Objective: To assess the frequency of variation in forced expiratory volume in one second after bronchodilator use in a sample of patients with chronic obstructive pulmonary disease, correlating such variation with clinical and demographic variables and evaluating the frequency of response presented in forced vital capacity, slow vital capacity, inspiratory capacity, residual volume, airway resistance and specific airway conductance. Methods: A total of 64 patients with chronic obstructive pulmonary disease were submitted to whole body plethysmography, and reversibility of bronchoconstriction after the administration 400 µg of fenoterol was quantified. Results: A response in forced expiratory volume in one second was observed in 31% of the patients. Excluding patients presenting a response in forced expiratory volume in one second, 5% presented responses in 5 of the other 6 parameters, 10% presented responses in 4 parameters, 17.5% in 3 parameters, 27.5% in 2 parameters, and 25% in only 1 parameter. Conclusion: When included in the evaluation of bronchodilator response together with forced expiratory volume in one second, static lung volumes, airway resistance and airway conductance allowed a broader evaluation of those patients presenting a functional pharmacodynamic response. These results are in accordance with the observation that bronchodilator use provides clinical improvement and relief of dyspnea to many patients with chronic obstructive pulmonary disease, even to those in whom such treatment leads to no improvement in forced expiratory volume in one second.

Keywords: Pulmonary disease, chronic obstructive/drug therapy; Bronchodilator agents/therapeutic use; Airway resistance/drug effects; Respiratory function tests; Vital capacity; Forced expiratory volume

Objective: To evaluate, using pulmonary function tests, the effectiveness of formoterol as a bronchodilator at 30 min after its administration in patients with poorly reversible COPD. Methods: A prospective study including 40 COPD patients not responding to the short-acting bronchodilator used in the spirometric test-variation of less than 200 mL and less than 7% of predicted in forced expiratory volume in one second (FEV1). All patients were classified as having stage II, III, or IV COPD (Brazilian Thoracic Society/Global Initiative for Chronic Obstructive Lung Disease) and presented FEV1 ≤ 70% of predicted value. The patients were randomized into two groups of 20, with similar clinical characteristics, receiving, via a dry powder inhaler, either formoterol or a placebo. The pulmonary function testing (plethysmography) was repeated at 30 min after formoterol or placebo administration. Results: In the formoterol group, the mean values obtained for FEV1, inspiratory capacity, and forced vital capacity were significantly greater than those obtained in the placebo group (p = 0.00065, p = 0.05, and p = 0.017, respectively), whereas that obtained for airway resistance was significantly lower (p = 0.010). Less pronounced differences were observed for residual volume, vital capacity and specific airway conductance, which were lower, higher and higher, respectively, in the formoterol group. Conclusions: In COPD patients not responding to the short-acting bronchodilator used in the spirometric test, formoterol promoted significant improvement in lung function at 30 min after of administration. Further studies are required to confirm whether formoterol can also be used as a medication for immediate relief of symptoms in COPD.

Keywords: Chronic obstructive pulmonary disease; Respiratory function tests; Bronchodilator agents.

Objective: Making the differential diagnosis between asthma and chronic obstructive pulmonary disease (COPD) based on the response to inhaled bronchodilators by means of spirometry is controversial.The objective of this study was to identify the most useful spirometric variables in order to distinguish between asthma and COPD. Methods: Retrospective study conducted from April of 2004 to January of 2006, comparing the spirometric parameters of 103 nonsmoking patients with asthma to those of 108 patients with COPD who were smokers for more than 10 pack-years. All of the patients included in the study were older than 40 and presented stable disease at the time of the test. Results: Initial forced expiratory volume in one second (FEV1) was the same in the two groups (pre-bronchodilator FEV1 = 51%). However, patients with COPD were older (66 ± 9 years vs. 59 ± 11 years, p < 0.001) and more frequently male (73% vs. 27%, p < 0,001).After the use of the bronchodilator, the median absolute difference in FEV1 was 0.25 L (range, −0.09 to 1.13 L) in patients with asthma and 0.09 L (range, −0.1 to 0.73 L) in those with COPD (p < 0.001).The highest sensitivity (55%), specificity (91%) and likelihood ratio (6.1) for asthma diagnosis was obtained when the percentage increase in postbronchodilator FEV1 in relation to the predicted FEV1 (Δ%predFEV1) was equal to or greater than 10%.Isolated significant increases in forced vital capacity were more common in patients with COPD. Conclusions: In patients over the age of 40 and presenting obstructive lung disease, a Δ%predFEV1 ≥ 10% is the best spirometric parameter to distinguish asthma from COPD.

