Negative-pressure pulmonary edema accompanied by hemorrhage as a manifestation of upper airway obstruction is an uncommon problem that is potentially life-threatening. The principal pathophysiological mechanism involved is the generation of markedly negative intrathoracic pressure, which leads to an increase in pulmonary vascular volume and pulmonary capillary transmural pressure, creating a risk of disruption of the alveolar-capillary membrane. We report the case of an adult male with diffuse alveolar hemorrhage following acute upper airway obstruction caused by the formation of a cervical and mediastinal abscess resulting from the insertion of a metallic tracheal stent. The patient was treated through drainage of the abscess, antibiotic therapy, and positive pressure mechanical ventilation. This article emphasizes the importance of including this entity in the differential diagnosis of acute lung injury after procedures involving upper airway instrumentation.

Keywords: Hemorrhage; Pulmonary edema; Airway obstruction; Abscess; Prostheses and implants.

In cases of recent asthma in which clinical control with the usual treatment (corticosteroids and bronchodilator) is unsatisfactory, it is important to consider other diagnoses, such as congestive heart failure, gastroesophageal reflux or other forms of airway obstruction. We report the case of a female patient with mucoepidermoid carcinoma of the trachea mimicking asthma. The patient presented cough and wheezing, as well as abnormal spirometry results with an obstructive pattern that was responsive to bronchodilators. One year later, the patient presented clinical and spirometric worsening. The chest X-ray revealed no abnormalities. A CT scan showed a vegetative lesion obstructing the tracheal lumen and located 1 cm from the carina. Fiberoptic bronchoscopy showed a finding similar to a bronchial carcinoid tumor. The anatomopathological diagnosis made after surgical resection was low-grade mucoepidermoid carcinoma, without lymph node involvement. Although the flow-volume curve was not suggestive of upper airway obstruction, the spirometry performed after the surgery showed a significant reduction in the degree of obstruction and greater reversibility after bronchodilator use. There was no evidence of recurrence of the disease or of the symptoms after a two-year follow-up period.

Keywords: Bronchial hyperreactivity; Carcinoma, mucoepidermoid; Trachea; Asthma; Lung diseases, obstructive.

Objective: To evaluate the influence of the surgical team (general surgery or thoracic surgery) and the surgical technique (with or without isthmectomy) on the incidence of postintubation injuries in the airways of tracheostomized patients. Methods: Between January 1st and August 31st, 2007, 164 patients admitted to the adult intensive care unit and tracheally intubated for more than 24 h were studied prospectively at the Sumaré State Hospital, located in the city of Sumaré, Brazil. When tracheostomy was necessary, these patients were randomly assigned to thoracic or general surgery teams. All of the patients were submitted to fiberoptic tracheoscopy for decannulation or late evaluation of the airway. Results: Of the 164 patients in the study, 90 (54.88%) died (due to causes unrelated to the procedure), 67 (40.85%) completed follow-up, and 7 (4.27%) were lost to follow-up. Of the 67 patients who completed follow-up, 32 had undergone tracheostomy (21 by the general surgery team and 11 by the thoracic surgery team), and 22 had been submitted to isthmectomy (11 by the general surgery team and 11 by the thoracic surgery team). There was no difference between the surgical teams in terms of the incidence of stoma complications. However, there was a significant difference when the surgical techniques (with or without isthmectomy) were compared. Conclusions: Not performing isthmectomy in parallel with tracheostomy leads the surgeon to open the tracheal stoma more distally than expected. In such cases, there were more stoma complications.

Keywords: Tracheostomy; Intensive care units; Tracheal stenosis.

This was a retrospective analysis of the medical charts of 145 patients treated at the Bronchoscopy and Thoracic Surgery Clinic of the Hospital das Clínicas da Universidade Estadual de Campinas (HC-Unicamp, State University of Campinas Hospital das Clínicas) over a period of 10 years. There was a significant difference related to the site of first medical visit (HC-Unicamp versus other institutions) in terms of the time elapsed between the suspicion of bronchial aspiration and the actual respiratory endoscopic examination. However, no significant difference was found in the rate of positive results. The low number of referral centers that provide emergency respiratory endoscopy can negatively influence the treatment of patients under suspicion of bronchial aspiration, jeopardizing the overall recovery in the mid- and long-term.

Keywords: Airway obstruction; Respiratory aspiration; Bronchoscopy.

Objective: To evaluate pleural drainage using a one-way flutter valve following elective lung resection. Methods: This was a prospective study, with descriptive analysis, of 39 lung resections performed using a one-way flutter valve to achieve pleural drainage during the postoperative period. Patients less than 12 years of age were excluded, as were those submitted to pneumonectomy or emergency surgery, those who were considered lost to follow-up and those in whom water-seal drainage was used as the initial method of pleural drainage. Lung expansion, duration of the drainage, hospital stay and postoperative complications were noted. Results: A total of 36 patients were included and analyzed in this study. The mean duration of pleural drainage was 3.0 ± 1.6 days. At 30 days after the surgical procedure, chest X-ray results were considered normal for 34 patients (95.2%). Postoperative complications occurred in 8 patients (22.4%) and were related to the drainage system in 3 (8.4%) of those. Conclusions: The use of a one-way flutter valve following elective lung resection was effective, was well tolerated and presented a low rate of complications.

Keywords: Drainage; Postoperative complications; Thoracic surgery.

