Update on the approach to smoking in patients with respiratory diseases.

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

Update on the approach to smoking in patients with respiratory diseases / Atualização na abordagem do tabagismo em pacientes com doenças respiratórias

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

RESUMO O tabagismo é o maior responsável pelas doenças respiratórias (DR). Os efeitos nocivos do tabaco sobre o aparelho respiratório se iniciam ainda intraútero e influenciam as respostas imunológicas ao longo da infância e vida adulta. Os tabagistas com DR possuem peculiaridades que podem dificultar a cessação tabágica, tais como maior grau de dependência e de abstinência de nicotina; níveis mais elevados de monóxido de carbono exalado; motivação e autoeficácia baixas; maior preocupação com ganho ponderal; e elevada prevalência de ansiedade e depressão. Além disso, requerem tratamento mais intensivo e prolongado. É necessário esclarecer sempre o paciente sobre o fato de que parar de fumar será a única medida que irá reduzir a progressão das DR e melhorar sua qualidade de vida, independentemente do tempo e da gravidade da doença. Os médicos devem sempre oferecer o tratamento de cessação tabágica. O tratamento ambulatorial ou hospitalar deve ser multidisciplinar, baseado em intervenções comportamentais e farmacoterapia, sendo eficaz e custo-efetivo, dobrando as chances de sucesso.

Cessação do tabagismo: revisão dos diferentes métodos / Tobacco cessation: a review of different methods

Objetivos: O artigo revisa os métodos de tratamento atualmente mais indicados para cessação do tabagismo. Métodos: Uma busca nas bases Medline/Pubmed e Lilacs foi realizada com termos referentes a cessação do tabagismo, produtos utilizados para cessar o tabagismo e taxa de abstinência. Foram selecionadas revisões sistemáticas e ensaios clínicos em texto completo, publicados nos últimos 5 anos, em língua inglesa ou portuguesa, tendo como participantes humanos adultos. Após análise foram incluídos 10 artigos para revisão. Resultados: Em relação à terapia comportamental, o emprego de aconselhamento telefônico teve pior desfecho em comparação aos contatos pessoais (p=0.01) e à combinação de ambos (p=0.01). A abordagem proativa favorece a taxa de abstinência (p<0.001). O incentivo financeiro, no entanto, não teve efeitos sobre a taxa de abstinência a longo prazo (p=0.95). Quanto à terapia farmacológica, a bupropiona (OR 1.84) e a vareniclina (OR 2.88), isoladamente, aumentaram a taxa de abstinência comparadas ao placebo, tendo a vareniclina demonstrado resultados superiores (OR 1.57). A Terapia de Reposição Nicotínica combinada com bupropiona ou nortriptilina não resultou em aumento na taxa de abstinência quando comparada à Terapia de Reposição de Nicotina em monoterapia (OR 0.99). A nortriptilina também aumentou a taxa de abstinência, com poucos efeitos adversos (RR 2.03). A associação de bupropiona e vareniclina gerou maior taxa de abstinência em um mês comparada à monoterapia com vareniclina (p=0.029). Não houve diferença significativa entre Terapia de Reposição de Nicotina por goma comparada ao adesivo transdérmico em relação à redução do tabagismo (p>0.05). Conclusões: Diversos medicamentos são eficazes e estão disponíveis para auxílio à cessação do tabagismo. Deve-se avaliar o contexto clínico de cada paciente, ofertando a terapia mais adequada a cada caso. Abordagens proativas e motivacionais, além da facilitação do acesso aos recursos de tratamento também melhoram as taxas de abstinência.

Aims: This article aims to present a review of tobacco cessation methods currently most indicated in order to update health professionals. Methods: It was performed a search in Medline/Pubmed and Lilacs using terms referring to smoking cessation, smoking cessation products and Abstinence Rate. Systematic reviews and clinical trials in full text articles, published in the last five years in English or Portuguese, having human adults as participants, were selected. After analysing adequacy to the subject, 10 articles were included to be reviewed. Results: Regarding to non-pharmacological therapies, telephone counselling showed worse results in comparison to personal therapy (p=0.01) and also comparing to the combination of them (p=0.01). Besides, a proactive approach enhances abstinence rate when compared to usual approach (p<0.001). Cash incentive did not result in a higher abstinences rates in long term when compared to control group (p=0.95). In relation to pharmacological therapy, bupropion (OR 1.84) and varenicline (OR 2.88), separately, increased abstinence rate in comparison to placebo, although varenicline showed superior results (OR 1.57). Nicotine Replacement Therapy in combination with bupropion or nortriptilin did not result in a higher abstinence rate when compared to Nicotine Replacement Therapy as monotherapy (OR 0.99). Nortriptilin enhances abstinence rate, with little adverse events (RR 2.03). Combination of bupropion and varenicline resulted in an increased abstinence rate in one month in comparison to varenicline as single therapy (p=0.029). There was no significant difference between Nicotine Replacement Therapy with nicotine gum and patch in relation to smoking reduction (p>0.05). Conclusions: Many medications were found to be effective and are available for smoking cessation. Clinical context of each patient should be evaluated, offering the most appropriate therapy. Proactive approaches and simplified access to resources also improve abstinence rates.