Keywords: Spirometry; Respiratory function tests; Lung diseases, obstructive.

Abstract Objective: To evaluate whether respiratory therapy techniques influence the number of cells within and quantity of induced sputum in patients with asthma or chronic obstructive pulmonary disease (COPD). Methods: Randomized clinical trial, in which patients with asthma or COPD under intervention (n = 16 and 10, respectively) were compared with control groups (n = 16 and 10). Patients in the asthma/intervention (A/I) and COPD/intervention (C/I) groups were submitted to oscillating positive expiratory pressure maneuvers for 5 min, followed by 10 forced expiratory technique sequences. These patients were also submitted to an induced sputum protocol with inhaled hypertonic saline (3%, 4% or 5%; A/I group) or inhaled isotonic saline (C/I group). The asthma/control (A/C) and COPD/control (C/C) groups were submitted only to the standard induced sputum protocol. Results: The final mean weight of the sputum samples was significantly greater in the A/I group than in the A/C group (2,767.25 ± 998.08 mg vs. 1,689.17 ± 1,189.96 mg; p = 0.03). The mean/median total cell counts (×106/mL) were higher in the A/I and C/I groups than in the A/C and C/C groups (4.06/0.95 and 0.63/0.39, p = 0.05, vs. 5.08/1.77 and 0.64/0.40, p = 0.02). There were no statistically significant differences among the groups in terms of cell viability. Conclusions: The use of respiratory therapy techniques can increase sputum sample weight in asthma patients, as well as increasing total cell counts in patients with asthma or COPD.

Keywords: Asthma; Pulmonary disease, obstructive chronic; Sputum; Physical therapy modalities.

Objective: To identify the role of bronchodilators in the maximal breath-hold time in patients with obstructive lung disease (OLD). Methods: We conducted a case-control study including patients with OLD and a control group. Spirometric tests were performed prior to and after the use of a bronchodilator, as were breath-hold tests, using an electronic microprocessor and a pneumotachograph as a flow transducer. Respiratory flow curves were displayed in real time on a portable computer. The maximal breath-hold times at end-inspiratory volume and at end-expiratory volume (BHTmaxVEI and BHTmaxVEE, respectively) were determined from the acquired signal. Results: A total of 35 patients with OLD and 16 controls were included. Prior to the use of a bronchodilator, the BHTmaxVEI was significantly lower in the OLD group than in the control group (22.27 ± 11.81 s vs. 31.45 ± 15.73 s; p = 0.025), although there was no significant difference between the two groups in terms of the post-bronchodilator values (24.94 ± 12.89 s vs. 31.67 ± 17.53 s). In contrast, BHTmaxVEE values were significantly lower in the OLD group than in the control group, in the pre- and post-bronchodilator tests (16.88 ± 6.58 s vs. 22.09 ± 7.95 s; p = 0.017; and 21.22 ± 9.37 s vs. 28.53 ± 12.46 s; p = 0.024, respectively). Conclusions: Our results provide additional evidence of the clinical usefulness of the breath-hold test in the assessment of pulmonary function and add to the existing knowledge regarding the role of the bronchodilator in this test.

Keywords: Respiratory function tests; Pulmonary disease, chronic obstructive; Bronchodilator agents; Apnea.

