Background: Gastroplasty has been increasingly used in the treatment of morbidly obese patients, who typically present pronounced alterations in lung volume and capacity. Objective: To evaluate post-gastroplasty lung volume, lung capacity, respiratory muscle strength and respiratory pattern, as well as any postoperative pulmonary complications. Method: 21 patients (3 of them men), with an average age of 39 ± 9.7 years and an average body mass index of 50.4 kg/m2, all candidates for gastroplasty, were evaluated during the preoperative period and again on the first, third and fifth postoperative days. Tidal volume, vital capacity, minute volume, maximal expiratory pressure and maximal inspiratory pressure, as well as chest and waist circumferences, were measured. Postoperative pulmonary complications and mortality were assessed. Results: On the first and third postoperative days, respectively, there were drops of 47% and 30.5% in vital capacity, 18% and 12.5% in minute volume, 28% and 21% in tidal volume, 47% and 32% in the diaphragmatic index, 51% and 26% in maximal inspiratory pressure, and 39.5% and 26% in maximal expiratory pressure (p < 0.05). On the fifth postoperative day, all variables analyzed were higher than on the first postoperative day, indicating a linear increase, with only tidal volume, minute volume diaphragmatic index returning to preoperative values. The incidence of postoperative pulmonary complications was 4.7%, and there were no deaths. Conclusion: Patients submitted to gastroplasty present reduced pulmonary function, following a pattern quite similar to that previously observed following other types of upper abdominal surgery.

Keywords: Key words: Gastroplasty. Obesity. Respiratory function tests. Postoperative care.

Objective: The aim of this study was to measure the changes in lung volume, pulmonary ventilation, maximum respiratory muscle strength, and the incidence of pulmonary complications in patients undergoing elective laparoscopic cholecystectomy. Type of study: Prospective study. Material and methods: Twenty patients (7 men and 13 women) with mean age of 42.7 years with normal respiratory function were studied. All patients in the preoperative period answered a long questionnaire, had a physical examination done, and had their lung volumes, respiratory muscle strength, diaphragmatic index and pulse oximetry determined. All measurements were repeated on the 1st, 2nd, 3rd and 6th postoperative days. Results: Patients showed a significant decrease (p < 0.05) on the first postoperative day: 26% ± 13% in tidal volume; 20% ± 14% in minute volume; 36% ± 17% in vital capacity; 47% ± 17% in maximum inspiratory pressure, 39% ± 27% in the maximum expiratory pressure and 36% ± 25% in diaphragmatic index. Tidal volume, minute volume and maximum expiratory pressure returned to their basal values on the third postoperative day; vital capacity, maximum inspiratory pressure and diaphragmatic index returned to their basal values between the 4th and 6th postoperative days. Among the 20 patients pulmonary complication was observed in just one patient (lobar atelectasis); there was a full recovery by the third postoperative day with the use of chest physical therapy techniques. Conclusion: The authors conclude that patients undergoing a laparoscopic cholecystectomy show a significant decrease in lung volume and in respiratory muscle strength on the first postoperative day. But, when these measurements are compared to the literature, return to their basal values is faster (between the 4th and 6th postoperative days) than with conventional surgery.

Keywords: Laparoscopic surgery, preoperative and postoperative care and respiratory muscle strength.

Objective: The aim of this study was to measure the changes in lung volume, pulmonary ventilation, maximum respiratory muscle strength, and the incidence of pulmonary complications in patients undergoing elective laparoscopic cholecystectomy. Type of study: Prospective study. Material and methods: Twenty patients (7 men and 13 women) with mean age of 42.7 years with normal respiratory function were studied. All patients in the preoperative period answered a long questionnaire, had a physical examination done, and had their lung volumes, respiratory muscle strength, diaphragmatic index and pulse oximetry determined. All measurements were repeated on the 1st, 2nd, 3rd and 6th postoperative days. Results: Patients showed a significant decrease (p < 0.05) on the first postoperative day: 26% ± 13% in tidal volume; 20% ± 14% in minute volume; 36% ± 17% in vital capacity; 47% ± 17% in maximum inspiratory pressure, 39% ± 27% in the maximum expiratory pressure and 36% ± 25% in diaphragmatic index. Tidal volume, minute volume and maximum expiratory pressure returned to their basal values on the third postoperative day; vital capacity, maximum inspiratory pressure and diaphragmatic index returned to their basal values between the 4th and 6th postoperative days. Among the 20 patients pulmonary complication was observed in just one patient (lobar atelectasis); there was a full recovery by the third postoperative day with the use of chest physical therapy techniques. Conclusion: The authors conclude that patients undergoing a laparoscopic cholecystectomy show a significant decrease in lung volume and in respiratory muscle strength on the first postoperative day. But, when these measurements are compared to the literature, return to their basal values is faster (between the 4th and 6th postoperative days) than with conventional surgery.

Keywords: Laparoscopic surgery, preoperative and postoperative care and respiratory muscle strength.

