Brazilian Journal of Pulmonology

ISSN (on-line): 1806-3756 | ISSN (printed): 1806-3713


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Year 2019 - Volume 45  - Number 3  (May/June)


3 - The importance of molecular characterization in lung cancer

A importância da caracterização molecular no câncer de pulmão

Gilberto de Castro Junior1,2,a, Guilherme Harada2,b, Evandro Sobroza de Mello3,c

J Bras Pneumol.2019;45(3):e20190139

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Continuing Education: Imaging

4 - Pulmonary cysts associated with calcified nodules

Cistos pulmonares associados a nódulos calcificados

Edson Marchiori1,a, Bruno Hochhegger2,b, Gláucia Zanetti1,c

J Bras Pneumol.2019;45(3):e20190099

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Continuing Education: Respiratory Physiology

Original Article

7 - Multidisciplinary education with a focus on COPD in primary health care

Perfil molecular do carcinoma pulmonar de células não pequenas no Nordeste brasileiro

Ana Claudia da Silva Mendes de Oliveira1,a, Antonio Vinicios Alves da Silva2,b, Marclesson Alves3,c, Eduardo Cronemberger3,d, Benedito Arruda Carneiro4,e, Juliana Carneiro Melo5,f, Francisco Martins Neto6,g, Fabio Tavora1,7,h

J Bras Pneumol.2019;45(3):e20180181

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the histological subtypes and mutational profiles of non-small cell lung cancer in Brazil, looking for correlations among histological subtypes, expression of anaplastic lymphoma kinase (ALK), EGFR mutation status, and programmed death-ligand 1 (PD-L1) expression. Methods: We evaluated 173 specimens obtained from patients with lung adenocarcinoma in northeastern Brazil. Expression of PD-L1 and ALK was evaluated by immunohistochemistry; EGFR mutation status was evaluated by sequencing. We categorized the histological subtypes in accordance with the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. Results: The most common histological subtypes of lung adenocarcinoma were solid predominant (in 46.8%), acinar predominant (in 37.0%), and lepidic predominant (in 9.8%). ALK expression was detected in 10.4% of the samples, and 22.0% of the tumors harbored EGFR mutations. The most common EGFR mutation was an exon 21 L858R point mutation (in 45.5%), followed by an exon 19 deletion (in 36.3%). The tumor proportion score for PD-L1 expression was ≥ 50% in 18.2% of the samples, 1-49% in 32.7%, and 0% in 49.5%. The solid predominant subtype was significantly associated with wild-type EGFR status (p = 0.047). Positivity for PD-L1 expression was not found to be significantly associated with ALK expression or EGFR mutation status. Conclusions: Our results suggest that the molecular profile of non-small cell lung cancer in northeastern Brazil differs from those of populations in other regions of the country, with ALK positivity being higher than the other biomarkers. Further studies including clinical and genetic information are required to confirm these differences, as well as studies focusing on populations living in different areas of the country.


Keywords: Anaplastic lymphoma kinase; ErbB receptors; B7-H1 antigen; Carcinoma, non-small-cell lung; Brazil.


8 - Lipoabdominoplasty: repercussions for diaphragmatic mobility and lung function in healthy women

Lipoabdominoplastia: repercussão na mobilidade diafragmática e função pulmonar em mulheres saudáveis

Sandra Fluhr1,a, Armèle Dornelas de Andrade1,b, Emanuel José Baptista Oliveira2,c, Taciano Rocha1,d, Ana Irene Carlos Medeiros1,e, Amanda Couto1,f, Juliana Netto Maia1,g, Daniella Cunha Brandão1,h

