Persistence of symptoms and lung function in mild cases of COVID-19 six months after infection: a cross-sectional study / Persistência de sintomas e função pulmonar em casos leves de COVID-19 seis meses após a infecção: um estudo transversal

ABSTRACT Objectives: To describe persistent symptoms and lung function in mild cases of COVID-19 six months after infection. Methods: Data collection was performed through a semi-structured questionnaire containing information on the participants' demographic and anthropometric data, the disease in the acute phase, and persistent symptoms six months after COVID-19 using spirometry and manovacuometry. Results: A total of 136 participants were evaluated, of whom 64% were male, with a mean age of 38.17 ± 14.08 years and a body mass index (BMI) of 29.71 ± 17.48 kg/m2. The main persistent symptoms reported were dyspnea on exertion (39.7%), memory loss (38.2%), and anxiety (48.5%). Considering lung function, the participants reached 88.87 ± 17.20% of the predicted forced vital capacity (FVC), 86.03 ± 22.01% of the forced expiratory volume in one second (FEV1), and 62.71 ± 25.04% of peak expiratory flow (PEF). Upon manovacuometry, 97.41 ± 34.67% of the predicted inspiratory force (Pimax) and 66.86 ± 22.97% of the predicted expiratory force (Pemax) were observed. Conclusions: Six months after COVID-19 infection, a reduction in PEF and MEP was observed. Among the most commonly reported persistent symptoms were fatigue, tiredness with the slightest exertion, anxiety and depression, memory loss, and deficits in concentration.

RESUMO Objetivos: Descrever os sintomas persistentes e a função pulmonar em casos leves de COVID-19 seis meses após a infecção. Métodos: A coleta de dados foi realizada por meio de um questionário semiestruturado contendo informações sobre dados demográficos e antropométricos dos participantes, a doença na fase aguda e os sintomas persistentes seis meses após a COVID-19, utilizando espirometria e manovacuometria. Resultados: Um total de 136 participantes foram avaliados, dos quais 64% eram do sexo masculino, com uma idade média de 38,17 ± 14,08 anos e índice de massa corporal (IMC) de 29,71 ± 17,48 kg/m2. Os principais sintomas persistentes relatados foram dispneia ao esforço (39,7%), perda de memória (38,2%) e ansiedade (48,5%). Considerando a função pulmonar, os participantes atingiram 88,87 ± 17,20% da capacidade vital forçada (CVF) prevista, 86,03 ± 22,01% do volume expiratório forçado no primeiro segundo (VEF1) e 62,71 ± 25,04% do pico de fluxo expiratório (PFE). Na manovacuometria, observou-se 97,41 ± 34,67% da força inspiratória prevista (Pimáx) e 66,86 ± 22,97% da força expiratória prevista (Pemáx). Conclusões: Seis meses após a infecção por COVID-19, observou-se uma redução no PFE e na PEM. Dentre os sintomas persistentes mais comumente relatados estavam fadiga, cansaço com o mínimo esforço, ansiedade e depressão, perda de memória e déficits de concentração.

Effects of Pulmonary Rehabilitation on Systemic Inflammation and Exercise Capacity in Bronchiectasis: A Randomized Controlled Trial.

INTRODUCTION: Bronchiectasis is a chronic condition that is becoming a global health concern. OBJECTIVE: To examine the effects of pulmonary rehabilitation (PR) on systemic inflammation, exercise capacity, and quality of life in participants with bronchiectasis. METHODS: Participants were randomized to receive PR (outpatient, three weekly sessions for 3 months) or control intervention (usual care + airway clearance therapy + breathing exercises). Data on laboratory (fibrinogen level) and patient-centered outcomes such as physical fitness [6-min walk test (6MWT)] and quality of life were collected. RESULTS: A total of 41 participants were evaluated (20 in the intervention group and 21 in the control group). The magnitude of change between baseline and the end of study was greater in the PR group than in the control group-the 6MWT distance increased by a mean of 54 m (54 vs 12 m; p < 0.01), fibrinogen showed a significant reduction (fibrinogen - 92.8 versus - 47.1 mg/dl; p < 0.01), and quality of life improved according to Saint George's Respiratory Questionnaire (SGRQ) (- 7.5 vs 3.2; p < 0.01), which exceeded the minimal clinically important difference of 4 points. CONCLUSION: PR effectively improved physical fitness, quality of life, and the degree of systemic inflammation, as reflected by changes in 6 MWT, fibrinogen levels and SGRQ scores. This study supports the inclusion of people with bronchiectasis in supervised PR programs.

ELMO, a new helmet interface for CPAP to treat COVID-19-related acute hypoxemic respiratory failure outside the ICU: a feasibility study / ELMO, uma nova interface do tipo capacete para CPAP no tratamento da insuficiência respiratória aguda hipoxêmica por COVID-19 fora da UTI: estudo de viabilidade

