Correlations between ambient air pollution and the prevalence of hospitalisations and emergency room visits for respiratory diseases in children: a systematic review.

OBJECTIVE: It is known that exposure to air pollution is associated with an increased risk for cardiovascular and respiratory diseases. This review aimed to summarise observational studies on the impact of short and long-term exposure to ambient air pollution on prevalence of hospitalisations and/or emergency department visits caused by respiratory diseases in children and adolescents. SOURCES: Pubmed, Scopus, Embase and Cochrane Library databases were searched for the years 2018 to December 2022, including studies in any language. SUMMARY OF THE FINDINGS: A total of 15 studies published between 2018 and 15 January 2022 were included in this review. PM2.5 was the most type of particulate matter studied. Short-term exposure to PM2,5, PM10, NO2, SO2 and O3, even at concentrations less than the current health-based guidelines, was significantly correlated with increased risk of outpatient/hospital visits and hospitalisations for respiratory diseases by children. CONCLUSIONS: Our findings emphasise the importance and urgency of long-term control of air pollution and pollution-related diseases, especially among children and adolescents. There is a need for further research employing more homogeneous methodologies for assessing exposure and outcome measurements, in order to enable systematic reviews with meta-analysis.

Bronchopulmonary dysplasia: temporal trend from 2010 to 2019 in the Brazilian Network on Neonatal Research.

OBJECTIVE: To evaluate the temporal trend of bronchopulmonary dysplasia (BPD) in preterm infants who survived to at least 36 weeks' post-menstrual age (PMA) and BPD or death at 36 weeks' PMA, and to analyse variables associated with both outcomes. DESIGN: Retrospective cohort with data retrieved from an ongoing national registry. SETTING: 19 Brazilian university public hospitals. PATIENTS: Infants born between 2010 and 2019 with 23-31 weeks and birth weight 400-1499 g. MAIN OUTCOME MEASURES: Temporal trend was evaluated by Prais-Winsten model and variables associated with BPD in survivors or BPD or death were analysed by logistic regression. RESULTS: Of the 11 128 included infants, BPD in survivors occurred in 22%, being constant over time (annual per cent change (APC): -0.80%; 95% CI: -2.59%; 1.03%) and BPD or death in 45%, decreasing over time (APC: -1.05%; 95% CI: -1.67%; -0.43%). Being male, small for gestational age, presenting with respiratory distress syndrome, air leaks, needing longer duration of mechanical ventilation, presenting with treated patent ductus arteriosus and late-onset sepsis were associated with an increase in the chance of BPD. For the outcome BPD or death, maternal bleeding, multiple gestation, 5-minute Apgar <7, late-onset sepsis, necrotising enterocolitis and intraventricular haemorrhage were added to the variables reported above as increasing the chance of the outcome. CONCLUSION: The frequency of BPD in survivors was constant and BPD or death decreased by 1.05% at each study year. These results show some improvement in perinatal care in Brazilian units which resulted in a reduction of BPD or death, but further improvements are still needed to reduce BPD in survivors.

Primary cardiac angiosarcoma presenting with haemoptysis.

A male patient in his 30s presented to the emergency room with a 1-week history of dyspnoea that progressed to haemoptysis, having coughed up approximately 200 mL of blood on two occasions. On diagnostic investigation, a mediastinal tumour infiltrating the free wall of the right atrium and multiple pulmonary nodules were discovered. The first suspicion was a neoplasm of pulmonary origin, and a bronchoscopy was performed, histology reported a probable cardiac origin for the neoplasm. A subsequent biopsy confirmed the presence of a primary cardiac angiosarcoma. An extension CT scan revealed brain metastases. The patient received chemotherapy treatment, resulting in a partial response to date. This case is one of the few reported instances of cardiac neoplasm presenting with respiratory symptoms.

Tear gas exposure and its association with respiratory emergencies in infants and older adults during the social uprising of 2019 in Chile: an observational, longitudinal, repeated measures study.