J Bras Pneumol.2019;45(3):e20170395

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Objective: To evaluate the impact of lipoabdominoplasty on diaphragmatic mobility (DM) and lung function in healthy women. Methods: This was a prospective cohort study using high-resolution ultrasound and forced spirometry to assess DM and lung function, respectively, prior to lipoabdominoplasty, as well as on postoperative day (POD) 10 and POD 30. DM was measured under two conditions: during tidal volume breathing and during a VC maneuver. Results: The sample consisted of 20 women, with a mean age of 39.85 ± 7.52 years and a mean body mass index of 26.21 ± 2.0 kg/m2. Comparing the preoperative and postoperative periods, we found that DM and lung function values were significantly lower after lipoabdominoplasty, the mean DM on POD 10 being 17% and 15% lower during tidal volume breathing and during the VC maneuver, respectively, in comparison with the preoperative mean (p = 0.009 and p < 0.001, respectively). In addition, FEV1, FVC, and PEF were significantly lower on POD 10 than in the preoperative period (p = 0.046, p = 0.002, and p < 0.001, respectively), returning to preoperative values by POD 30. Conclusions: Lipoabdominoplasty appears to have negative short-term repercussions for DM and lung function in healthy women. However, lung function and DM are both apparently restored to preoperative conditions by POD 30. ( identifier: NCT02762526 [])


Keywords: Abdominoplasty; Lipectomy; Ultrasonography; Diaphragm/physiology; Diaphragm/physiopathology; Lung/physiology; Lung/physiopathology; Respiratory mechanics; Spirometry; Respiratory function tests.


9 - Melatonin effects on pulmonary tissue in the experimental model of Hepatopulmonary Syndrome

Efeitos da melatonina sobre o tecido pulmonar no modelo experimental de Síndrome Hepatopulmonar

Adriane Dal Bosco1,a, Filipe Boeira Schedler2,b, Josieli Raskopf Colares2,c, Elisângela Gonçalves Schemitt2,3,d, Renata Minuzzo Hartmann2,3,e, Luiz Alberto Forgiarini Junior4,f, Alexandre Simões Dias2,3,g, Norma Possa Marroni2,3,h

J Bras Pneumol.2019;45(3):e20170164

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Objective: To evaluate the pulmonary alterations of animals with Hepatopulmonary Syndrome (HPS) submitted to Biliary Duct Ligature (BDL), as well as the antioxidant effect of Melatonin (MEL). Methods: Sixteen male Wistar rats, divided into four Sham groups: BDL group, Sham + MEL group and BDL + MEL. The pulmonary and hepatic histology, lipoperoxidation and antioxidant activity of lung tissue, alveolar-arterial O2 difference and lung / body weight ratio (%) were evaluated. Results: When comparing the groups, could be observed an increase of vasodilation and pulmonary fibrosis in the BDL group and the reduction of this in relation to the BDL + MEL group. It was also observed significant changes in the activity of catalase, ApCO2, ApO2 in the LBD group when compared to the other groups. Conclusion: The use of MEL has been shown to be effective in reducing vasodilation, fibrosis levels and oxidative stress as well as gas exchange in an experimental HPS model.


Keywords: Bile duct; Hepatopulmonary Syndrome; Melatonin; Lung.


10 - Effects of manual chest compression on expiratory flow bias during the positive end-expiratory pressure-zero end-expiratory pressure maneuver in patients on mechanical ventilation

Efeitos da compressão torácica manual sobre o flow bias expiratório durante a manobra positive end-expiratory pressure-zero end-expiratory pressure em pacientes sob ventilação mecânica invasiva

Ana Carolina Otoni Oliveira1,a, Daiane Menezes Lorena1,b, Lívia Corrêa Gomes2,c, Bianca Lorrane Reges Amaral2,d, Márcia Souza Volpe3,e