Patología pulmonar asociada al consumo de marihuana / Lung disease associated with marijuana use

La marihuana es la droga ilícita más consumida en el mundo con prevalencia de 2,5 a 5% y la segunda sustancia fumada después del tabaco. Los componentes del humo por la combustión de esta sustancia son similares a los producidos en la combustión del tabaco, pero difieren en la sustancia psicoactiva y en la práctica de fumar. La inhalación del humo de cannabis produce consecuencias sobre el aparato respiratorio. Por ello se hace necesario actualizar la evidencia disponible para ofrecer información científica al neumólogo. En este artículo se revisa el impacto del consumo de cannabis en los pulmones, teniendo en cuenta que la ruta más popular de la ingestión de cannabis es a través de las vías respiratorias (AU)

Marijuana is the most widely used illegal drug in the world, with a prevalence of 2.5%-5%, and the second most commonly smoked substance after tobacco. The components of smoke from combustion of marijuana are similar to those produced by the combustion of tobacco, but they differ in terms of psychoactive components and use. Inhalation of cannabis smoke affects the respiratory tract, so the available evidence must be updated in order to provide pulmonologists with the latest scientific information. In this article, we review the impact of cannabis consumption on the lungs, taking into account that the respiratory route is the most popular route of cannabis consumption (AU)

Lung Disease Associated With Marijuana Use. / Patología pulmonar asociada al consumo de marihuana.

Marijuana is the most widely usedillegal drug in the world, with a prevalence of 2.5%-5%, and the second most commonly smoked substance after tobacco. The components of smoke from combustion of marijuana are similar to those produced by the combustion of tobacco, but they differ in terms of psychoactive components and use. Inhalation of cannabis smoke affects the respiratory tract, so the available evidence must be updated in order to provide pulmonologists with the latest scientific information. In this article, we review the impact of cannabis consumption on the lungs, taking into account that the respiratory route is the most popular route of cannabis consumption.

Tromboembolismo pulmonar pós-operatório em cirurgia geral / Postoperative pulmonary thromboembolism in general surgery

Objetivos: O objetivo dessa revisão é fornecer subsídios para o diagnóstico, manejo e profilaxia do quadro de tromboembolismo pulmonar (TEP) em pacientes em pós-operatório. Métodos: Foi realizada uma revisão e síntese da literatura disponível, procurando escolher os temas mais relevantes e contemporâneos. Resultados: A clínica de TEP é diversa e o diagnóstico desafiador, sendo prudente o uso de algoritmos específicos que evitam exames desnecessários e permitem o início do tratamento com a brevidade merecida. A escolha da estratégia de profilaxia deve ser feita baseada no risco estratificado pelo escore de Caprini. TEP é uma entidade prevalente e significante nos hospitais de todo o mundo e pacientes no período pós-operatório apresentam um maior risco de desenvolver esta condição. Após a estabilização clínica do paciente, anticoagulação deverá ser iniciada. Caso exista contra-indicação absoluta, existem alternativas terapêuticas a serem aventadas. A duração da anticoagulação é individualizada, durando pelo menos 3 meses. Conclusões: Por ser uma causa prevenível de morte, a profilaxia, identificação e manejo precoce do quadro são de suma importância.

Aims: The objective of this review is to provide subsidies for the diagnosis, management and prophylaxis of pulmonary embolism (PE) in postoperative patients. Methods: A review and synthesis of the available literature was done by searching for the most relevant and recent themes. Results: The clinical presentation of PE is diverse and the diagnosis is challenging, so the use of specific algorithms to avoid unnecessary tests and to allow the treatment as soon as possible is advisable. The choice of the prophylactic strategy ought to be made based on the risk as stratified by the Caprini Score. After clinical stabilization, anticoagulation must be initiated. In case of absolute contraindication, there are therapeutic alternatives to be explored. The duration of the anticoagulation is individualized, lasting for at least 3 months. PE is a prevalent and relevant entity in hospital settings throughout the world, and postoperative patients are at an increased risk of developing this condition. Conclusions: Being a preventable cause of death, prophylaxis, early identification and treatment of the disease is of utmost importance.

