Carcinoma of the lung can present in a number of guises and a number of possible and often complementary diagnostic approaches are available. The choice of procedure should reflect the presentation of the tumor, local expertise, intended management and patient preference. There are different methods of investigation: sputum cytology, fiberbronchoscopy, transbronchial biopsy, transbronchial needle aspiration, transthoracic fine needle aspiration, etc. The association of all of these methods increases the power of diagnosis. Staging is the measurement of the anatomical extent of a tumor in any given patient. The staging of cancer began with Denoix's TNM classification system, and, although several modifications were developed, it remains the basis of lung cancer staging systems up to now. Assigning patients to a particular TNM stage allows choosing the most appropriate therapy and provides prognostic information. Also, the impact of new therapeutic methods can be evaluated for efficacy and a comparison of the expected survival rates can be predicted.

Introduction: Smoking is the major preventable risk of morbidity and mortality. However, its prevalence is high in developed countries and increasing in developing countries, even though its effects are now better known. The purpose of this study was to compare the exhaled carbon monoxide concentration (exCO) between smokers and nonsmokers, evaluate the factors that influence this parameter among smokers and the potential influence of passive smoking by measuring exCO in workers and patients of Instituto do Coração HC-FMUSP. Materials and methods: This cross study included 256 volunteers who responded to a questionnaire and were submitted to exCO measuring with the MicroCo meter device. Results: There were 106 males and 150 females. Mean age was 43.4 years (Vmin-max: 15-83). There were 107 smokers, 118 nonsmokers and 31 passive smokers. Mean exCO was 14.01 ppm (Vmin-max: 1-44) among smokers, 2.03 ppm (Vmin-max: 0-5) among passive smokers and 2.50 ppm (Vmin-max: 0-9) among nonsmokers. Significant statistical difference was observed between smokers and the other groups (p < 0.001), but not between nonsmokers and passive smokers. A positive correlation was found between the number of cigarettes smoked per day and exCO values while there was a negative correlation between the exCO values and the timing of the last cigarette. For a reference limit value of 6 ppm, sensitivity was 70% and specificity was 96%. Conclusion: exCO metering is easy to perform, low-cost, noninvasive and allows the obtention of immediate results and the reference limit value of 6 ppm has good specificity to evaluate the smoking habit.

Keywords: Smoking. Carbon monoxide. Tobacco smoke pollution. Brazil.

Background: Pectus excavatum is characterized by concave growth of costal cartilage and depression of the lower sternum. Clinical means of classifying these malformations are few and difficult to apply. Objective: To devise clinical tools for quantifying the deformity and comparing preoperative and postoperative findings. Method: A total of 10 pectus excavatum patients who underwent surgery in which the modified Robicsek technique was used by the Thoracic Surgery Group of the Hospital das Clínicas of the University of São Paulo School of Medicine, were clinically and radiologically evaluated in the preoperative and postoperative periods. Ten control individuals, presenting no thoracic or radiological abnormalities, were submitted to identical evaluations. Deformities at the sternum notch level and at the point of maximum deformity were assessed using the anthropometric index and the Haller index. Results: Multivariate analysis of anthropometric index means revealed significant differences between preoperative and control values and between preoperative and postoperative values, as well as a non-significant difference between postoperative and control values. The same results were obtained when Haller index means were analyzed. A paired comparison of preoperative and postoperative means showed two distinct groups. An 86% canonical correlation was found between the anthropometric index and the Haller index. Conclusion: Patients with pectus excavatum can be quantitatively assessed in the preoperative and postoperative periods through the use of the anthropometric index, which allows objective, comparative evaluation of the results and is easily performed.

Keywords: Funnel Chest. Anthropometry/methods.