J Bras Pneumol.2019;45(3):e20180058

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Objective: To investigate the effects of manual chest compression (MCC) on the expiratory flow bias during the positive end-expiratory pressure-zero end-expiratory pressure (PEEP-ZEEP) airway clearance maneuver applied in patients on mechanical ventilation. The flow bias, which influences pulmonary secretion removal, is evaluated by the ratio and difference between the peak expiratory flow (PEF) and the peak inspiratory flow (PIF). Methods: This was a crossover randomized study involving 10 patients. The PEEP-ZEEP maneuver was applied at four time points, one without MCC and the other three with MCC, which were performed by three different respiratory therapists. Respiratory mechanics data were obtained with a specific monitor. Results: The PEEP-ZEEP maneuver without MCC was enough to exceed the threshold that is considered necessary to move secretion toward the glottis (PEF − PIF difference > 33 L/min): a mean PEF − PIF difference of 49.1 ± 9.4 L/min was achieved. The mean PEF/PIF ratio achieved was 3.3 ± 0.7. Using MCC with PEEP-ZEEP increased the mean PEF − PIF difference by 6.7 ± 3.4 L/min. We found a moderate correlation between respiratory therapist hand grip strength and the flow bias generated with MCC. No adverse hemodynamic or respiratory effects were found. Conclusions: The PEEP-ZEEP maneuver, without MCC, resulted in an expiratory flow bias superior to that necessary to facilitate pulmonary secretion removal. Combining MCC with the PEEP-ZEEP maneuver increased the expiratory flow bias, which increases the potential of the maneuver to remove secretions.


Keywords: Physical therapy modalities; Critical care; Respiration, artificial; Bodily secretions.


11 - Microbiological contamination of nebulizers used by cystic fibrosis patients: an underestimated problem

Contaminação microbiológica de nebulizadores usados por pacientes com fibrose cística: um problema subestimado

Barbara Riquena1,a, Luciana de Freitas Velloso Monte2,b, Agnaldo José Lopes3,c, Luiz Vicente Ribeiro Ferreira da Silva-Filho4,5,d, Neiva Damaceno6,e, Evanirso da Silva Aquino7,f, Paulo Jose Cauduro Marostica8,9,g, José Dirceu Ribeiro10,h

J Bras Pneumol.2019;45(3):e20170351

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Objective: Home nebulizers are routinely used in the treatment of patients with cystic fibrosis (CF). This study aims to evaluate the contamination of nebulizers used for CF patients, that are chronically colonized by Pseudomonas aeruginosa, and the association of nebulizer contamination with cleaning, decontamination and drying practices. Methods: A cross-sectional, observational, multicenter study was conducted in seven CF reference centers in Brazil to obtain data from medical records, structured interviews with patients/caregivers were performed, and nebulizer's parts (interface and cup) were collected for microbiological culture. Results: overall, 77 CF patients were included. The frequency of nebulizer contamination was 71.6%. Candida spp. (52.9%), Stenotrophomonas maltophilia (11.9%), non-mucoid P. aeruginosa (4.8%), Staphylococcus aureus (4.8%) and Burkholderia cepacia complex (2.4%) were the most common isolated pathogens. The frequency of nebulizers' hygiene was 97.4%, and 70.3% of patients reported cleaning, disinfection and drying the nebulizers. The use of tap water in cleaning method and outdoor drying of the parts significantly increased (9.10 times) the chance of nebulizers' contamination. Conclusion: Despite the high frequency hygiene of the nebulizers reported, the cleaning and disinfection methods used were often inadequate. A significant proportion of nebulizers was contaminated with potentially pathogenic microorganisms for CF patients. These findings support the need to include patients/caregivers in educational programs and / or new strategies for delivering inhaled antibiotics.


Keywords: Cystic fibrosis; Pseudomonas aeruginosa; Nebulizers and vaporizers; Equipment contamination; Decontamination.


