Objective: To compare the influence of two different ventilation strategies-volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV)-on the functional performance of lung grafts in a canine model of unilateral left lung transplantation using donor lungs harvested after three hours of normothermic cardiocirculatory arrest under mechanical ventilation. Methods: The study comprised 40 mongrel dogs, randomized into two groups: VCV and PCV. Of the 20 recipients, 5 did not survive the transplant, and 5 died before the end of the post-transplant assessment period. The remaining 10 survivors (5 in each group) were evaluated for 360 min after lung transplantation. The functional performance of the grafts was evaluated regarding respiratory mechanics, gas exchange, and lung graft histology. Results: There were no significant differences between the groups regarding respiratory mechanics (peak inspiratory pressure, plateau pressure, mean airway pressure, dynamic compliance, and static compliance) or gas exchange variables (PaO2, venous oxygen tension, PaCO2, venous carbon dioxide tension, and the arterial-venous oxygen content difference). The histopathological findings were consistent with nonspecific acute lung injury and did not differ between the groups. Conclusions: This model of lung transplantation showed that the functional performance of lung grafts was not influenced by the ventilation strategy employed during the first six hours after reperfusion.

Keywords: Pulmonary ventilation; Respiration, artificial; Lung transplantation; Dogs; Organ preservation.

We report the case of a 56-year-old patient who underwent left single lung transplantation for idiopathic pulmonary fibrosis (IPF). Despite the high level of immunosuppression after the surgery, there was rapid progression to IPF in the native (right) lung as demonstrated by thoracoscopic lung biopsy. After 104 days on mechanical ventilation, the patient underwent right lung transplant and was discharged from the hospital on postoperative day 26.

Keywords: Idiopathic pulmonary fibrosis; Lung transplantation; Case reports [publication type].

Objective: Brain death (BD) triggers important hemodynamic and inflammatory alterations, compromising the viability of organs suitable for transplantation. To better understand the mi-crocirculatory alterations in donor lungs caused by BD. The present study investigated the pul-monary microcirculation in a rodent model of BD via intravital microscopy. Methods: Male Wistar rats were anaesthetized and mechanically ventilated. They were trepanned and BD was induced through the increase in intracranial pressure. As control group, sham-operated (SH) rats were trepanned only. In both groups, expiratory O2 and CO2 were monitored and after three hours, a thoracotomy was performed, and a window was created to observe the lung surface using an epi-fluorescence intravital microscopy. Lung expression of intercellular adhesion molecule (ICAM)-1 and endothelial nitric oxide synthase (eNOS) was evaluated by immunohistochemistry, and cytokines were measured in lung samples. Results: Three hours after the surgical proce-dures, pulmonary perfusion was 73% in the SH group. On the other hand, BD animals showed an important decrease in organ perfusion to 28% (p = 0.036). Lung microcirculatory compromise after BD induction was associated with an augmentation of the number of leukocytes recruited to lung tissue, and with a reduction in eNOS expression and an increase in ICAM-1 expression on lung endothelial cells. BD rats showed higher values of expiratory O2 and lower values of CO2 in comparison with SH animals after three hours of monitoring. Conclusion: Data presented showed that BD triggers an important hypoperfusion and inflammation in the lungs, compromis-ing the donor pulmonary microcirculation

Keywords: Brain death; Inflammation; Intravital microscopy; Lung microcirculation.

Objective: To investigate the impact of a pulmonary rehabilitation program on the functional capacity and on the quality of life of patients on waiting lists for lung transplantation. Methods: Patients on lung transplant waiting lists were referred to a pulmonary rehabilitation program consisting of 36 sessions. Before and after the program, participating patients were evaluated with the six-minute walk test and the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36). The pulmonary rehabilitation program involved muscle strengthening exercises, aerobic training, clinical evaluation, psychiatric evaluation, nutritional counseling, social assistance, and educational lectures. Results: Of the 112 patients initially referred to the program, 58 completed it. The mean age of the participants was 46  14 years, and females accounted for 52%. Of those 58 patients, 37 (47%) had pulmonary fibrosis, 13 (22%) had pulmonary emphysema, and 18 (31%) had other types of advanced lung disease. The six-minute walk distance was significantly greater after the program than before (439 ± 114 m vs. 367 ± 136 m, p = 0.001), the mean increase being 72 m. There were significant point increases in the scores on the following SF-36 domains: physical functioning, up 22 (p = 0.001), role-physical, up 10 (p = 0.045); vitality, up 10 (p < 0.001); social functioning, up 15 (p = 0.001); and mental health, up 8 (p = 0.001). Conclusions: Pulmonary rehabilitation had a positive impact on exercise capacity and quality of life in patients on lung transplant waiting lists.

