O "cansaço" como categoria norteadora das experiências de adoecidos pulmonares / "Fatigue" as a guiding category for the experiences of pulmonary diseased

As doenças pulmonares obstrutivas crônicas (DPOC) e as fibroses pulmonares intersticiais têm recebido pouca atenção da antropologia. Bastante estudadas do seu ponto de vista fisiológico e terapêutico, vale também atentar para seu quadro social, especialmente porque a debilidade provocada pelo comprometimento pulmonar e a oxigenoterapia, geralmente prescrita nas últimas etapas do adoecimento, são quadros que dependem de um arranjo familiar e clínico bastante complexo. Em particular, neste artigo, repousarei o foco sobre o "cansaço", uma categoria bastante central para as pessoas entrevistadas ao narrarem suas experiências com as DPOC. Ao todo, 28 pessoas foram entrevistadas em suas casas, muitas vezes em companhia de suas cuidadoras, numa grande metrópole brasileira, a partir de roteiro semiestruturado. O cansaço figura como principal sintoma identificado e referido ao longo dos itinerários diagnósticos e terapêuticos pelos diferentes serviços de saúde da cidade, de menor a maior complexidade. O cansaço retoma, ao final, como categoria que descreve também a busca que adoecidos e familiares empreenderam por atendimento, internação, medicação e disponibilização dos equipamentos para a oxigenoterapia domiciliar. Ao final, discuto alguns dos motivos que levaram os entrevistados a concentrar sua longa resposta na busca por tratamento, embora essa etapa tenha acontecido há muitos anos. Atenta à forma e ao conteúdo das narrativas dos adoecidos, conforme sugere Arthur Frank, percebo como pode ser mais heroico essas pessoas escolherem contar aventuras, sobressaltos e coragem no passado (quando buscavam os primeiros atendimentos), do que falar sobre dependência, enfado e cansaço, no presente (quando enfrentam o cotidiano da oxigenoterapia paliativa).

Abstract Chronic obstructive pulmonary diseases (COPD) and pulmonary fibrosis have received little attention from Anthropology. Studied from the physiological and therapeutical perspectives, their social conundrum is also worthy of note, especially because the weakness caused by pulmonary limitation and oxygen therapy-usually prescribed during the last stages of the disease-depend on complex familial and clinical arrangements. In particular, this paper will focus on "fatigue", as the central category pointed out by the respondents that narrated their experiences with COPD. In total, 28 people were interviewed in their home-usually in the company of their caretakers-in a big Brazilian metropolis, using a semi-structured list of questions. Fatigue was the main symptom identified and referred throughout the diagnostic and therapeutic itineraries around different health services-of lower and higher complexity-of the city. Fatigue resumes, in the end, as a category that also describes the search the respondents and their families endured for treatment, hospitalization, medication and in-home oxygen therapy equipment. In the end, I discuss some of the reasons that led respondents to focus their long answers in the search for treatment, although the search took place a long time ago. Form and content of the narratives are taken into account, as suggested by Arthur Frank, and I realize that it can be more heroic to tell tales of adventure, overcoming, and courage in the past (when they searched for the first treatments); than tales of dependence, boredom, and fatigue in the present (when they have to deal with daily palliative oxygen therapy).

Grado de cumplimiento de la técnica inhalatoria aplicada por las madres en niños menores de 3 años con Síndrome Bronquial Obstructivo Recurrente, hospitalizados en emergencia del Hospital Nacional Dos de Mayo desde Marzo al 30 de Abril del 2011 / Level of compliance of the inhalation technique applied for mothers in children under 3 years with Recurrent Bronchial Obstructive Syndrome, hospitalized in the Emergency at the National Hospital Dos de Mayo from March to April 2011