ABSTRACT Objective: To assess the feasibility of using a new helmet interface for CPAP, designated ELMO, to treat COVID-19-related acute hypoxemic respiratory failure (AHRF) outside the ICU. Methods: This was a proof-of-concept study involving patients with moderate to severe AHRF secondary to COVID-19 admitted to the general ward of a public hospital. The intervention consisted of applying CPAP via the ELMO interface integrated with oxygen and compressed air flow meters (30 L/min each) and a PEEP valve (CPAP levels = 8-10 cmH2O), forming the ELMOcpap system. The patients were monitored for cardiorespiratory parameters, adverse events, and comfort. Results: Ten patients completed the study protocol. The ELMOcpap system was well tolerated, with no relevant adverse effects. Its use was feasible outside the ICU for a prolonged amount of time and was shown to be successful in 60% of the patients. A CPAP of 10 cmH2O with a total gas flow of 56-60 L/min improved oxygenation after 30-to 60-min ELMOcpap sessions, allowing a significant decrease in estimated FIO2 (p = 0.014) and an increase in estimated PaO2/FIO2 ratio (p = 0.008) within the first hour without CO2 rebreathing. Conclusions: The use of ELMOcpap has proven to be feasible and effective in delivering high-flow CPAP to patients with COVID-19-related AHRF outside the ICU. There were no major adverse effects, and ELMO was considered comfortable. ELMOcpap sessions significantly improved oxygenation, reducing FIO2 without CO2 rebreathing. The overall success rate was 60% in this pilot study, and further clinical trials should be carried out in the future. (ClinicalTrials.gov identifier: NCT04470258 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Avaliar a viabilidade do uso de uma nova interface do tipo capacete para CPAP, denominada ELMO, para o tratamento da insuficiência respiratória aguda (IRpA) hipoxêmica por COVID-19 fora da UTI. Métodos: Estudo de prova de conceito envolvendo pacientes com IRpA hipoxêmica moderada a grave secundária à COVID-19, internados na enfermaria geral de um hospital público. A intervenção consistiu na aplicação de CPAP por meio da interface ELMO integrada a fluxômetros de oxigênio e ar comprimido (30 L/min cada) e a uma válvula de PEEP (níveis de CPAP = 8-10 cmH2O), formando o sistema ELMOcpap. Os pacientes foram monitorados quanto a parâmetros cardiorrespiratórios, eventos adversos e conforto. Resultados: Dez pacientes completaram o protocolo do estudo. O sistema ELMOcpap foi bem tolerado, sem efeitos adversos relevantes. Seu uso foi viável fora da UTI por tempo prolongado e mostrou-se bem-sucedido em 60% dos pacientes. Uma CPAP de 10 cmH2O com fluxo total de gás de 56-60 L/min melhorou a oxigenação após sessões de ELMOcpap de 30-60 min, permitindo redução significativa da FIO2 estimada (p = 0,014) e aumento da PaO2/FIO2 estimada (p = 0,008) na primeira hora, sem reinalação de CO2. Conclusões: O uso do ELMOcpap mostrou-se viável e eficaz no fornecimento de CPAP de alto fluxo a pacientes com IRpA hipoxêmica por COVID-19 fora da UTI. Não houve nenhum efeito adverso importante, e o ELMO foi considerado confortável. As sessões de ELMOcpap melhoraram significativamente a oxigenação, reduzindo a FIO2 sem reinalação de CO2. A taxa global de sucesso foi de 60% neste estudo piloto, e novos ensaios clínicos devem ser realizados. (ClinicalTrials.gov identifier: NCT04470258 [http://www.clinicaltrials.gov/])

Isolation of and risk factors for airway infection with Pseudomonas aeruginosa in patients with non-cystic fibrosis bronchiectasis.

OBJECTIVE: To identify microorganisms in sputum samples of patients with stable non-cystic fibrosis bronchiectasis and to determine risk factors related to the isolation of Pseudomonas aeruginosa (PA) in those patients. METHODS: Consecutive patients were recruited from a tertiary hospital outpatient clinic in the city of Fortaleza, Brazil. The patients were submitted to spirometry, six-minute walk test, HRCT, and sputum collection. Data on serum fibrinogen levels, disease severity, sputum color, and history of azithromycin treatment were collected. RESULTS: The study included 112 patients, and females predominated (68%). The mean age was 51.6 ± 17.4 years. Most patients presented with mild-to-moderate disease (83%). The mean six-minute walk distance was 468.8 ± 87.9 m. Mean FEV1 and FVC, in % of predicted values, were 60.4 ± 21.8% and 69.9 ± 18.5%, respectively. The mean serum fibrinogen level was 396.1 ± 76.3 mg/dL. PA was isolated in 47 patients, other potentially pathogenic microorganisms (PPMs) were isolated in 31 patients, and non-PPMs were isolated in 34 patients. Purulent sputum was identified in 77 patients (68%). The patients with PA, when compared with those without it, presented with more severe disease, higher serum fibrinogen levels, and lower FVC%. In addition, purulent sputum and long-term azithromycin treatment were more common in those with PA. The multivariate regression analysis showed that the independent factors associated with PA were serum fibrinogen level > 400 mg/dL (OR = 3.0; 95% CI: 1.1-7.7) and purulent sputum (OR = 4.3; 95% CI: 1.6-11.3). CONCLUSIONS: In our sample, the prevalence of PA in sputum was 42%. Sputum color and inflammatory markers were able to predict the isolation of PA, emphasizing the importance of routine sputum monitoring.

Isolation of and risk factors for airway infection with Pseudomonas aeruginosa in patients with non-cystic fibrosis bronchiectasis / Isolamento de Pseudomonas aeruginosa e fatores de risco de infecção das vias aéreas pela bactéria em pacientes com bronquiectasias não fibrocísticas

