Brazilian Journal of Pulmonology

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

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Year 2019 - Volume 45  - Number 4  (July/August)

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Continuing Education: Imaging

4 - Pneumomediastinum

Pneumomediastino

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

J Bras Pneumol.2019;45(4):e20190169

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Continuing Education: Respiratory Physiology

Original Article

7 - State-dependent changes in the upper airway assessed by multidetector CT in healthy individuals and during obstructive events in patients with sleep apnea

Alterações nas vias aéreas superiores avaliadas por TC multidetectores durante a vigília e o sono em indivíduos saudáveis e em pacientes com apneia do sono durante eventos obstrutivos

Ula Lindoso Passos1,a, Pedro Rodrigues Genta1,b, Bianca Fernandes Marcondes2,c, Geraldo Lorenzi-Filho2,d, Eloisa Maria Mello Santiago Gebrim1,e

J Bras Pneumol.2019;45(4):e20180264

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine whether airway narrowing during obstructive events occurs predominantly at the retropalatal level and results from dynamic changes in the lateral pharyngeal walls and in tongue position. Methods: We evaluated 11 patients with severe obstructive sleep apnea (OSA) and 7 healthy controls without OSA during wakefulness and during natural sleep (documented by full polysomnography). Using fast multidetector CT, we obtained images of the upper airway in the waking and sleep states. Results: Upper airway narrowing during sleep was significantly greater at the retropalatal level than at the retroglossal level in the OSA group (p < 0.001) and in the control group (p < 0.05). The retropalatal airway volume was smaller in the OSA group than in the control group during wakefulness (p < 0.05) and decreased significantly from wakefulness to sleep only among the OSA group subjects. Retropalatal pharyngeal narrowing was attributed to reductions in the anteroposterior diameter (p = 0.001) and lateral diameter (p = 0.006), which correlated with an increase in lateral pharyngeal wall volume (p = 0.001) and posterior displacement of the tongue (p = 0.001), respectively. Retroglossal pharyngeal narrowing during sleep did not occur in the OSA group subjects. Conclusions: In patients with OSA, upper airway narrowing during sleep occurs predominantly at the retropalatal level, affecting the anteroposterior and lateral dimensions, being associated with lateral pharyngeal wall enlargement and posterior tongue displacement.

 


Keywords: Multidetector computed tomography; Oropharynx; Sleep apnea, obstructive; Polysomnography; Diagnostic imaging; Sleep.

 

8 - Prevalence of smoking and reasons for continuing to smoke: a population-based study

Prevalência de tabagismo e motivos para continuar a fumar: estudo de base populacional

Simone Aparecida Vieira Rocha1,a, Andréa Thives de Carvalho Hoepers1,b, Tânia Silvia Fröde2,c, Leila John Marques Steidle3,d, Emilio Pizzichini3,e, Márcia Margaret Menezes Pizzichini3,f

J Bras Pneumol.2019;45(4):e20170080

Abstract PDF PT PDF EN Portuguese Text

Objective: To investigate the prevalence of smoking and the reasons for continuing to smoke among adults in Brazil. Methods: This was a cross-sectional, population-based study including 1,054 individuals ≥ 40 years of age, residents of the city of Florianopolis, Brazil, of whom 183 were smokers. All of the smokers completed the University of São Paulo Reasons for Smoking Scale (USP-RSS). Depressive symptoms were evaluated with the Hospital Anxiety and Depression Scale, and spirometry was performed to screen for COPD. Results: Of the 183 smokers, 105 (57.4%) were female, 138 (75.4%) were White, and 125 (63.8%) were in a low economic class. The mean level of education among the smokers was 9.6 ± 6.1 years. The mean smoking history was 29 ± 15 pack-years, 59% of the men having a ≥ 30 pack-year smoking history. Approximately 20% of the smokers had COPD, and 29% had depressive symptoms, which were more common in the women. The USP-RSS scores were highest for the pleasure of smoking (PS), tension reduction (TR), and physical dependence (PD) domains (3.9 ± 1.1, 3.6 ± 1.2, and 3.5 ± 1.3, respectively). Scores for the PS, TR, and weight control (WC) domains were significantly higher in women. Smokers with a > 20 pack-year smoking history scored significantly higher on the PD, PS, automatism, and close association (CA) domains. Smoking history was associated with the PD, PS, TR, and CA domains. Depressive symptoms were associated with the PD, social smoking, and CA domains (p = 0.001; p = 0.01; p = 0.09, respectively). Female gender and a low level of education were associated with the PS domain (p = 0.04) and TR domain (p < 0.001). Conclusions: The prevalence of smoking in our sample was relatively high (17.4%). The USP-RSS domains PS, TR, and WC explain why individuals continue smoking, as do depressive symptoms.