Keywords: Rehabilitation; Lung transplantation; Quality of life; Exercise; Exercise tolerance.

Objective: To evaluate the changes in lung function in the first year after single lung transplantation in patients with idiopathic pulmonary fibrosis (IPF). Methods: We retrospectively evaluated patients with IPF who underwent single lung transplantation between January of 2006 and December of 2012, reviewing the changes in the lung function occurring during the first year after the procedure. Results: Of the 218 patients undergoing lung transplantation during the study period, 79 (36.2%) had IPF. Of those 79 patients, 24 (30%) died, and 11 (14%) did not undergo spirometry at the end of the first year. Of the 44 patients included in the study, 29 (66%) were men. The mean age of the patients was 57 years. Before transplantation, mean FVC, FEV1, and FEV1/FVC ratio were 1.78 L (50% of predicted), 1.48 L (52% of predicted), and 83%, respectively. In the first month after transplantation, there was a mean increase of 12% in FVC (400 mL) and FEV1 (350 mL). In the third month after transplantation, there were additional increases, of 5% (170 mL) in FVC and 1% (50 mL) in FEV1. At the end of the first year, the functional improvement persisted, with a mean gain of 19% (620 mL) in FVC and 16% (430 mL) in FEV1. Conclusions: Single lung transplantation in IPF patients who survive for at least one year provides significant and progressive benefits in lung function during the first year. This procedure is an important therapeutic alternative in the management of IPF.

Keywords: Pulmonary fibrosis; Respiratory function tests; Lung transplantation.

Background: Lung volume reduction surgery may be a viable treatment alternative for emphysema patients suffering from severe respiratory insufficiency. Objectives: To evaluate functional and morphological aspects of emphysematous rat lungs, prior to and following lung volume reduction surgery. Method: Wistar rats were divided into two experimental groups (papain without surgery and papain with surgery) and three control groups (saline without surgery, saline with surgery and papain without mechanical ventilation). After approximately 40 days of endotracheal instillation of papain or saline solution, animals in the papain with surgery and saline with surgery groups were submitted to bilobectomy of the middle lobes by right thoracotomy along the posterior border of the superior vena cava. After 1 week, the same animals were submitted to a mechanical ventilation study, which involved measurement of lung elasticity and airway resistance. For all of the animals studied, lung tissue was analyzed in order to determine alveolar diameter and the elastic fiber quantity. Results: Morphometric analysis revealed higher mean alveolar diameter in the lungs of all animals exposed to papain as compared to those exposed to saline. Elastic fiber counts in the alveolar septa of animals treated with papain were lower than those of animals receiving saline. In the animals submitted to bilobectomy and papain, lung elasticity was greater than in those receiving papain without surgery and was statistically equal to that seen in animals receiving saline (with or without surgery). Conclusion: In the respiratory systems of animals with pulmonary emphysema submitted to lung volume reduction by bilobectomy, the capacity for elastic recoil returned to values equivalent to those of the control group animals.

Keywords: Key words: Pulmonary emphysema. Papain/drugs efects. Case-control studies. Disease models, animal. Respiratory mechanics/drugs efects. Lung/sugery. Lung/anatomy & histology.

