asfixiante: síndrome de Jeune / Asphyxiating thoracic dysplasia: Jeune syndrome

Se describe el caso de un recién nacido con síndrome de Jeune, un trastorno genético cuya principal característica es la insuficiencia respiratoria por hipoplasia pulmonar secundaria a tórax estrecho.

Aumento da transparência pulmonar na infância: ensaio iconográfico / Increased radiolucency of the lungs in infancy: iconographic essay

Assimetrias torácicas representadas pelo aumento da transparência pulmonar são causas importantes de morbidade na populacão pediátrica. A avaliacão dos pacientes afetados freqüentemente requer múltiplas modalidades de imagem para diagnosticar a anomalia e planejar a correcão cirúrgica. Os autores analisam e ilustram os aspectos de assimetrias torácicas comuns e raras, com ênfase nas manifestacões radiológicas. A aplicabilidade das diversas modalidades de imagem no diagnóstico e tratamento é avaliada. Diagnósticos diferenciais, assim como armadilhas e dificuldades diagnósticas, são incluídas.

Video assisted thoracoscopic surgery at the Queen Elizabeth Hospital Barbados / Cirugía toracoscópica asistida por video en el Hospital Queen Elizabeth de Barbados

Video assisted thoracoscopic surgery (VATS) is now an established technique for diagnostic and therapeutic intervention in patients with thoracic pathology at the Queen Elizabeth Hospital (QEH). This article reviews the experience with 50 patients over the period May 1996 to February 2003, looking at various factors and outcomes in an attempt to ascertain the viability of this procedure at this institution. It serves as a follow-up article to the publication of the initial experience in 1999 (1). There were 24 males and 26 females included in the study. Video assisted thoracoscopic surgery was used for diagnosis in 27 cases (54), therapeutic indication in 17 cases (34) and as both a diagnostic and therapeutic modality in six cases (12). In 92of cases, the operations were completed thoracoscopically with a conversion rate of 8. The morbidity and mortality rates were 18and 2respectively. Video assisted thoracoscopic surgery is an effective tool for the treatment and investigation of selected thoracic pathology at the QEH with complications and mortality rates comparable to other institutions (2, 3).

La cirugía toracoscópica asistida por video (CTAV) es ya una técnica establecida para el diagnóstico y la intervención terapéutica de pacientes con patologías toráxicas en el Hospital Queen Elizabeth. Este articulo pasa revista a nuestra experiencia con 50 pacientes en el transcurso del período de mayo de 1996 a febrero de 2003, prestando atención a varios factores y resultados en un intento por corroborar la viabilidad de ese procedimiento en nuestra institución. El trabajo sirve como un artículo de seguimiento a la publicación de nuestra experiencia en el año 1999(1). El estudio abarcó 24 hombres y 26 mujeres. La CTAV se usó para el diagnóstico en 27 casos (54%), como indicación terapéutica en 17 casos (34%), tanto en la modalidad de diagnóstico como en la terapéutica en seis casos (12%). En el 92% de los casos, las operaciones fueron completadas toracoscópicamente con una tasa de conversión de 8%. Las tasas de morbilidad y mortalidad fueron 18% y 2% respectivamente. La CTAV resultó ser un instrumento efectivo para el tratamiento y la investigación de patologías toráxicas seleccionadas en nuestra institución, con complicaciones y tasas de mortalidad comparables a la de otras (2) (3).

False Positive and False Negative FDG-PET Scans in Various Thoracic Diseases

Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is being used more and more to differentiate benign from malignant focal lesions and it has been shown to be more efficacious than conventional chest computed tomography (CT). However, FDG is not a cancer-specific agent, and false positive findings in benign diseases have been reported. Infectious diseases (mycobacterial, fungal, bacterial infection), sarcoidosis, radiation pneumonitis and post-operative surgical conditions have shown intense uptake on PET scan. On the other hand, tumors with low glycolytic activity such as adenomas, bronchioloalveolar carcinomas, carcinoid tumors, low grade lymphomas and small sized tumors have revealed false negative findings on PET scan. Furthermore, in diseases located near the physiologic uptake sites (heart, bladder, kidney, and liver), FDG-PET should be complemented with other imaging modalities to confirm results and to minimize false negative findings. Familiarity with these false positive and negative findings will help radiologists interpret PET scans more accurately and also will help to determine the significance of the findings. In this review, we illustrate false positive and negative findings of PET scan in a variety of diseases.

Video-assisted thoracoscopic surgery (VATS) in the diagnosis and treatment of intrathoracic diseases at Ratchaburi Hospital.

OBJECTIVE: To review the authors' experience and benefit in diagnosis and management of intrathoracic diseases by Video-assisted thoracoscopic surgical procedures (VATS) using a non trocar technique. MATERIAL AND METHOD: Retrospective review of sixty-eight consecutive patients who underwent seventy-one VATS procedures between January 1997 and December 2004. Indications included recurrent or persistent pneumothorax (n = 21 patients), empyema thoracis (17), lung nodules or masses (8), clot haemothorax (6), pleural effusion (4), pleural thickening or masses (3), mediastinal masses or cysts (3), pericardial effusion (2), removal of bullets from the pleural cavity (2), bronchiectasis with hemoptysis (1) and inspection of diaphragmatic injury (1) (Table. 1). An alternative method of manipulating thoracoscopic instruments without using a trocar was described. RESULTS: Of the 71 VATS procedures in 68 patients, 62 (87.3%) procedures were successfully performed in 59 patients. Three of them underwent VATS bilaterally. (1 Tuberculous empyema and 2 spontaneous pneumothorax). Four patients requried conversion to thoracotomy due to bleeding in 1 who had excision lung bleb, extensive adhesion in 2 with chronic empyema thoracis and unlocated lesion in 1 with solitary pulmonary nodule (SPN). There were 5 postoperative complications: prolonged air leak for more than 7 days was seen in 4 patients. This complication occurred in a patient with spontaneous pneumothorax (3 patients) and bilateral tuberculous empyema at the left side (1 patient). Wound infection and mild effusion occurred in 1 patient with unilateral tuberculous empyema (no additional drainage was required). VATS in diagnostic procedures were effective in 90% (9 of 10 patients) and the procedures were 4 wedge excision, 3 pleural biopsies, 1 wedge excision for interstitial lung disease 1 inspection of diaphragmatic injury and 1 required conversion. Sixty one therapeutic procedures were effective in 50 patients (85.9%) (50 of 58 patients). None of them had a recurrence of pneumothorax after VATS procedures or other complications. Only small doses of analgesics were needed. There was no intraoperative mortality. The mean operative time was 67 minutes and the average postoperative hospital stay was 5.4 days for successful VATS group. CONCLUSION: VATS using of a non-trocar technique is a safe and effective method for diagnosis and treatment of intrathoracic diseases. Patients had benefit in reduced postoperative pain, short hospitalization, short recovery times and good cosmetic result.

