It is reported a case of a previously healthy man with seizures of sudden onset. A contrast head computerized tomogram (CT) showed a right frontoparietal expanding lesion suggesting to be metastatic. No prior disease was found on investigation. The histologic exam of the brain revealed tuberculoma. The seizures were controlled with Hidantoin 300 mg/day and antituberculosis chemotherapy for 18 months. Central nervous system tuberculosis (5-15% of the extrapulmonary forms) is highly lethal. The case reported herein is specially rare in immunocompetent patients. It may have good prognosis and should be considered in the differential diagnosis of brain tumours.

Keywords: Intracranial tuberculomas. Central nervous system tuberculosis. Diagnosis.

A pneumonia por Pneumocystis carinii (PPC), que é a infecção oportunista que mais comumente põe em risco a vida de pacientes com síndrome da imunodeficiência adquirida (SIDA), tem sido há bastante tempo associada a outros estados de imunodeficiência. Os relatos iniciais sugeriram que a apresentação clínica da PPC em SIDA difere de sua apresentação em outras situações, embora ambas tenham sofrido modificações nos últimos anos. O objetivo do presente estudo é comparar os achados clínicos e laboratoriais da PPC em SIDA com os de pacientes portadores de PPC sem SIDA. Foram revisados os prontuários médicos de todos os pacientes em nossa instituição que tiveram o diagnóstico confirmado de PPC e SIDA durante o ano de 1994 (17 pacientes) e sem SIDA no período de 1992-1994 (dez pacientes). Quando da apresentação, os pacientes sem SIDA tinham uma duração de sintomas significativamente menor (8,4 ± 7,7 vs 19,5 ± 10,2 dias, p < 0,05), menor PaO2 média a ar ambiente (47 ± 8,2 vs 63 ± 10mmHg, p < 0,05), e mais freqüente infiltrado unilateral no radiograma do tórax (60 vs 6%, p < 0,05). O índice de mortalidade da PPC foi marcadamente maior nos pacientes sem SIDA (40 vs 6%, p < 0,05), e este fato estava associado com retarde no início do tratamento específico nestes pacientes. Devido a seu curso mais agudo, apresentação radiológica atípica e alto índice de mortalidade, concluímos que o diagnóstico de PPC deve ser afastado em pacientes que recebem terapia imunossupressora e que profilaxia anti-PPC deve ser fortemente considerada em pacientes que serão imunossuprimidos.

Keywords: PPC-AIDS. PPC não-AIDS.

Objetivo: Realizar a tradução para a língua portuguesa e a adaptação cultural para uso no Brasil do Quality of Communication Questionnaire (QOC) para pacientes com DPOC em cuidados paliativos. Métodos: Após a aprovação do autor do questionário e do comitê de ética da instituição, a versão original do QOC com 13 itens foi traduzida, de forma independente, por dois tradutores brasileiros com fluência na língua inglesa. Uma síntese das duas traduções foi realizada por uma médica bilíngue e os dois tradutores, que chegaram a um consenso, gerando uma versão na língua portuguesa. Essa versão foi retraduzida por dois tradutores nativos de países de língua inglesa com fluência na língua portuguesa. Para resolver quaisquer discrepâncias, um comitê de especialistas comparou a versão original com todas as versões produzidas e, assim, obteve-se a versão pré-final do QOC. O pré-teste foi aplicado em 32 pacientes internados em UTIs de três hospitais públicos da grande Florianópolis (SC) para avaliar a clareza e a aceitabilidade cultural da versão pré-final do QOC. Resultados: A média de idade dos pacientes foi de 48,5 ± 18,8 anos. A maioria dos itens foi bem compreendida e aceita, recebendo pontuações ≥ 8. Um item, sobre morte, suscitou dificuldades na compreensão dos participantes do pré-teste. Ao submeter a retradução ao autor do QOC, ele solicitou alterações em dois itens, que foram acatadas. Após essas alterações, a versão final foi aprovada. Conclusões: A tradução e a adaptação cultural do QOC para uso no Brasil foi concluída com sucesso.