Pneumonia da comunidade: diagnóstico e manejo inicial / Community pneumonia: diagnosis and initial management

A Pneumonia é a principal causa de morte por doença infecciosa em países subdesenvolvidos.¹ No Brasil, a pneumonia adquirida na comunidade é uma das principais causas de internação por doença. Afeta principalmente homens, com taxas de hospitalização mais elevadas em menores de 5 e maiores de 80 anos.²

Pneumonia is the first cause of death in underdeveloped countries.¹ In Brazil, Community-Acquired Pneumonia is one of the main causes of hospitalization due to disease. It affects mostly males, with higher hospital admission rates in those with less than 5 and more than 80 years old.²

Abordagens terapêuticas na cessação do tabagismo / Therapeutic approaches in smoking cessation

Apesar das políticas governamentais investirem na prevenção e em estratégias de combate ao fumo, o tabagismo segue sendo considerada uma pandemia pela Organização Mundial da Saúde. Nesse contexto é importante que todo profissional de saúde conheça abordagens terapêuticas disponíveis, já que os desfechos da doença são desfavoráveis.

Despite government policies invest in the prevention and combat strategies to smoking, it is still considered pandemic by the World Health Organization. In this context it is important that all health care professionals has notions of the therapeutic approaches available, since the outcomes of the disease are extremely unfavorable.

Avaliação de gravidade de pneumonia da comunidade em sala de emergência / Pneumonia gravity assessment of community emergency room

A pneumonia adquirida na comunidade (PAC) é uma patologia frequente em salas de emergências. A avaliação da gravidade da doença e a escolha do local de tratamento - ambulatorial ou hospitalar - é de extrema importância na prática clínica. O objetivo deste artigo é abordar os principais escores existentes para avaliação de mortalidade e de definição do local mais adequado para o tratamento.

The Community-acquired pneumonia (CAP) is a common condition in emergency rooms. The assessment of disease severity and the siting of treatment - outpatient or hospital - is extremely important in clinical practice. The aim of this article is to address the main scores to evaluate mortality and determining the most appropriate place for treatment.

Evaluation of the exhaled carbon monoxide levels in smokers with COPD.

OBJECTIVE: To measure exhaled carbon monoxide (COex) levels in smokers with and without COPD. METHODS: Smokers treated at outpatient clinics of São Lucas Hospital in the city of Porto Alegre, Brazil, between September of 2007 and March of 2009 were invited to participate in this study. The participants completed a questionnaire regarding demographic and epidemiologic characteristics and were submitted to spirometry, as well as to determination of COex and urinary cotinine levels. The participants were divided into two groups: those with COPD and those without COPD. RESULTS: The study involved 294 smokers, of whom 174 (59.18%) had been diagnosed with COPD. All of the participants presented with urinary cotinine levels > 50 ng/mL. Smokers with COPD presented significantly higher median values for age and pack-years than did those without COPD (p < 0.001 and p = 0.026, respectively). No other statistically significant differences were found. When adjusted for gender, age at smoking onset, number of cigarettes/day and urinary cotinine level, the mean values of COex were higher, but not statistically so, in the COPD group than in the non-COPD group (17.8 +/- 0.6 ppm and 16.6 +/- 0.7 ppm, respectively; p = 0.200). The differences remained nonsignificant when plotted logarithmically. A wide dispersion of COex values was found when the participants were classified by FEV1 level (r = -0.06; p = 0.53) or by Global Initiative for Chronic Obstructive Lung Disease classification (r = 0.08; p = 0.34). The proportions of false-negative results for smoking were 18.4% and 6.7%, respectively, in the COPD and non-COPD groups (p = 0.007). CONCLUSIONS: Since COex values did not differ significantly between smokers with COPD and those without, there seem to be no major contraindications to their use in smokers with COPD.

Avaliação da concentração de monóxido de carbono no ar exalado em tabagistas com DPOC / Evaluation of the exhaled carbon monoxide levels in smokers with COPD