Objective: Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation (MV). However, data on VAP in patients on prolonged MV (PMV) are scarce. We aimed to describe the characteristics of VAP patients on PMV and to identify factors associated with mortality. Methods: This was a retrospective cohort study including VAP patients on PMV. We recorded baseline characteristics, as well as 30-day and 90-day mortality rates. Variables associated with mortality were determined by Kaplan-Meier survival analysis and Cox regression model. Results: We identified 80 episodes of VAP in 62 subjects on PMV. The medians for age, Charlson Comorbidity Index, SOFA score, and days on MV were, respectively, 69.5 years, 5, 4, and 56 days. Episodes of VAP occurred between days 21 and 50 of MV in 28 patients (45.2%) and, by day 90 of MV, in 48 patients (77.4%). The 30-day and 90-day mortality rates were 30.0% and 63.7%, respectively. There were associations of 30-day mortality with the SOFA score (hazard ratio [HR] = 1.30; 95% CI: 1.12-1.52; p < 0.001) and use of vasoactive agents (HR = 4.0; 95% CI: 1.2-12.9; p = 0.02), whereas 90-day mortality was associated with age (HR = 1.03; 95% CI: 1.00-1.05; p = 0.003), SOFA score (HR = 1.20; 95% CI: 1.07-1.34; p = 0.001), use of vasoactive agents (HR = 4.07; 95% CI: 1.93-8.55; p < 0.001), and COPD (HR = 3.35; 95% CI: 1.71-6.60; p < 0.001). Conclusions: Mortality rates in VAP patients on PMV are considerably high. The onset of VAP can occur various days after MV initiation. The SOFA score is useful for predicting fatal outcomes. The factors associated with mortality could help guide therapeutic decisions and determine prognosis.

Keywords: Pneumonia, ventilator-associated; Critical care; Ventilators, mechanical.

Background: It is questionable whether pressure-controlled ventilation (PCV) has advantages over volume-cycled ventilation (VCV). Objectives: To compare PCV to VCV with decelerating flow profile during assisted and controlled modes in an acute lung injury experimental model. Methods: Severe acute lung injury (PaO2/FIO2 < 100 mmHg) was induced by oleic acid IV infusion (0.05 mg/kg) in seven dogs. The animals were submitted to PCV and VCV in a randomized sequence. After 40 minutes in the assisted mode, ventilation was changed to the controlled mode after neuromuscular blockade. The tidal volume and the inspiratory time were kept constant throughout the experiment. Results: There were no differences in gas exchange (PaO2 and PaCO2), cardiac output or oxygen delivery (DO2) between VCV and PCV. The same was observed regarding maximum airway and plateau pressures, and also to the static compliance. Oxygen consumption (VO2) after neuromuscular blockade was 124 ± 48 in VCV versus 143 ± 50 ml/min in PCV, p = 0.42. In the assisted mode, there was a statistical trend of a higher VO2 in PCV (219 ± 72 versus 154 ± 67 ml/min in VCV, p = 0.06), that was associated with a statistical trend of a higher oxygen cost of breathing (OCB) during assisted PCV, although without statistical significance (31 ± 77 in VCV versus 75 ± 96 ml/min in PCV, p = 0.23), and also in a lower PvO2 (34 ± 7 in PCV versus 42 ± 6 ml/min in VCV, p = 0.02). These occurred despite a higher maximum inspiratory flow in the assisted mode in PCV (58 ± 9 versus 48 ± 4 L/min in VCV, p = 0.01). In both VCV and PCV the institution of controlled ventilation reduced cardiac debit and DO2 in as much as 20% relative to the assisted mode. Conclusions: The implementation of controlled ventilation improved the oxygen delivery/consumption relationship in this severe and with high OCB acute lung injury model. The PCV offered no additional benefits to VCV and it was associated with a higher OCB during the assisted mode.

Keywords: Artificial respiration. Pulmonary gas exchange. Tidal volume.

Objective: To compare histopathological findings and the degree of apoptosis among rat lungs preserved with low-potassium dextran (LPD) solution, histidine-tryptophan-ketoglutarate (HTK) solution, or normal saline (NS) at two ischemia periods (6 h and 12 h) using an experimental rat model of ex vivo lung perfusion. Methods: Sixty Wistar rats were anesthetized, randomized, and submitted to antegrade perfusion via pulmonary artery with one of the preservation solutions. Following en bloc extraction, the heart-lung blocks were preserved for 6 h or 12 h at 4°C and then reperfused with homologous blood for 60 min in an ex vivo lung perfusion system. At the end of the reperfusion, fragments of the middle lobe were extracted and processed for histopathological examination. The parameters evaluated were congestion, alveolar edema, alveolar hemorrhage, inflammatory infiltrate, and interstitial infiltrate. The degree of apoptosis was assessed using the TdT-mediated dUTP nick end labeling method. Results: The histopathological examination showed that all of the lungs preserved with NS presented alveolar edema after 12 h of ischemia. There were no statistically significant differences among the groups in terms of the degree of apoptosis. Conclusions: In this study, the histopathological and apoptosis findings were similar with the use of either LPD or HTK solutions, whereas the occurrence of edema was significantly more common with the use of NS.