ABSTRACT Objective: To identify microorganisms in sputum samples of patients with stable non-cystic fibrosis bronchiectasis and to determine risk factors related to the isolation of Pseudomonas aeruginosa (PA) in those patients. Methods: Consecutive patients were recruited from a tertiary hospital outpatient clinic in the city of Fortaleza, Brazil. The patients were submitted to spirometry, six-minute walk test, HRCT, and sputum collection. Data on serum fibrinogen levels, disease severity, sputum color, and history of azithromycin treatment were collected. Results: The study included 112 patients, and females predominated (68%). The mean age was 51.6 ± 17.4 years. Most patients presented with mild-to-moderate disease (83%). The mean six-minute walk distance was 468.8 ± 87.9 m. Mean FEV1 and FVC, in % of predicted values, were 60.4 ± 21.8% and 69.9 ± 18.5%, respectively. The mean serum fibrinogen level was 396.1 ± 76.3 mg/dL. PA was isolated in 47 patients, other potentially pathogenic microorganisms (PPMs) were isolated in 31 patients, and non-PPMs were isolated in 34 patients. Purulent sputum was identified in 77 patients (68%). The patients with PA, when compared with those without it, presented with more severe disease, higher serum fibrinogen levels, and lower FVC%. In addition, purulent sputum and long-term azithromycin treatment were more common in those with PA. The multivariate regression analysis showed that the independent factors associated with PA were serum fibrinogen level > 400 mg/dL (OR = 3.0; 95% CI: 1.1-7.7) and purulent sputum (OR = 4.3; 95% CI: 1.6-11.3). Conclusions: In our sample, the prevalence of PA in sputum was 42%. Sputum color and inflammatory markers were able to predict the isolation of PA, emphasizing the importance of routine sputum monitoring.

RESUMO Objetivo: Identificar microrganismos em amostras de escarro de pacientes com bronquiectasia não fibrocística estável e determinar os fatores de risco relacionados com o isolamento de Pseudomonas aeruginosa (PA) nesses pacientes. Métodos: Pacientes consecutivos foram recrutados em um ambulatório de um hospital terciário em Fortaleza (CE). Os pacientes foram submetidos a espirometria, teste de caminhada de seis minutos, TCAR e coleta de escarro. Foram coletados dados referentes ao fibrinogênio sérico, gravidade da doença, cor do escarro e histórico de tratamento com azitromicina. Resultados: O estudo incluiu 112 pacientes, com predomínio do sexo feminino (68%). A média de idade foi de 51,6 ± 17,4 anos. A maioria dos pacientes apresentou doença leve a moderada (83%). A média da distância percorrida no teste de caminhada de seis minutos foi de 468,8 ± 87,9 m. A média do VEF1 em % do previsto foi de 60,4 ± 21,8%, e a da CVF em % do previsto foi de 69,9 ± 18,5%. A média do fibrinogênio sérico foi de 396,1 ± 76,3 mg/dL. PA foi isolada em 47 pacientes; outros microrganismos potencialmente patogênicos (MPP) foram isolados em 31; não MPP foram isolados em 34. Escarro purulento foi identificado em 77 pacientes (68%). Os pacientes com PA, em comparação com aqueles sem, apresentaram doença mais grave, fibrinogênio sérico mais elevado e menor CVF%. Além disso, escarro purulento e tratamento prolongado com azitromicina foram mais comuns naqueles com PA. A análise de regressão multivariada mostrou que os fatores independentes relacionados com PA foram fibrinogênio sérico > 400 mg/dL (OR = 3,0; IC95%: 1,1-7,7) e escarro purulento (OR = 4,3; IC95%: 1,6-11,3). Conclusões: Em nossa amostra, a prevalência de PA no escarro foi de 42%. A cor do escarro e os marcadores inflamatórios foram capazes de prever o isolamento de PA, o que enfatiza a importância do monitoramento rotineiro do escarro.

Aplicabilidade das equações de referência brasileiras para o teste de caminhada de 6 minutos em pacientes com câncer de pulmão / Aplicabilidad de las ecuaciones de referencia brasileñas para la prueba de caminata de 6 minutos en pacientes con cáncer de pulmón / Applicability of Brazilian reference equations for the 6-minute walk test in patients with lung cancer

RESUMO O objetivo deste estudo foi verificar o impacto da utilização de diferentes equações de referência brasileiras para a distância percorrida no teste da caminhada de 6 minutos (TC6min) na avaliação da capacidade funcional de exercício em pacientes com câncer de pulmão (CP). Este estudo transversal incluiu 48 pacientes com CP (idade média de 60±12 anos). Os participantes foram submetidos à avaliação de características sociodemográficas, clínicas e da sua capacidade funcional de exercício com o TC6min, seguindo recomendações internacionais. Foram analisadas cinco equações. A distância percorrida pelos pacientes (503±102 metros) foi relativamente próxima às distâncias previstas pelas equações de referência (82-94% do previsto), embora estatisticamente inferior (p<0,05 para todas).

RESUMEN El objetivo de este estudio fue verificar el impacto de diferentes ecuaciones de referencia brasileñas para la distancia recorrida en la prueba de caminata de 6 minutos (PC6min) en la evaluación de la capacidad de ejercicio funcional en pacientes con cáncer de pulmón (CP). Este estudio transversal incluyó a 48 pacientes con CP (promedio de edad de 60±12 años). Se evaluó las características sociodemográficas, clínicas y la capacidad funcional de los participantes para ejercitarse en la PC6min según los criterios internacionales. Se analizaron cinco ecuaciones. La distancia recorrida por los pacientes (503±102 metros) estuvo relativamente cerca de las distancias predichas por las ecuaciones de referencia (82-94% del predicho), aunque son estadísticamente menores (p<0,05 para todas).

ABSTRACT The aim of this study was to verify the impact of using different Brazilian reference equations for the distance covered in the 6-minute walk test (6MWT) in the evaluation of functional exercise capacity in patients with lung cancer (LC). This cross-sectional study included 48 patients with LC (average age of 60±12 years-old). The participants underwent an assessment of sociodemographic and clinical characteristics and their functional exercise capacity with the 6MWT, following international recommendations. Five equations were analyzed. The distance covered by the patients (503±102 meters) was relatively close to the distances predicted by the reference equations (82-94% of the predicted), although statistically lower (p<0.05 for all).