Objective: Pulmonary rehabilitation (PR) improves exercise capacity in most but not all COPD patients. The factors associated with treatment success and the role of chest wall mechanics remain unclear. We investigated the impact of PR on exercise performance in COPD with severe hyperinflation. Methods: We evaluated 22 COPD patients (age, 66 ± 7 years; FEV1 = 37.1 ± 11.8% of predicted) who underwent eight weeks of aerobic exercise and strength training. Before and after PR, each patient also performed a six-minute walk test and an incremental cycle ergometer test. During the latter, we measured chest wall volumes (total and compartmental, by optoelectronic plethysmography) and determined maximal workloads. Results: We observed significant differences between the pre- and post-PR means for six-minute walk distance (305 ± 78 vs. 330 ± 96 m, p < 0.001) and maximal workload (33 ± 21 vs. 39 ± 20 W; p = 0.02). At equivalent workload settings, PR led to lower oxygen consumption, carbon dioxide production (VCO2), and minute ventilation. The inspiratory (operating) rib cage volume decreased significantly after PR. There were 6 patients in whom PR did not increase the maximal workload. After PR, those patients showed no significant decrease in VCO2 during exercise, had higher end-expiratory chest wall volumes with a more rapid shallow breathing pattern, and continued to experience symptomatic leg fatigue. Conclusions: In severe COPD, PR appears to improve oxygen consumption and reduce VCO2, with a commensurate decrease in respiratory drive, changes reflected in the operating chest wall volumes. Patients with severe post-exercise hyperinflation and leg fatigue might be unable to improve their maximal performance despite completing a PR program.

Keywords: Pulmonary disease, chronic obstructive/rehabilitation; Exercise therapy; Respiratory therapy.

In lung function laboratories, statistical responses after bronchodilators (Bd) administration are widely used in patients with airflow limitation. However, their clinical relevance is debatable. Objective: To determine which spirometric parameters best reflect improvement in both exercise tolerance and exertional dyspnea in response to bronchodilators in obstructive lung diseases. Methods: Fifty patients with persistent asthma and/or COPD (FEV1/FVC = 41 ± 11%) were submitted to slow and forced vital capacity testing, MVV and a six-minute walking test (6 MW) following practice, before and after a 400 mg dose of salbutamol was given by MDI. Responses to Bd were expressed in absolute values and considered as increments to the initial values and predicted values. Responses to Bd were considered clinically significant if distance was longer than 30 m in the 6 MW test and/or if there was a 2-point decrease in the Borg scale in the walking distance. Results: 32 patients were responsive (R) to Bd and 18 were non-responsive (NR). As DMW correlated with age, (rs = -0.38 - p < 0.01) an analysis on spirometric data, including age as covariant, was performed and expressed as x ± SE. No difference in FEV1 was observed between the groups (R = 255 ± 57 ml; NR = 256 ± 43 ml). The same occurred regarding MVV (R = 11± 2 L/min; NR = 10 ± 2 L/min.). The best separation (p < 0.01) was given by changes in inspiration capacity (IC) followed by changes in slow vital capacity (SVC): IC% of initial R = 23 ± 3% and NR = 3 ± 4%; absolute IC = 411 ± 58 ml and NR = 163 ± 77 ml; predicted IC%: R = 19 ± 3% and NR = 3 ± 4%. For SVC, the values were: % initial - R = 18 ± 2% and NR = 9 ± 3%; absolute changes - R = 448 ± 52 ml and NR = 256 ± 70 ml. Increases in IC > 15% of the initial values and 0.3 L and increases in SVS > 15% of the initial values and 0.4 L determined responsive patients with positive predicted values as approximately 90%. Conclusion: Variations in FEV1, FVC and MVV do not predict improvement in exercise capacity after Bd. This is best reflected by 15% of increases in IC and/or in the SVC initial values.

Keywords: Obstructive lung diseases. Spirometry. Predictive value of tests. Bronchodilator agents. Exercise tolerance. Dyspnea.

Objective: To quantify elastic fibers (EFs) and smooth muscle (SM) cells, as well as CD4+ and CD8+ T lymphocytes, in stable chronic obstructive pulmonary disease (COPD). Methods: Surgical specimens were obtained from 15 COPD patients, 18 smokers without airflow limitation, and 14 nonsmokers. Histological and immunohistochemical methods were employed in order to quantify EFs, SM cells, CD4+ T cells, and CD8+ T cells. Results: There was no significant difference in EF numbers among the three groups (p > 0.05). The number of EFs per unit area of lung tissue (mm2) and the percentage of EFs in the lung tissue were similar among the three groups. The numbers of SM cells were found to be higher in the COPD patients than in the smokers (p = 0.003) or in the nonsmokers (p = 0.009). There was a tendency toward an increase in CD8+ T-cell counts in the COPD patients. In specimens collected from the COPD patients, CD4+ T-cell counts were lower than in those collected from the smokers (p = 0.015) or from the nonsmokers (p = 0.003). There was a weak correlation between CD4+ T-cell count and the ratio of forced expiratory volume in one second to forced vital capacity (r2 = 0.003). Conclusions: The EF counts were similar among the three groups. Hypertrophy/hyperplasia of airway wall SM cells was found in the COPD patients and in the smokers, indicating that airway remodeling occurs in smokers. The CD4/CD8 ratio was lower in the COPD patients.