OBJECTIVE: To evaluate if extensive use of tear gas during the Chilean social uprising of 2019 was associated with a higher frequency of respiratory emergencies and bronchial diseases in a residential vulnerable population. DESIGN: Observational, longitudinal, repeated measures study. SETTINGS: Six healthcare centres (one emergency department and five urgent care centres) in the city of Concepción, Chile during 2018 and 2019. PARTICIPANTS: This study was conducted on daily respiratory emergencies and diagnosis. Daily frequency of urgency and emergency visits are administrative data, publicly available and previously de-identified. PRIMARY AND SECONDARY OUTCOME MEASURES: Absolute and relative frequency of daily respiratory emergencies in infants and older adults. A secondary outcome was the relative frequency of bronchial diseases (International Classification of Diseases 10th Revision, ICD-10: J20-J21; J40-J46) in both age groups. We finally measured the rate ratio (RR) of bronchial diseases above the daily grand mean, since the number of visits with these diagnoses in several days was zero. Tear gas exposure was assessed as the uprising period. Models were adjusted by weather and air pollution information. RESULTS: Percentage of respiratory emergencies during the uprising rose by 1.34 percentage points (95% CI 1.26 to 1.43) in infants and 1.44 percentage points (95% CI 1.34 to 1.55) in older adults. In infants, the emergency department experienced a larger increment in respiratory emergencies (6.89 percentage points; 95% CI 1.58 to 2.28) than the urgent care centres (1.67 percentage points; 95% CI 1.46 to 1.90). The RR of bronchial diseases above the daily grand mean during the uprising period was 1.34 in infants (95% CI 1.15 to 1.56) and 1.50 in older adults (95% CI 1.28 to 1.75). CONCLUSIONS: The massive use of tear gas increases the frequency and probability of respiratory emergencies and particularly bronchial diseases in the vulnerable population; we recommend revising public policy to restrict its use.

Fibrinolytic therapy in patients with COVID-19 and ARDS: protocol for a systematic review and meta-analysis.

INTRODUCTION: In COVID-19-related acute respiratory distress syndrome (ARDS), the clot play a role in gas exchange abnormalities. Fibrinolytic therapy can improve alveolar ventilation by restoring blood flow. In this systematic review and meta-analysis protocol, we aim to assess the safety and efficacy of fibrinolytic therapy in such a population. METHODS: We will perform a systematic search in MEDLINE, EMBASE, Cochrane CENTRAL and LILACS databases without language restrictions for relevant randomised controlled trials (RCTs) and quasi-RCTs. Two review authors will independently perform data extraction and quality assessments of data from included studies. In case of divergence, a third author will be contacted. The Cochrane handbook will be used for guidance. If the results are not appropriate for a meta-analysis, a descriptive analysis will be performed. DISCUSSION: This systematic review and meta-analysis protocol will provide current evidence about the safety and efficacy of fibrinolytic therapy in patients with COVID-19 and ARDS. These findings will provide if fibrinolytic therapy might be an option for a desperate clinical setting, where all medical efforts have been used. PROSPERO REGISTRATION NUMBER: PROSPERO CRD42020187482. ETHICS AND DISSEMINATION: Ethics committee approval is not necessary. We intend to update the public registry, report any protocol amendments and publish the results in a widely accessible journal.

Closed-loop oxygen control for patients with hypoxaemia during hospitalisation: a living systematic review and meta-analysis protocol.

INTRODUCTION: Oxygen is the most common drug used in critical care patients to correct episodes of hypoxaemia. The adoption of new technologies in clinical practice, such as closed-loop systems for an automatic oxygen titration, may improve outcomes and reduce the healthcare professionals' workload at the bedside; however, certainty of the evidence regarding the safety and benefits still remains low. We aim to evaluate the effectiveness, efficacy and safety of the closed-loop oxygen control for patients with hypoxaemia during the hospitalisation period by conducting a systematic review and meta-analysis. METHODS AND ANALYSIS: MEDLINE, CENTRAL, EMBASE, LILACS, CINAHL and LOVE evidence databases will be searched. Randomised controlled trials and cross-over studies investigating the PICO (Population, Intervention, Comparator and Outcome) framework will be included. The primary outcomes will be the time in the peripheral oxygen saturation target. Secondary outcomes will include time for oxygen weaning time; length of stay; costs; adverse events; mortality; healthcare professionals' workload, and percentage of time with hypoxia and hyperoxia. Two reviewers will independently screen and extract data and perform quality assessment of included studies. The Cochrane risk of bias tool will be used to assess risk of bias. The RevMan V.5.4 software will be used for statistical analysis. Heterogeneity will be analysed using I2 statistics. Mean difference or standardised mean difference with 95% CI and p value will be used to calculate treatment effect for outcome variables. ETHICS AND DISSEMINATION: Ethical approval is not required because this systematic review and meta-analysis is based on previously published data. Final results will be published in peer-reviewed journals and presented at relevant conferences and events. PROSPERO REGISTRATION NUMBER: CRD42022306033.