12 - Reference values for pulmonary volumes by plethysmography in a Brazilian sample of white adults

Valores de referência para volumes pulmonares por pletismografia em uma amostra brasileira de adultos da raça branca

Thamine Lessa1,a, Carlos Alberto de Castro Pereira2,b, Maria Raquel Soares2,c, Renato Matos3,d, Virgínia Pacheco Guimarães4,e, Giancarlo Sanches5,f, Roberto Helou Rassi6,g, Israel Maia7,h

J Bras Pneumol.2019;45(3):e20180065

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Objective: To derive reference values for healthy white Brazilian adults who have never smoked and to compare the obtained values with reference values derived by Crapo and by Neder. Methods: Reference equations by quantile regressions were derived in 122 men and 122 women, non-obese, living in seven cities in Brazil. Age ranged from 21 to 92 years in women and from 25 to 88 years in men. Lung function tests were performed using SensorMedics automated body plethysmographies according ATS/ERS recommendations. Lower and upper limits were derived by specific equations for 5 and 95 percentiles. The results were compared to those suggested by Crapo in 1982, and Neder in 1999. Results: Median values for total lung capacity (TLC) were influenced only by stature in men, and by stature and age in women. Residual volume was influenced by age and stature in both genders. Weight was directly related to inspiratory capacity and inversely with functional residual capacity and expiratory reserve volume in both genders. A comparison of observed TLC data with values predicted by Neder equations showed significant lower values by the present data. Mean values were similar between data from present study and those derived by Crapo. Conclusion: New predicted values for lung volumes were obtained in a sample of white Brazilians. The values differ from those derived by Neder, but are similar to those derived by Crapo.


Keywords: Pulmonary volumes; Pulmonary function tests; Reference values; Pulmonary plethysmography


13 - Effects of exercise on sleep symptoms in patients with severe obstructive sleep apnea

Efeitos do exercício nos sintomas do sono em pacientes com apneia obstrutiva do sono

Roberto Pacheco da Silva1,a, Denis Martinez1,2,3,b, Kelly Silveira da Silva Bueno1,c, Jhoana Mercedes Uribe-Ramos2,d

J Bras Pneumol.2019;45(3):e20180085

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Objective: To investigate the extent to which exercise is associated with symptoms in patients with severe obstructive sleep apnea (OSA). Methods: We included subjects with an apnea-hypopnea index (AHI) > 30 events/h who completed validated sleep and exercise questionnaires. We compared symptom frequency/scores between exercisers and nonexercisers, adjusting for the usual confounders. Results: The sample included 907 nonexercisers and 488 exercisers (mean age, 49 ± 14 years; mean AHI, 53 ± 20 events/h; 81% men). Nonexercisers and exercisers differed significantly in terms of obesity (72% vs. 54%), the mean proportion of sleep in non-rapid eye movement stage 3 sleep (9 ± 8% vs. 11 ± 6%), and tiredness (78% vs. 68%). Nonexercisers had a higher symptom frequency/scores and poorer sleep quality. Adjustment for exercise weakened the associations between individual symptoms and the AHI, indicating that exercise has a mitigating effect. In binary logistic models, exercise was associated with approximately 30% lower adjusted questionnaire1 score > 2, tiredness; poor-quality sleep, unrefreshing sleep, and negative mood on awakening. Although the odds of an Epworth Sleepiness Scale score > 10 were lower in exercisers, that association did not withstand adjustment for confounders. Conclusions: Exercise is associated with lower frequency/intensity of symptoms in patients with severe OSA. Because up to one third of patients with severe OSA might exercise regularly and therefore be mildly symptomatic, it is important not to rule out a diagnosis of OSA in such patients.


Keywords: Sleep apnea syndromes; Exercise; Sleepiness; Polysomnography.