Keywords: Doença pulmonar obstrutiva crônica; Inquéritos e questionários; Comunicação; Unidades de terapia intensiva.

Objective: To evaluate the best time to perform thoracoscopy for the treatment of complicated parapneumonic pleural effusion in the fibrinopurulent phase in patients ≤ 14 years of age, regarding the postoperative evolution and occurrence of complications. Methods: This was a retrospective comparative study involving patients with parapneumonic pleural effusion presenting with septations or loculations on chest ultrasound who underwent thoracoscopy between January of 2000 and January of 2013. The patients were divided into two groups: early thoracoscopy (ET), performed by day 5 of hospitalization; and late thoracoscopy (LT), performed after day 5 of hospitalization. Results: We included 60 patients, 30 in each group. The mean age was 3.4 years; 28 patients (46.7%) were male; and 47 (78.3%) underwent primary thoracoscopy (no previous simple drainage). The two groups were similar regarding gender, age, weight, and type of thoracoscopy (p > 0.05 for all). There was a significant difference between the ET and the LT groups regarding the length of the hospital stay (14.5 days vs. 21.7 days; p < 0.001). There were also significant differences between the groups regarding the duration of fever in days; the total number of days from admission to the initiation of drainage; and the total number of days with the drain in place. Eight patients (13.6%) had at least one post-thoracoscopy complication, there being no difference between the groups. There were no deaths. Conclusions: Performing ET by day 5 of hospitalization was associated with shorter hospital stays, shorter duration of drainage, and shorter duration of fever, although not with a higher frequency of complications, requiring ICU admission, or requiring blood transfusion.

Keywords: Empyema, pleural; Thoracoscopy; Pneumonia.

Objective: The emergence of tuberculosis/HIV co-infection and the increase in the number of cases of infection with nontuberculous mycobacteria (NTM) require rapid laboratory test results in the isolation and identification of mycobacteria. The objective of this study was to evaluate the identification of mycobacteria by means of gene probes in comparison with that obtained using classical biochemical methods. Methods: Between 2002 and 2004, 178 mycobacterial cultures, all testing positive for acid-fast bacilli, were analyzed. Samples were obtained from clinical specimens of patients with respiratory symptoms or with clinical suspicion of pulmonary tuberculosis/mycobacteriosis who were treated in the greater metropolitan area of Santos. Results: The gene probe identified 137 samples (77%) as Mycobacterium tuberculosis complex and 41 (23%) as NTM. Discordant results between the methods (3%) were obtained only in the year of implementation (2002). When comparing the methods, the sensitivity, specificity, positive predictive value and negative predictive value of the gene probe method were 98%, 93%, 98% and 93%, respectively. Conclusions: Despite the cost, the identification of mycobacteria using the molecular technique is faster: maximum 3 h vs. 28-30 days for classical methods. The use of gene probes is a validated molecular technique. It is fast, easy to use and readily available on the market. It has high specificity and sensitivity, which justifies its implementation and routine use in referral laboratories, since it facilitates the diagnosis providing agile clinical interventions.

Keywords: Mycobacterium tuberculosis; Tuberculosis/diagnosis; Mycobacterium/classification; DNA probes.

O prejuízo funcional parece diferir entre membros superiores e membros inferiores de pacientes com DPOC. Dois possíveis mecanismos explicam os sintomas importantes de dispneia e fadiga relatados pelos pacientes ao executar tarefas com membros superiores não sustentados: a disfunção neuromecânica dos músculos respiratórios e a alteração dos volumes pulmonares durante as atividades realizadas com membros superiores. A disfunção neuromecânica está relacionada à alteração do padrão respiratório e à simultaneidade de estímulos aferentes e eferentes musculares, o que causaria a dissincronia na ação dos músculos respiratórios em pacientes com DPOC durante esse tipo de exercício. Adicionalmente, o aumento da ventilação durante os exercícios com membros superiores em pacientes com DPOC induz à hiperinsuflação dinâmica em diferentes cargas de trabalho. Nos membros inferiores, há redução da força e da endurance muscular do quadríceps femoral nos pacientes com DPOC comparados a indivíduos saudáveis. Uma explicação para essas reduções é a anormalidade no metabolismo muscular (diminuição da capacidade aeróbia), a dependência do metabolismo glicolítico e o acúmulo rápido de lactato durante o exercício. Quando contrastadas as atividades de membros superiores e membros inferiores, os exercícios com membros superiores resultam em maior demanda metabólica e ventilatória com mais intensa sensação de dispneia e fadiga. Devido às diferenças nas adaptações morfofuncionais dos músculos dos membros superiores e membros inferiores em pacientes com DPOC, protocolos específicos de treinamento de força e/ou endurance devem ser desenvolvidos e testados para os grupos musculares desses segmentos corporais.

