Background: Pulmonary thromboembolism (PTE) is still an enigmatic disorder in many epidemiological and clinical features, remaining one of the most commonly misdiagnosed disorders. Objective: To describe the prevalence and pathological findings of PTE in a series of autopsies, to correlate these findings with underlying diseases, and to verify the frequency of PTE clinically suspected before death. Method: The reports on 5261 consecutive autopsies performed from 1979 to 2002 in a Brazilian tertiary referral medical school were reviewed for a retrospective study. From the medical records and autopsy reports of the patients found with macroscopically and/or microscopically documented PTE, were gathered data on demographics, underlying diseases, antemortem suspicion of PTE, and probable PTE site of origin. Results: The autopsy rate was 42.0% and PTE was found in 544 patients. In 225 cases, PTE was the main cause of death (fatal PTE). Infections (p=0.0003) were associated with nonfatal PTE and trauma (p=0.007) with fatal PTE. The rate of antemortem unsuspected PTE was 84.6% and 40.0% of these patients presented fatal PTE. Diseases of the circulatory system (p=0.0001), infections (p<0.0001), diseases of the digestive system (p=0.0001), neoplasia (p=0.024) and trauma (p=0.005) were associated with unsuspected PTE. The most frequent PTE site of origin was the lower limbs (48.9%). Probable PTE sites of origin such as right-sided cardiac chambers (p=0.012) and pelvic veins (p=0.015) were associated with fatal PTE. Conclusion: A large number of cases do not have antemortem suspicion of PTE. Special attention should be paid to the possibility of PTE in patients with diseases of the circulatory system, infections, diseases of the digestive system, neoplasia, and trauma.

Keywords: Autopsy. Epidemiology. Pulmonary Thromboembolism.

Objective: To present the pulmonary histopathological alterations found in the autopsies of patients with acute respiratory failure (ARF) and determine whether underlying diseases and certain associated risk factors increase the incidence of these histopathological patterns. Methods: Final autopsy reports were reviewed, and 3030 autopsies of patients > 1 year of age with an underlying disease and associated risk factors were selected. All had developed diffuse infiltrates and died of ARF-related pulmonary alterations. Results: The principal pulmonary histopathological alterations resulting in immediate death were diffuse alveolar damage (DAD), pulmonary edema, lymphocytic interstitial pneumonia (LIP) and alveolar hemorrhage. The principal underlying diseases were AIDS, bronchopneumonia, sepsis, liver cirrhosis, pulmonary thromboembolism, acute myocardial infarction (AMI), cerebrovascular accident, tuberculosis, cancer, chronic kidney failure and leukemia. The principal associated risk factors were as follows: age ≥ 50 years; arterial hypertension; congestive heart failure; chronic obstructive pulmonary disease; and diabetes mellitus. These risk factors and AIDS correlated with a high risk of developing LIP; these same risk factors, if concomitant with sepsis or liver cirrhosis, correlated with a risk of developing DAD; thromboembolism and these risk factors correlated with a risk of developing alveolar hemorrhage; these risk factors and AMI correlated with a risk of developing pulmonary edema. Conclusion: Pulmonary findings in patients who died of ARF presented four histopathological patterns: DAD, pulmonary edema, LIP and alveolar hemorrhage. Underlying diseases and certain associated risk factors correlated positively with specific histopathological findings on autopsy.

Keywords: Respiratory insufficiency; Autopsy; Lung diseases, interstitial; Pulmonary edema; Hemorrhage.