OBJETIVO: Medir os níveis de monóxido de carbono no ar exalado (COex) em tabagistas com e sem DPOC. MÉTODOS: Tabagistas frequentadores dos ambulatórios do Hospital São Lucas em Porto Alegre (RS) entre setembro de 2007 e março de 2009 foram convidados a participar do estudo. Os participantes responderam a um questionário com características demográficas e epidemiológicas e realizaram espirometria, medição de cotinina urinária e de COex. Os participantes foram agrupados conforme a presença de DPOC. RESULTADOS: Foram incluídos 294 tabagistas, 174 (59,18 por cento) diagnosticados com DPOC. Todos os participantes apresentavam níveis de cotinina urinária > 50 ng/mL. Os fumantes com DPOC apresentaram medianas significativamente superiores as do grupo sem DPOC para as variáveis idade e maços-ano (p < 0,001 e p = 0,026, respectivamente). Não houve diferença significativa nas demais variáveis. Quando ajustados para sexo, início do tabagismo, cigarros/dia e cotinina urinária, os valores médios de COex foram mais altos no grupo DPOC que no grupo sem DPOC, mas sem significância estatística (17,8 ± 0,6 ppm e 16,6 ± 0,7 ppm, respectivamente; p = 0,200). As diferenças permaneceram não significativas quando o método de base logarítmica foi usado. Uma ampla dispersão dos valores de COex foi encontrada quando os participantes foram classificados conforme os valores de VEF1 (r = -0,06; p = 0,53) ou o sistema de classificação de Global Initiative for Chronic Obstructive Lung Disease (r = 0,08; p = 0,34). As proporções de resultados falso-negativos para tabagismo foram de 18,4 por cento e 6,7 por cento, respectivamente, nos grupos com e sem DPOC (p = 0,007). CONCLUÕES: Esse estudo mostrou que os valores de COex não apresentaram diferenças significativas em fumantes com ou sem DPOC. Desse modo, parece não haver nenhuma restrição relevante para a sua aplicabilidade em fumantes com DPOC.

OBJECTIVE: To measure exhaled carbon monoxide (COex) levels in smokers with and without COPD. METHODS: Smokers treated at outpatient clinics of São Lucas Hospital in the city of Porto Alegre, Brazil, between September of 2007 and March of 2009 were invited to participate in this study. The participants completed a questionnaire regarding demographic and epidemiologic characteristics and were submitted to spirometry, as well as to determination of COex and urinary cotinine levels. The participants were divided into two groups: those with COPD and those without COPD. RESULTS: The study involved 294 smokers, of whom 174 (59.18 percent) had been diagnosed with COPD. All of the participants presented with urinary cotinine levels > 50 ng/mL. Smokers with COPD presented significantly higher median values for age and pack-years than did those without COPD (p < 0.001 and p = 0.026, respectively). No other statistically significant differences were found. When adjusted for gender, age at smoking onset, number of cigarettes/day and urinary cotinine level, the mean values of COex were higher, but not statistically so, in the COPD group than in the non-COPD group (17.8 ± 0.6 ppm and 16.6 ± 0.7 ppm, respectively; p = 0.200). The differences remained nonsignificant when plotted logarithmically. A wide dispersion of COex values was found when the participants were classified by FEV1 level (r = -0.06; p = 0.53) or by Global Initiative for Chronic Obstructive Lung Disease classification (r = 0.08; p = 0.34). The proportions of false-negative results for smoking were 18.4 percent and 6.7 percent, respectively, in the COPD and non-COPD groups (p = 0.007). CONCLUSIONS: Since COex values did not differ significantly between smokers with COPD and those without, there seem to be no major contraindications to their use in smokers with COPD.

Tabagismo / Smoking

A dependência ao tabaco é reconhecida como uma condição crônica cujo tratamento pode necessitar repetidas intervenções. O consumo de tabaco é responsável por várias doenças, configurando um importante problema de saúde pública. Atualmente, diversas terapêuticas estão ao alcance dos clínicos, tornando o tabagismo uma doença que deve ser diagnosticada e tratada pelos médicos.

Pneumonia adquirida na comunidade: quando internar / Community acquired pneumonia: when to hospitalized

A decisão sobre internação ou de pacientes com pneumonia adquirida na comunidade (PAC) nem sempre é fácil, o que tem levado o número excessivo de hospitalizações. Em vista disso, o artigo procura fazer breve revisão sobre a doença e os seus principais escores de gravidade (PSI e CURB-65).

[Primary tracheobronchial amyloidosis]. / Amiloidose traqueobrônquica primária.

Amyloidosis is a disease characterized by extracellular deposition of fibrillar protein in organs and tissues. Primary tracheal amyloidosis is rare. We report here a case of a 55-year-old man with tracheal amyloidosis hospitalized for acute respiratory insufficiency and with a history of recent episodes of pneumonia. Chest X-ray and chest computed tomography showed tracheal obstruction due to a tumor. A passage was created in order to relieve the symptoms. Histological examination (Congo red staining) revealed amyloid deposits but no evidence of neoplasia. Although this is a rare clinical condition, its importance is discussed regarding the differential diagnosis of tracheal tumors and the repercussions for therapeutic decision-making.