14 - Pediatric Asthma Control and Communication Instrument: translation into Portuguese and cross-cultural adaptation for use in Brazil

Pediatric Asthma Control and Communication Instrument: tradução e adaptação transcultural para a língua portuguesa falada no Brasil

Thayla Amorim Santino1,a, João Carlos Alchieri2,b, Raquel Emanuele de França Mendes1,c, Ada Cristina Jácome1,d, Tácito Zaildo de Morais Santos1,e, Linda Kahn-D'Angelo3,f, Cecilia M. Patino4,g, Karla Morganna Pereira Pinto de Mendonça1,h

J Bras Pneumol.2019;45(3):e20180169

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To translate the Pediatric Asthma Control and Communication Instrument (PACCI) to Portuguese and adapt it for use in Brazil, ensuring the cultural validity of the content and semantic equivalence of the target version. Methods: The Brazilian Portuguese-language version of the PACCI was developed according to the most commonly used methodology, which included the following steps: translation; synthesis of the translation; review by the author of the original questionnaire; back-translation; synthesis of the back-translation; review by a native external researcher who is a native speaker of English; approval of the author of the original questionnaire; review by a specialist in Portuguese; review by a multidisciplinary committee of experts to determine the agreement of the items, considering the clarity of each and its appropriateness in the cultural context; cognitive debriefing; and development of the final version. The cognitive debriefing involved 31 parents/legal guardians of children 1-21 years of age with a clinical diagnosis of asthma, as defined by the Global Initiative for Asthma, with the objective of determining the comprehensibility and clarity of the items for the target population. Results: The multidisciplinary committee of experts indicated that the items on the questionnaire were clear and comprehensible, with kappa values above 0.61, indicating substantial agreement. In the cognitive debriefing, the parents/legal guardians presented no difficulties in understanding any of the items (agreement > 0.90); therefore, no further changes were needed.Conclusions: The translation and cross-cultural adaptation of the PACCI for use in Brazil were successful.


Keywords: Surveys and questionnaires; Translating; Asthma; Child; Adolescent.


15 - Temporal evolution of and factors associated with asthma and wheezing in schoolchildren in Brazil

Evolução temporal e fatores associados a asma e sibilância em escolares no Brasil

Gabriela Ávila Marques1,2,a, Andrea Wendt2,b, Fernando César Wehrmeister2,c

J Bras Pneumol.2019;45(3):e20180138

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Objective: To estimate the evolution of the prevalence of asthma and wheezing among schoolchildren in Brazil from 2012 to 2015, as well as to identify factors associated with both conditions. Methods: This was a cross-sectional study using data from the Brazilian National School-Based Adolescent Health Survey for 2012 and 2015. To characterize the evolution of the prevalence of asthma and wheezing, we used linear regression with weighted-least-squares estimation and presented the annual percent change (APC). Results: During the study period, there was a reduction in the prevalence of wheezing, from 23.2% in 2012 to 22.4% in 2015 (APC, −0.27). The prevalence of asthma increased from 12.4% in 2012 to 16.0% in 2015 (APC, 1.20). The increase in the prevalence of asthma was greatest in the southern region of the country (APC, 2.17). Having any history of smoking and having consumed alcohol in the last 30 days were factors that influenced the prevalence of wheezing and the prevalence of a self-reported diagnosis of asthma during the two years evaluated. Conclusions: There has been an increase in the prevalence of asthma in recent years in Brazil. Our data underscore the importance of improving health strategies and policies aimed at the control of asthma.


Keywords: Asthma/epidemiology; Respiratory sounds; Students.


Brief Communication

16 - Translation of the quality-of-life measure for adults with primary ciliary dyskinesia and its application in patients in Brazil

Tradução do questionário de qualidade de vida para pacientes adultos com discinesia ciliar primária no Brasil

Ana Paula Lima de Queiroz1,a, Rodrigo Abensur Athanazio2,b, Mary Anne Kowal Olm3,c, Bruna Rubbo4,5,d, Yuri Reis Casal1,e, Jane Lucas4,5,f, Laura Behan4,5,6,g

J Bras Pneumol.2019;45(3):e20170358

Abstract PDF PT PDF EN Portuguese Text Appendix

Primary ciliary dyskinesia (PCD) is a genetic disorder that is typically inherited in an autosomal recessive manner. It is clinically characterized by recurrent respiratory infections. However, its repercussions for patient quality of life should not be overlooked. Studies have shown that PCD has a significant impact on the lives of patients, although there are as yet no PCD-specific markers of quality of life. To address that problem, researchers in the United Kingdom developed a quality-of-life questionnaire for patients with PCD. The present communication focuses on the process of translating that questionnaire into Brazilian Portuguese, through a partnership between researchers in Brazil and those in the United Kingdom, as well as its subsequent application in patients in Brazil.