A case of chronic chest wall sinus.

A 17-year-old Muslim female presented with a swelling over the chest wall underneath her left breast. The swelling was aspirated and the cytology report of the aspirated material showed it to be of pyogenic origin. An incision and drainage was done, after which the patient presented with a non-healing discharging sinus at the same site. The exact nature of the disease was known only after excising the sinus tract with the affected rib.

Resonancia magnética en pediatría / Magnetic resonance in pediatrics

La resonancia magnética se ha convertido en una herramienta diagnóstica valiosa en la prática médica. Sus ventajas incluyen excelente definición anatómica, capacidad de efectuar cortes en múltiples planos, muy buen contraste de los tejidos blandos y el hecho de que no usa radiación ionizante ni medios de contraste yodados. Se revisa su historia, sus bases físicas y técnicas, sus ventajas y desventajas, sus aplicaciones médicas en el estudio de patología del SNC, tórax, abdomen y sistema necrosis avascular y las futuras áreas del desarrollo

La toracoscopia y cirugía videoasistida en tórax / Thoracoscopy and video-assisted thoracic surgery

La toracoscopia es una técnica que data de los inicios del siglo XX utilizada inicialmente para romper adherencias pleurales y permitir el colapso pulmonar por neumotórax para el tratamiento de la tuberculosis. Ahora, la toracoscopia videoasistida (TVA) es el método quirúrgico de elección para muchos procedimientos que anteriormente se realizaban con grandes heridas y mucho dolor postoperatorio. La toracoscopia y la cirugía de invasión mínima videoasistida han llegado al campo torácico para quedarse. Muestra de ello es el trabajo del Dr. Patricio Santillán y colaboradores, pioneros en México en este campo. En su trabajo muestran la experiencia en 310 procedimientos, de los cuales incluyen 60 biopsias pulmonares por enfermedad pulmonar difusa y 71 resecciones de nódulos pulmonares. Con el procedimiento se presentan complicaciones leves y graves que dependen de la selección de pacientes y de la experiencia del equipo que realiza la biopsia y que cuida al enfermo. En el trabajo mencionado, la morbilidad en la enfermedad difusa fue de 5% y la mortalidad de 11% atribuida en general a la gravedad de la enfermedad por la que hizo la biopsia. Las ventajas de la cirugía de mínima invasión en el tórax son la disminución del dolor, debido a las heridas más pequeñas. Se tiene que aceptar, sin embargo, que la cirugía sigue siendo dolorosa y que requiere para su control de narcóticos cuando menos en los primeros días. En general, la frecuencia de complicaciones importantes se espera similar a la cirugía tradicional, ya que la intervención en los órganos de la cavidad torácica y los riesgos anestésicos son los mismos, salvo los dependientes del dolor postoperatorio. Por otro lado, estas ventajas sólo pueden esperarse de cirujanos expertos en el procedimiento, lo que sólo puede dar la práctica repetida....

Transthoracic aspiration cytology for the diagnosis of thoracic infection.

The article describes the use and results of transthoracic aspiration cytology for diagnosis of thoracic infection in a Thai referral chest center. We reviewed 60 cytologic samples, initially diagnosed as thoracic infection or inflammation among a total of 532 percutaneous transthoracic needle aspirations obtained from patients with clinical suspicion of malignancy in a period of 6 years. Follow-up clinical data were collected and correlated with cytologic diagnosis. We found specific microorganisms in 8 samples (13.33%). These included 4 cases of actinomycosis, 3 cases of cryptococcosis and a case of aspergillosis. Granulomatous inflammation was found in 12 samples (20.00%). Among these patients, 10 cases were verified as having tuberculosis. The remaining 40 samples (66.67%) revealed acute inflammatory exudate with no specific microorganism. Follow-up clinical data confirmed or assumed infection in 27 cases. Therefore, in patients with thoracic infection who presented with clinical suspicion of malignancy, from our experience, aspiration cytology revealed adequate morphology for accurate diagnosis which resulted in prompt specific treatment and better prognosis.

Utilidad diagnóstica del ultrasonido en la patología torácica / Diagnostic usefulness of ultrasound in thorax pathology

Se demuestra la utilidad diagnóstica del ultrasonido en la patología del tórax, ya que es un método accesible y poco costoso, se puede transportar al lado de la cama del paciente en los casos en que éste se encuentre muy grave para ser trasladado.Es un método que identifica perfectamente la diferencia entre sólido y líquido y puede ser de gran utilidad en las lesiones de pared, tejidos blandos y pleura. Asimismo, muestra utilidad en algunos procedimientos intervencionistas para diagnóstico y tratamiento.