Objective: To evaluate the health-related quality of life of patients submitted to resection of the pulmonary parenchyma due to neoplasia. Methods: The Medical Outcomes Study 36-item Short-Form Health Survey was used to evaluate patients in the preoperative period and on postoperative days 30, 90 and 180. We used the GEE statistical model, in which the dependent variable (quality of life) changes for each patient over the course of the evaluation. Independent variables were gender, age, educational level, type of surgery, radiotherapy, chemotherapy, forced vital capacity and 6-minute walk test. The level of significance adopted was 5%. Results: The final study sample comprised 36 patients, 20 of whom were men. Of those 36 patients, 17 were submitted to lobectomy, 10 to pneumonectomy, 6 to segmentectomy, and 3 to bilobectomy. Chemotherapy was used in 15 patients, radiotherapy in 2, and a combination of radiotherapy and chemotherapy in 2. Improved quality of life was seen in the following domains: social (on postoperative day 90); physical/functional (some patients presenting better forced vital capacity and 6-minute walk test performance); and physical (in patients undergoing smaller resections). Lowered quality of life was seen in the following domains: social (for female patients); physical/social (resulting from radiotherapy, chemotherapy or both); and physical/functional (by postoperative day 30). Conclusions: It is important that studies evaluating the various determinants of quality of life, as well as the impact that cancer treatment modalities have on such variables, be conducted. The knowledge provided by such studies can contribute to improving the quality of life of patients undergoing pulmonary resection due to neoplasia.

Keywords: Lung neoplasms/surgery; Pneumonectomy; Quality of life; Questionnaires

Objective: To determine whether pre-operative nutritional status and post-operative time on mechanical ventilation, as well as others factors, are correlated with post-operative complications (general or pulmonary) in patients undergoing elective thoracic surgery. Methods: A prospective study was conducted, involving 71 patients undergoing elective pulmonary resection. The data collected pre-operatively included gender, age, smoking status, pre-albumin level, lymphocyte count, and body mass index. The peri-operative data included type of surgery and surgical time, as well as post-operative time on mechanical ventilation. Results: Post-operative complications were found to correlate with low pre-albumin concentration, type of resection, surgical time, and post-operative time on mechanical ventilation. Surgical time and post-operative time on mechanical ventilation were also implicated in the post-operative pulmonary complications observed in 22 (30.99%) of the patients studied. Conclusion: Our results suggest that pre-albumin concentration, type of surgery and surgical time, as well as post-operative time on mechanical ventilation, serve as predictive indices of post-operative complications in patients undergoing elective pulmonary resection. In the analysis of the post-operative pulmonary complications, statistically significant correlations were found between such complications and increases in surgical time or post-operative time on mechanical ventilation.

Keywords: Thoracic surgery; Postoperative complications; Mechanical ventilation; Nutritional status; Prealbumin

Objective: To determine the incidence of residual pneumothorax after video-assisted thoracic sympathectomy, with and without postoperative pleural drainage, and to evaluate the possible influence of this type of pneumothorax on postoperative pain within the first 28 postoperative days. Methods: All patients presenting symptoms consistent with primary palmoplantar hyperhidrosis and treated at the Thoracic Surgery Outpatient Clinic of the State Hospital of Sumaré between July and December of 2006 were included. All were submitted to sympathectomy up to the third ganglion using video-assisted thoracoscopy and were randomized to receive or not receive postoperative pleural drainage for 3 h. Chest X-rays and low-dose computed tomography scans of the chest were performed on the first postoperative day in order to determine the incidence of residual pneumothorax. At different time points up to postoperative day 28, patient pain was assessed using a visual numeric scale and by measuring the quantity of opioid analgesics required. Results: This study comprised 56 patients, 27 submitted to bilateral pleural drainage and 29 not submitted to drainage. There was no statistical difference between the two groups in terms of the incidence of post-sympathectomy residual pneumothorax. Residual pneumothorax diagnosed through any of the methods did not influence pain within the first 28 postoperative days. Conclusion: Performing closed pleural drainage for 3 h immediately after video-assisted thoracic sympathectomy did not affect lung re-expansion or the incidence of residual pneumothorax. When residual pneumothorax was present, it did not affect pain within the first 28 postoperative days.

Keywords: Hyperhidrosis; Sympathectomy; Pain, postoperative; Pneumothorax; Drainage; Pleura.

Objective: To describe demographic characteristics, surgical results, postoperative complications, and overall survival rates in surgically treated patients with lung metastases. Methods: This was a retrospective analysis of 119 patients who underwent a total of 154 lung metastasis resections between 1997 and 2011. Results: Among the 119 patients, 68 (57.1%) were male and 108 (90.8%) were White. The median age was 52 years (range, 15-75 years). In this sample, 63 patients (52.9%) presented with comorbidities, the most common being systemic arterial hypertension (69.8%) and diabetes (19.0%). Primary colorectal tumors (47.9%) and musculoskeletal tumors (21.8%) were the main sites of origin of the metastases. Approximately 24% of the patients underwent more than one resection of the lesions, and 71% had adjuvant treatment prior to metastasectomy. The rate of lung metastasis recurrence was 19.3%, and the median disease-free interval was 23 months. The main surgical access used was thoracotomy (78%), and the most common approach was wedge resection with segmentectomy (51%). The rate of postoperative complications was 22%, and perioperative mortality was 1.9%. The overall survival rates at 12, 36, 60, and 120 months were 96%, 77%, 56%, and 39%, respectively. A Cox analysis confirmed that complications within the first 30 postoperative days were associated with poor prognosis (hazard ratio = 1.81; 95% CI: 1.09-3.06; p = 0.02). Conclusions: Surgical treatment of lung metastases is safe and effective, with good overall survival, especially in patients with fewer metastases.

Keywords: Neoplasm metastasis; Survival analysis; Thoracic surgery; Metastasectomy.