Objective: To report the experience of a routine follow-up program based on medical visits and chest CT. Methods: This was a retrospective study involving patients followed after complete surgical resection of non-small cell lung cancer between April of 2007 and December of 2015. The follow-up program consisted of clinical examination and chest CT. Each follow-up visit was classified as a routine or non-routine consultation, and patients were considered symptomatic or asymptomatic. The outcomes of the follow-up program were no evidence of cancer, recurrence, or second primary lung cancer. Results: The sample comprised 148 patients. The median time of follow-up was 40.1 months, and 74.3% of the patients underwent fewer chest CTs than those recommended in our follow-up program. Recurrence and second primary lung cancer were found in 17.6% and 11.5% of the patients, respectively. Recurrence was diagnosed in a routine medical consultation in 69.2% of the cases, 57.7% of the patients being asymptomatic. Second primary lung cancer was diagnosed in a routine medical appointment in 94.1% of the cases, 88.2% of the patients being asymptomatic. Of the 53 patients who presented with abnormalities on chest CT, 41 (77.3%) were diagnosed with cancer. Conclusion: Most of the cases of recurrence, especially those of second primary lung cancer, were confirmed by chest CT in asymptomatic patients, indicating the importance of a strict follow-up program that includes chest CTs after surgical resection of lung cancer.

Keywords: Lung neoplasms/surgery; Neoplasm recurrence, local; Neoplasms, second primary.

The presence of mediastinal lymph node metastasis in lung cancer has a great influence on treatment selection and prognosis, and the diagnosis of lymphatic metastasis must be accurate. CT chest scans and mediastinoscopy are the diagnostic tools available to detect mediastinal lymph node metastases and to establish preoperative staging. Lymph node size evaluated by CT scans is not an acceptable criterion in the patients studied here. The aim of this study was to find out a representative pattern of size to indicate the possibility of neoplastic invasion in the population studied. Fifty consecutive patients were operated on and were submitted to pulmonary resection and mediastinal dissection to treat lung cancer. Seventy-four percent of the lymph nodes with transverse section of more than 3 cm had no neoplastic invasion. CT scans and mediastinoscopy have similar sensitivity (close to 65%), but mediastinoscopy has higher specificity (100%). This means that the authors must have histologic confirmation of any suspected lymph node to achieve a correct staging.

Keywords: Carcinoma, non-small cell. Lung neoplasias. Lymph nodes. Lymphatic metastasis. Mediatinoscopy. Neoplasm, staging. CT scanning.

There are few reports in the medical literature about association between bronchiolitis obliterans with organizing pneumonia (BOOP) and aspergilloma. This report shows the presence of both BOOP and pulmonary aspergilloma in a patient with adult T cell leukemia-lymphoma. It is suggested that these findings represent a random association rather than the expression of a nosologic unity.

Keywords: bronchiolitis obliterans; aspergillosis; T cell lymphoma; pneumonia

The treatment of typical carcinoid tumors in bronchus is usually done by a small pulmonary resection with or without bronchoplasty. The authors report the case of a patient with typical carcinoid tumor in the left lower lobar bronchus, next to the lobar carina. They performed a longitudinal bronchotomy, tumor resection, and suture of the bronchus, preserving the lung tissue. The patient is currently well, three years after surgery, without any evidence of recurrence in the bronchoscopic control.

Keywords: Bronchial carcinoid tumor. Bronchoplasty. Bronchotomy. Lung tissue. Surgery.

Ependymomas are rare tumors of the central nervous system that most often occur at the cauda equina. These tumors seldom metastasize. A 35 year-old man, nine years after the resection of an ependymoma of the coccygeal region developed pleuritic pain, dyspnea, cough and night sudoresis. Lung X-ray revealed pleural congestion and metastic nodes in both lungs. Histopathological and immunohistochemical examinations of the tissue obtained through open pulmonary biopsy confirmed the diagnosis of a pendymoma, chemotherapy was administered and after 43 months of follow up the patient's evolution has been good.

Keywords: Ependymoma. Lung neoplasms. Neoplasm metastasis.

Objective: To determine the efficacy of the scoring system, recommended by the Brazilian National Ministry of Health (NMH), for the diagnosis of pulmonary tuberculosis (TB) in children and adolescents, regardless of their HIV status. Methods: This was a cross-sectional analytical study carried out between January of 2002 and December of 2006, involving 239 individuals less than 15 years of age. The patients were divided into four groups: latent TB (LTB group; n = 81); no-TB (NTB group; n = 41); TB group (n = 104); and TB/HIV group (n = 13). We studied the clinical, radiological and laboratory findings according to the scoring system. Results: Reports of fever, cough, asthenia and weight loss for at least two weeks were significantly higher in the TB group (p < 0.0001). The proportion of cases with a history of any contact and household contact with a TB patient was, respectively, 95.0% and 86.1% in the TB group, versus 75.0% and 58.3% in the TB/HIV group. In the TB and TB/HIV groups, respectively, chest X-rays revealed parenchymal alterations in 75.0% and 53.9%, revealing combined parenchymal/lymph node alterations in 18.2% and 30.8%. There were no significant differences among the groups regarding the tuberculin skin test results. In the TB group, 16.3% of the patients were malnourished (p < 0.005 vs. the LTB group). The mean NMH system scores in the LTB, NTB, TB and TB/HIV groups were, respectively, 24.2, 18.5, 45.3 and 41.5. Conclusions: The NMH system scores were significantly higher in the TB and TB/HIV groups than in the other two groups. Therefore, this scoring system was valid for the diagnosis of pulmonary TB in this population, regardless of HIV status.