Objective: To determine the prevalence of nosocomial pneumonia in autopsies at a public university hospital; to identify the risk factors for nosocomial pneumonia and the potential prognostic factors associated with fatal nosocomial pneumonia and with fatal aspiration pneumonia; and to determine whether anatomopathological findings correlate with nosocomial pneumonia or aspiration pneumonia. Methods: A retrospective study involving 199 autopsied patients, older than 1 year of age, who had been admitted to the São Paulo State University Botucatu School of Medicine Hospital das Clínicas and died of nosocomial pneumonia (underlying or contributing cause), between 1999 and 2006. Demographic, clinical and anatomopathological variables were tested regarding their association with the outcomes (fatal nosocomial pneumonia and fatal aspiration pneumonia). The significant variables were analyzed using multivariate analysis. Results: The mean age was 59 ± 19 years. The prevalence of nosocomial pneumonia in autopsies was 29%, and the disease was the cause of death in 22.6% of the autopsied patients. Fatal nosocomial pneumonia correlated with the following anatomopathological findings: tobacco‑associated structural lesions (OR = 3.23; 95% CI: 1.26-2.95; p = 0.02) and bilateral pneumonia (OR = 3.23; 95% CI: 1.26-8.30; p = 0.01). None of the variables were found to be significantly associated with fatal aspiration pneumonia. Conclusions: In our sample, there was a high prevalence of nosocomial pneumonia, which was responsible for almost 25% of all of the deaths. Smoking-related structural lesions and bilateral pneumonia all favored mortality. These findings corroborate the results of various clinical studies on nosocomial pneumonia.

Keywords: Autopsy; Risk factors; Prognosis; Pneumonia, aspiration; Pneumonia/mortality.

Objective: To compare the American-European Consensus Conference (AECC) definition of acute respiratory distress syndrome (ARDS) to autopsy findings. Methods: All patients who died in the intensive care unit of the Federal University of Juiz de Fora University Hospital between 1995 and 2003 and were submitted to autopsy were included in the study. Patient clinical charts were reviewed to establish whether cases met the AECC criteria for a diagnosis of ARDS, histologically defined as the presence of diffuse alveolar damage (DAD). Results: During the study period, 592 patients died, and 22 were submitted to autopsy. Of those 22 patients, 10 (45%) met the AECC criteria, and 7 (32%) met the histopathological criteria for DAD. The AECC clinical criteria presented a sensitivity of 71% (95%CI: 36-92%) and a specificity of 67% (95%CI: 42-85%). The positive and negative predictive values were, respectively, 50 and 83%, whereas the positive and negative likelihood ratios were, respectively, 2.33 and 0.47. The histopathological findings in the 5 patients who met AECC criteria but did not present DAD were pneumonia (n = 2), pulmonary embolism (n = 1), tuberculosis (n = 1), and cryptococcosis (n = 1). Conclusion: The accuracy of the AECC definition of ARDS was godless than satisfactory. Due to the low positive predictive value and the low positive likelihood ratio, other hypotheses must be considered when ARDS is suspected.

Keywords: Respiratory distress syndrome, adult; Diagnostic Techniques and Procedures; Autopsy.

Pulmonary thromboembolism (PTE) should be suspected in patients with risk factors for deep venous thrombosis (DVP) who present, either isolated or in association, malaise, dyspnea/tachypnea, sudden collapse or pulmonary hemorrhage syndrome. The diagnostic approach starts with basic tests (chest X-rays electrocardiographs, and arterial blood gas tensions) the results of which associated to medical history and to physical examination allow the classification of clinical suspicion as high, intermediate or low probability. This phase is important, both to support clinical suspicion of PTE and to exclude alternative diagnoses. In order to confirm or exclude PTE, one or several sophisticated imaging exams (lung isotope scanning, leg imaging, and pulmonary angiography) should be performed next, according to the findings of the chest X-ray. If there is undue delay in arranging investigations for patients with high clinical probability, heparin should be started, unless high risk to anticoagulation is present. In this review the diagnostic methods are discussed and some strategies for rapid investigation of PTE are shown with the main purpose of adapting them to Brazilian reality.

Keywords: Pulmonary thromboembolism. Diagnosis. Management strategy.

Acute pulmonary thromboembolism (APTE) is a highly prevalent condition (104-183 cases per 100,000 person-years) and is potentially fatal. Approximately 20% of patients with APTE are hypotensive, being considered at high risk of death. In such patients, immediate lung reperfusion is necessary in order to reduce right ventricular afterload and to restore hemodynamic stability. To reduce pulmonary vascular resistance in APTE and, consequently, to improve right ventricular function, lung reperfusion strategies have been developed over time and widely studied in recent years. In this review, we focus on advances in the indication and use of systemic thrombolytic agents, as well as lung reperfusion via endovascular and classical surgical approaches, in APTE.