Amiloidose traqueobrônquica primária / Primary tracheobronchial amyloidosis

A amiloidose é uma doença caracterizada pelo depósito extracelular de proteínas fibrilares em órgãos e tecidos. A forma traqueal primária isolada é rara. Relata-se o caso de um homem, 55 anos de idade, portador de amiloidose traqueal que interna por insuficiência respiratória aguda, com história de pneumonias prévias recentes. Radiograma de tórax seguido de tomografia computadorizada de tórax revelou obstrução da traquéia por tumoração. Foi realizada tunelização para alívio temporário dos sintomas. Os achado histológicos não revelaram neoplasia, mas identificaram substância amilóide pelo vermelho congo. Embora a baixa freqüência desta situação clínica, é discutida sua importância no diagnóstico diferencial de tumores de traquéia e a repercussão na conduta terapêutica.

Amyloidosis is a disease characterized by extracellular deposition of fibrillar protein in organs and tissues. Primary tracheal amyloidosis is rare. We report here a case of a 55-year-old man with tracheal amyloidosis hospitalized for acute respiratory insufficiency and with a history of recent episodes of pneumonia. Chest X-ray and chest computed tomography showed tracheal obstruction due to a tumor. A passage was created in order to relieve the symptoms. Histological examination (Congo red staining) revealed amyloid deposits but no evidence of neoplasia. Although this is a rare clinical condition, its importance is discussed regarding the differential diagnosis of tracheal tumors and the repercussions for therapeutic decision-making.

Asthma mortality in southern Brazil: is there a changing trend?

BACKGROUND: Mortality from asthma increased during the last decades but is now declining in some countries. Little is known about this trend in Brazil. OBJECTIVE: The objective of the study was to determine the trends in asthma mortality in Southern Brazil. METHODS: We reviewed death certificates of 566 people in the state of Rio Grande do Sul, Brazil, between 5 and 39 years of age in whom asthma was reported to be the underlying cause of death during the period of 1981-2003. Population data were available in 5-year age groups. Mortality rates were submitted to linear and quadratic regression procedures. RESULTS: Among children and teenagers (5-19 years), there were 170 asthma deaths, ranging from 4 to 13 deaths each year with rates of 0.154/100,000 to 0.481/100,000. In young adults (20-39 years), 396 asthma deaths occurred, ranging from 9 to 32 each year, with rates from 0.276/100,000 to 1.034/100,000. There was an initial increase in rates, with later stabilization, and then the start of a decline beginning in the late 1990s and the early part of this decade. This trend occurred in both age subgroups examined but was more evident in males. CONCLUSIONS: Asthma mortality in southern Brazil remains low and appears to be decreasing after reaching a peak in the mid-1990s. The reason for these trends remains unknown.

Exhaled carbon monoxide as a marker for evaluating smoking abstinence in a Brazilian population sample.

BACKGROUND: Exhaled carbon monoxide (CO(Exh)) measurement is used to confirm smoking status in smoking cessation programs, but the cut-off level is still a matter for discussion. The objective of this study was to compare CO(Exh) levels in smokers and non-smokers to validate the method in a Brazilian population and to estimate the probability of the patient still smoking according to different cut-off points. METHODS: In this cross-sectional study we studied non-atopic Caucasian volunteers with no respiratory infection or steroid therapy in the preceding four weeks. Exclusion criteria were: pregnancy; breast feeding; age<18 and >65 years old; and subjects not signing informed consent. Participants filled out a questionnaire and had their CO(Exh) levels measured. Bayes' theorem was used to calculate the posttest probabilities. RESULTS: We included 393 subjects of whom 239 (61%) were smokers. The mean CO(Exh) was 14.7 +/- 9.4 ppm and 4.3 +/- 2.5 ppm (p<0.001) in smokers and nonsmokers, respectively. Patients with CO(Exh) below 8 ppm had a likelihood ratio below 1 of still smoking. The levels 9 ppm and 10 ppm provided likelihood ratios of 1.50 and 1.93, respectively. Better discriminant power was obtained at >11 ppm, when the likelihood ratio became 63.80 (95%CI 16.1-253.1). CONCLUSIONS: In smoking cessation practice, a likelihood ratio approach may be useful to determine the probability that an individual is still smoking according to various CO(Exh) cut-off points instead of using a fixed value for all patients.

Atualização em tuberculose / Update in tuberculosis

Os autores fazem uma revisão sobre a infecção pelo Mycobacterium Tuberculosis e sobre a doença tuberculosa. É dada ênfase ao comprometimento pulmonar e ao perfil da doença como problema de saúde pública no Brasil