Keywords: Pulmonary disease, chronic obstructive; Muscle fatigue; Upper extremity; Lower extremity.

Com o objetivo de determinar a necessidade de confirmação microscópica do diagnóstico de pneumonia por Pneumocystis carinii (PPC), comparando grupos de pacientes tratados empiricamente com aqueles com confirmação diagnóstica, foram revisados os dados clínicos e laboratoriais de 82 pacientes internados em nossa instituição com infecção respiratória durante o ano de 1994. Estes pacientes formaram um grupo PPC (n = 37), dos quais 17 tiveram diagnóstico confirmado e 20 foram tratados empiricamente; e um grupo não-PPC (n = 45), com infecção respiratória que não PPC. O grupo PPC diferiu significativamente dos pacientes não-PPC por apresentarem maior duração dos sintomas, dispnéia mais freqüente, predomínio de lesões radiológicas bilaterais, menor contagem de células CD4 e menor uso de profilaxia anti-PPC. Quando comparamos os pacientes tratados empiricamente para PPC com os que tiveram confirmação diagnóstica de PPC, não observamos diferença estatisticamente significativa em qualquer das variáveis estudadas, exceto por um maior nível sérico de DHL nos pacientes com diagnóstico confirmado. Portanto, concluímos que confirmação microscópica pode não ser essencial em pacientes infectados pelo HIV com achados típicos de PPC e que tratamento empírico baseado no diagnóstico clínico pode ser uma alternativa razoável neste grupo de pacientes.

Keywords: PCP management. Empiric treatment.

Objective: To clarify whether, in healthy individuals, practicing yoga can modify maximal inspiratory pressure and spirometric indices when compared with the practice of aerobic exercise. Methods: A controlled clinical trial. A total of 31 healthy volunteers were allocated to practice aerobic exercise (n = 15) or to practice yoga (n = 16). Those in the first group served as controls and engaged in aerobic exercise for 45-60 minutes, twice a week for three months. Those in the second group practiced selected yogic techniques, also in sessions of 45-60 minutes, twice a week for three months. Forced vital capacity, forced expiratory volume in one second and maximal inspiratory pressure were measured before and after the three months of training. Results: No significant alterations were seen in the spirometric indices. A slight, although not significant, improvement in maximal inspiratory pressure was seen in both groups. However, there was a significant difference, seen in both genders, between the absolute delta (final value minus baseline value) of maximal inspiratory pressure for the group practicing yoga and that obtained for the group engaging in aerobic exercise (males: 19.5 cm H2O versus 2.8 cm H2O, p = 0.05; females: 20 cm H2O versus 3.9 cm H2O, p = 0.01). Conclusion: Neither yoga nor aerobic exercise provided a statistically significant improvement in maximal inspiratory pressure after three months. However, the absolute variation in maximal inspiratory pressure was greater among those practicing yoga.