Keywords: : Organ preservation; Organ preservation solutions; Lung transplantation; Reperfusion injury; Apoptosis.

Small animal models are particularly suitable for lung preservation studies, because they are simple and cost-effective. This brief communication focuses on the technical description of an ex vivo lung perfusion model in rats by means of a commercially available apparatus, which was the first to be installed in a thoracic surgery research laboratory in Brazil. The model and its preparation, together with its applications for lung preservation studies, are described in detail. All technical details can also be seen in a video posted on the website of the Brazilian Journal of Pulmonology.

Keywords: Lung transplantation; Reperfusion injury; Rats; Models, animal.

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.

Keywords: Masks; Noninvasive ventilation; Thermography.

Objetivo: Avaliar a aplicabilidade da escala London Chest Activity of Daily Living (LCADL), em pacientes em lista de transplante pulmonar. Métodos: Estudo transversal com 26 pacientes em lista de espera para transplante de pulmão, de ambos os sexos, entre maio e setembro de 2010 tratados no Programa de Reabilitação Pulmonar, Complexo Hospitalar Santa Casa de Misericórdia de Porto Alegre, em Porto Alegre, RS. Todos os pacientes foram submetidos ao teste de caminhada de seis minutos (TC6) e a teste de função pulmonar e foram obtidos os escores das escalas LCADL e de Borg modificada para dispneia e fadiga das pernas. O teste alfa de Cronbach foi utilizado para verificar a consistência interna da escala LCADL. A análise de regressão linear foi utilizada para identificar associações entre o escore total em porcentagem da escala LCADL e as variáveis estudadas. Resultados: Segundo os resultados da LCADL, 69% dos pacientes indicaram que suas atividades de vida diária são muito comprometidas pela dispnéia. A consistência interna da escala LCADL foi de 0,89. Houve associações negativas estatisticamente significativas entre o escore total da escala LCADL e distância percorrida no TC6 (β = −0,087; p < 0,001) e trabalho realizado no TC6 (β = −0,285; p < 0,001), quando os dados foram ajustados por idade e VEF1. Conclusões: Esses achados sugerem que a escala LCADL é um instrumento útil para avaliar o desempenho funcional dos pacientes em listas de transplante pulmonar.

Keywords: Atividades cotidianas; Transplante de pulmão; Dispneia.

Objective: This study aimed to investigate acute and chronic effects of varenicline on lung tissue in an experimental study. Methods: A total of 34 rats were randomly allocated into study (varenicline) and control groups. The rats were divided into two groups (i) control group, (ii) varenicline group. Then, the rats in the each group were sub‑divided equally in turn as acute (C1; V1) and chronic (C2; V2) ; all rats of acute and chronic groups were sacrificed under the anesthesia on the 45th day for acute group [C1 (n=5) and V1 (n=12)] and the 90th day for chronic group [C2 (n=5) and V2 (n=12)], respectively. Thus, biochemical and histopathological analysis were carried out. Results: Thirty four rats completed the study, 24 were in varenicline group and 10 were in control group. In chronic exposure to varenicline, oxidant levels comprising of malondialdehyde (MDA), and myeloperoxidase (MPO) increased and superoxide dismutase (SOD), catalase (CAT), glutathione (GSH) and glutathione peroxidase (GPx) levels, named as antioxidants, decreased significantly when compared to the control group. MDA and MPO levels were also significantly higher and SOD, CAT, GPx, GSH levels were also significantly lower in chronic varenicline group when compared to acute varenicline group. These findings were also supported by histopathological observations. Conclusion: This is the first study, which evaluated pulmonary effects of varenicline experimentally on an animal model. It was observed that chronic varenicline treatments cause inflammation and lung cell injury.

Keywords: Varenicline; Lung tissue; Oxidative stress; Pulmonary toxicity.