Assessment of religious coping in patients with COPD / Avaliação do coping religioso em pacientes com DPOC

ABSTRACT Objective: To compare religious coping (RC) in patients with COPD and healthy individuals, as well as to determine whether RC is associated with demographic characteristics, quality of life, depression, and disease severity in the patients with COPD. Methods: This was a cross-sectional study conducted between 2014 and 2016, involving outpatients with moderate to severe COPD seen at one of two hospitals in Fortaleza, Brazil, as well as gender- and age-matched healthy controls. The Brief RCOPE scale assessed RC in all of the participants. We also evaluated the COPD group patients regarding symptoms, quality of life, and depression, as well as submitting them to spirometry and a six-minute walk test. Results: A total of 100 patients were evaluated. The mean age was 67.3 ± 6.8 years, and 54% were men. In the COPD group, the mean positive RC score was significantly higher than was the mean negative RC score (27.17 ± 1.60 vs. 8.21 ± 2.12; p = 0.001). The mean positive RC score was significantly higher in women than in men (27.5 ± 1.1 vs. 26.8 ± 2.8; p = 0.02). Negative RC scores were significantly higher in the COPD group than in the control group (p = 0.01). Negative RC showed an inverse association with six-minute walk distance (6MWD; r = −0.3; p < 0.05) and a direct association with depressive symptoms (r = 0.2; p < 0.03). Positive RC correlated with none of the variables studied. Multiple regression analysis showed that negative RC was associated with 6MWD (coefficient = −0.009; 95% CI: −0.01 to −0.003). 6MWD explained the variance in negative RC in a linear fashion. Conclusions: Patients with COPD employ negative RC more often than do healthy individuals. Exercise capacity and depressive symptoms are associated with negative RC.

RESUMO Objetivo: Comparar o coping religioso (CR) entre pacientes portadores de DPOC e indivíduos saudáveis e investigar associações entre CR e características demográficas, qualidade de vida, depressão e gravidade da doença nesses pacientes. Métodos: Estudo transversal realizado entre 2014 e 2016 com pacientes ambulatoriais com DPOC moderada a grave de dois hospitais em Fortaleza (CE) e controles saudáveis pareados por sexo e idade. A escala Brief RCOPE avaliou a CR de todos os participantes. O grupo DPOC também foi avaliado quanto a sintomas, qualidade de vida e depressão e foi submetido a espirometria e teste de caminhada de seis minutos (TC6). Resultados: Foram avaliados 100 pacientes, com média de idade de 67,3 ± 6,8 anos (54% homens). A média dos escores de CR positivo no grupo DPOC foi significativamente maior que a de CR negativo (27,17 ± 1,60 vs. 8,21 ± 2,12; p = 0,001). A média dos escores de CR positivo foi significativamente maior nas mulheres que nos homens (27,5 ± 1,1 vs. 26,8 ± 2,8; p = 0,02). O grupo DPOC apresentou escores de CR negativo significativamente maiores que os controles (p = 0,01). O CR negativo apresentou uma associação inversa com a distância percorrida no TC6 (DTC6; r = −0,3; p < 0,05) e uma associação direta com sintomas depressivos (r = 0,2; p < 0,03). O CR positivo não apresentou correlações com nenhuma variável estudada. A análise de regressão múltipla mostrou que CR negativo associou-se com DTC6 (coeficiente = −0,009; IC95%: −0,01 a −0,003). A DTC6 explicou linearmente a variação do CR negativo. Conclusões: Pacientes com DPOC utilizam CR negativo mais frequentemente que indivíduos saudáveis. A capacidade de exercício e sintomas depressivos estão associados a CR negativo.

Recommendations for the pharmacological treatment of COPD: questions and answers / Recomendações para o tratamento farmacológico da DPOC: perguntas e respostas

ABSTRACT The treatment of COPD has become increasingly effective. Measures that range from behavioral changes, reduction in exposure to risk factors, education about the disease and its course, rehabilitation, oxygen therapy, management of comorbidities, and surgical and pharmacological treatments to end-of-life care allow health professionals to provide a personalized and effective therapy. The pharmacological treatment of COPD is one of the cornerstones of COPD management, and there have been many advances in this area in recent years. Given the greater availability of drugs and therapeutic combinations, it has become increasingly challenging to know the indications for, limitations of, and potential risks and benefits of each treatment modality. In order to critically evaluate recent evidence and systematize the major questions regarding the pharmacological treatment of COPD, 24 specialists from all over Brazil gathered to develop the present recommendations. A visual guide was developed for the classification and treatment of COPD, both of which were adapted to fit the situation in Brazil. Ten questions were selected on the basis of their relevance in clinical practice. They address the classification, definitions, treatment, and evidence available for each drug or drug combination. Each question was answered by two specialists, and then the answers were consolidated in two phases: review and consensus by all participants. The questions answered are practical questions and help select from among the many options the best treatment for each patient and his/her peculiarities.

RESUMO O tratamento da DPOC vem se tornando cada vez mais eficaz. Medidas que envolvem desde mudanças comportamentais, redução de exposições a fatores de risco, educação sobre a doença e seu curso, reabilitação, oxigenoterapia, manejo de comorbidades, tratamentos cirúrgicos e farmacológicos até os cuidados de fim de vida permitem ao profissional oferecer uma terapêutica personalizada e efetiva. O tratamento farmacológico da DPOC constitui um dos principais pilares desse manejo, e muitos avanços têm sido atingidos na área nos últimos anos. Com a maior disponibilidade de medicações e combinações terapêuticas fica cada vez mais desafiador conhecer as indicações, limitações, potenciais riscos e benefícios de cada tratamento. Com o intuito de avaliar criticamente a evidência recente e sistematizar as principais dúvidas referentes ao tratamento farmacológico da DPOC, foram reunidos 24 especialistas de todo o Brasil para elaborar a presente recomendação. Foi elaborado um guia visual para a classificação e tratamento adaptados à nossa realidade. Dez perguntas foram selecionadas pela relevância na prática clínica. Abordam a classificação, definições, tratamento e evidências disponíveis para cada medicação ou combinação. Cada pergunta foi respondida por dois especialistas e depois consolidadas em duas fases: revisão e consenso entre todos os participantes. As questões respondidas são dúvidas práticas e ajudam a selecionar qual o melhor tratamento, entre as muitas opções, para cada paciente com suas particularidades.