 


Keywords: Smoking/epidemiology; Tobacco use disorder/psychology; Smoking cessation/methods; Prevalence.

 

9 - NACHT, LRR, and PYD domains-containing Protein 3 and LL-37: prognostic value of new biomarkers in community-acquired pneumonia

Proteína 3 contendo um domínio NACHT, porção C-terminal rica em repetições de leucina e de domínio pirina e LL-37: valor prognóstico de novos biomarcadores em pneumonia adquirida na comunidade

Chuanan Zhu1,a, Yingfan Zhou2,b, Jiabin Zhu3,c, Ye Liu1,d, Mengyi Sun1,e

J Bras Pneumol.2019;45(4):e20190001

Abstract PDF PT PDF EN Portuguese Text

Objective: This study aimed to determine the serum levels of NACHT, Leucine-rich repeat (LRR), and Pyrin (PYD) domains-containing Protein 3 (NLRP3) and cathelicidin LL-37, and investigate their prognostic significance in community-acquired pneumonia (CAP). Methods: The sample of this prospective study was composed of 76 consecutive patients with CAP. Demographic data and clinical characteristics were collected. Serum levels of NLRP3 and LL-37 were determined by ELISA. Spearman's analysis was used to evaluate the correlation between NLRP3 and LL-37. Association of NLRP3 and LL 37 with 30-day survival and mortality rates was assessed using the Kaplan-Meier curve and logistic regression analysis. Results: Serum NLRP3 significantly increased whereas serum LL-37 significantly decreased in patients with severe CAP. Significant correlation was observed between serum NLRP3 and LL-37 in CAP patients. Patients with higher levels of NLRP3 and lower levels of LL-37 showed lower 30-day survival rate and higher mortality compared with those with lower NLRP3 and higher LL-37 levels. Conclusion: Severe CAP patients tend to present higher serum NLRP3 and lower serum LL-37, which might serve as potential biomarkers for CAP prognosis.

 


Keywords: Community-acquired pneumonia; Prognosis; Biomarkers; Prospective study.

 

10 - Disability and its clinical correlates in pulmonary hypertension measured through the World Health Organization Disability Assessment Schedule 2.0: a prospective, observational study

Deficiência e seus correlatos clínicos na hipertensão pulmonar medidos pelo World Health Organization Disability Assessment Schedule 2.0: um estudo prospectivo e observacional

Abílio Reis1,a, Mário Santos1,2,3,b, Inês Furtado4,c, Célia Cruz4,d, Pedro Sa-Couto5,e, Alexandra Queirós6,7,f, Luís Almeida8,g, Nelson Rocha7,9,h

J Bras Pneumol.2019;45(4):e20170355

Abstract PDF PT PDF EN Portuguese Text Appendix

Objective: To characterise the degree of disability in pulmonary hypertension (PH) patients based on the World Health Organisation Disability Assessment Schedule 2.0 (WHODAS 2.0). Method: A prospective and observational study of patients with documented PH (N = 46). Patients completed the WHODAS 2.0 questionnaire during a scheduled routine clinical visit, and their demographic and clinical characteristics were retrieved from electronic medical records (EMR). In subsequent visits, selected clinical variables were registered to assess disease progression. Results: WHODAS 2.0 scores were indicative of mild to moderate disability for the domains of mobility (22.0 ± 23.2), life activities (23.7 ± 25.5), and participation in society (17.2 ± 15.9), as well as total WHODAS 2.0 score (15.3 ± 15.2). For the domains of cognition (9.1 ± 14.1), self-care (8.3 ± 14.4), and interpersonal relationships (11.7 ± 15.7), scores were lower. Disability scores were, generally, proportional to the PH severity. The main baseline correlates of disability were World Health Organisation (WHO) functional class, fatigue, dyspnoea, 6-minute walking distance (6MWD), and N-terminal pro b-type natriuretic peptide (NT-proBNP). Baseline WHODAS 2.0 scores showed significant associations with disease progression. However, this effect was not transversal to all domains, with only a few domains significantly associated with disease progression variables. Conclusions: This PH population shows mild disability, with higher degree of disability in the domains of mobility and life activities. This study is the first one to assess disability in PH using WHODAS 2.0. Further studies should apply this scale to larger PH populations with suitable representations of more severe PH forms.