Objective: To evaluate the effects of high-intensity interval training (HIIT), in comparison with those of continuous exercise, on functional capacity and cardiovascular variables in patients with COPD, through a systematic review and meta-analysis of randomized controlled trials. Methods: We searched PubMed, the Physiotherapy Evidence Database, the Cochrane Central Register of Controlled Trials, and EMBASE, as well as performing hand searches, for articles published up through January of 2017. We included studies comparing exercise regimens of different intensities, in terms of their effects on functional capacity and cardiovascular variables in patients with COPD. Results: Of the 78 articles identified, 6 were included in the systematic review and meta-analysis. Maximal oxygen consumption (VO2max) did not differ significantly between HIIT and control interventions. That was true for relative VO2max (0.03 mL/kg/min; 95% CI: −3.05 to 3.10) and absolute VO2max (0.03 L/min, 95% CI: −0.02 to 0.08). Conclusions: The effects of HIIT appear to be comparable to those of continuous exercise in relation to functional and cardiovascular responses. However, our findings should be interpreted with caution because the studies evaluated present a high risk of bias, which could have a direct influence on the results.

Keywords: Pulmonary disease, chronic obstructive; Exercise; Oxygen consumption.

Objective: To determine the effectiveness of oscillating positive expiratory pressure (OPEP) using predetermined expiratory pressures on the viscosity and transportability of sputum in patients with bronchiectasis. Methods: The study involved 15 stable patients with bronchiectasis (7 males; mean age = 53 ± 16 years), submitted to two consecutive OPEP interventions, with a 24-h interval between the two, using positive expiratory pressures set at 15 cmH2O (P15) and 25 cmH2O (P25). The protocol consisted of a voluntary cough; another voluntary cough 20 min later, designated time zero (T0); a 10-min rest period; and two 10-min series (S1 and S2, using OPEP at P15 and P25 in both), with a 10-min interval between the two. The viscosity and transportability of sputum were evaluated by viscometry, relative transport velocity on frog palate, transport in a simulated cough machine and contact angle. Sputum samples were collected at T0, after S1 and after S2. Specific statistical tests were performed depending on the type of data distribution. Results: In comparison with the values obtained at T0, sputum viscosity decreased significantly after S1 at P15 and after S2 at P25. There were no significant differences among all of the samples in terms of transportability. Conclusions: The fact that sputum viscosity decreased whether OPEP was performed at P15 or at P25 suggests that there is no need to generate high expiratory pressure to achieve the desired result.

Keywords: Viscosity; Bronchiectasis; Physical therapy (specialty); Sputum.

Objective: To evaluate the effects of immunization with a DNA-hsp65 vaccine in an experimental model of pulmonary fibrosis. Methods: A total of 120 male C57BL/6 mice were distributed into four groups: SS, injected with saline (placebo) and then receiving intratracheal (IT) instillation of saline; SB, injected with saline (placebo) and then receiving IT instillation of bleomycin; PB, treated with plasmid only, without bacterial genome, and then receiving IT instillation of bleomycin; and BB, treated with the vaccine and then receiving IT instillation of bleomycin. Bleomycin was instilled 15 days after the last immunization, and the animals were killed six weeks thereafter. The left and right lungs were removed, the former for morphological analysis and the latter for hydroxyproline measurements. Results: The proportion of deaths within the first 48 h after the IT instillation (deaths attributed to the surgical procedure) was higher in the SB group than in the SS group (57.7% vs. 11.1%). The mean area of pulmonary interstitial septa was greater in the SB and PB groups (53.1 ± 8.6% and 53.6 ± 9.3%, respectively) than in the SS and BB groups (32.9 ± 2.7% and 34.3 ± 6.1%, respectively). The mean area of interstitial septa stained by picrosirius was greater in the SB, PB and BB groups than in the SS group (8.2 ± 4.9%, 7.2 ± 4.2% and 6.6 ± 4.1%, respectively, vs. 2.0 ± 1.4%). The total hydroxyproline content in the lung was significantly lower in the SS group (104.9 ± 20.9 pg/lung) than in the other groups (SB: 160.4 ± 47.8 pg/lung; PB: 170.0 ± 72.0 pg/lung; and BB: 162.5 ± 39.7 pg/lung). Conclusions: Immunization with the DNA-hsp65 vaccine reduced the deposition of noncollagen matrix in a model of bleomycin-induced lung lesion.

Keywords: Pulmonary fibrosis; Bleomycin; Collagen.