Keywords: Yoga; Exercise; Respiratory muscles; Respiratory function tests; Maximal voluntary ventilation; Spirometry; Inspiratory capacity/physiology

Objective: To compare the effects of early tracheostomy and of late tracheostomy in patients with acute severe brain injury. Methods: A retrospective study involving 28 patients admitted to the ICU of the Federal University of Juiz de Fora University Hospital in Juiz de Fora, Brazil, diagnosed with acute severe brain injury and presenting with a Glasgow coma scale (GCS) score < 8 within the first 48 h of hospitalization. The patients were divided into two groups: early tracheostomy (ET), performed within the first 8 days after admission; and late tracheostomy (LT), performed after postadmission day 8. At admission, we collected demographic data and determined the following scores: Acute Physiology and Chronic Health Evaluation (APACHE) II, GCS and Sequential Organ Failure Assessment (SOFA). Results: There were no significant differences between the groups (ET vs. LT) regarding the demographic data or the scores: APACHE II (26 ± 6 vs. 28 ± 8; p = 0.37), SOFA (6.3 ± 2.7 vs. 7.2 ± 3.0; p = 0.43) and GCS (5.4 ± 1.7 vs. 5.5 ± 1.7; p = 0.87). The 28-day mortality rate was lower in the ET group (9% vs. 47%; p = 0.04). Nosocomial pneumonia occurring within the first 7 days was less common in the ET group, although the difference was not significant (0% vs. 23%; p = 0.13). There were no differences regarding the occurrence of late pneumonia or in the duration of mechanical ventilation between the groups. Conclusions: On the basis of these findings, early tracheostomy should be considered in patients with acute severe brain injury.

Keywords: Tracheostomy; Pulmonary ventilation; Coma.

Objective: To assess cost differences between EBUS-TBNA and mediastinoscopy for mediastinal staging of non-small cell lung cancer (NSCLC). Methods: This was an economic evaluation study with a cost-minimization analysis. We used a decision analysis software program to construct a decision tree model to compare the downstream costs of mediastinoscopy, EBUS-TBNA without surgical confirmation of negative results, and EBUS-TBNA with surgical confirmation of negative results for the mediastinal staging of NSCLC. The study was conducted from the perspective of the Brazilian public health care system. Only direct medical costs were considered. Results are shown in Brazilian currency (Real; R$) and in International Dollars (I$). Results: For the base-case analysis, initial evaluation with EBUS-TBNA without surgical confirmation of negative results was found to be the least costly strategy (R$1,254/I$2,961) in comparison with mediastinoscopy (R$3,255/I$7,688) and EBUS-TBNA with surgical confirmation of negative results (R$3,688/I$8,711). The sensitivity analyses also showed that EBUS-TBNA without surgical confirmation of negative results was the least costly strategy. Mediastinoscopy would become the least costly strategy if the costs for hospital supplies for EBUS-TBNA increased by more than 300%. EBUS-TBNA with surgical confirmation of negative results, in comparison with mediastinoscopy, will be less costly if the prevalence of mediastinal lymph node metastasis is = 38%. Conclusions: This study has demonstrated that EBUS-TBNA is the least costly strategy for invasive mediastinal staging of NSCLC in the Brazilian public health care system.

Keywords: Lung Neoplasms; Neoplasm Staging; Costs and cost analysis; Bronchoscopy; Mediastinoscopy.

Objective: Talc pleurodesis is a widely used treatment option for malignant pleural effusion (MPE). However, the optimal form of administration remains controversial. Thus, we performed a systematic review and meta-analysis to assess the effectiveness of talc slurry (TS) in comparison with thoracoscopic talc insufflation/poudrage (TTI) for MPE treatment. Methods: We searched PubMed, EMBASE, and Cochrane Library databases for studies that compared TS with TTI in patients with MPE. We used a random-effects model with a 95% CI to pool the data. Heterogeneity was assessed with I² statistics. Results: We included eight studies involving 1,163 patients, 584 of whom (50.21%) underwent TS. Pleurodesis failure rates were similar between the procedures (OR = 1.07; 95% CI: 0.56-2.06; p = 0.83; I² = 62%); and 68% of patients (95% CI: 0.31-1.47; p = 0.33; I² = 58%) had postoperative complications, which were lower in patients in the TS group than in the TTI group. In a subgroup analysis considering only randomized clinical trials, the failure rate was significantly lower in the TS treatment group (OR = 0.62; 95% CI: 0.42-0.90; p = 0.01; I² = 0%). Similarly, dyspnea was less common in the TS group (OR = 0.74; 95% CI: 0.41-1.34; p = 0.32; I² = 55%). Adverse effects were reported in 86 patients, and no significant difference was seen between the TS and TTI groups: empyema (OR = 1.43; 95% CI: 0.36-5.64; p = 0.86; I² = 0%), pain (OR = 1.22 (95% CI: 0.67-2.21; p = 0.51; I² = 38%), and pneumonia (OR = 1.15; 95% CI: 0.30-4.46; p = 0.86; I² = 27%). Conclusions: Our findings suggest that TS is an effective treatment for MPE, with no significant increase in adverse events. Results suggest equivalent efficacy and safety for both procedures.