Volume sweep imaging lung teleultrasound for detection of COVID-19 in Peru: a multicentre pilot study.

OBJECTIVES: Pulmonary disease is a significant cause of morbidity and mortality in adults and children, but most of the world lacks diagnostic imaging for its assessment. Lung ultrasound is a portable, low-cost, and highly accurate imaging modality for assessment of pulmonary pathology including pneumonia, but its deployment is limited secondary to a lack of trained sonographers. In this study, we piloted a low-cost lung teleultrasound system in rural Peru during the COVID-19 pandemic using lung ultrasound volume sweep imaging (VSI) that can be operated by an individual without prior ultrasound training circumventing many obstacles to ultrasound deployment. DESIGN: Pilot study. SETTING: Study activities took place in five health centres in rural Peru. PARTICIPANTS: There were 213 participants presenting to rural health clinics. INTERVENTIONS: Individuals without prior ultrasound experience in rural Peru underwent brief training on how to use the teleultrasound system and perform lung ultrasound VSI. Subsequently, patients attending clinic were scanned by these previously ultrasound-naïve operators with the teleultrasound system. PRIMARY AND SECONDARY OUTCOME MEASURES: Radiologists examined the ultrasound imaging to assess its diagnostic value and identify any pathology. A random subset of 20% of the scans were analysed for inter-reader reliability. RESULTS: Lung VSI teleultrasound examinations underwent detailed analysis by two cardiothoracic attending radiologists. Of the examinations, 202 were rated of diagnostic image quality (94.8%, 95% CI 90.9% to 97.4%). There was 91% agreement between radiologists on lung ultrasound interpretation among a 20% sample of all examinations (κ=0.76, 95% CI 0.53 to 0.98). Radiologists were able to identify sequelae of COVID-19 with the predominant finding being B-lines. CONCLUSION: Lung VSI teleultrasound performed by individuals without prior training allowed diagnostic imaging of the lungs and identification of sequelae of COVID-19 infection. Deployment of lung VSI teleultrasound holds potential as a low-cost means to improve access to imaging around the world.

Effects of respiratory physiotherapy interventions on pulmonary mechanics of newborns: a protocol for a systematic review.

INTRODUCTION: Although respiratory physiotherapy techniques may reduce respiratory load in newborns, manual contact with the ribcage may interfere with pulmonary mechanics. Therefore, this systematic review aims to evaluate the effects of conventional and non-conventional respiratory physiotherapies on pulmonary mechanics of newborns. METHODS AND ANALYSIS: We will search PubMed, LILACS, SciELO, ScienceDirect, Cochrane Central and Web of Science databases. Searches will be conducted from September 2022. We will include randomised clinical trials reporting thoracoabdominal synchrony, lung volumes and capacities, respiratory discomfort and pain in newborns aged between 1 hour and 28 days and admitted to neonatal intensive care units. We will exclude studies not fully available or incomplete and studies conducted with newborns presenting structural alterations. Two independent researchers will perform the study selection, data extraction and quality assessment. After consensus, one reviewer will proceed with the process. We will include studies published in English or Portuguese, without publication date restriction. An overview of the included studies and extracted information will be reported and the quality of studies will be assessed. A meta-analysis will be conducted if data regarding between-group comparisons are available. ETHICS AND DISSEMINATION: Ethics approval is not required for this systematic review. Results will be presented in journals and national and international conferences, and findings will be shared on social media using accessible language. PROSPERO REGISTRATION NUMBER: CRD42021266729.

Chronic lung lesions in COVID-19 survivors: predictive clinical model.