Keywords: Quality of life; Kartagener syndrome; Surveys and questionnaires.


Special Article

17 - Update on the approach to smoking in patients with respiratory diseases

Atualização na abordagem do tabagismo em pacientes com doenças respiratórias

Maria Penha Uchoa Sales1,a, Alberto José de Araújo2,b, José Miguel Chatkin3,c, Irma de Godoy4,d, Luiz Fernando Ferreira Pereira5,e, Maria Vera Cruz de Oliveira Castellano6,f, Suzana Erico Tanni4,g, Adriana Ávila de Almeida7,h, Gustavo Chatkin3,i, Luiz Carlos Côrrea da Silva8,j, Cristina Maria Cantarino Gonçalves9,k, Clóvis Botelho12,13,l, Ubiratan Paula Santos14,m, Carlos Alberto de Assis Viegas15,n, Maristela Rodrigues Sestelo16,o, Ricardo Henrique Sampaio Meireles10,11,p, Paulo César Rodrigues Pinto Correa17,q, Maria Eunice Moraes de Oliveira18,r, Jonatas Reichert19,s, Mariana Silva Lima6,t, Celso Antonio Rodrigues da Silva20,u

J Bras Pneumol.2019;45(3):e20180314

Abstract PDF PT PDF EN Portuguese Text

Smoking is the leading cause of respiratory disease (RD). The harmful effects of smoking on the respiratory system begin in utero and influence immune responses throughout childhood and adult life. In comparison with "healthy" smokers, smokers with RD have peculiarities that can impede smoking cessation, such as a higher level of nicotine dependence; nicotine withdrawal; higher levels of exhaled carbon monoxide; low motivation and low self-efficacy; greater concern about weight gain; and a high prevalence of anxiety and depression. In addition, they require more intensive, prolonged treatment. It is always necessary to educate such individuals about the fact that quitting smoking is the only measure that will reduce the progression of RD and improve their quality of life, regardless of the duration and severity of the disease. Physicians should always offer smoking cessation treatment. Outpatient or inpatient smoking cessation treatment should be multidisciplinary, based on behavioral interventions and pharmacotherapy. It will thus be more effective and cost-effective, doubling the chances of success.


Keywords: Respiratory tract diseases/therapy; Respiratory tract diseases/drug therapy; Tobacco use disorder/epidemiology; Smoking cessation; Counseling; Lung neoplasms.


Letters to the Editor

18 - Endobronchial ultrasound in esophageal cancer - when upper gastrointestinal endoscopy is not enough

Ultrassonografia endobrônquica no câncer de esôfago - quando a endoscopia digestiva alta não é suficiente

Lília Maia Santos1,2,a, Márcia Jacomelli1,b, Paulo Rogério Scordamaglio1,c, Paulo Francisco Guerreiro Cardoso3,d, Viviane Rossi Figueiredo1,e

J Bras Pneumol.2019;45(3):e20180312

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19 - Lung cancer and parenchymal lung disease in a patient with neurofibromatosis type

Câncer de pulmão e doença pulmonar parenquimatosa em um paciente com neurofibromatose tipo 1

Alessandro Severo Alves de Melo1,a, Sérgio Ferreira Alves Jr2,b, Paulo de Moraes Antunes1,c, Gláucia Zanetti2,d, Edson Marchiori2,e

J Bras Pneumol.2019;45(3):e20180285

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