Keywords: Talc; Pleurodesis; Pleural effusion, malignant.

For patients with stage III (A or B) non-small cell lung cancer, radiation is still the standard treatment. However, long-term survival remains poor and new alternatives and therapeutic associations are being studied. Recently, chemotherapy has been in focus, with several combinations with radiation therapy and/or surgery. An update of the recently published data about the controversies on whether or not one should combine chemotherapy with radiation in locally advanced lung tumors was done. Cisplatin-based chemotherapy regimens combined with radiation are favorable, with a possible increase in survival of 3% in 2 years and 2% in 5 years. Neither the best drug combination nor the ideal association regimen have been defined yet. The indication of a combined treatment must be based on patient's clinical conditions and on a balance between quality of life, toxicity, and cost of chemotherapy.

Keywords: Lung neoplasms. Radiation therapy. Chemotherapy.

A total of 287 bronchoscopies were performed in 267 patients infected with the human immunodeficiency virus (HIV). Bronchoalveolar lavage (BAL) and transbronchial biopsies (TBB) were sequentially performed in the same lung, in all cases. Specimens were examined after routine laboratory procedures for microbiologic and histologic analysis. Age ranged from 16 to 78 (median 37.2); 228 were men (85.4%) and 39 were women. Dyspnea was the main symptom in 198 cases (69.0%) and interstitial infiltrates (diffuse or localized) were the most common findings at chest radiographs (179 patients, 62.4%). Endoscopic view was normal in 246 patients (85.7%). Mucosal lesions suggestive of Kaposi's sarcoma (KS) were visible in 12 cases (4.2%). BAL detected 97 infectious agents, simultaneous co-infection occurred in 3 cases. TBB identified 165 pathogens (9 of them in association), anticipating a better yield than BAL in the diagnosis of P. carinii (84 versus 51, respectively) and cytomegalovirus (35 v. 0). Biopsies were unique in establishing the appropriate diagnosis of extrabronchial cancer and describing inespecific pneumonitis. Altogether, a definite diagnosis was obtained by bronchoscopic examination (including endoscopic view, BAL and TBB) in 271 of 287 cases (94.4%). Infections were caused by P. carinii in 105 patients (36.6%), Mycobacterium sp in 40 (13.9%), cytomegalovirus in 35 (12.2%), C. neoformans in 13 (4.5%) etc. Malignancies (including KS) were found in 16 patients (5.6%). More than one pathologic process was present in 28 (9.8%). Nonspecific pneumonitis was diagnosed in 56 cases (19.5%) and normal lung in 20 (7.0%). Complications related to bronchoscopy were pneumothorax (8 patients, 2.8%), haemorrhage (8), thoracic pain (2) and distal pneumonia (2). Chest tubes were required in 4 patients, including one fatal case (mortality rate of 0.3%). Combining BAL and TBB results increases the diagnostic yield of bronchoscopy in AIDS, with a low complication rate. If both techniques are performed, a higher number of infectious agents and more multiple causes of pulmonary disease may be identified.

Keywords: Bronchoscopy/methods. Acquired Immunodeficiency Syndrome/complications. Opportunistic infections related to AIDS/diagnosis.