Influence of the ventilatory mode on acute adverse effects and facial thermography after noninvasive ventilation / Influência do modo ventilatório nos efeitos adversos agudos e na termografia da face após ventilação não invasiva

ABSTRACT Objective: To compare the incidence and intensity of acute adverse effects and the variation in the temperature of facial skin by thermography after the use of noninvasive ventilation (NIV). Methods: We included 20 healthy volunteers receiving NIV via oronasal mask for 1 h. The volunteers were randomly divided into two groups according to the ventilatory mode: bilevel positive airway pressure (BiPAP) or continuous positive airway pressure (CPAP). Facial thermography was performed in order to determine the temperature of the face where it was in contact with the mask and of the nasal dorsum at various time points. After removal of the mask, the volunteers completed a questionnaire about adverse effects of NIV. Results: The incidence and intensity of acute adverse effects were higher in the individuals receiving BiPAP than in those receiving CPAP (16.1% vs. 5.6%). Thermographic analysis showed a significant cooling of the facial skin in the two regions of interest immediately after removal of the mask. The more intense acute adverse effects occurred predominantly among the participants in whom the decrease in the mean temperature of the nasal dorsum was lower (14.4% vs. 7.2%). The thermographic visual analysis of the zones of cooling and heating on the face identified areas of hypoperfusion or reactive hyperemia. Conclusions: The use of BiPAP mode was associated with a higher incidence and intensity of NIV-related acute adverse effects. There was an association between acute adverse effects and less cooling of the nasal dorsum immediately after removal of the mask. Cutaneous thermography can be an additional tool to detect adverse effects that the use of NIV has on facial skin.

RESUMO Objetivo: Comparar a incidência e a intensidade de efeitos adversos agudos e a variação da temperatura da pele da face através da termografia após a aplicação de ventilação não invasiva (VNI). Métodos: Foram incluídos 20 voluntários sadios, de ambos os gêneros, submetidos à VNI com máscara oronasal por 1 h e divididos aleatoriamente em dois grupos de acordo com o modo ventilatório: bilevel positive airway pressure (BiPAP) ou continuous positive airway pressure (CPAP). A termografia da face foi realizada para determinar a temperatura na região de contato da máscara e no dorso do nariz em momentos diferentes. Os voluntários preencheram um questionário de efeitos adversos após a retirada da VNI. Resultados: A incidência e a intensidade dos efeitos adversos agudos foram maiores naqueles submetidos a BiPAP em relação aos submetidos a CPAP (16,1% vs. 5,6%). A análise termográfica evidenciou um esfriamento significativo da pele facial nas duas regiões de estudo imediatamente após a retirada da máscara. Os efeitos adversos agudos em maior intensidade ocorreram predominantemente no grupo de participantes cuja redução da temperatura média no dorso do nariz foi menor (14,4% vs. 7,2%). A análise visual termográfica de zonas de esfriamento e aquecimento na face identificou regiões de hipoperfusão ou hiperemia reativa. Conclusões: O uso do modo BiPAP associou-se a maior incidência e intensidade de efeitos adversos agudos associados à VNI. Houve associação entre efeitos adversos agudos e menor esfriamento da pele do dorso do nariz imediatamente após a retirada da máscara. A termografia cutânea pode ser uma ferramenta adicional na detecção de efeitos adversos na pele da face associados ao uso da VNI.

Patients with severe accidental tetanus admitted to an intensive care unit in Northeastern Brazil: clinical-epidemiological profile and risk factors for mortality

Abstract Introduction Tetanus, an acute infectious disease, is highly prevalent worldwide, especially in developing countries. Due to respiratory failure and hemodynamic instability associated with dysautonomia, severe cases require intensive care, but little has been published regarding the management in the Intensive Care Unit. Objective To draw a 10-year clinical–epidemiological profile of Intensive Care Unit patients with severe tetanus, observe their evolution in the Intensive Care Unit and identify risk factors for mortality. Methods In this retrospective study, we used a standardized questionnaire to collect information from the records of patients with severe tetanus admitted to the intensive care unit of a referral hospital for infectious and contagious diseases in Northeastern Brazil. Results The initial sample included 144 patients, of whom 29 were excluded due to incomplete information, leaving a cohort of 115 subjects. The average age was 49.6 ± 15.3 years, most patients had no (or incomplete) vaccination against tetanus, and most were male. The main intensive care-related complications were pneumonia (84.8%) and dysautonomia (69.7%). Mortality (44.5%) was higher than expected from the mean APACHE II score (11.8), with shock/multiple organ failure as the main cause of death (72.9%). The independent factors most predictive of mortality were APACHE II score, dysautonomia, continuous neuromuscular blockade and age. Conclusion A high mortality rate was observed in our cohort of Intensive Care Unit patients with severe tetanus and a number of risk factors for mortality were identified. Our results provide important insights for the development of intervention protocols capable of reducing complications and mortality in this patient population.

