Objective: To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU. Methods: This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days. Results: On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days). Conclusions: Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.

Keywords: Hand disinfection; Health personnel; Pneumonia, ventilator-associated; Respiration, artificial; Guideline adherence.

Objective: To compare the effects that prone and supine positioning during high-frequency oscillatory ventilation (HFOV) have on oxygenation and lung inflammation, histological injury, and oxidative stress in a rabbit model of acute lung injury (ALI). Methods: Thirty male Norfolk white rabbits were induced to ALI by tracheal saline lavage (30 mL/kg, 38°C). The injury was induced during conventional mechanical ventilation, and ALI was considered confirmed when a PaO2/FiO2 ratio < 100 mmHg was reached. Rabbits were randomly divided into two groups: HFOV in the supine position (SP group, n = 15); and HFOV with prone positioning (PP group, n = 15). For HFOV, the mean airway pressure was initially set at 16 cmH2O. At 30, 60, and 90 min after the start of the HFOV protocol, the mean airway pressure was reduced to 14, 12, and 10 cmH2O, respectively. At 120 min, the animals were returned to or remained in the supine position for an extra 30 min. We evaluated oxygenation indices and histological lung injury scores, as well as TNF-α levels in BAL fluid and lung tissue. Results: After ALI induction, all of the animals showed significant hypoxemia, decreased respiratory system compliance, decreased oxygenation, and increased mean airway pressure in comparison with the baseline values. There were no statistically significant differences between the two groups, at any of the time points evaluated, in terms of the PaO2 or oxygenation index. However, TNF-α levels in BAL fluid were significantly lower in the PP group than in the SP group, as were histological lung injury scores. Conclusions: Prone positioning appears to attenuate inflammatory and histological lung injury during HFOV in rabbits with ALI.

Keywords: Respiration, artificial/adverse effects; Prone position; Lung/physiopathology; Pneumonia; Respiratory distress syndrome, adult; Acute lung injury; Disease models, animal; Rabbits.

Objective: To describe the clinical, functional, and radiological features of index cases of familial pulmonary fibrosis (FPF) in Brazil. Methods: We evaluated 35 patients with FPF - of whom 18 (51.4%) were women - with a median age of 66.0 years (range, 35.5-89.3 years). All of the patients completed a standardized questionnaire, as well as undergoing pulmonary function tests and HRCT of the chest. In 6 cases, lung tissue samples were obtained: from surgical biopsies in 5 cases; and from an autopsy in 1 case. Results: A history of smoking and a history of exposure to birds or mold were reported in 45.7% and 80.0% of the cases, respectively. Cough and marked dyspnea were reported by 62.8% and 48.6% of the patients, respectively. Fine crackles were detected in 91.4% of the patients. In 4 patients, the findings were suspicious for telomere disease. The median FVC and DLCO, as percentages of the predicted values, were 64.9% (range, 48.8-105.7%) and 38.9% (range, 16.0-60.0%), respectively. Nine patients had reduced DLCO despite having normal spirometry results. Regarding HRCT, patterns typical of usual interstitial pneumonia were found in 6 patients (17.1%). In 25 cases (71.5%), the HRCT features were consistent with a diagnosis other than idiopathic pulmonary fibrosis. In 11 cases (31.4%), the radiological patterns were uncharacteristic of interstitial lung disease. Of the six lung tissue samples analyzed, four showed interstitial pneumonia with bronchiolocentric accentuation, and, on the basis of the clinical and radiological data, the corresponding patients were diagnosed with hypersensitivity pneumonitis. Conclusions: Patients with FPF can present with a wide variety of clinical features. Most HRCT scans of these patients exhibit patterns not typical of usual interstitial pneumonia. The family history of fibrotic lung diseases should be investigated in all patients under suspicion, regardless of their age.

Keywords: Idiopathic pulmonary fibrosis; Respiratory function tests; Tomography, X-ray computed.

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.

Objective: To analyze determinants of prognosis in patients with bronchial carcinoid tumors treated surgically and the potential concomitance of such tumors with second primary neoplasms. Methods: This was a retrospective analysis of 51 bronchial carcinoid tumors treated surgically between 2007 and 2016. Disease-free survival (DFS) was calculated by the Kaplan-Meier method, and determinants of prognosis were evaluated. Primary neoplasms that were concomitant with the bronchial carcinoid tumors were identified by reviewing patient charts. Results: The median age was 51.2 years, 58.8% of the patients were female, and 52.9% were asymptomatic. The most common histology was typical carcinoid (in 80.4%). Five-year DFS was 89.8%. Ki-67 expression was determined in 27 patients, and five-year DFS was better among the patients in whom Ki-67 expression was ≤ 5% than among those in whom it was > 5% (100% vs. 47.6%; p = 0.01). Concomitant primary neoplasms were observed in 14 (27.4%) of the 51 cases. Among the concomitant primary neoplasms that were malignant, the most common was lung adenocarcinoma, which was observed in 3 cases. Concomitant primary neoplasms were more common in patients who were asymptomatic and in those with small tumors. Conclusions: Surgical resection is the mainstay treatment of bronchopulmonary carcinoid tumors and confers a good prognosis. Bronchial carcinoid tumors are likely to be accompanied by second primary neoplasms.