Lung retrieval following cardio-circulatory arrest has been studied experimentally, however severe ischemia/reperfusion injury requires improved methods of graft preservation. Allograft perfusion with crystalloid solution delivered via pulmonary artery (antegrade perfusion) remains the standard procedure, however it does not provide adequate washout of the blood retained within the bronchial circulation which may trigger reperfusion injury. This has led the authors to test the impact of antegrade versus retrograde (via left atrium) perfusion of lung grafts submitted to 3 hours of warm ischemia after cardio-circulatory arrest in a dog model of left lung allotransplantation. Twelve donor dogs were sacrificed with thiopental sodium and kept under mechanical ventilation at room temperature for 3 hours. They were randomized and the heart-lung blocks harvested after being perfused in a retrograde (group I, n = 6) or antegrade (group II, n = 6) fashion with modified Euro-Collins solution. Twelve recipient animals were submitted to a left lung transplant receiving the grafts from both groups and the assessment was performed during 6 hours. Hemodynamic parameters were similar for animals in both groups. The gas exchange (arterial PaO2 and PaCO2) in recipients of group I (retrograde perfusion) was significantly better when compared to recipients of grafts perfused via pulmonary artery. Intracellular ATP did not show difference between the groups, however there was a measurable drop in its values when samples obtained upon extraction were compared to those measured after reperfusion and at the end of the assessment. The authors concluded that retrograde perfusion yields better pulmonary function after 6 hours of reperfusion in this animal model of left lung allotransplantation following 3 hours of normothermic ischemia under mechanical ventilation.

Keywords: Lung. Ischemia. Preservation. Retrograde perfusion. ATP.

Objective: To investigate the validity of field walking tests to identify exercise-induced hypoxemia and to compare cardiorespiratory responses and perceived effort between laboratory-based and field-based exercise tests in subjects with bronchiectasis. Methods: This was a cross-sectional study involving 72 non-oxygen-dependent participants (28 men; mean age = 48.3 ± 14.5 years; and mean FEV1 = 54.1 ± 23.4% of the predicted value). The participants underwent cardiopulmonary exercise testing (CPET) on a treadmill and constant work-rate exercise testing (CWRET) on the same day (1 h apart). In another visit, they underwent incremental shuttle walk testing (ISWT) and endurance shuttle walk testing (ESWT; 1 h apart). Desaturation was defined as a reduction in SpO2 ≥ 4% from rest to peak exercise. Results: CPET results were compared with ISWT results, as were CWRET results with ESWT results. There was no difference in the magnitude of desaturation between CPET and ISWT (−7.7 ± 6.3% vs. −6.6 ± 5.6%; p = 0.10) and between CWRET and ESWT (−6.8 ± 5.8% vs. −7.2 ± 6.3%; p = 0.50). The incremental tests showed an agreement in the magnitude of desaturation in the desaturation and no desaturation groups (42 and 14 participants, respectively; p < 0.01), as did the endurance tests (39 and 16 participants; p < 0.01). The magnitude of desaturation was similar among the participants who did or did not reach at least 85% of the maximum predicted HR. Conclusions: Field exercise tests showed good precision to detect desaturation. Field tests might be an alternative to laboratory tests when the clinical question is to investigate exercise-induced desaturation in subjects with bronchiectasis.

Keywords: Bronchiectasis; Oxygen; Hypoxia; Exercise test.

Objective: To assess and compare the prevalence of comorbidities and risk factors for cardiovascular disease (CVD) in COPD patients according to disease severity. Methods: The study included 25 patients with mild-to-moderate COPD (68% male; mean age, 65 ± 8 years; mean FEV1, 73 ± 15% of predicted) and 25 with severe-to-very severe COPD (males, 56%; mean age, 69 ± 9 years; mean FEV1, 40 ± 18% of predicted). Comorbidities were recorded on the basis of data obtained from medical charts and clinical evaluations. Comorbidities were registered on the basis of data obtained from medical charts and clinical evaluations. The Charlson comorbidity index was calculated, and the Hospital Anxiety and Depression Scale (HADS) score was determined. Results: Of the 50 patients evaluated, 38 (76%) had been diagnosed with at least one comorbidity, 21 (42%) having been diagnosed with at least one CVD. Twenty-four patients (48%) had more than one CVD. Eighteen (36%) of the patients were current smokers, 10 (20%) had depression, 7 (14%) had dyslipidemia, and 7 (14%) had diabetes mellitus. Current smoking, depression, and dyslipidemia were more prevalent among the patients with mild-to-moderate COPD than among those with severe-to-very severe COPD (p < 0.001, p = 0.008, and p = 0.02, respectively). The prevalence of high blood pressure, diabetes mellitus, alcoholism, ischemic heart disease, and chronic heart failure was comparable between the two groups. The Charlson comorbidity index and HADS scores did not differ between the groups. Conclusions: Comorbidities are highly prevalent in COPD, regardless of its severity. Certain risk factors for CVD, themselves classified as diseases (including smoking, dyslipidemia, and depression), appear to be more prevalent in patients with mild-to-moderate COPD.