The success of the therapy inhalation (aerosol therapy), depends on the quality that is conducted, with the inhalation technique (TI), probably more important than the characteristics of the administered drug, the inhalation system, the patient's age and his respiratory condition. Also considering the frequent readmissions to the emergency of children with obstructive lower airways, clinically manifested by wheezing, we ask the following question: What is the degree of compliance with the inhalation technique applied by mothers of children under 3 years with recurrent wheezing bronchitis, hospitalized in the hospital emergency at the National Dos de Mayo from March to April 30, 2011?. The degree of compliance with the inhalation technique shake the inhaler applied by mothers of children under 3 years with recurrent Bronchial Obstructive Syndrorne. hospitalized in the emergency, was 90 per cent, 83 per cent meets insert the inhaler in the holding chamber and administered a single puff, 80 per cent to repeat the whole cycle, 70 per cent expect 10 seconds to 10 aspirations of the patient, 67 per cent correctly press the holding chamber, 60 per cent correctly positioning the patient, 53 per cent stir again inhaler, 27 per cent wait 30 to 60 seconds before repeating the cycle, and 23 per cent removes the holding chamber. Inhalation technique applied by the mothers of children under 3 years, diagnosed with recurrent obstructive bronchial syndrome treated in emergency at the National Hospital Dos de Mayo is not effective.

Study of 2-min walk test and 15-step exercise oximetry test in the assessment of exercise tolerance in Egyptian patients with chronic obstructive pulmonary diseass

The present study was conducted to study the 2-min walk test and 15-step exercise oximetry test in determination of exercise tolerance in Egyptian patients with chronic obstructive pulmonary disease. Sixty male patients with COPD were included in this study who were divided into three groups [mild, moderate and severe]. All of the patients were subjected cardio pulmonary exercise test using ramp protocol, 6 min walk test, 2-min walk test and 15 step exercise oximetry test. In this study we found significant difference between mild, moderate and severe groups as regards VO2% predicted, distance walked during 6-MWT, distance walked during 2-MWT, and saturation difference% and exercise time/s during 15-step exercise oximetry test [p value <0.05].We found also significant correlation between 2-MWT and 6-MWT and VO2 in the mild, moderate and severe groups. [r = 0.9 and 0.85, respectively for the mild, r = 0.52 and 0.48, respectively for the moderate and r = 0.94 and 0.45, respectively for the severe p <0.05 for all]. We did not find such correlation between exercise time in 15-step exercise oximetry test and both 6-MWT and VO2 in the three groups. [r = -0.066 and -0.067, respectively for the mild, r = -0.08 and -0.07, respectively for the moderate and r = -0.07 and -0.021, respectively for the severe, P > 0.05 for all]. Also there was non-significant correlation between saturation difference in 15-step exercise oximetry test and both 6-MWT and VO2 in the three groups[r = -0.371 and -0.378, respectively for the mild, r = -0.086 and -0.061, respectively for the moderate and r = -0.051 and -0.013, respectively for the severe p > 0.05 for all]. The study shows that the 2MWT is a valid test for the assessment of exercise capacity in patients with COPD. It is practical, simple, and well-tolerated by patients with severe COPD

Estrategia de hospitalización abreviada en el síndrome bronquial obstructivo del lactante. Experiencia de tres años en Unidades de Terapia Inhalatoria. / Strategy brief hospitalization in infant wheezing bronchitis. Experience of three years in Inhalation Therapy Units

Introducción: el síndrome broncoobstructivo del lactante (SBOL) constituye el principal motivo de consulta por patología respiratoria en menores de 2 años en el invierno. Desde el año 2008 se implementaron en Montevideo y área metropolitana diez Unidades de Terapia Inhalatoria (UTIs) en un régimen de hospitalización abreviada. Se describen las características clínicas de esta población y el tratamiento instituido. Material y métodos: fueron enrolados en forma prospectiva los niños entre 1 y 24 meses con diagnóstico de SBOL moderado, sin factores de riesgo, que ingresaron a las UTIs durante los meses de invierno, entre 2008 y 2010. Fueron tratados siguiendo un algoritmo terapéutico que incluyó dos horas con salbutamol inhalado y una tercera hora con adrenalina nebulizada, según la respuesta terapéutica; se administró prednisolona a los niños con dos episodios previos o más. Resultados: se incluyeron 2.183 pacientes. La estadía media fue de 3 horas; la mediana del escore de tal al ingreso fue 5 y al egreso de 3. Requirieron 2 horas de tratamiento con salbutamol 819 niños (38%); 707 pacientes (32%) completaron tres horas y 419 (19%) recibieron además corticoides. Fueron derivados al domicilio desde la UTI 1.314 pacientes (62%), y un 13% adicional luego de observación en emergencia, con un 8% de reconsultas. Los pacientes que recibieron hasta dos horas de tratamiento tuvieron más probabilidad de alta (p<0,005). Conclusiones: la estrategia de hospitalización abreviada, mediante la protocolización de un tratamiento aplicable en el primer y segundo nivel de atención, resultó útil para el manejo del SBOL.