Sponsored multicentric clinical research conducted in Brazil in the respiratory area - losses and gains / Pesquisas clínicas multicêntricas patrocinadas realizadas na área respiratória no Brasil - Perdas e ganhos

Summary Objective: To evaluate the sponsored centers for clinical trial in the respiratory care setting in Brazil: profile; logistics and structure. Methods: Principal investigators (29) and subinvestigators (30) of 39 research centers completed the questionnaires that addressed personal identification and training of researchers, the centers' facilities and advantages and/or disadvantages of performing sponsored trials. Results: 75.6% of the centers were located in southern and southeastern Brazil. Most principal investigators were men with a mean age of 53.4 years. The clinical trials in the respiratory care setting focus on asthma and chronic obstructive pulmonar disease (COPD). 80% of the researchers cited delay of the Conep and Anvisa as a barrier to performing research. The advantages of participating in clinical trials were updating knowledge of the researcher and the team, and additional income for the team. The main disadvantages mentioned by the researchers included low financial compensation for the performed workload, and time availability. The median number of professionals per research center was six people, predominantly physicians. Conclusion: The number of research centers in the respiratory care setting in Brazil is still relatively small. The teams have good training for performing the clinical trials. Asthma and COPD are the most studied diseases in sponsored clinical trials. The main barrier is delay by the Conep and Anvisa. The factors that lead investigators to participate range from being updated along with the team, to site and staff financial issues; the main disadvantage is the low compensation for the required workload demand.

Resumo Objetivo: avaliar nos centros de pesquisas clínicas patrocinadas na área respiratória no Brasil o perfil, a logística e a estrutura. Método: questionários foram respondidos por pesquisadores principais (29) e subinvestigadores (30) de 39 centros de pesquisa relativos a identificação e formação dos pesquisadores, instalações dos centros e vantagens e desvantagens quanto à participação nas pesquisas patrocinadas. Resultados: setenta e cinco por cento (75,6%) dos centros se localizavam nas regiões Sul e Sudeste do Brasil. A maioria dos investigadores principais eram homens com média de idade de 53,4 anos. As pesquisas na área respiratória se concentravam no estudo da asma e da doença pulmonar obstrutiva crônica (DPOC). Oitenta por cento dos pesquisadores citaram a demora na Comissão Nacional de Ética em Pesquisa (Conep) e na Agência Nacional de Vigilância Sanitária (Anvisa) como fator de entrave para a realização das pesquisas. As vantagens em participar das pesquisas clínicas foram a atualização própria ou da equipe envolvida, com rendimento adicional para a equipe. A principal desvantagem apontada pelos pesquisadores foi a baixa compensação financeira em relação ao volume de trabalho e disponibilidade de tempo. A mediana de profissionais por centro de pesquisa foi de seis pessoas, com predominância de médicos. Conclusão: o número de centros na área respiratória no Brasil ainda é relativamente pequeno. As equipes apresentam boa formação para a realização das pesquisas. Asma e DPOC são as doenças mais estudadas pelas pesquisas clínicas patrocinadas. O principal entrave é a demora da Conep e da Anvisa. Os fatores que levam os investigadores a participarem variam desde atualização própria/equipe até questões financeiras para a equipe e o centro; a principal desvantagem relatada é a baixa remuneração diante da demanda de trabalho exigida.

The impact of lung cancer resection surgery on fibrinogen and C-reactive protein and their relationship with patients outcomes: A prospective follow up study.

BACKGROUND: Major thoracic surgery is characterized by release of inflammatory markers.The objective of this study was to assess the preoperative and postoperative systemic inflammatory markers of patients undergoing lung cancer resection. METHODS: This is a prospective follow up study conducted with 48 patients submitted to lung cancer resection.All patients were assessed before and 1 month after surgery through measurement of fibrinogen and C-reative protein(CRP), pulmonary function tests, 6- minute Walk Test (6 MWT), maximal inspiratory pressure (PImax) and maximal expiratory pressure (PEmax), anxiety and depression scale and karnofsky performance status scale. RESULTS: Both fibrinogen and CRP were higher 1 month after surgery, although only the change in CRP was statistically significant (p= 0.03). The following functional parameters: 6 MWT, PImax, PEmax, FEV1(%) and FVC(%) decreased after surgery with p ≤ 0.001 for all the parameters. Anxiety and depression improved and Karnofsky decrease after surgery (p= 0.03, p= 0.01 and p= 0.02; respectively). Change in CRP score following lung resection correlated significantly with changes in fibrinogen (r= 0.40; p= 0.003), change in Karnofsky scale (r= -0.50; p< 0.001) and a borderline significant trend with the 6 MWT (r= -0.28; p= 0.05). With the exception of video-assisted thoracoscopic surgery (VATS), who had a significantly lower fibrinogen level 1 month after surgery compared with thoracotomy (p= 0.01), no significant differences in fibrinogen or CRP were noted in other subgroups of patients considered at increased risk for higher levels of inflammation compared with lower risk counterparts. CONCLUSION: Lung cancer resection surgery was associated with increased level of CRP, 1 month after surgery, and correlated directly with change in fibrinogen and inversely with measurement of performance status. VATS provided lower level of fibrinogen after surgery.

Leprosy nephropathy: a review of clinical and histopathological features.

Leprosy is a chronic disease caused by Mycobacterium leprae, highly incapacitating, and with systemic involvement in some cases. Renal involvement has been reported in all forms of the disease, and it is more frequent in multibacillary forms. The clinical presentation is variable and is determined by the host immunologic system reaction to the bacilli. During the course of the disease there are the so called reactional states, in which the immune system reacts against the bacilli, exacerbating the clinical manifestations. Different renal lesions have been described in leprosy, including acute and chronic glomerulonephritis, interstitial nephritis, secondary amyloidosis and pyelonephritis. The exact mechanism that leads to glomerulonephritis in leprosy is not completely understood. Leprosy treatment includes rifampicin, dapsone and clofazimine. Prednisone and non-steroidal anti-inflammatory drugs may be used to control acute immunological episodes.