Keywords: Pulmonary disease, chronic obstructive; Spirometry; Cardiovascular diseases; Risk factors.

Objective: To compare a once-daily long-acting β2 agonist (indacaterol 150 µg) with a once-daily long-acting anticholinergic (tiotropium 5 µg) in terms of their effects on exercise endurance (limit of tolerance, Tlim) in patients with moderate COPD. Secondary endpoints were their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Methods: This was a randomized, single-blind, crossover pilot study involving 20 patients (mean age, 60.9 ± 10.0 years; mean FEV1, 69 ± 7% of predicted). Spirometric parameters, Transition Dyspnea Index scores, Tlim, and exertional dyspnea were compared after three weeks of each treatment (with a one-week washout period between treatments). Results: Nineteen patients completed the study (one having been excluded because of COPD exacerbation). Improvement in Tlim from baseline tended to be greater after treatment with tiotropium than after treatment with indacaterol (96 ± 163 s vs. 8 ± 82 s; p = 0.06). Tlim significantly improved from baseline after treatment with tiotropium (having increased from 396 ± 319 s to 493 ± 347 s; p = 0.010) but not after treatment with indacaterol (having increased from 393 ± 246 to 401 ± 254 s; p = 0.678). There were no differences between the two treatments regarding improvements in Borg dyspnea scores and lung hyperinflation at "isotime" and peak exercise. There were also no significant differences between treatments regarding Transition Dyspnea Index scores (1.5 ± 2.1 vs. 0.9 ± 2.3; p = 0.39). Conclusions: In patients with moderate COPD, tiotropium tends to improve Tlim in comparison with indacaterol. No significant differences were observed between the two treatments regarding their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Future studies, including a larger number of patients, are required in order to confirm our findings and explore mechanistic explanations. (ClinicalTrials.gov identifier: NCT01693003 [http://www.clinicaltrials.gov/])

Keywords: Pulmonary disease, chronic obstructive; Exercise; Bronchodilator agents.

Objective: To determine the clinical profile of COVID-19 inpatients who were vaccinated prior to hospitalization and to compare the risk factors for death and the 28-day survival rate of between those inpatients vaccinated with one, two, or three doses and unvaccinated COVID-19 inpatients. Methods: This was a retrospective observational cohort study involving COVID-19 patients admitted to a referral hospital in the city of Recife, Brazil, between July of 2020 and June of 2022. Results: The sample comprised 1,921 inpatients, 996 of whom (50.8%) were vaccinated prior to hospitalization. After adjusting the mortality risk for vaccinated patients, those undergoing invasive mechanical ventilation (IMV) had the highest mortality risk (adjusted OR [aOR] = 7.4; 95% CI, 3.8-14.1; p < 0.001), followed by patients > 80 years of age (aOR = 7.3; 95% CI, 3.4-15.4; p < 0.001), and those needing vasopressors (aOR = 5.6; 95% CI, 2.9-10.9; p < 0.001). After adjusting the mortality risk for all patients, having received three vaccine doses (aOR = 0.06; 95% CI, 0.03-0.11; p < 0.001) was the most important protective factor against death. There were progressive benefits of vaccination, reducing the frequency of ICU admissions, use for IMV, and death (respectively, from 44.9%, 39.0% and 39.9% after the first dose to 16.7%, 6.2% and 4.4% after the third dose), as well as significant improvements in survival after each subsequent dose (p < 0.001). Conclusions: Vaccines were effective in reducing illness severity and death in this cohort of COVID-19 inpatients, and the administration of additional doses conferred them with accumulative vaccine protection.

