Presence of arterial hypoxemia in hepatic cirrhosis is a well-documented fact. Physiopathogenic mechanisms have been widely studied. It is assumed that there are alterations in pulmonary vessels which determine small and numerous arteriovenous shunts. Presence of anatomic intrapulmonary shunts, although well-documented, is small and could hardly explain such low levels of arterial oxigenation in cirrhotic patients. It is a premise that alterations occur in the pulmonary dynamics and that the diffusion of gases may be altered. Purpose: To evaluate the pulmonary function and arterial oxygenation levels in 55 patients with hepatic cirrhosis, with no other pulmonary, cardiac or hematologic diseases. They were submitted to evaluation of the pulmonary function through measurement of the forced vital capacity, forced expiratory volume in one second, and residual volume as well as diffusion capacity for carbon monoxide. Finally, arterial oxygenation was evaluated through arterial gasometry during air breathing and with 100% oxygen. Analysis of results allowed the authors to observe the presence of normal pulmonary flows and volumes (average of: FVC = 104.6%; FEV1 = 102.4%; residual volume = 117.4%); and diffusion capacity was diminished (average = 70.8%) in relation to predicted values. Arterial blood gases showed a mean PaO2 of 81.20 mmHg during air breathing and 515.4 mmHg when 100% oxygen was breathed. No correlations among PaO2 (with air breathing and with oxygen) and diffusion capacity were observed. In this study, flows and pulmonary volumes were normal in relation to the predicted values; however, diffusion of carbon monoxide was diminished. This diminished diffusion corroborates the existing idea of the so-called diffusion-perfusion imbalance as one of the mechanisms involved in the physiopathology of the hepatic pulmonary syndrome, even with no evidence of intrapulmonary morphological arteriovenous shunt.

Keywords: Hepatopulmonary syndrome. Pulmonary function. Hepatic cirrhosis.

Depression is the most prevalent psychiatric disorder among hospitalized patients. Chronic obstructive pulmonary disease (COPD) is the most common pulmonary disease, responsible for a high incidence of hospitalization. The purpose of this study is to determine the prevalence of major depression in patients hospitalized due to COPD and correlate such depression with PaCO2, PaO2, respiratory infection, degree of functional airflow obstruction, and steroid therapy. Depression was diagnosed according to DSM IV criteria for major depressive disorders, and assessed by the Beck Depression Inventory. The interview, spirometry, and arterial blood gas analysis were performed between the third and the tenth day of hospitalization. The authors made a prospective study of 51 patients, 34 male and 17 female, with a mean age of 61 ± 11 years. Respiratory infection was the most frequent cause of hospital admission. Major depression was present in 26.9% (n = 11) of the patients, and proportionally higher in females (8 vs 3, p = 0.003). PaCO2 was higher in depressive patients than in non-depressive ones (60.1 ± 18.0 vs 45.8 ± 10.0 mmHg, p = 0.004). Other variables did not display significant differences. The authors conclude that major depression is highly prevalent among patients with COPD, specially in hypercapnic individuals and women.

Keywords: Chronic obstructive pulmonary disease. Steroid. Hypercapnia. Hypoxemia. Depression.

Objectives: To evaluate clinical, laboratorial, epidemiological, and therapeutic aspects of patients presenting with multiresistant tuberculosis (MRTB). Patients and methods: From January 1993 to December 1994, a prospective, non-randomized study of patients presenting MRTB, characterized by failures under treatment schemes E-1 and E-3 according to the classification of the Brazilian Ministry of Health, and resistance to isoniazid and rifampicin was carried out. Clinical and laboratorial aspects were considered: age, gender, ethnical group, duration of condition, cavity occurrences in conventional X-rays, resistance to drugs by the indirect method according to Canetti's et al. proportional criteria; epidemiological aspects such as risk predictor factors for multiresistance and treatment results. This study consisted in two alternative chemotherapy courses combining an aminoglycoside, amikacin (Group A), or S, if sensitive (Group B), ofloxacin, clofazimine, in addition to other drugs, such as thiacetazone, ethambutol, or pyrazinamide, according to the sensitivity or to the prior limited use for a minimum of twelve months. Patients with unilateral radiologic lesions, functional possibilities, and who have accepted the indication were submitted to surgery (Group C). Treatment was at the outpatient clinic, self-administered, or under indirect supervision, with hospital admission allowed for clinical reasons, for a limited time, or when surgery was indicated. Patients with prior alternative treatment, those infected with HIV, pregnant patients, and those with renal failure were excluded from the study. Evaluation extended to twelve months after completion of treatment. Results: 70 patients with mean age of 37 years, 42 male, 44 caucasian, and 26 non-caucasian (two orientals), average duration of the condition of four years, and bilateral cavitary lesions in 55 (78.6%). Resistance to two drugs in 28.6%, 51.4% to three drugs, and 20% to four drugs. The most frequent risk predictor factor for MRTB was abandonment (54.3%) followed by recurrence after cure with treatment scheme E1 and failure at retreatment (14.3%), intolerance to drugs (11.4%), contact with MRTB (8.6%). The risk predictor factor could not be determined in 11%, acquired multiresistance being considered in 80%, and primary multiresistance in only 8.6% of the patients. Cure was observed in 25 patients of Group A (n = 39), 11 patients of Group B (n = 24), and 3 of Group C (n = 7). Only two discontinued treatment (A) and only two died during treatment (C). In the control period, three patients had recurrences (1 in A, and 2 in B), and 7 died (3 in A, 2 in B, and 2 in C). The effectiveness of Group A was 67.6% (25/37) at completion of treatment, and 64.9% during the post-treatment control. The effectiveness of Group B was 45.8% (11/24) at completion of treatment, and 37.5% during the post-treatment control. The effectiveness of Group C was 42.8% (3/7) at completion of treatment and during the post-treatment control. After twelve months, effectiveness at treatment completion in Group A fell from 64.1% to 61.5%, in Group B, it fell from 45.8% to 37.5%, and it remained unchanged in 42.8% in Group C, where the four cases of failure died. Drug discontinuation due to adverse effects occurred late in two cases, and other adverse effects were noted, but did not foster discontinuation of treatment.