Keywords: Tuberculosis/diagnosis; HIV seropositivity; Diagnostic techniques and procedures.

Objective: To determine the association between smoking and pulmonary tuberculosis treatment failure. Methods: This was a case-control study conducted at the Brazilian Institute for Tuberculosis Research in the city of Salvador, Brazil, between 2007 and 2015. We evaluated 284 patients treated for pulmonary tuberculosis, comparing 50 cases of treatment failure with 234 control cases in which the final outcome was cure. Results: Treatment failure was attributed to smoking and age rather than to gender, income, level of education, alcohol consumption, or marital status. Therefore, even after adjustment for age, the risk of treatment failure was 2.1 times (95% CI: 1.1-4.1) higher among the patients with a history of smoking. In addition, being over 50 years of age was found to increase the likelihood of treatment failure by 2.8 times (95% CI: 1.4-6.0). Conclusions: Smoking and aging are both associated with pulmonary tuberculosis treatment failure. Therefore, as part of a tuberculosis control program, health personnel should be prepared to offer strategies to promote smoking cessation and should be more careful with older patients.

Keywords: Tobacco use disorder; Tuberculosis; Treatment failure.

Objective: To investigate the accuracy of chest auscultation in detecting abnormal respiratory mechanics. Methods: We evaluated 200 mechanically ventilated patients in the immediate postoperative period after cardiac surgery. We assessed respiratory system mechanics - static compliance of the respiratory system (Cst,rs) and respiratory system resistance (R,rs) - after which two independent examiners, blinded to the respiratory system mechanics data, performed chest auscultation. Results: Neither decreased/abolished breath sounds nor crackles were associated with decreased Cst,rs (≤ 60 mL/cmH2O), regardless of the examiner. The overall accuracy of chest auscultation was 34.0% and 42.0% for examiners A and B, respectively. The sensitivity and specificity of chest auscultation for detecting decreased/abolished breath sounds or crackles were 25.1% and 68.3%, respectively, for examiner A, versus 36.4% and 63.4%, respectively, for examiner B. Based on the judgments made by examiner A, there was a weak association between increased R,rs (≥ 15 cmH2O/L/s) and rhonchi or wheezing (ϕ = 0.31, p < 0.01). The overall accuracy for detecting rhonchi or wheezing was 89.5% and 85.0% for examiners A and B, respectively. The sensitivity and specificity for detecting rhonchi or wheezing were 30.0% and 96.1%, respectively, for examiner A, versus 10.0% and 93.3%, respectively, for examiner B. Conclusions: Chest auscultation does not appear to be an accurate diagnostic method for detecting abnormal respiratory mechanics in mechanically ventilated patients in the immediate postoperative period after cardiac surgery.

Keywords: Diagnostic tests, routine; Physical examination; Respiratory sounds; Respiratory mechanics; Data accuracy; Respiration, artificial.

This article addresses the evolution of pleurodesis since the beginning of the 20th century and defines the characteristics of the ideal sclerosing agent. Emphasis is placed on the current tendency towards minimally invasive procedures where insertion of catheters is usually given priority over certain surgical procedures such as placement of drains or thoracoscopy. Among the sclerosing drugs, talc is the one preferred throughout the world. However, the possible appearance of respiratory distress syndrome, which is sometimes fatal, caused the awakening of interest in other drugs. Anti neoplastic drugs do not induce a very efficient pleurodesis and still have the disadvantage of causing important side effects. Sodium hydroxide and silver nitrate produce effective pleurodesis. Both can be used in humans.