Oxigenoterapia domiciliar prolongada em crianças e adolescentes: uma análise do uso clínico e de custos de um programa assistencial / Long-term home oxygen therapy in children and adolescents: analysis of clinical use and costs of a home care program

OBJETIVOS: Descrever as características clínicas e laboratoriais dos pacientes em oxigenoterapia domiciliar prolongada acompanhados pelo programa de atendimento domiciliar do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, durante um período de 8 anos, e comparar os grupos com e sem hipertensão pulmonar secundária. Estimar o custo do programa utilizando concentradores versus cilindros de oxigênio arcados pela instituição. MÉTODOS: Estudo descritivo retrospectivo e de coorte dos pacientes em oxigenoterapia domiciliar prolongada, em seguimento no período de 2002 a 2009, na Unidade de Pneumologia do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. RESULTADOS: Foram estudados 165 pacientes, 53 por cento do sexo masculino, com as medianas: idade de início da oxigenoterapia - 3,6 anos; tempo de oxigenoterapia - 7 anos; e tempo de sobrevida após início da oxigenoterapia - 3,4 anos. Os principais diagnósticos foram: fibrose cística (22 por cento), displasia broncopulmonar (19 por cento) e bronquiolite obliterante (15 por cento). Dos 33 pacientes que realizaram espirometria, 70 por cento apresentavam distúrbio ventilatório obstrutivo grave. O exame ecocardiográfico foi executado em 134 pacientes; 51 por cento deles tinham hipertensão pulmonar secundária. Houve associação estatisticamente significante entre: presença de hipertensão pulmonar e necessidade de maiores fluxos de oxigênio (qui-quadrado, p = 0,011); e presença de hipertensão pulmonar e maior tempo de oxigenoterapia (Logrank, p = 0,0001). Não houve diferença estatisticamente significante entre tempo de sobrevida após início da oxigenoterapia e presença de hipertensão pulmonar. Os custos médios mensais do programa foram: US$ 7.392,93 para os concentradores e US$ 16.630,92 para cilindros. CONCLUSÕES: A oxigenoterapia domiciliar prolongada foi empregada em distintas doenças crônicas, predominantemente em lactentes e pré-escolares. Houve alta frequência de hipertensão pulmonar associada a maiores períodos de uso e fluxos de oxigênio, sem associação à sobrevida. A substituição dos cilindros por concentradores poderá reduzir custos significativamente.

OBJECTIVES: To describe the clinical and laboratory characteristics of patients on long-term home oxygen therapy followed up by the home care program of Hospital das Clínicas, School of Medicine, Universidade de São Paulo, during a period of 8 years; to compare groups with and without secondary pulmonary hypertension; and to estimate the cost of the program using oxygen concentrators versus oxygen cylinders provided by the hospital. METHODS: A descriptive, retrospective cohort study of patients on long-term home oxygen therapy followed up from 2002 to 2009 at the Unit of Pulmonology, Children's Institute, Hospital das Clínicas, School of Medicine, Universidade de São Paulo. RESULTS: We studied 165 patients, of whom 53 percent were male, with the following medians: age at the beginning of oxygen therapy - 3.6 years; duration of oxygen therapy - 7 years; and survival time after beginning of oxygen therapy - 3.4 years. The main diagnoses were: cystic fibrosis (22 percent), bronchopulmonary dysplasia (19 percent), and bronchiolitis obliterans (15 percent). Of the 33 patients who underwent spirometry, 70 percent had severe obstructive lung disease. Echocardiogram was performed in 134 patients; 51 percent of them had secondary pulmonary hypertension. There was a statistically significant association between pulmonary hypertension and need of higher oxygen flows (chi-square, p = 0.011), and between pulmonary hypertension and longer duration of oxygen therapy (Logrank, p = 0.0001). There was no statistically significant difference between survival time after the beginning of oxygen therapy and pulmonary hypertension. The average monthly costs of the program were US$ 7,392.93 for concentrators and US$ 16,630.92 for cylinders. CONCLUSIONS: Long-term home oxygen therapy was used to treat different chronic diseases, predominantly in infants and preschool children. There was a high frequency of pulmonary hypertension associated with longer periods of oxygen use and greater oxygen flow, without association with survival rate. The use of concentrators instead of cylinders may reduce costs significantly.