Because it has direct and indirect action on lung tissue, oleic acid (OA) has been used experimentally as a model of fat embolism and acute respiratory distress syndrome (ARDS). The aim of this study was to describe acute and chronic pulmonary lesions induced in rats by intravenous injection of OA. Male Wistar rats were injected a 0.05 ml dose of OA. Groups of 5 animals were sacrificed 2, 24, 48 hours, and 5, 10, 30, and 90 days after injection. Diffuse alveolar edema, foci of intra-alveolar hemorrhage, and foci of ischemic necrosis were observed by light microscopic from 2 to 48 hours. At this period of time, severe endothelial injuries and type II alveolar cell lesions were observed on electron microscopy. After the fifth day, no injury was observed and discrete morphological sequelae were found. The lungs of the animals sacrificed at the thirtieth and ninetieth days were identical to those of the control groups. The present model allows animal to survive, being suitable for studies on fat embolism and on ARDS.

Keywords: Oleic acid. Fat embolism. Acute respiratory distress syndrome, ARDS. Experimental model.

Lung volume reduction surgery is intended to improve pulmonary function in selected patients with severe emphysema by improving diaphragmatic and chest wall mechanisms. An increasing body of scientific evidence demonstrates that lung volume reduction surgery provides significant palliation, with long-run benefits for at least two years. Measurements of pulmonary function have also confirmed significant improvement in objective physiologic parameters such as airway obstruction, elastic recoil, and gas exchange. However, some questions concerning these issues have not been answered yet: long-term efficacy, patient's outcome predictors, cost-benefit analyses, and clarification of the indication for different surgical approaches.

Keywords: Emphysema. Lung reduction surgery.

A case of polycystic hydatid disease with radiological manifestations that mimicked pulmonary metastatic lesions is reported. The patient, from Brasília, DF, was admitted to the Brasilia University Hospital in February 1996, with a six-month history of unproductive cough, progressive dyspnea, thoracic pain and an episode of hemoptysis. Besides the pulmonary lesions, a CT scan showed hypodense lesions and calcifications in the right lobe of the liver. Repeated examinations of the sputum and bronchoalveolar lavage revealed no malignant cells. An open lung biopsy was then performed and allowed the authors to recognize the helminthic nature of the disease. Protoscolices, probably of Echinococcus vogeli, were found in tissue sections. The source of infection was supposed to be some hunting dog lodged in a kennel kept by the patient. Administration of albendazole brought no significant improvement to the pulmonary lesions, after one year of treatment not yet interrupted.

Keywords: Polycystic hydatid disease. Polycystic echinococcosis. Neotropical echinococcosis. Echinococcus vogeli.

A case of obstructive sleep apnea syndrome (OSAS) with narcoleptic features is described; polysomnographic studies were carried out and revealed a severe nocturnal respiratory impairment due to apneic episodes. A multiple sleep latency test (MSLT) showed early REM sleep onset in two out of five series. Nasal CPAP utilization improved the quality of nocturnal sleep and reverted all narcoleptic features in the next day's MSLT.

Keywords: Obstructive sleep apnea syndrome (OSAS). Narcolepsy. Sleep deprivation. CPAP.

Incidence of metastatic disease to the hypothalamic-pituitary area is low (1 to 6% in most studies), the lung and the prostate being the most common primary sites in men. Clinical presentation as panhypopituitarism is rare (0.2 to 0.8%) in patients with bronchogenic carcinoma. The authors describe a case of a man with diagnosis of squamous cell carcinoma of the lung that, during the clinical course of the disease, presented clinical and laboratorial evidence of panhypopituitarism, with an expansive sellar and supra-sellar lesion image in the CT scan of the brain.

Keywords: Panhypopituitarism. Bronchogenic carcinoma. Hypothalamic-pituitary metastases.