Keywords: Carcinoid tumor/diagnosis; Carcinoid tumor/surgery; Neoplasms, second primary; Lung neoplasms.

Objective: To translate the King's Brief Interstitial Lung Disease (K-BILD) questionnaire to Portuguese and culturally adapt it for use in Brazil. The K-BILD quantifies the health status of patients with ILD. Methods: The process involved the following steps: authorization from the author of the original (English-language) questionnaire; translation of the questionnaire to Portuguese by three translators, working independently; merging of the translations by a committee of specialists; back-translation of the questionnaire to English; revision and readjustment of the back-translation by the committee of specialists; evaluation by the original author; revision of the back-translation; cognitive debriefing (verification of the clarity and acceptability of the Portuguese-language version in the target population-i.e., patients with ILD); and finalization of the Portuguese-language version. Results: In the cognitive debriefing step, 20 patients with ILD were interviewed. After the interviews, the clarity and acceptability index of each question was ≥ 0.8, which is considered acceptable. Conclusions: The Portuguese-language version of K-BILD appears to be easily administered to and understood by patients with ILD in Brazil. To our knowledge, this is the only instrument in Brazilian Portuguese that is designed to evaluate the impact that ILD has on the various aspects of the lives of those it affects.

Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Surveys and questionnaires.

Objective: Clinical trials have shown that nintedanib 150 mg twice daily (bid) reduces disease progression in patients with idiopathic pulmonary fibrosis (IPF), with an adverse event profile that is manageable for most patients. Prior to the approval of nintedanib as a treatment for IPF in Brazil, an expanded access program (EAP) was initiated to provide early access to treatment and to evaluate the safety and tolerability of nintedanib in this patient population. Methods: Patients with a diagnosis of IPF within the previous five years, forced vital capacity (FVC) ≥ 50% predicted and diffusing capacity of the lungs for carbon monoxide (DLco) 30% to 79% predicted were eligible to participate in the EAP. Patients received nintedanib 150 mg bid open-label. Safety assessments included adverse events leading to permanent discontinuation of nintedanib and serious adverse events. Results: The EAP involved 57 patients at eight centers. Most patients were male (77.2%) and white (87.7%). At baseline, mean (SD) age was 70.7 (7.5) years and FVC was 70.7 (12.5) % predicted. Mean (SD) exposure to nintedanib was 14.4 (6.2) months; maximum exposure was 22.0 months. The most frequently reported adverse events considered by the investigator to be related to nintedanib treatment were diarrhea (45 patients, 78.9%) and nausea (25 patients, 43.9%). Adverse events led to permanent discontinuation of nintedanib in 16 patients (28.1%). Sixteen patients (28.1%) had a serious adverse event. Conclusion: In the Brazilian EAP, nintedanib had an acceptable safety and tolerability profile in patients with IPF, consistent with data from clinical trials.

Keywords: Drug tolerance; Expanded access program; Interstitial lung disease; Tyrosine kinase inhibitor.

Objective: This study evaluated the factors related to the use of hookah among medical students, the level of knowledge about the involved harms, and their relationship with the use and intention to stop using it. Methods: Students of the 1st and 6th year of medical school were evaluated. A multivariate logistic regression model was used to evaluate the association between the outcome (use of hookah in the last 30 days) and demographic, subjective psychosocial data and level of knowledge about the harms of hookah use. Results: The experimentation rate of hookah and current use was high (59.6% and 27.7%, respectively), with no difference between the 1st and 6th year groups (p=0.70). The 6th grade students were more knowledgeable about the harm of using hookah when compared to the 1st year students (p <0.0001), and there was no association between the use of hookah in the last 30 days and the knowledge about its harms. Cigarette smoking and the use of alcoholic beverages were associated with the use of hookah in the last 30 days, with unadjusted Odds Ratio (OR) of 11.3; 95% CI 4.62‑27.7; p <0.0001 and OR 8.74; 95% CI 3.78-20.2; p <0.0001; respectively. Conclusion: There is a high experimentation, current use of hookah and cigarettes among medical students. Sixth year students are more knowledgeable about the harms involved. There was no association between the use of hookah in the last 30 days and the knowledge about its harms. Smoking and the use of alcoholic beverages are independent predictors of use of hookah.