OBJECTIVE: This study aimed to propose a simple, accessible and low-cost predictive clinical model to detect lung lesions due to COVID-19 infection. DESIGN: This prospective cohort study included COVID-19 survivors hospitalised between 30 March 2020 and 31 August 2020 followed-up 6 months after hospital discharge. The pulmonary function was assessed using the modified Medical Research Council (mMRC) dyspnoea scale, oximetry (SpO2), spirometry (forced vital capacity (FVC)) and chest X-ray (CXR) during an in-person consultation. Patients with abnormalities in at least one of these parameters underwent chest CT. mMRC scale, SpO2, FVC and CXR findings were used to build a machine learning model for lung lesion detection on CT. SETTING: A tertiary hospital in Sao Paulo, Brazil. PARTICIPANTS: 749 eligible RT-PCR-confirmed SARS-CoV-2-infected patients aged ≥18 years. PRIMARY OUTCOME MEASURE: A predictive clinical model for lung lesion detection on chest CT. RESULTS: There were 470 patients (63%) that had at least one sign of pulmonary involvement and were eligible for CT. Almost half of them (48%) had significant pulmonary abnormalities, including ground-glass opacities, parenchymal bands, reticulation, traction bronchiectasis and architectural distortion. The machine learning model, including the results of 257 patients with complete data on mMRC, SpO2, FVC, CXR and CT, accurately detected pulmonary lesions by the joint data of CXR, mMRC scale, SpO2 and FVC (sensitivity, 0.85±0.08; specificity, 0.70±0.06; F1-score, 0.79±0.06 and area under the curve, 0.80±0.07). CONCLUSION: A predictive clinical model based on CXR, mMRC, oximetry and spirometry data can accurately screen patients with lung lesions after SARS-CoV-2 infection. Given that these examinations are highly accessible and low cost, this protocol can be automated and implemented in different countries for early detection of COVID-19 sequelae.

IgG4-related lung disease as a differential diagnosis of a lymphoproliferative disease: atypical presentation of an atypical disease.

IgG4-related disease (IgG4-RD) is an immunomodulated inflammatory disease that usually affects the pancreas and parotid glands. Although lung involvement is rare, it has been recently reported and could mimic various other diagnoses. We present a case of IgG4-RD whose symptoms and images raised the suspicion of a malignant lymphoproliferative lung neoplasm. It is imperative to differentiate both diseases, since their treatment and prognosis vary.

Dexamethasone for treating SARS-CoV-2 infection: a systematic review and meta-analysis

ABSTRACT BACKGROUND: Considering the disruptions imposed by lockdowns and social distancing recommendations, coupled with overwhelmed healthcare systems, researchers worldwide have been exploring drug repositioning strategies for treating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). OBJECTIVE: To compile results from randomized clinical trials on the effect of dexamethasone, compared with standard treatment for management of SARS-CoV-2. DESIGN AND SETTING: We conducted a systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in a Brazilian public university. METHODS: We sought to compile data from 6724 hospitalized patients with confirmed or suspected SARS-CoV-2 infection. RESULTS: Treatment with dexamethasone significantly reduced mortality within 28 days (risk ratio, RR: 0.89; 95% confidence interval, CI: 0.82-0.97). Dexamethasone use was linked with being discharged alive within 28 days (odds ratio, OR: 1.20; 95% CI: 1.07-1.33). CONCLUSIONS: This study suggests that dexamethasone may significantly improve the outcome among hospitalized patients with SARS-CoV-2 infection and associated severe respiratory complications. ­Further studies need to consider both dose-dependent administration and outcomes in early and later stages of the disease. PROSPERO platform: CRD42021229825.

Buteyko method for people with asthma: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Buteyko method is recommended as a non-pharmacological treatment for people with asthma. Although the worldwide interest in the Buteyko method, there is a paucity of studies gathering evidence to support its use. Therefore, we aim to conduct a systematic review and meta-analysis to assess the effects of the Buteyko method in children and adults with asthma. METHODS AND ANALYSIS: We will search on Cochrane Central Register of Controlled Trials, MEDLINE, Embase, US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for studies focusing on the Buteyko method for children and adults with asthma. The searches will be carried out in September 2021 from database's inception to the present. We will include randomised controlled trials comparing Buteyko method alone with asthma education or inactive control intervention. There will be no restriction on language. Primary outcomes include quality of life, asthma symptoms and adverse events/side effects. Two review authors will independently screen the studies for inclusion and extract data. We will assess the quality of the included studies using the 'Risk of Bias' tool. The certainty of the evidence will be assessed using the GRADE approach. Data synthesis will be conducted using Review Manager software. Reporting of the review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance and the Cochrane Handbook for Systematic Reviews of Interventions. ETHICS AND DISSEMINATION: This study will assess and provide evidence for the use of the Buteyko method in people with asthma. We will analyse secondary data and this does not require ethics approval. The findings will be published in peer-reviewed journals, at relevant conferences and will be shared in plain language in social media. Moreover, the findings of this review could guide the direction of healthcare practice and research. PROSPERO REGISTRATION NUMBER: CRD42020193132.