Keywords: Pleurodesis. Sclerosing solutions. Clinical procedures.

Objective: To determine the rate of compliance with preventive treatment of moderate and severe persistent asthma. Methods: Physicians at various medical centers across the country were invited to nominate patients for participation in the study. Inclusion criteria were being over the age of 12 and presenting moderate or severe persistent asthma. Participating patients received salmeterol/fluticasone 50/250 µg by dry powder inhaler for 90 days and were instructed to return the empty packages at the end of the study as a means of determining the total quantity used. In order to evaluate compliance, a member of the research team contacted each patient via telephone at the study outset and again at the end of the 90-day study period. Asthma patients were considered compliant with the treatment if they used at least 85% of the prescribed dose. The following variables were studied: gender, age, race, marital status, years of schooling, smoking habits, other atopic conditions, comorbidities, asthma severity, use of other medication and number of hospital admissions for asthma. Results: A total of 131 patients from fifteen states were included. The overall rate of compliance was found to be 51.9%. There was a significant difference in compliance in relation to asthma severity: compliance was greater among patients with severe persistent asthma than among those with moderate persistent asthma (p = 0.02). There were no statistically significant differences among any of the other variables. Conclusion: The overall rate of compliance with maintenance treatment of asthma was low.

Keywords: Asthma/drug therapy; Asthma/prevention & control; Patient compliance; Patient education; Physician-patient relations

Objective: To assess the frequency and severity of 24-hour respiratory symptoms according to COPD GOLD-ABCD classification (2017-version), the distribution of the patients with COPD into GOLD categories using mMRC (=2) or CAT (=10) scores, and agreement between these cut-off points. Methods: In this cross-sectional study (LASSYC study), 24-hour day respiratory symptoms were assessed by the Evaluating Respiratory Symptoms in COPD (E-RS) questionnaire, Nighttime Symptoms of COPD Instrument (NiSCI), Early Morning Symptoms of COPD Instrument (EMSCI), CAT and mMRC scores. Results: Among the 734 patients with COPD, 61% were male, age 69.6±8.7 years, FEV1% post-BD 49.1±17.5%, mMRC 1.8±1.0 and CAT 15.3±.8.1. By mMRC 33.7% were group-A, 29.2% group-B, 10.2% group-C and 26.9% group-D. By CAT 22.3% were group-A, 41% group-B, 4.8% group-C and 31.9% group-D. Using the mMRC the severity of E-RS, NiSCI and EMSCI scores increased from group A to D. Using the CAT, the groups B and D had the higher scores. Agreement between mMRC and CAT was 89.5% (Kappa statistics=75.7%). For mMRC score of 2, CAT score of =11 showed the maximum Youden's index (1.34). For mMRC score of 1, CAT score of =9 and =10 showed the maximum Youden's index (1.48). Conclusion: GOLD COPD classification by CAT seems to better discriminate 24-hour symptoms. Results do not support the equivalent use of CAT=10 and mMRC=2 for assessing symptoms.

Keywords: Chronic obstructive pulmonary disease; Symptoms and COPD.

Background: Tuberculosis is a disease linked to poverty, unequal distribution of wealth, and urbanization, as well as the epidemics of acquired immunodeficiency syndrome epidemic and multidrug resistance. Objective: To analyze indicators of tuberculosis morbidity and mortality in the city of São José do Rio Preto, Brazil from 1985 to 2003, compared with those in the state of São Paulo and in Brazil at large, and to determine the relationship between the risk of occurrence and socioeconomic level. Method: The following official information systems were utilized: the Sistema de Informação de Mortalidade (SIM, Mortality database), the Notificação de Tuberculose (Epi-Tb, Tuberculosis Notification database), the Sistema de Informação de Agravos de Notificação (SINAN, Case-registry database), the Departamento de Informação e Informática do Sistema Único de Saúde (DATASUS, Information Department of the Brazilian Health Ministry) and the Instituto Brasileiro de Geografia e Estatística (IBGE, Brazilian Institute of Geography and Statistics database). New cases reported in 2003 in the urban area were georeferenced and analyzed. A map of the sectors, each classified as representing one of three socioeconomic classes, was drawn up, showing the respective tuberculosis incidence coefficients. Results: Comparing Brazil as a whole to the state of São Paulo, total incidence coefficients and mortality rates were similar, as were gender-related values. In the city of São José do Rio Preto the rates were consistently lower. The proportion of cases presenting tuberculosis/human immunodeficiency virus coinfection varied from 29% to 37%. In 2002, 59% and 65% of tuberculosis-only and coinfected tuberculosis patients, respectively, were under supervised treatment, with a cure rate of 81% and a treatment-abandonment rate of 1%. The risk of developing active tuberculosis was three times higher in the area presenting the lowest socioeconomic levels. Conclusion: Identification of the areas with different levels of risks for tuberculosis enables the Municipal Health Department to deal with the peculiarities of each region and to prioritize those presenting higher incidences of the disease.