Leprosy nephroptthy: a review of clinical and histopathological features / Nefropatia da hanseníase: revisão dos aspectos clínicos e histopatológicos

Leprosy is a chronic disease caused by Mycobacterium leprae, highly incapacitating, and with systemic involvement in some cases. Renal involvement has been reported in all forms of the disease, and it is more frequent in multibacillary forms. The clinical presentation is variable and is determined by the host immunologic system reaction to the bacilli. During the course of the disease there are the so called reactional states, in which the immune system reacts against the bacilli, exacerbating the clinical manifestations. Different renal lesions have been described in leprosy, including acute and chronic glomerulonephritis, interstitial nephritis, secondary amyloidosis and pyelonephritis. The exact mechanism that leads to glomerulonephritis in leprosy is not completely understood. Leprosy treatment includes rifampicin, dapsone and clofazimine. Prednisone and non-steroidal anti-inflammatory drugs may be used to control acute immunological episodes.

A hanseníase é doença crônica causada pelo Mycobacterium leprae, altamente incapacitante e com envolvimento sistêmico em alguns casos. O envolvimento renal tem sido relatado em todas as formas da doença, sendo mais frequente nas formas multibacilares. A apresentação clínica é variável e determinada pela reação do sistema imunológico do hospedeiro ao bacilo. Durante o curso da doença podem ocorrer os chamados estados reacionais, nos quais o sistema imune reage contra o bacilo, exacerbando as manifestações clínicas. Diferentes lesões renais tem sido descritas na hanseníase, incluindo glomerulonefrites, nefrite intersticial, amiloidose secundária e pielonefrite. O mecanismo exato que leva à glomerulonefrite na hanseníase ainda não está completamente esclarecido. O tratamento da hanseníase inclui o uso de rifampicina, dapsona e clofazimina. Prednisona e antiinflamatórios não-hormonais podem ser usados no controle dos episódios imunológicos agudos.

Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial.

BACKGROUND: Systemic inflammation plays an important role in the initiation, promotion, and progression of lung carcinogenesis. In patients with non-small cell lung cancer (NSCLC), fibrinogen levels correlate with neoplasia. Here we compared the effects of pulmonary rehabilitation (PR) with chest physical therapy (CPT) on fibrinogen and albumin levels in patients with LC and previous inflammatory lung disease awaiting lung resection. METHODS: We conducted a randomized clinical trial with 24 patients who were randomly assigned to Pulmonary Rehabilitation (PR) and Chest Physical Therapy (CPT) groups. Each group underwent training 5 days weekly for 4 weeks. All patients were assessed before and after four weeks of training through clinical assessment, measurement of fibrinogen and albumin levels, spirometry, 6-minute Walk Test (6MWT), quality of life survey, and anxiety and depression scale. PR involved strength and endurance training, and CPT involved lung expansion techniques. Both groups attended educational classes. RESULTS: A mixed between-within subjects analysis of variance (ANOVA) revealed a significant interaction between time (before and after intervention) and group (PR vs. CPT) on fibrinogen levels (F(1, 22)=0.57, p<0.0001) and a significant main effect of time (F(1, 22)=0.68, p=0.004). Changes in albumin levels were not statistically significant relative to the interaction effect between time and group (F(1, 22)=0.96, p=0.37) nor the main effects of time (F(1, 22)=1.00, p=1.00) and group (F(1, 22 )=0.59, p=0.45). A mixed between-within subjects ANOVA revealed significant interaction effects between time and group for the peak work rate of the unsupported upper limb exercise (F(1, 22)=0.77, p=0.02), endurance time (F(1, 22)=0.60, p=0.001), levels of anxiety (F(1, 22)=0.60, p=0.002) and depression (F(1, 22)=0.74, p=0.02), and the SF-36 physical component summary (F(1, 22)=0.83, p=0.07). CONCLUSION: PR reduced serum fibrinogen levels, improved functional parameters, and quality of life of patients with LC and inflammatory lung disease awaiting lung resection. TRIAL REGISTRATION: Current Controlled Trials RBR-3nm5bv.

Portuguese-language version of the COPD Assessment Test: validation for use in Brazil / Validacao do teste de avaliacao da DPOC em portugues para uso no Brasil

OBJECTIVE: To validate a Portuguese-language version of the COPD assessment test (CAT) for use in Brazil and to assess the reproducibility of this version. METHODS: This was multicenter study involving patients with stable COPD at two teaching hospitals in the city of Fortaleza, Brazil. Two independent observers (twice in one day) administered the Portuguese-language version of the CAT to 50 patients with COPD. One of those observers again administered the scale to the same patients one week later. At baseline, the patients were submitted to pulmonary function testing and the six-minute walk test (6MWT), as well as completing the previously validated Portuguese-language versions of the Saint George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (MMRC) dyspnea scale, and hospital anxiety and depression scale (HADS). RESULTS: Inter-rater and intra-rater reliability was excellent (intraclass correlation coefficient [ICC] = 0.96; 95% CI: 0.93-0.97; p < 0.001; and ICC = 0.98; 95% CI: 0.96-0.98; p < 0.001, respectively). Bland Altman plots showed good test-retest reliability. The CAT total score correlated significantly with spirometry results, 6MWT distance, SGRQ scores, MMRC dyspnea scale scores, and HADS-depression scores. CONCLUSIONS: The Portuguese-language version of the CAT is a valid, reproducible, and reliable instrument for evaluating patients with COPD in Brazil. .