Recommendations for hygiene of masks and circuits in mechanically home ventilated patients

Home mechanical ventilation requires equipment, consisting of a generator of pressure, a tubing and an interface to deliver air to the patient. Instructions for equipment maintenance are generally not based on scientific evidence. Studies however have reported that tubing and masks used at home are the most commonly found as very dirty and contaminated. Dirtiness and contamination of equipment potentially expose patients to a higher risk of airway colonization, which, in turn, should cause respiratory infections. For this reason, published hygiene instructions include the use of disinfectant solution. Nevertheless, they generally fail to explain how basic maintenance may be achieved by simple cleaning with soap and water. The instructions for post-cleaning disinfection will depend upon the relative sensitivity of patients to respiratory tract infections and the related risks for bacterial colonization of the airways. Restrictive and obstructive disease patients are not equally sensitive to infections and, as a consequence, should not require similarly elaborate disinfection level. According with the restrictive or obstructive origin of respiratory insufficiency, the current educational review suggests simple and adequate rules for hygiene of tubing and masks in the home setting. Written instructions on how to clean the equipment for home ventilation are useful and sufficient in restrictive patients. In obstructive patients, cleaning always precedes disinfection. After cleaning, rinsing and drying are important. An effective weekly 20-minute disinfection may be achieved by using an hypochlorite solution of soaking in a concentration of 0.5 percent.

Efeito da atividade física sobre a evolução do enfisema pulmonar: um estudo experimental em ratos Wistar / Effects of physical activity on the development pulmonar emphysema in rats: experimental study in rats Wistar

O propósito da presente investigação foi avaliar o papel da atividade física no desenvolvimento de enfisema induzido por papaina em ratos. Para tanto, ratos Wistar foram radomicamente divididos em quatro grupos (n = 10 para cada grupo) que receberam, respectivamente, infusão intra-traqueal de papaína (6 mg em 1 ml de NaCI 0,9 por cento) ou veículo e foram submetidos ou não ao protocolo de exercício em uma esteira ergométrica. Os ratos exercitaram-se a 13,3 m/min, 6 dias por semana, durante 9 semanas (o tempo de exercício foi aumentado gradualmente, de 10 a 35 min) / The purpose of the present study was to evaluate the role of exercise trainning on the development of papain-induced emphysema in rats. Wistar rats were randomly assigned to four groups (n = 10 for each group) that receiveid, respectively, intratracheal infusion of papain (6 mg in 1 ml NaCI 0,9 per cent) or vehicle and were submitted or not to a protocol of exercise on a treadmill...

Estudo da celularidade inflamatória na doença pulmonar obstrutiva crônica / Inflammatory cellularity in chronic obstructive pulmonary disease

Acreditando na importância da inflamação na DPOC (Doença Pulmonar Obstrutiva Crônica) e na existência de características superponíveis com a asma que levam a evoluções diferentes da doença, estudamos o processo inflamatório por métodos não invasivos (composição evolutiva da celularidade do escarro e medidas de NO exalado) em pacientes com DPOC em uso crônico de corticóide oral, durante redução gradativa. Foram 16 pacientes (98 coletas) mostrando que a exacerbação clínica se caracterizou por um aumento dos eosinófilos no escarro induzido e aumento do óxido nítrico exalado, com piora no questionário de qualidade de vida St George, nos índices de dispnéia e teste de caminhada de 6 minutos /Inflammation is important in COPD (Chronic Obstructive Pulmonary Disease) and shares similar characteristics with asthma, leading however to different progression outcomes. We have used non-invasive methods (sputum cellularity and exhaled nitric oxide) to study the inflammatory process in patients with COPD who had chronically used oral steroids, during gradual dose tapering. We have investigated 16 patients (98 samples) and concluded that clinical exacerbation was characterized by increase in eosinophils count in sputum and increase in exhaled nitric oxide. The exacerbation has correlated with worsening in St. George quality of life questionnaire, dyspnea indexes and six-minute walk test...