Keywords: Tuberculosis. Epidemiology. Socioeconomic class. Supervised Treatment. Infection. HIV.

Background: Structural alterations to the pulmonary circulation characterize the vascular remodeling process and are likely correlated with local variations in flow and ischemia. Objective: To define the histological alterations to the pulmonary circulation seen after experimentally-induced ischemia of the pulmonary artery and to correlate those alterations with known patterns of blood redistribution and vascular remodeling. Method: Wistar rats (n = 48) were randomized into two groups with ligation of the pulmonary artery and without (controls) and were sacrificed on post-ischemia days 1, 7, 30 and 60. Lungs were removed and inspected for signs of parenchymal injury. External diameters, as well as wall thicknesses in the pulmonary, alveolar and bronchial end arterioles, were measured. Internal diameter and wall thickness percentage were calculated. Results: Infarction, necrosis and hemorrhage occurred only in ischemic lungs. In nonischemic lungs, there was a sustained increase in the internal and external arteriolar diameters, with an initial reduction in wall thickness on day 1, and day-60 values were similar to those seen in controls. In ischemic lungs, there was a transitory reduction in the internal and external diameters of the pulmonary and bronchial end arterioles, together with an initial, equally transitory, increase in their wall thickness. The alveolar arterioles presented sustained and progressive increases in external diameter and wall thickness, with concomitant reductions in internal diameter. Conclusion: This model mimics distal arterial disease in patients with chronic pulmonary thromboembolism. The vascular response in nonischemic lungs was consistent with a pattern of flow remodeling, whereas that seen in ischemic lungs was more consistent with flow and ischemia. In the pulmonary and bronchial end arterioles, the response was transitory, in contrast to the sustained and progressive response seen in the alveolar arterioles, which was probably caused by delayed local flow.

Keywords: Key-words: Pulmonary embolism. Pulmonary circulation. Vascular remodelling. Pulmonary artery.

Objective: To cross-culturally adapt the Wisconsin Smoking Withdrawal Scale (WSWS) for use in Brazil and evaluate the reproducibility of the new (Brazilian Portuguese-language) version. Methods: The original English version of the WSWS was translated into Brazilian Portuguese. For cross-cultural adaptation, the Brazilian Portuguese-language version of the WSWS was administered to eight volunteers, all of whom were smokers. After adjustments had been made, the WSWS version was back-translated into English. The Brazilian Portuguese-language version was thereby found to be accurate. The final Brazilian Portuguese-language version of the WSWS was applied to 75 smokers at three distinct times. For the assessment of interobserver reproducibility, it was applied twice within a 30-min interval by two different interviewers. For the assessment of intraobserver reproducibility, it was applied again 15 days later by one of the interviewers. Intraclass correlation coefficients (ICCs) were used in order to test the concordance of the answers. The significance level was set at p < 0.05. Results: Of the 75 volunteers, 43 (57.3%) were female. The overall mean age was 46.3 years. Interobserver and intraobserver reproducibility was determined for each of the WSWS seven domains, the ICCs for which ranged from 0.87 to 0.94 and from 0.76 to 0.92, respectively. The mean time to completion of the WSWS was 6 min and 44 s, and the response time per question ranged from 4.2 to 12.6 s. Conclusions: The Brazilian Portuguese-language version of the WSWS is reproducible, fast, and simple. It can therefore be used as a tool for assessing the severity of the symptoms of nicotine withdrawal syndrome.

Keywords: Nicotine; Tobacco use disorder; Substance withdrawal syndrome; Reproducibility of results.