OBJETIVO: Realizar a validação e verificar a reprodutibilidade da versão em português do Brasil do COPD Assessment Test (CAT). MÉTODOS: Estudo multicêntrico, no qual foram selecionados pacientes com DPOC estável em dois hospitais de ensino na cidade de Fortaleza, CE. A versão do CAT foi aplicada duas vezes a 50 pacientes com DPOC por dois observadores independentes no mesmo dia. Após uma semana, esse mesmo questionário foi aplicado novamente aos mesmos pacientes por um dos observadores. No primeiro dia, os pacientes foram submetidos à prova de função pulmonar e ao teste de caminhada de seis minutos (TC6) e responderam as versões validadas de qualidade de vida relacionada à saúde (QVRS). (SGRQ), escala de dispneia Modified Medical Research Council (MMRC) e hospital anxiety and depression scale (HADS). RESULTADOS: As reprodutibilidades interobservador e intraobservador foram excelentes (coeficiente de correlação intraclasse [CCI] = 0,96; IC95%: 0,93-0,97; p < 0,001; e CCI = 0,98; IC95%: 0,96-0,98; p < 0,001, respectivamente). As disposições gráficas de Bland Altman demonstraram boa confiabilidade teste-reteste. Houve correlações significativas do escore total do CAT com os resultados de espirometria, TC6, SGRQ, escala de dispneia MMRC e HADS-depressão. CONCLUSÕES: A versão brasileira do CAT é um instrumento válido, reprodutível ...

Lesão renal aguda em pacientes com doença pulmonar: interação rim-pulmão / Acute kidney injury in critically ill patients with lung disease: kidney-lung crosstalk

OBJETIVO: Investigar os fatores associados à lesão renal aguda e o prognóstico em pacientes com doença pulmonar. MÉTODOS: Foi realizado estudo prospectivo com cem pacientes consecutivos admitidos em uma unidade de terapia intensiva respiratória em Fortaleza (CE). Foram investigados fatores de risco para lesão renal aguda e mortalidade em um grupo de pacientes com doenças pulmonares. RESULTADOS: A média de idade foi de 57 anos, sendo 50% do gênero masculino. A incidência de lesão renal aguda foi maior nos pacientes com PaO2/FiO2<200 mmHg (54% versus 23,7%; p=0,02). O óbito ocorreu em 40 casos. A mortalidade no grupo com lesão renal aguda foi maior (62,8% versus 27,6%; p=0,01). A relação PaO2/FiO2<200 mmHg foi fator independente associado à lesão renal aguda (p=0,01); PEEP na admissão (OR: 3,6; IC95%: 1,3-9,6; p=0,009) e necessidade de hemodiálise (OR: 7,9; IC95%: 2,2-28,3; p=0,001) foram fatores de risco independentes para óbito. CONCLUSÃO: Houve maior mortalidade no grupo com lesão renal aguda. Mortalidade aumentada foi associada com ventilação mecânica, PEEP alta, ureia e necessidade de diálise. Estudos futuros devem ser realizados para melhor estabelecer as inter-relações entre lesão renal e pulmonar e seu impacto no prognóstico.

OBJECTIVE: To examine the factors associated with acute kidney injury and outcome in patients with lung disease. METHODS: A prospective study was conducted with 100 consecutive patients admitted to a respiratory intensive care unit in Fortaleza (CE), Brazil. The risk factors for acute kidney injury and mortality were investigated in a group of patients with lung diseases. RESULTS: The mean age of the study population was 57 years, and 50% were male. The incidence of acute kidney injury was higher in patients with PaO2/FiO2<200 mmHg (54% versus 23.7%; p=0.02). Death was observed in 40 cases and the rate of mortality of the acute kidney injury group was higher (62.8% versus 27.6%; p=0.01). The independent factor that was found to be associated with acute kidney injury was PaO2/FiO2<200 mmHg (p=0.01), and the independent risk factors for death were PEEP at admission (OR: 3.6; 95%CI: 1.3-9.6; p=0.009) and need for hemodialysis (OR: 7.9; 95%CI: 2.2-28.3; p=0.001). CONCLUSION: There was a higher mortality rate in the acute kidney injury group. Increased mortality was associated with mechanical ventilation, high PEEP, urea and need for dialysis. Further studies must be performed to better establish the relationship between kidney and lung injury and its impact on patient outcome.

Melatonin reduces lung oxidative stress in patients with chronic obstructive pulmonary disease: a randomized, double-blind, placebo-controlled study.

Chronic obstructive pulmonary disease (COPD), a major cause of death and disability, is attributed to an abnormal inflammatory response by the lungs to noxious substances, primarily from cigarette smoke. Although oxidative stress is regarded as central to the pathogenesis of COPD, very few studies have examined the effects of antioxidants in this condition. This was a randomized, double-blind, placebo-controlled study on the effects of melatonin in COPD. Thirty-six consecutive patients with clinically stable moderate to very severe COPD (30 men; mean±S.D.=66.6±7.8yr) were randomized to receive 3mg melatonin (N=18) or placebo for 3 months. Oxidative stress was evaluated by 8-isoprostane levels in exhaled breath condensate at baseline (T0) and after one (T1), two (T2), and three months (T3) of treatment. Additionally, exhaled breath condensate levels of IL-8, dyspnea severity (Medical Research Council scale), lung function (spirometry), and functional exercise capacity (six min walk test) were compared at baseline and after treatment. Patients receiving melatonin showed a decrease in 8-isoprostane (T0: mean±S.E.M.=20.41±2.92pg/mL; T1: 18.56±2.68pg/mL; T2: 12.68±2.04pg/mL; T3: 12.70±2.18pg/mL; P=0.04; repeated measures ANOVA) with significant differences from baseline after 2 (P=0.03) and 3months (P=0.01). Dyspnea was improved by melatonin (P=0.01), despite no significant changes in lung function or exercise capacity. Placebo-treated patients, but not those who were given melatonin, showed an increase in IL-8 (P=0.03). In summary, melatonin administration reduced oxidative stress and improved dyspnea in COPD. Further studies are necessary to determine the potential role for melatonin in the long-term management of these patients.