Keywords: Pulmonary disease, chronic obstructive; CD4 Lymphocyte Count; Elastic tissue; Muscle, smooth.

Chronic obstructive pulmonary disease is progressive and is characterized by abnormal inflammation of the lungs in response to inhalation of noxious particles or toxic gases, especially cigarette smoke. Although this infirmity primarily affects the lungs, diverse extrapulmonary manifestations have been described. The likely mechanisms involved in the local and systemic inflammation seen in this disease include an increase in the number of inflammatory cells (resulting in abnormal production of inflammatory cytokines) and an imbalance between the formation of reactive oxygen species and antioxidant capacity (leading to oxidative stress). Weakened physical condition secondary to airflow limitation can also lead to the development of altered muscle function. Chronic obstructive pulmonary disease presents diverse systemic effects including nutritional depletion and musculoskeletal dysfunction (causing a reduction in exercise tolerance), as well as other effects related to the comorbidities generally observed in these patients. These manifestations have been correlated with survival and overall health status in chronic obstructive pulmonary disease patients. In view of these facts, the aim of this review was to discuss findings in the literature related to the systemic manifestations of chronic obstructive pulmonary disease, emphasizing the role played by systemic inflammation and evaluating various therapeutic strategies.

Keywords: Pulmonary disease, chronic obstructive/complications; Nutritional status; Exercise tolerance;

Background: Chronic obstructive pulmonary disease is detrimental to lung mechanics and peripheral muscles. The physical programs developed for this condition are usually targeted to an improvement on aerobics capacity. Programs that approach specifically the changes in thoracic mobility and thoracic muscles are rare. Objective: To assess the effects of a physical exercise program designed to increase chest wall mobility on functional and psychosocial capacity in moderate to severe chronic obstructive pulmonary disease patients. Methods: Thirty patients with moderate to severe chronic obstructive pulmonary disease were studied. They were randomized to 2 groups: control group (CG) and treated group (TG). The CG was submitted to an educational program and the TG was submitted to an educational program plus a physical exercise program aiming to increase chest wall mobility. Variables included spirometry, thoracic mobility, quality of life, anxiety and depression levels and a six minute walk test (6MWT). Results: After 2 months of training, only the TG presented improvements on chest wall mobility (from 4.20 ± 0.58 cm to 5.27 ± 0.58 cm; p = 0.05) and 6MWT (from 469.73 ± 31.99 m to 500.60 ± 27.38 m; p = 0.01). It was also observed that the TG presented improvement on the St. George's Respiratory Questionnaire (SGRQ) score, Chronic Respiratory Questionnaire (CRQ), and Beck's depression scale after 2 months of treatment. Pulmonary function did not improve either in the CG or in the TG group. Conclusion: Our results suggest that exercises aimed to the increasing of chest wall mobility improve thoracic mobility, quality of life, submaximal exercise capacity, and reduce dyspnea and depression symptoms in chronic obstructive pulmonary disease patients.

Keywords: COPD. Thoracic mobility. Quality of life. Capacity of exercise. Dyspnea.

Objective: Current debates on the bronchodilator response in COPD patients and whether the variation in FEV1 can be considered as an indicator of complete reversibility in such patients motivated us to conduct this study. The objective of the study was to determine the effect of albuterol on the resistive and reactive properties of the respiratory system in COPD patients. Methods: We evaluated 70 patients with COPD, divided into two groups based on spirometry findings: bronchodilator (BD)-negative (n = 39); and BD-positive (n = 31). We used the forced oscillation technique (FOT) to evaluate the following parameters: resistance at the intercept (R0), associated with the total resistance of the respiratory system; mean resistance (Rm), associated with central airway resistance; dynamic compliance (Cdyn); and the slope of resistance (S) and mean reactance (Xm), both of which are associated with the homogeneity of the respiratory system. Results: The use of albuterol resulted in significant reductions in R0 (p < 0.00002) and Rm (p < 0.0002). There were also significant increases in S (p < 0.0001), Cdyn (p < 0.0001) and Xm (p < 0.00004). These modifications occurred in both groups, the changes in FOT parameters being greater than those observed for spirometric parameters. Conclusions: The use of albuterol improved the resistive and reactive properties of the respiratory system of the COPD patients under study. These changes occurred regardless of the FEV1-based classification, thereby indicating that the use of this parameter in isolation might not suffice to identify the physiological effects involved.