 


Keywords: Pulmonary hypertension; International Classification of Functioning, Disability and Health; Disability evaluation; Quality of Life.

 

11 - Evaluating the extremely elderly at a pulmonary function clinic for the diagnosis of respiratory disease: frequency and technical quality of spirometry

Velhice extrema em um centro diagnóstico respiratório: frequência e qualidade técnica da espirometria

Saulo Maia d'Avila Melo1,a, Larissa Alves de Oliveira2,b, José Lucas Farias Wanderley3,c, Rodrigo dos Anjos Rocha4,d

J Bras Pneumol.2019;45(4):e20180232

Abstract PDF PT PDF EN Portuguese Text

Objective: To determine the frequency of spirometry in elderly people, by age group, at a pulmonary function clinic, to assess the quality of spirometry in the extremely elderly, and to determine whether chronological age influences the quality of spirometry. Methods: This was a cross-sectional retrospective study evaluating information (spirometry findings and respiratory questionnaire results) obtained from the database of a pulmonary function clinic in the city of Aracaju, Brazil, for the period from January of 2012 to April of 2017. In the sample as a whole, we determined the total number of spirometry tests performed, and the frequency of the tests in individuals ≥ 60 years of age, ≥ 65 years of age, and by decade of age, from age 60 onward. In the extremely elderly, we evaluated the quality of spirometry using criteria of acceptability and reproducibility, as well as examining the variables that can influence that quality, such a cognitive deficit. Results: The sample comprised a total of 4,126 spirometry tests. Of those, 961 (23.30%), 864 (20.94%), 102 (2.47%), and 26 (0.63%) were performed in individuals ≥ 60, ≥ 65, ≥ 86, and ≥ 90 years of age (defined as extreme old age), respectively. In the extremely elderly, the criteria for acceptability and reproducibility were met in 88% and 60% of the spirometry tests (95% CI: 75.26-100.00 and 40.80-79.20), respectively. The cognitive deficit had a negative effect on acceptability and reproducibility (p ≤ 0.015 and p ≤ 0.007, respectively). Conclusions: A significant number of elderly individuals undergo spirometry, especially at ≥ 85 years of age, and the majority of such individuals are able to perform the test in a satisfactory manner, despite their advanced age. However, a cognitive deficit could have a negative effect on the quality of spirometry.

 


Keywords: Spirometry; Aging; Aged, 80 and over.

 

12 - Pulmonary arteriovenous malformations: diagnostic and treatment characteristics

Malformações arteriovenosas pulmonares: características diagnósticas e de tratamento

William Salibe-Filho1,a, Bruna Mamprim Piloto1,b, Ellen Pierre de Oliveira1,c, Marcela Araújo Castro1,d, Breno Boueri Affonso2,e, Joaquim Maurício da Motta-Leal-Filho2,f, Edgar Bortolini2,g, Mário Terra-Filho1,h

J Bras Pneumol.2019;45(4):e20180137

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Objective: To present a case series of pulmonary arteriovenous malformations (PAVMs), describing the main clinical findings, the number/location of pulmonary vascular abnormalities, the clinical complications, and the treatment administered. Methods: This was a retrospective observational study evaluating patients with PAVM divided into two groups: hereditary hemorrhagic telangiectasia (HHT); and idiopathic PAVM (iPAVM). Results: A total of 41 patients were selected for inclusion, but only 33 had PAVMs. After clinical evaluation, 27 and 6 were diagnosed with HHT and iPAVM, respectively. In the HHT group, the mean age was 49.6 years and 88.9% were female. In that group, 4 patients had an SpO2 of < 90% and the most common clinical finding was epistaxis. In the iPAVM group, the mean age was 48.1 years and 83.3% were female. In that group, 3 patients had an SpO2 of < 90%. Computed tomographic pulmonary angiography showed that most of the PAVMs were in the lower lobes: 56.4% in the HHT group and 85.7% in the iPAVM group. Embolization was performed in 23 patients (in both groups). At this writing, 10 patients are scheduled to undergo the procedure. One of the patients who underwent embolization was subsequently referred for pulmonary resection. Conclusions: In both of the PAVM groups, there was a predominance of women and of fistulas located in the lower lobes. Few of the patients had respiratory symptoms, and most had an SpO2 > 90%. The treatment chosen for all patients was percutaneous transcatheter embolization.