Weaning from mechanical ventilation in people with neuromuscular disease: a systematic review.

OBJECTIVE: This systematic review aimed in assessing the effects of different weaning protocols in people with neuromuscular disease (NMD) receiving invasive mechanical ventilation, identifying which protocol is the best and how different protocols can affect weaning outcome success, duration of weaning, intensive care unit (ICU) and hospital stay and mortality. DESIGN: Systematic review. DATA SOURCES: Electronic databases (MEDLINE, EMBASE, Web of Science and Scopus) were searched from January 2009 to August 2020. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Randomised controlled trials (RCTs) and non-RCT that evaluated patients with NMD (adults and children from 5 years old) in the weaning process managed with a protocol (pressure support ventilation; synchronised intermittent mandatory ventilation; continuous positive airway pressure; 'T' piece). PRIMARY OUTCOME: Weaning success. SECONDARY OUTCOMES: Weaning duration, ICU stay, hospital stay, ICU mortality, complications (pneumothorax, ventilation-associated pneumonia). DATA EXTRACTION AND SYNTHESIS: Two review authors assessed the titles and the abstracts for inclusion and reviewed the full texts independently. RESULTS: We found no studies that fulfilled the inclusion criteria. CONCLUSIONS: The absence of studies about different weaning protocols for patients with NMD does not allow concluding the superiority of any specific weaning protocol for patients with NMD or determining the impact of different types of protocols on other outcomes. The result of this review encourages further studies. PROSPERO REGISTRATION NUMBER: CRD42019117393.

Bronchobiliary fistula: a rare postoperative complication of spilled gallstones from laparoscopic cholecystectomy.

Bronchobiliary fistula (BBF) is defined as the abnormal connection between the biliary system and the bronchial tree, which presents clinically as an irritant cough with bilioptysis. Many conditions can lead to its development. We present a case of an acquired BBF in a 61-year-old man with a significant history of spilled gallstones from a prior laparoscopic cholecystectomy and subsequent presentation of intermittent right upper quadrant pain and recurrent pneumonia. Imaging studies revealed a liver and subdiaphragmatic abscess with right middle lobe pneumonia and a BBF traversing the right hemidiaphragm. The patient was surgically managed by takedown of fistula with drainage of the abscess and removal of spilled gallstone, followed by a resection of the right middle lobe. While previous studies indicate spilled gallstones are benign, this case demonstrates its potential for serious complications. Therefore, early diagnosis and proper management is essential as BBF has a high morbidity and mortality rate.

Adults' experiences of living with pulmonary hypertension: a thematic synthesis of qualitative studies.

OBJECTIVES: Pulmonary hypertension is a life-shortening disease that has a considerable impact on quality of life. Improving our understanding of how individuals are affected and cope with the disease will help to improve services and outcomes. This review synthesises the published qualitative research that has listened to adults discuss their experiences of living with the disease. DESIGN: A comprehensive systematic search of four databases was conducted in May 2020: Web of Science, PubMed, PsycINFO and Cochrane Library. Suitable studies were evaluated using the Critical Appraisal Skills programme. Findings from the studies were extracted and subjected to a thematic synthesis. RESULTS: Nineteen articles were identified reflecting the experiences of over 1900 individuals impacted by pulmonary hypertension from Europe, North and South America and Asia. Ten studies did not report participant's WHO functional class of pulmonary hypertension, which resulted in comparing experiences between different severity difficult. All studies met the majority of the quality assessment items. Six descriptive themes emerged discussing participant's experiences of diagnosis, treatment, prognosis, healthcare professionals, impact and coping with pulmonary hypertension. Four higher order analytical themes were developed from the descriptive themes, reflecting: (i) uncertainties and anxiety that participants encountered related to pulmonary hypertension; (ii) lack of recognition of the impact of the condition; (iii) frustration at the paucity of awareness of pulmonary hypertension in society and healthcare settings and (iv) participant's accounts of transitioning through different stages of living with the disease. CONCLUSIONS: These findings form the first synthesis of experiences of life in individuals impacted by pulmonary hypertension and illustrate the multifaceted impact of the condition. The voices of numerous groups are missing from the literature highlighting the need for additional research. The results have implications for clinical practice emphasising the role of educational and psychological therapies to support those with the disease.