Keywords: Pulmonary disease, chronic obstructive; Bronchodilator agents; Spirometry; Albuterol.

Pulmonary thromboembolism and exacerbation of chronic obstructive pulmonary disease are common conditions. Chronic obstructive pulmonary disease is a clinical risk factor for pulmonary thromboembolism. The presentation of acute pulmonary thromboembolism and acute exacerbation of chronic obstructive pulmonary disease often mimic each other so closely that they cannot be distinguished clinically. The structural abnormalities of the lungs in chronic obstructive pulmonary disease make also difficult to interpret the results of noninvasive tests like ventilation-perfusion lung scans. Therefore, diagnosing acute pulmonary thromboembolism in patients with underlying chronic obstructive pulmonary disease is a challenging task. In order to update knowledge of the subject and offer suggestions regarding conduct, we evaluated various studies addressing this theme, including case reports and case series. In addition, we reviewed diagnostic approaches to acute pulmonary thromboembolism, and we reflect upon that topic. The clinical probability of pulmonary thromboembolism concomitant to chronic obstructive pulmonary disease is typically intermediate, as is positivity on the ventilation-perfusion lung scan. Diagnostic algorithms should take that into consideration.

Keywords: Pulmonary disease, chronic obstructive/complications; Pulmonary embolism/diagnosis; Pulmonary embolism/epidemiology; Ventilation-perfusion ratio

Objective: To describe and analyze clinical symptoms and spirometric alterations of patients with chronic obstructive pulmonary disease (COPD) and history of exposure to wood and tobacco smoke. Methods: We retrospectively evaluated data related to 170 patients distributed into 3 groups: 34 exposed only to wood smoke, 59 patients exposed only to tobacco smoke and 77 patients exposed to both. Results: The groups did not differ significantly in terms of age (p = 0.225) or degree of exposure, considering each type of exposure in isolation or in combination (p = 0.164 and p = 0.220, respectively). Females predominated in the group exposed to wood smoke. There were no differences among the groups regarding respiratory symptoms (p > 0.05), and moderate dyspnea predominated in the three groups (p = 0.141). The group exposed to wood smoke presented higher percentages of forced expiratory volume in one second/forced vital capacity ratio and of forced expiratory volume in one second (p < 0.05). Positive results on bronchodilator testing occurred more frequently in the group exposed to tobacco smoke. The percentage of severe and extremely severe obstruction was significantly higher in the group exposed to tobacco smoke (44.1%) than in that exposed to wood smoke (11.8%; p = 0.006). Conclusions: Respiratory symptoms and pulmonary function alterations consistent with COPD were observed in the groups of patients exposed to wood smoke. However, those alterations were not as significant as the alterations observed in the groups exposed to tobacco smoke. This study emphasizes the importance of prospective studies in evaluating the risk of wood-smoke-related COPD in Brazil, as well as the need for preventive measures in this area.

Keywords: Pulmonary disease, chronic obstructive; Smoking; Air pollution, indoor; Smoke.