 


Keywords: Telangiectasia, hereditary hemorrhagic; Arteriovenous malformations/diagnosis; Arteriovenous malformations/therapy.

 

13 - Translation and cultural adaptation of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-Lung Cancer Module for quality of life assessment in patients with lung cancer in Brazil

Tradução e adaptação cultural do Quality of Life Questionnaire-Lung Cancer Module da European Organisation for Research and Treatment of Cancer para avaliação da qualidade de vida relacionada à saúde em pacientes com câncer de pulmão no Brasil

Ana Paula Ramos Marinho1,2,a, Gracielle Fin3,4,b, Antuani Rafael Baptistella3,c, Rudy José Nodari Júnior3,d, Magnus Benetti4,e

J Bras Pneumol.2019;45(4):e20170458

Abstract PDF PT PDF EN Portuguese Text

Objective: To translate the European Organisation for Research and Treatment of Cancer (EORTC) 29-item Quality of Life Questionnaire-Lung Cancer Module (QLQ-LC29, developed for the assessment of quality of life in patients with lung cancer) to Portuguese, conducting a pilot study of the Portuguese-language version and adapting it for use in Brazil. Methods: For the translation, cultural adaptation, and pilot testing of the QLQ-LC29, we followed the guidelines established by the EORTC. The translation (English → Portuguese) and back-translation (Portuguese → English) were both carried out by translators, working independently, who were native speakers of one language and fluent in the other. After review, a draft version was created for pilot testing in lung cancer patients in Brazil. Results: A total of 15 patients diagnosed with lung cancer completed the Portuguese-language version of the questionnaire. At the end of the process, we conducted a structured interview to identify any patient difficulty in understanding any of the questions. The final versions were sent to the EORTC and were approved. Conclusions: The Portuguese-language version of the EORTC QLQ-LC29 appears to be a useful, important, reliable questionnaire that is a valid tool for assessing quality of life in patients with lung cancer in Brazil.

 


Keywords: Surveys and Questionnaires; Lung neoplasms; Quality of Life; Brazil; Translations.

 

14 - Thoracic calcifications on magnetic resonance imaging: correlations with computed tomography

Calcificações torácicas na ressonância magnética: correlações com a tomografia computadorizada

Juliana Fischman Zampieri1,a, Gabriel Sartori Pacini1,b, Matheus Zanon1,c, Stephan Philip Leonhardt Altmayer1,2,d, Guilherme Watte1,2,e, Marcelo Barros1,2,f Evandra Durayski2,g, Gustavo de Souza Portes Meirelles3,h, Marcos Duarte Guimarães4,5,i, Edson Marchiori6,j, Arthur Soares Souza Junior7,k, Bruno Hochhegger1,2,l