Objective: To evaluate the relationship between obesity and asthma. Methods: This was a preliminary cross-sectional analysis involving 925 subjects with mild-to-moderate or severe asthma evaluated between 2013 and 2015. Obesity was defined on the basis of body mass index (BMI) and abdominal circumference. We collected clinical, laboratory, and anthropometric parameters, as well as pulmonary function test results and data regarding comorbidities. The subjects also completed asthma control and quality of life questionnaires. Results: Obese individuals had a significantly higher number of neutrophils in peripheral blood than did nonobese individuals (p = 0.01). Among the obese individuals, 163 (61%) had positive skin-prick test results, as did 69% and 71% of the individuals classified as being overweight or normal weight, respectively. Obese individuals showed lower spirometric values than did nonobese individuals, and 32% of the obese individuals had uncontrolled asthma, a significantly higher proportion than that found in the other groups (p = 0.02). Conclusions: Obese individuals with asthma seem to present with poorer asthma control and lower pulmonary function values than do nonobese individuals. The proportion of subjects with nonatopic asthma was higher in the obese group. Our results suggest that obese individuals with asthma show a distinct inflammatory pattern and are more likely to present with difficult-to-control asthma than are nonobese individuals.

Keywords: Asthma; Obesity; Overweight; Eosinophilia.

Objective: To determine the frequency of active smoking among patients with asthma and individuals without asthma by self-report and urinary cotinine measurement. Methods: This was a cross-sectional study conducted in the city of Salvador, Brazil, and involving 1,341 individuals: 498 patients with severe asthma, 417 patients with mild-to-moderate asthma, and 426 individuals without asthma. Smoking status was determined by self-report (with the use of standardized questionnaires) and urinary cotinine measurement. The study variables were compared with the chi-square test and the Kruskal-Wallis test. Results: Of the sample as a whole, 55 (4.1%) reported being current smokers. Of those, 5 had severe asthma, 17 had mild-to-moderate asthma, and 33 had no asthma diagnosis. Of the 55 smokers, 32 (58.2%) were daily smokers and 23 (41.8%) were occasional smokers. Urinary cotinine levels were found to be high in self-reported nonsmokers and former smokers, especially among severe asthma patients, a finding that suggests patient nondisclosure of smoking status. Among smokers, a longer smoking history was found in patients with severe asthma when compared with those with mild-to-moderate asthma. In addition, the proportion of former smokers was higher among patients with severe asthma than among those with mild-to-moderate asthma. Conclusions: Former smoking is associated with severe asthma. Current smoking is observed in patients with severe asthma, and patient nondisclosure of smoking status occurs in some cases. Patients with severe asthma should be thoroughly screened for smoking, and findings should be complemented by objective testing.

Keywords: Asthma; Smoking; Cotinine.

Cystic fibrosis (CF) is a genetic disease that results in dysfunction of the CF transmembrane conductance regulator (CFTR) protein, which is a chloride and bicarbonate channel expressed in the apical portion of epithelial cells of various organs. Dysfunction of that protein results in diverse clinical manifestations, primarily involving the respiratory and gastrointestinal systems, impairing quality of life and reducing life expectancy. Although CF is still an incurable pathology, the therapeutic and prognostic perspectives are now totally different and much more favorable. The purpose of these guidelines is to define evidence-based recommendations regarding the use of pharmacological agents in the treatment of the pulmonary symptoms of CF in Brazil. Questions in the Patients of interest, Intervention to be studied, Comparison of interventions, and Outcome of interest (PICO) format were employed to address aspects related to the use of modulators of this protein (ivacaftor, lumacaftor+ivacaftor, and tezacaftor+ivacaftor), use of dornase alfa, eradication therapy and chronic suppression of Pseudomonas aeruginosa, and eradication of methicillin-resistant Staphylococcus aureus and Burkholderia cepacia complex. To formulate the PICO questions, a group of Brazilian specialists was assembled and a systematic review was carried out on the themes, with meta-analysis when applicable. The results obtained were analyzed in terms of the strength of the evidence compiled, the recommendations being devised by employing the GRADE approach. We believe that these guidelines represent a major advance to be incorporated into the approach to patients with CF, mainly aiming to favor the management of the disease, and could become an auxiliary tool in the definition of public policies related to CF.

Keywords: Cystic fibrosis; GRADE approach; Cystic fibrosis/drug treatment; Clinical practice guide.