Background: Measurement of maximal respiratory pressures and vital capacity are essential in evaluating respiratory function. However, methodological variations may interfere with the interpretation of results. Objective: To compare values obtained using mouthpiece and face-mask evaluation methods in the measurement of maximal respiratory pressures and vital capacity. Method: We studied 30 patients (16 male), with a mean age of 55.9 ± 15.7, in the preoperative phase of abdominal surgery. Maximal inspiratory pressure and maximal expiratory pressure, as well as vital capacity, were evaluated using either a rigid flanged mouthpiece or a face mask, in randomized order. Results: Evaluation with a face mask did not significantly alter vital capacity and maximal inspiratory pressure values, although maximal expiratory pressure values were significantly lower than when measured using a rigid mouthpiece. During measurement of maximal expiratory pressure, air leakage from around the mask was observed in 60% of cases. When maximal expiratory pressure measurements in which there was no such leakage were considered in isolation, face-mask values were higher than those obtained with the moutpiece. Conclusion: With a face mask, maximal inspiratory pressure and vital capacity can be accurately evaluated. Maximal expiratory pressure can also be adequately evaluated using a face mask, provided that air leakage from the mask edges can be avoided. However, such leakage and the consequent reduction in the values obtained are common and limit the use of this method of evaluation.

Keywords: Respiratory function tests. Maximal voluntary ventilation. Respiratory muscles.

Objective: To compare the incidences of pulmonary and cardiopulmonary postoperative complications estimated using, respectively, the scoring systems devised by Torrington and Henderson and by Epstein in a populational sample undergoing lung resection for the treatment of lung cancer. Methods: Prospective data from patients submitted to resection of one or more pulmonary lobes were selected from the databases of two tertiary-care hospitals. The outcome measures were pulmonary complications, cardiac complications and mortality rates. Fisher's exact test was used to evaluate the concordance between the predicted and observed complications. Results: The Torrington and Henderson scoring system was applied to 50 patients, in which the risk was found to be mild in 12, moderate in 32, and high in 6. Although accurately identifying patients at high risk, the Torrington and Henderson scale underestimated the rate of postoperative cardiopulmonary complications in the mild and moderate risk categories (p = 0.0003 and p = 0.0006, respectively). The Epstein scoring system was applied to 38 patients, 4 of which were found to be at high risk, and 34 of which were found to be at mild risk. The Epstein scale also underestimated the risk in the patients (the majority) that were classified as being at mild risk (p < 0.0001) and yet, like the Torrington and Henderson scale, accurately identified those at high risk. Conclusion: Neither of the two scoring systems analyzed were found to be appropriate for predicting the risk of pulmonary and cardiopulmonary complications in most cases.

Keywords: Postoperative complications; Preoperative care; Thoracic surgical procedures/mortality; Lung neoplasms/surgery; Pneumonectomy; Respiratory function tests; Risk factors; Risk assessment

The direct costs incurred in managing patients with poorly controlled asthma are high and educational programs could decrease these costs. Aim: The objectives of this study were to compare the direct cost of the implementation of an educational program for adult asthmatic patients with the cost of the usual care delivered to asthmatics by specialists. Methods: Five years ago, a six-month study demonstrated that an educational program improved clinical outcomes (22 in educational program-E and 20 patients in control group-C). Throughout the educational intervention period all cases of hospitalization, emergency and regular calls involving patients from both groups were recorded. The basis for the values utilized in the calculation of costs was the healthcare database of the Brazilian government (DATASUS). The overall medication cost/patient in both groups was based on the amount of medication taken during the month preceding the last call. The final values were converted into US dollars. Results: The mean direct cost/patient in the educational (E) and control (C) groups and the difference (Δ) between groups were: hospitalizations (C = US$ 183, E = 0, Δ = US$ 183); emergency calls (C = US$ 14, E = US$ 5, Δ = US$ 9); regular calls (C = US$ 10, E = US$ 24, Δ = -US$ 14); medication (C = US$ 124,3, E = US$ 195,6, Δ = -US$ 71,3). The total cost was US$ 33/patient in group C and US$ 224/patient in group E with an average cost saving of US$ 107/patient. Conclusion: The expenses with medication is higher in E group because the regular use of maintenance drugs, however the study suggested that the application of the asthma education program reduced the total direct costs of asthma.

Keywords: Asthma. Cost-benefit. Patient education.

Objective: To determine morbidity and mortality rates by risk category in accordance with the American College of Chest Physicians guidelines, to determine what role pulmonary function tests play in this categorization process, and to identify risk factors for perioperative complications (PCs). Methods: This was a historical cohort study based on preoperative and postoperative data collected for cases of lung cancer diagnosed or suspected between 2001 and 2010. Results: Of the 239 patients evaluated, only 13 (5.4%) were classified as being at high risk of PCs. Predicted postoperative FEV1 (FEV1ppo) was sufficient to define the risk level in 156 patients (65.3%); however, cardiopulmonary exercise testing (CPET) was necessary for identifying those at high risk. Lung resection was performed in 145 patients. Overall morbidity and mortality rates were similar to those reported in other studies. However, morbidity and mortality rates for patients at an acceptable risk of PCs were 31.6% and 4.3%, respectively, whereas those for patients at high risk were 83.3% and 33.3%. Advanced age, COPD, lobe resection, and lower FEV1ppo were correlated with PCs. Conclusions: Although spirometry was sufficient for risk assessment in the majority of the population studied, CPET played a key role in the identification of high-risk patients, among whom the mortality rate was seven times higher than was that observed for those at an acceptable risk of PCs. The risk factors related to PCs coincided with those reported in previous studies.