J Bras Pneumol.2019;45(4):e20180168

Abstract PDF PT PDF EN Portuguese Text

Objective: To identify the characteristics of thoracic calcifications on magnetic resonance (MR) imaging, as well as correlations between MR imaging and CT findings. Methods: This was a retrospective study including data on 62 patients undergoing CT scans and MR imaging of the chest at any of seven hospitals in the Brazilian states of Rio Grande do Sul, São Paulo, and Rio de Janeiro between March of 2014 and June of 2016 and presenting with calcifications on CT scans. T1- and T2-weighted MR images (T1- and T2-WIs) were semiquantitatively analyzed, and the lesion-to-muscle signal intensity ratio (LMSIR) was estimated. Differences between neoplastic and non-neoplastic lesions were analyzed. Results: Eighty-four calcified lesions were analyzed. Mean lesion density on CT was 367 ± 435 HU. Median LMSIRs on T1- and T2-WIs were 0.4 (interquartile range [IQR], 0.1-0.7) and 0.2 (IQR, 0.0-0.7), respectively. Most of the lesions were hypointense on T1- and T2-WIs (n = 52 [61.9%] and n = 39 [46.4%], respectively). In addition, 19 (22.6%) were undetectable on T1-WIs (LMSIR = 0) and 36 (42.9%) were undetectable on T2-WIs (LMSIR = 0). Finally, 15.5% were hyperintense on T1-WIs and 9.5% were hyperintense on T2-WIs. Median LMSIR was significantly higher for neoplastic lesions than for non-neoplastic lesions. There was a very weak and statistically insignificant negative correlation between lesion density on CT and the following variables: signal intensity on T1-WIs, LMSIR on T1-WIs, and signal intensity on T2-WIs (r = −0.13, p = 0.24; r = −0.18, p = 0.10; and r = −0.16, p = 0.16, respectively). Lesion density on CT was weakly but significantly correlated with LMSIR on T2-WIs (r = −0.29, p < 0.05). Conclusions: Thoracic calcifications have variable signal intensity on T1- and T2-weighted MR images, sometimes appearing hyperintense. Lesion density on CT appears to correlate negatively with lesion signal intensity on MR images.

 


Keywords: Calcification, physiologic; Thorax/diagnostic imaging; Tomography, X-ray computed; Magnetic resonance imaging.

 

15 - Do N-terminal pro-brain natriuretic peptide levels determine the prognosis of community acquired pneumonia?

Os níveis de pró-peptídeo natriurético cerebral N-terminal determinam o prognóstico de pneumonia adquirida na comunidade?

Evrim Eylem Akpınar1,a, Derya Hoşgün2,b, Serdar Akpınar3,c, Can Ateş4,d, Ayşe Baha5,e, Esen Sayın Gülensoy1,f, Nalan Ogan1,g

J Bras Pneumol.2019;45(4):e20180417

Abstract PDF PT PDF EN Portuguese Text

Objective: Pneumonia is a leading cause of mortality worldwide, especially in the elderly. The use of clinical risk scores to determine prognosis is complex and therefore leads to errors in clinical practice. Pneumonia can cause increases in the levels of cardiac biomarkers such as N-terminal pro-brain natriuretic peptide (NT-proBNP). The prognostic role of the NT-proBNP level in community acquired pneumonia (CAP) remains unclear. The aim of this study was to evaluate the prognostic role of the NT-proBNP level in patients with CAP, as well as its correlation with clinical risk scores. Methods: Consecutive inpatients with CAP were enrolled in the study. At hospital admission, venous blood samples were collected for the evaluation of NT-proBNP levels. The Pneumonia Severity Index (PSI) and the Confusion, Urea, Respiratory rate, Blood pressure, and age ≥ 65 years (CURB-65) score were calculated. The primary outcome of interest was all-cause mortality within the first 30 days after hospital admission, and a secondary outcome was ICU admission. Results: The NT-proBNP level was one of the best predictors of 30-day mortality, with an area under the curve (AUC) of 0.735 (95% CI: 0.642-0.828; p < 0.001), as was the PSI, which had an AUC of 0.739 (95% CI: 0.634-0.843; p < 0.001), whereas the CURB-65 had an AUC of only 0.659 (95% CI: 0.556-0.763; p = 0.006). The NT-proBNP cut-off level found to be the best predictor of ICU admission and 30-day mortality was 1,434.5 pg/mL. Conclusions: The NT-proBNP level appears to be a good predictor of ICU admission and 30-day mortality among inpatients with CAP, with a predictive value for mortality comparable to that of the PSI and better than that of the CURB-65 score.

 


Keywords: Pneumonia/diagnosis; Pneumonia/mortality; Natriuretic peptide, brain; Community-acquired infections.

 

Brief Communication

16 - Effect of vaporized perfluorocarbon on oxidative stress during the cold ischemia phase of lung graft preservation

Efeito do perfluorocarbono vaporizado sobre o estresse oxidativo no período de isquemia fria durante a preservação pulmonar

Renata Salatti Ferrari1,a, Leonardo Dalla Giacomassa Rocha Thomaz2,b, Lucas Elias Lise Simoneti2,c, Jane Maria Ulbrich1,3,d, Cristiano Feijó Andrade1,3,e

J Bras Pneumol.2019;45(4):e20170288

Abstract PDF PT PDF EN Portuguese Text

Liquid perfluorocarbon (PFC) instillation has been studied experimentally as an adjuvant therapy in the preservation of lung grafts during cold ischemia. The objective of this study was to evaluate whether vaporized PFC is also protective of lung grafts at different cold ischemia times. We performed histological analysis of and measured oxidative stress in the lungs of animals that received only preservation solution with low-potassium dextran (LPD) or vaporized PFC together with LPD. We conclude that vaporized PFC reduces the production of free radicals and the number of pulmonary structural changes resulting from cold ischemia.