Estruturação de currículo baseado em competências e atividades profissionais confiáveis para formação do Especialista em pneumologia da Santa Casa de Belo Horizonte / Structuring a curriculum based on competencies and entrustable professional activities for the training of pulmonology specialists at Santa Casa de Belo Horizonte

O programa de especialização em Pneumologia da Santa Casa de Belo Horizonte (SCBH), criado em 1984, propôs ter bem estabelecidas as competências que caracterizam o médico pneumologista ali formado, assim como as atividades profissionais a ele confiadas. O presente trabalho teve como propósito estruturar um currículo baseado em atividades profissionais confiáveis (EPA - entrustable professional activities) para formação do médico especialista em pneumologia da Santa Casa de Belo Horizonte. O estudo envolveu elaboração de uma matriz de competências essenciais à formação de um especialista a partir do perfil almejado para o egresso do programa de especialização em pneumologia. Esta matriz de competência foi embasada na matriz de competências de Pneumologia publicada pela Comissão Nacional de Residência Médica do Ministério da Educação do Brasil (CNRM/MEC), no programa educacional baseado em competências desenvolvido pela Unidade de Ensino e Pesquisa da SCBH e na matriz do Royal College of Physicians and Surgeons of Canada (CanMeds). As competências foram agrupadas em seis grandes domínios: 1. Autogestão do Conhecimento; 2. Comunicação; 3. Expertise Técnica; 4. Liderança Colaborativa; 5. Profissionalismo; 6. Responsabilidade Social. Posteriormente, foram definidas e elaboradas as Atividades Profissionais Confiáveis (EPA ­ entrustable professional activities) que foram usadas para a formação do espectro de construção e atuação do especialista em pneumologia da SCBH. Em um segundo momento, as EPAs elaboradas foram discutidas e aprimoradas com um comitê de especialistas em pneumologia. Obteve-se uma matriz de competências com 143 objetivos educacionais distribuídos pelos seis domínios: autogestão do conhecimento (4%), comunicação (17%), expertise técnica (64%), liderança colaborativa (4%), profissionalismo (5%) e responsabilidade social (5%). A partir desta matriz, foram elaboradas 11 EPAs: 1 ­ Cuidado clínico ao paciente com problemas respiratórios em qualquer cenário; 2 ­ Registro em prontuário médico; 3 ­ Prescrição médica do paciente com problemas respiratórios; 4 ­ Solicitação e interpretação de exames complementares; 5 ­ Cuidado ao paciente com insuficiência respiratória; 6 ­ Interconsulta e cuidado ambulatorial de pacientes com problemas respiratórios complexos; 7 ­ Cuidado ao paciente crítico; 8 ­ Manejo dos testes de função pulmonar; 9 ­ Análise diagnóstica do tórax pela imagem; 10 ­ Condução na alta responsável; 11 ­ Procedimento em situação de óbito. A obtenção do currículo baseado em EPAs para formação do especialista em pneumologia da Santa Casa BH favorecerá a avaliação dos especializandos no cenário do serviço e contribuirá para a excelência do cuidado aos portadores de doenças respiratórias

The specialization program in Pulmonology at Santa Casa de Belo Horizonte (SCBH), created in 1984, needed to have well-established skills that characterize the pulmonologists trained there, as well as the professional activities entrusted to them. This work aimed at structuring a curriculum based on entrustable professional activities (EPA) for the training of the pulmonology specialists at Santa Casa de Belo Horizonte. This is a study applied to the reality of the health service, which involved the organization of a matrix of essential competencies for the formation of a specialist in pulmonology from the desired profile of the egress of the pulmonology specialization program, using as reference the matrix of competencies of Pulmonology published by the National Commission of Medical Residency of the Brazilian Ministry of Education (CNRM/MEC - Comissão Nacional de Residência Médica do Ministério da Educação do Brasil), the competency-based educational program developed by the Teaching and Research Unit of SCBH, and the matrix of the Royal College of Physicians and Surgeons of Canada (CanMeds). The competencies were grouped into six major domains: 1. Self-Management of Knowledge; 2. Communication; 3. Technical Expertise; 4. Collaborative Leadership, 5. Professionalism; 6. Social Responsibility. Sequentially, the Entrustable Professional Activities (EPA) were defined and elaborated, characterizing the spectrum of training and practice of specialists in pulmonology by the SCBH. The elaborated EPAs were then discussed and improved by a committee of specialists in pulmonology. A competency matrix was obtained with 143 educational objectives distributed across the six domains: self-management of knowledge (4%), communication (17%), technical expertise (64%), collaborative leadership (4%), professionalism (5%) and social responsibility (5%). From the matrix, 11 EPAs were developed: 1 - Clinical care for patients with respiratory problems in any scenario; 2 - Data entry in medical records; 3 - Medical prescription for the patient with respiratory problems; 4 - Request and interpretation of complementary tests; 5 - Care of the patient with respiratory failure; 6 - Referral and outpatient care of patients with complex respiratory problems; 7 - Care of the critically ill patient; 8 - Management of pulmonary function tests; 9 - Diagnostic image analysis of the thorax; 10 - Responsible discharge; 11 - Procedure in the event of death. The development of the curriculum based on EPAs in the formation of pulmonology specialists at SCBH will favor the evaluation of future specialists in the service scenario and contribute to the excellent care of those with respiratory diseases