Keywords: Algorithms; Lung neoplasms; Postoperative complications.

Objective: To determine whether the use of a set of preoperative variables can predict the need for postoperative ICU admission. Methods: This was a prospective observational cohort study of 120 patients undergoing elective pulmonary resection between July of 2009 and April of 2012. Prediction of ICU admission was based on the presence of one or more of the following preoperative characteristics: predicted pneumonectomy; severe/very severe COPD; severe restrictive lung disease; FEV1 or DLCO predicted to be < 40% postoperatively; SpO2 on room air at rest < 90%; need for cardiac monitoring as a precautionary measure; or American Society of Anesthesiologists physical status ≥ 3. The gold standard for mandatory admission to the ICU was based on the presence of one or more of the following postoperative characteristics: maintenance of mechanical ventilation or reintubation; acute respiratory failure or need for noninvasive ventilation; hemodynamic instability or shock; intraoperative or immediate postoperative complications (clinical or surgical); or a recommendation by the anesthesiologist or surgeon to continue treatment in the ICU. Results: Among the 120 patients evaluated, 24 (20.0%) were predicted to require ICU admission, and ICU admission was considered mandatory in 16 (66.6%) of those 24. In contrast, among the 96 patients for whom ICU admission was not predicted, it was required in 14 (14.5%). The use of the criteria for predicting ICU admission showed good accuracy (81.6%), sensitivity of 53.3%, specificity of 91%, positive predictive value of 66.6%, and negative predictive value of 85.4%. Conclusions: The use of preoperative criteria for predicting the need for ICU admission after elective pulmonary resection is feasible and can reduce the number of patients staying in the ICU only for monitoring.

Keywords: Thoracic surgery; Risk factors; Intensive care units.

Abstract Objective: To evaluate the influence of pleural drainage on the distance covered on the six-minute walk test, pain intensity and vital capacity in patients submitted to pulmonary resection. Methods: Thirteen consecutive patients from the Thoracic Surgery Infirmary of Hospital São Paulo, Brazil, submitted to closed pleural drainage (0.5-in multiperforated chest tube) in the postoperative period following pulmonary resection (lobectomy, segmentectomy and pulmonary nodule resection) were evaluated. The decision for chest tube removal followed clinical criteria defined by the surgical team, who did not participate in the study. Vital capacity, pain intensity (using a visual analog pain scale) and the distance covered on the six-minute walk test were determined 30 min prior to and 30 min after the removal of the chest tube. The statistical analysis was performed using paired t-tests, and the level of significance was set at 0.05. Results: After the removal of the chest tube, the visual analog scale pain scores were significantly lower (3.46 cm vs. 1.77 cm; p = 0.001) and the distance covered on the six-minute walk test was significantly higher (374.34 m vs. 444.62 m; p= 0.03). Vital capacity prior to and after chest tube removal was not significantly affected (2.15 L and 2.25 L, respectively; p = 0.540). Conclusions: The results of the present study suggest that the presence of a chest tube is a factor significantly associated with postoperative pain and functional limitation in patients submitted to pulmonary resection.

Keywords: Thoracic surgery; Exercise test; Respiratory function tests; Pain, postoperative.

Objective: To evaluate the capacity of the criteria described in Complementary Directive SAS/MS 12, issued on November 12, 2002, to identify patients with severe asthma, describing and comparing clinical, functional and treatment data of such patients. Methods: This was a nested case-control study using a structured database for adult asthma outpatients. We defined cases as asthma patients who met the inclusion criteria described in the directive, defining controls as those who did not. We collected and compared data related to the following: demographic characteristics; history of asthma; medications in use; comorbidities; history of tobacco use; number of exacerbations within the last 12 months, asthma-related hospitalizations and intensive care unit admissions within the last 12 months; spirometry; and sputum cytology. Results: The case and control groups consisted of 29 and 31 patients, respectively. The number of asthma exacerbations and emergency room visits within the last 12 months, as well as the number of patients that received at least one pulse of oral corticosteroids, was significantly higher in the case group than in the control group. In addition, prebronchodilator FVC was lower among the cases than among the controls. Furthermore, cytology revealed that eosinophil counts were significantly higher in the induced sputum of cases than in that of controls. Conclusions: The criteria described in the directive are suited to stratifying patients with severe asthma.

Keywords: Asthma; Budesonide; Combined modality therapy.