Introduction: The term quality of life has gained increasing importance in the scientific context. This study describes the adaptation of a disease-specific questionnaire developed by Paul Jones et al. in 1991, the St. George's Respiratory Questionnaire (SGRQ), to the Brazilian language and culture. This questionnaire evaluates the quality of life in patients with chronic obstructive pulmonary disease (COPD) and contains three domains (symptoms, activity, and impacts) divided in 76 items. The questionnaire is self-administrated, but it may be read to illiterate persons. Goal: To verify if the St. George's Respiratory Questionnaire is a valid tool to measure quality of life in patients with chronic obstructive pulmonary disease in Brazil. Methods: In order to validate the questionnaire in Brazil, it was initially translated into Portuguese and afterwards a back-translation into English, that was compared to the original version. A final Portuguese version was then written. This final version was, then, answered by 30 clinically stable COPD patients, according to the spirometry and oximetry values. Patients answered the questionnaire twice, within a 15 day interval. The length of time the patients took to answer the questionnaire and their doubts were noted. Wilcoxon test was used for the calculation of r probability between every single question between the two days; interclass correlation ratio was calculated to test the trustworthiness and reliability of the questionnaire. Results: Among the 30 participant patients, 10 were female and 20 were male. Mean age was 65.9 years. Most of the patients were found to be in stage 2 (56.7 %) of COPD, according to the American Thoracic Society classification. The interclass correlation ratio for the total score of the questionnaire was a = 0.79 and Wilcoxon p = 0.2110 (not statistically significant). The mean answering time for the two days of interview was, respectively, 11 minutes and 50 seconds and 10 minutes and 31 seconds. As concerns the doubts about the questions, the patients reported difficulties in answering Sections 4 and 5, each one of these questions written in a negative form. Conclusion: It can be concluded that the Brazilian version of the St. George's Respiratory Questionnaire is a valid and reliable tool to measure quality of life in patients with COPD in Brazil.

Keywords: obstructive lung diseases, questionnaire, quality of life, reproducibility of results, evolution studies

Long-acting b2-agonists can produce the same level of bronchodilation as anticholinergic drugs in patients with COPD, but due to their lipophilicity, the action persists for 12 h after inhalation. Comparative studies between salmeterol and formoterol demonstrate an equivalent potency of salmeterol 50 mcg and formoterol 24 or 12 mcg when administered respectively by a metered dose inhaler or a turbuhaler. One must consider the inhaler in order to establish the equivalent potency between these two agents. Patients with COPD and associated cardiac diseases can use the long-acting b2-agonists safely. In this particular high-risk group of patients, salmeterol, a partial agonist, is considered safer than formoterol. A reassessment of the bronchodilator therapy in COPD might be considered. Tiotropium bromide is a new anticholinergic drug, the action of which prolongs for more than 1-3 days. It is the most promising new bronchodilator for COPD patients.

Keywords: COPD, long-acting b2-agonists, bronchodilators

Chronic obstructive pulmonary disease is a prevalent condition and is currently the forth leading cause of mortality in the US. The prevalence of respiratory disturbance during sleep, or overlap syndrome as it was commonly known in the past, is still undetermined as conflicting reports have been published. Because of the adverse effects of sleep-related respiratory impairment in patients with underlying pulmonary disease, this condition deserves further investigation. In this report, we will briefly discuss the mechanisms involved in generating respiratory disturbance during sleep in Chronic Obstructive Pulmonary Disease and will guide the reader into distinguishing those patients who would benefit from a more detailed sleep evaluation, discussing management issues and treatment options.

Keywords: Key words: COPD. Sleep disorder breathing. Sleep apnea. Hypoxemia. Hypoventilation

Introduction: The patient with COPD has his global physical activity decreased due to a progressive worsening of the lung function resultant from any kind of physical effort he may perform. Pulmonary rehabilitation (PR) is used in the United States and Europe as an alternative therapy in COPD treatment. Objective: To evaluate the effectiveness of PR as an ancillary treatment for COPD. Patients and methods: 30 patients prospectively submitted to the PR program developed in six weeks with three weekly sessions. Evaluation included clinical history and complete physical examination, the six-minute walking distance test, maximum workload test for upper limbs, maximum load test for lower limbs, a questionnaire of effort perception, spirometry and analysis of blood gases. Results: Concerning spirometry and analysis of blood gases, pre and post PR program, no statistically significant change was observed (p > 0.05). Pre and post PR program, statistically significant values (p < 0.05) were observed in the decrease in effort perception and increase in functional physical capacity, maximum workload test for upper limbs and incremental test for lower limbs used to determine the maximum workload. Conclusions: The authors concluded that, in the group studied, the PR program increased the patients' physical capacity and maximum workload for upper limbs whereas no changes were observed in the data regarding spirometry and analysis of blood gases.

Keywords: Rehabilitation. Therapeutical approaches. Lung diseases obstructive. Treatment outcome. Exercise therapy.