Weaning from mechanical ventilation in people with neuromuscular disease: protocol for a systematic review.

INTRODUCTION: Neuromuscular diseases (NMD) are characterised by progressive muscular impairment. The muscle weakness is directly related to respiratory muscles weakness, causing reduction in vital capacity, especially when associated with mechanical ventilation (MV). Conventional MV weaning in NMD is generally difficult. Weaning process can be conducted in protocols such as: 'T' piece or Pressure Support Ventilaton. Weaning failure is frequent because of muscle weakness. Protocol aim is to assess the effects of different weaning protocols in NMD patients receiving invasive MV in weaning success rate, duration of weaning, intensive care unit (ICU) stay, hospital stay and ICU mortality. METHODS AND ANALYSIS: A search will be carried in the Cochrane Neuromuscular Specialised Register, MEDLINE, EMBASE, Web of Science, Scopus, United States National Institutes of Health Clinical Trials Registry, ClinicalTrials.gov and WHO International Clinical Trial Registry Protal, of randomised controlled trials (RCTs) and quasi-RCTs. Inclusion criteria of individuals are adults (above 16 years old) and children (from 5 to 16 years old), with clinical diagnosis of NMD (muscular dystrophy, amyotrophic lateral sclerosis, congenital myasthenia, myasthenia gravis, congenital myopathy, spinal muscular atrophy, Guillian Barré Syndrome, severe inherited neuropathies, metabolic myopathies, inflammatory myopathies, mitochondrial diseases) of any gender. All patients ventilated for at least 48 hours due to respiratory failure and clinically considered ready for weaning. Other respiratory or cardiovascular diagnosis associated will not be included. Intervention assessed will be weaning from MV using a protocol with 30 min to 2 hours of spontaneous breathing trial at the end point. All comparisons of different protocols will be considered. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected, since it will be a systematic review. All studies included should have ethical committee approval. The results will be disseminated through a peer-reviewed publication and in conferences and congresses or symposia. PROSPERO REGISTRATION NUMBER: CRD42019117393.

The Fraction Exhaled Nitric Oxide as a Biomarker of Asthma Control.

INTRODUCTION AND OBJECTIVE: The main goal of asthma treatment is to achieve and maintain clinical control of the disease. The exhaled fraction nitric oxide (FeNO) level is a biomarker of T-helper cell type 2 (Th2) inflammation of the airways. Our objective was to determine whether the FeNO level can be used to discriminate between patients with controlled, partially controlled, and uncontrolled asthma. MATERIALS AND METHODS: The FeNO level and asthma control were evaluated in a retrospective and analytic cross-sectional study through data collected from asthmatic patients who were assessed by clinical history, asthma control, physical examination, spirometry, and FeNO level. Asthma control was determined by the criteria of the Global Initiative for Asthma and classified as controlled asthma, partially controlled asthma, and uncontrolled asthma. The FeNO values were classified as low (<25 ppb) or intermediate/high (⩾25 ppb) based on the American Thoracic Society recommendations. RESULTS: The symptoms of 81 asthmatic patients were classified as controlled (34 [42%] patients), partially controlled (27 [33.3%] patients), and uncontrolled (20 [24.7%] patients). The FeNO level discriminated between the uncontrolled and controlled groups (P = .01) and between the uncontrolled and partially controlled groups (P = .01), but not between the controlled and partially controlled groups (P = .98). An FeNO level >30 ppb was associated with uncontrolled asthma (P = .0001) with an area under the receiver operating characteristic curve of 0.78 (95% confidence interval = 0.65-0.89). CONCLUSIONS: FeNO level could be helpful in determining asthma control as >30 ppb was associated with uncontrolled asthma.