 


Keywords: Ischemia; Reperfusion; Fluorocarbons; Lung transplantation; Oxidative stress.

 

Special Article

17 - Brazilian consensus on non-cystic fibrosis bronchiectasis

Consenso brasileiro sobre bronquiectasias não fibrocísticas

Mônica Corso Pereira1,a, Rodrigo Abensur Athanazio2,b, Paulo de Tarso Roth Dalcin3,4,c, Mara Rúbia Fernandes de Figueiredo5,d, Mauro Gomes6,7,e, Clarice Guimarães de Freitas8,f, Fernando Ludgren9,g, Ilma Aparecida Paschoal1,h, Samia Zahi Rached2,i, Rosemeri Maurici10,j

J Bras Pneumol.2019;45(4):e20190122

Abstract PDF PT PDF EN Portuguese Text

Bronchiectasis is a condition that has been increasingly diagnosed by chest HRCT. In the literature, bronchiectasis is divided into bronchiectasis secondary to cystic fibrosis and bronchiectasis not associated with cystic fibrosis, which is termed non-cystic fibrosis bronchiectasis. Many causes can lead to the development of bronchiectasis, and patients usually have chronic airway symptoms, recurrent infections, and CT abnormalities consistent with the condition. The first international guideline on the diagnosis and treatment of non-cystic fibrosis bronchiectasis was published in 2010. In Brazil, this is the first review document aimed at systematizing the knowledge that has been accumulated on the subject to date. Because there is insufficient evidence on which to base recommendations for various treatment topics, here the decision was made to prepare an expert consensus document. The Brazilian Thoracic Association Committee on Respiratory Infections summoned 10 pulmonologists with expertise in bronchiectasis in Brazil to conduct a critical assessment of the available scientific evidence and international guidelines, as well as to identify aspects that are relevant to the understanding of the heterogeneity of bronchiectasis and to its diagnostic and therapeutic management. Five broad topics were established (pathophysiology, diagnosis, monitoring of stable patients, treatment of stable patients, and management of exacerbations). After this subdivision, the topics were distributed among the authors, who conducted a nonsystematic review of the literature, giving priority to major publications in the specific areas, including original articles, review articles, and systematic reviews. The authors reviewed and commented on all topics, producing a single final document that was approved by consensus.

 


Keywords: Bronchiectasis; Tomography, X-ray; Radiography, thoracic.

 

Letters to the Editor

18 - Video-assisted thoracoscopic thoracic duct ligation with near-infrared fluorescence imaging with indocyanine green

Fluorescência com verde de indocianina para auxiliar na ligadura do ducto torácico por videotoracoscopia

Benoit Jacques Bibas1,a, Rafael Lucas Costa-de-Carvalho1,b, Flavio Pola-dos-Reis1,c, Leticia Leone Lauricella1,d, Paulo Manoel Pêgo-Fernandes1,e, Ricardo Mingarini Terra1,f

J Bras Pneumol.2019;45(4):e20180401

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19 - Pulmonary benign metastasizing leiomyoma presenting as small, diffuse nodules

Leiomioma metastático benigno pulmonar apresentando padrão de pequenos nódulos difusos

Jean-Michel Dossegger1,a, Leonardo Hoehl Carneiro1,b, Rosana Souza Rodrigues1,2,c, Miriam Menna Barreto1,d, Edson Marchiori1,e

J Bras Pneumol.2019;45(4):e20180318

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20 - Occupational exposure to dust: an underestimated health risk?

Exposição ocupacional a poeira: um risco à saúde subestimado?

Sandra Saleiro1,a, Luís Rocha1,2,b, João Bento1,2,c, Luís Antunes3,d, José Torres da Costa4,e

J Bras Pneumol.2019;45(4):e20170396

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Images in Pulmonary Medicine

 


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