Keywords: COVID-19; Risk factors; Hospital mortality; Vaccination.

Background: It is questionable whether pressure-controlled ventilation (PCV) has advantages over volume-cycled ventilation (VCV). Objectives: To compare PCV to VCV with decelerating flow profile during assisted and controlled modes in an acute lung injury experimental model. Methods: Severe acute lung injury (PaO2/FIO2 < 100 mmHg) was induced by oleic acid IV infusion (0.05 mg/kg) in seven dogs. The animals were submitted to PCV and VCV in a randomized sequence. After 40 minutes in the assisted mode, ventilation was changed to the controlled mode after neuromuscular blockade. The tidal volume and the inspiratory time were kept constant throughout the experiment. Results: There were no differences in gas exchange (PaO2 and PaCO2), cardiac output or oxygen delivery (DO2) between VCV and PCV. The same was observed regarding maximum airway and plateau pressures, and also to the static compliance. Oxygen consumption (VO2) after neuromuscular blockade was 124 ± 48 in VCV versus 143 ± 50 ml/min in PCV, p = 0.42. In the assisted mode, there was a statistical trend of a higher VO2 in PCV (219 ± 72 versus 154 ± 67 ml/min in VCV, p = 0.06), that was associated with a statistical trend of a higher oxygen cost of breathing (OCB) during assisted PCV, although without statistical significance (31 ± 77 in VCV versus 75 ± 96 ml/min in PCV, p = 0.23), and also in a lower PvO2 (34 ± 7 in PCV versus 42 ± 6 ml/min in VCV, p = 0.02). These occurred despite a higher maximum inspiratory flow in the assisted mode in PCV (58 ± 9 versus 48 ± 4 L/min in VCV, p = 0.01). In both VCV and PCV the institution of controlled ventilation reduced cardiac debit and DO2 in as much as 20% relative to the assisted mode. Conclusions: The implementation of controlled ventilation improved the oxygen delivery/consumption relationship in this severe and with high OCB acute lung injury model. The PCV offered no additional benefits to VCV and it was associated with a higher OCB during the assisted mode.

Keywords: Artificial respiration. Pulmonary gas exchange. Tidal volume.

Objective: To present a model of prostaglandin I2 (PGI2) administration (inhaled vs. parenteral) and to assess the functional performance of the lungs in an ex vivo lung perfusion system. Methods: Forty Wistar rats were anesthetized and placed on mechanical ventilation followed by median sterno-laparotomy and anticoagulation. The main pulmonary artery was cannulated. All animals were maintained on mechanical ventilation and were randomized into four groups (10 rats/group): inhaled saline (IS); parenteral saline (PS); inhaled PGI2 (IPGI2); and parenteral PGI2 (PPGI2). The dose of PGI2 used in the IPGI2 and PPGI2 groups was 20 and 10 µg/kg, respectively. The heart-lung blocks were submitted to antegrade perfusion with a low potassium and dextran solution via the pulmonary artery, followed by en bloc extraction and storage at 4°C for 6 h. The heart-lung blocks were then ventilated and perfused in an ex vivo lung perfusion system for 50 min. Respiratory mechanics, hemodynamics, and gas exchange were assessed. Results: Mean pulmonary artery pressure following nebulization decreased in all groups (p < 0.001), with no significant differences among the groups. During the ex vivo perfusion, respiratory mechanics did not differ among the groups, although relative oxygenation capacity decreased significantly in the IS and PS groups (p = 0.04), whereas mean pulmonary artery pressure increased significantly in the IS group. Conclusions: The experimental model of inhaled PGI2 administration during lung extraction is feasible and reliable. During reperfusion, hemodynamics and gas exchange trended toward better performance with the use of PGI2 than that with the use of saline.

Keywords: Prostaglandins; Lung transplantation; Reperfusion; Models, animal; Rats.