Keywords: Water pipe smoking; Tobacco for water-pipe; Smoking; Medical education.

Objective: To evaluate the trends in smoking prevalence in all Brazilian capitals between 2006 and 2017. Methods: This was a study of temporal trends in smoking, based on information from the Telephone-based System for the Surveillance of Risk and Protective Factors for Chronic Diseases. The trends in smoking prevalence were stratified by gender, age, level of education, and capital of residence. We used linear regression analysis with a significance level of 5%. Results: From 2006 to 2017, the overall prevalence of smoking in the Brazilian capitals declined from 19.3% to 13.2% among men and from 12.4% to 7.5% among women (p < 0.05 for both). Despite the overall decline in the prevalence of smoking in all of the capitals, the rate of decline was lower in the more recent years. There was also a reduction in the prevalence of former smoking (22.2% in 2006 to 20.3% in 2017). In contrast, there was an upward trend in the prevalence of former smoking among individuals with a lower level of education (from 27.9% in 2006 to 30.0% in 2017). In 2017, the prevalence of smoking among men was highest in the cities of Curitiba, São Paulo, and Porto Alegre, whereas it was highest among women in the cities of Curitiba, São Paulo, and Florianópolis. Conclusions: There have been improvements in smoking prevalence in Brazil. Annual monitoring of smoking prevalence can assist in the battle against chronic noncommunicable diseases.

Keywords: Smoking; Tobacco use disorder; Health surveys.

Objective: To evaluate the different components of the resistance of the respiratory system, respiratory muscle strength and to investigate the occurrence of expiratory flow limitation (EFL) in patients with morbid obesity (MO) when seated. Methods: The sample was composed of MO (BMI≥40 kg/m2) and non-obese individuals (NO) with a BMI between 18 and 30 kg/m2. The protocol consisted of the anthropometric assessment and the following measures of respiratory function: spirometry, maximal inspiratory and expiratory pressures (MIP and MEP, respectively) and impulse oscillometry. The group comparison was performed using T-test for unpaired samples. The correlations were evaluated by the Pearson test with a significance level of 5%. Results: Fifty MO (age 40±10.4 years, 1.64±0.09 m, 138.8±33.6 kg and 50.7±8.9 kg/m2), and 30 NO (age 37.6±11.5 years, 1.67±0.09 m, 65.2±10.3 kg and 23.2±22 kg/m2) were evaluated. The MO showed higher values of total, peripheral, airways, tissue and central resistance when compared to the NO. No patient showed EFL. The waist circumference was associated with spirometric variables, MIP, and MEP. The waist-to-hip ratio was correlated to respiratory mechanics and spirometric variables, MIP, and MEP. Conclusion: Morbidly obese patients with no obstructive spirometric pattern show increased total, airway, peripheral, and tissue respiratory system resistance when compared to nonobese. These individuals, however, do not present with expiratory flow limitation and reduced respiratory muscles strength.

Keywords: Respiratory mechanics; Obesity; Impulse oscillometry; Pulmonary resistance; Respiratory system impedance.

Objective: To derive reference values from white race adults, for DCO in a sample from different sites in Brazil, through the same equipment model (Sensormedics), and compare the results with the derivatives from Crapo, Miller, Neder equations and from the Global Lung Initiative (GLI) proposal. Methods: The tests were performed according to the norms suggested by ATS/ERS in 2005 in six Brazilian cities, with 120 adult volunteers of each gender, non-smokers, without referred anemia and without lung or cardio diseases. The expected values were derived from linear regressions and the differences between the values forecasted by some authors and the ones observed in the current study were calculated. Results: Among men, the age varied between 25 and 88 years old, and the height varied between 140 and 176 cm. DCO was correlated significantly and positively with the height and negatively with the age. The values forecasted by Crapo, Neder, and Miller equations were higher in comparison with the ones obtained by the current study (p<0.01) in both genders. Among men, the values did not differ when compared to the ones calculated by GLI (p=0.29); among women, the values derived by GLI were slightly higher: 0.99 ml/min/mmHg (p<0.01). Conclusion: new values forecasted for DCO were derived in a sample of white adults in Brazil. The forecasted values are similar to the ones complied by GLI equations and differ from the previously proposed equations.

Keywords: Transfer factor; Pulmonary diffusing capacity; Diffusion; Carbon monoxide; Reference values; Lung function tests.