Edema pulmonar postobstructivo: reporte de 3 casos / Postobstructive pulmonary edema: report 3 cases

El edema pulmonar postobstructivo (EPPO) es una complicación postoperatoria cuyo manejo adecuado depende de un diagnóstico etiológico correcto. El EPPO se clasifica en dos tipos. El tipo I es secundario a la obstrucción aguda de la vía aérea superior. Por su parte, el tipo II ocurre luego de corregir quirúrgicamente una obstrucción crónica de la vía aérea. Fisiopatológicamente, el mecanismo que explica el cuadro es una disminución marcada de la presión intersticial en el nivel pericapilar pulmonar resultante de la inspiración forzada. Lo anterior produce fuga capilar y el consecuente edema de pulmón. El manejo de este cuadro requiere de soporte respiratorio que incluye ventilación mecánica e incluso presión positiva al final de la espiración (PEEP). El pronóstico es muy bueno si el diagnóstico es correcto y oportuno. Se reportan 3 casos que ilustran la entidad, su diagnóstico y manejo. Descriptores: Edema pulmonar postobstructivo, complicación postoperatoria.

Adaptación a un esquema de entrenamiento físico en pacientes con enfermedad pulmonar obstructiva crónica avanzada / Adaptation to a physical training protocol of severe chronic obstructive pulmonary disease patients

El ejercicio físico es un elemento básico en la rehabilitación en pacientes con EPOC. Sin embargo, los resultados son variables, lo que puede deberse a las diferentes estrategias de entrenamiento utilizadas. En 22 pacientes con EPOC avanzada (VEF, 35,6 ñ 15,7 por ciento: edad 63 ñ 15 años; x ñ DS) Evaluamos su adaptación a un esquema de entrenamiento (E) en bicicleta ergométrica que consistió en aplicar inicialmente una carga inicial de 30 por ciento de la máxima previamente determinada (CM) y aumentarla en 15 a 20 por ciento en las sesiones siguientes cuando el paciente era capaz de mantenerla por 45 minutos, hasta alcanzar la meta de 75 por ciento de la CM. La intensidad del E se midió en watts calculando el área bajo la curva de la relación entre las cargas aplicadas y el número de sesiones de entrenamiento. El efecto del E se evaluó a través de los cambios en la carga y el VO2 máximos, la duración de un ejercicio submáximo, la frecuencia cardíaca, (FC), disnea, fatiga de las extremidades inferiores y lactato sanguíneo para una misma carga y tiempo de ejercicio. La CM de E fue 61 ñ 23 por ciento (x ñ DS) del máximo. Seis pacientes no fueron capaces de alcanzar la carga establecida como meta. En los restantes ésta se alcanzó en un número variable de sesiones (12 ñ 7). La intensidad del entrenamiento fue de 952 ñ 325 watt. El E produjo un aumento de la CM (p<0,02) y del tiempo de ejercicio (p<0,0001) y una disminución significativa de la FC, disnea, fatigabilidad y lactato sanguíneo. La duración del ejercicio se correlacionó con la reducción de la disnea (r= -0,448; p<0,05) y la intensidad del entrenamiento con la disminución de la fatiga (r= -0,5176; p = 0,014) y también del lactato sanguíneo (r= -0,488; p = 0,021). Los resultados demuestran que aún cuando la adaptación al esquema de entrenamiento fue variable de acuerdo a la capacidad individual y no pudo ser aplicada a todos los pacientes, la mayoría de ellos obtuvo efectos beneficiosos