Keywords: Embolism; Shock; Hypotension; Thrombolytic therapy; Reperfusion; Hemorrhage.

Objective: This study aimed to assess the adequacy of venous thromboembolism (VTE) prophylaxis prescription after a protocol implementation. Methods: This was a before‑and‑after study conducted in a tertiary care hospital in Rio Grande do Sul, Southern Brazil. Medical and surgical inpatients aged 18 years or older were assessed for VTE risk and subsequently for thromboprophylaxis adequacy, according to their risk. The evaluations occurred before and after the protocol strategy implementation; it consisted of an online platform to access the protocol, a public posting of the protocol diagram, clinical alerts on the medical staff TV, e-mail alerts, and pop-up alerts on the computerized physician order entry system. The main outcome measure was the adequacy of VTE prophylaxis prescription according to the protocol. Results: A total of 429 patients were evaluated for thromboprophylaxis adequacy (213 before and 216 after). The prevalence of adequacy increased from 54% to 63% (pre and post‑intervention, respectively), and after adjustment for patient type and phase of the study, the prevalence ratio reached (PR)=1.20, 95% confidence interval (CI) 1.02-1.42. Conclusion: The results showed that the overall appropriateness of thromboprophylaxis prescription was weakly improved. Despite these results, this study provides evidence to date a bunch of strategies for protocol implementations in private institutions in middle‑income countries with an open medical staff, as there are few studies investigating these simple and pragmatic interventions.

Keywords: Venous thromboembolism; Guideline adherence; Prevention; Thromboprophylaxis.

The diagnosis of acute pulmonary thromboembolism is based on the clinical probability, use of D-dimer (when available) and imaging. The main imaging modalities used in the diagnosis are ventilation-perfusion (V/Q), angiography, and computed tomography (CT). In the last decade several studies have demonstrated that spiral CT has a high sensitivity and specificity in the diagnosis of acute pulmonary thromboembolism. The evaluation of the pulmonary arteries has further improved with the recent introduction of multidetector spiral CT scanners. Various investigators have suggested that spiral CT pulmonary angiography should replace scintigraphy in the assessment of patients whose symptoms are suggestive of acute PE. This article discusses the role of the various imaging modalities in the diagnosis of acute pulmonary thromboembolism with emphasis on the role of spiral CT.

Keywords: Diagnostic imaging. Pulmonary embolism./diagnosis. Angiography. Lung diseases/radionuclide imaging. Tomography, emission-computed single-photon/methods.

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 present the high-resolution computed tomography (HRCT) findings of pulmonary alveolar microlithiasis. Methods: The HRCT scans of 10 adult patients (seven females and three males; mean age, 38.7 years) were retrospectively analyzed. The films were studied independently by two radiologists. Results: The most common tomographic findings were ground-glass attenuation and linear subpleural calcifications, which were seen in 90% of the patients. Other relevant findings were small parenchymal nodules, calcification along the interlobular septa, nodular cissures, subpleural nodules, subpleural cysts, dense consolidations, and a mosaic pattern of attenuation. Conclusions: The HRCT findings presented by individuals with pulmonary alveolar microlithiasis are distinct. In most cases, such findings can form the basis of the diagnosis, eliminating the need to perform a lung biopsy.

Keywords: Tomography, X-Ray Computed; Lithiasis/lung; Lung diseases.

Objectives: The purpose of this study is to establish the prevalence of pulmonary thromboembolism (PTE) in autopsies and its rate of antemortem suspicion at Hospital de Clínicas de Porto Alegre (HCPA). Design: Cohort study with historical data. Setting: School hospital with 728 beds. Patients and methods: The adult autopsy reports were studied from 1985 to 1995 as well as the records of patients whose autopsies diagnosed PTE. Antemortem suspicion of PTE was considered from explicit notes on patients records, from requests of lung scan, or from full anticoagulation. Results: In the period mentioned, 9,607 deaths occurred, and 767 (7.98%) autopsies were performed. Significant PTE (> 1 pulmonary subsegment) in 30 (3.9%) patients. In 3 (10%) patients, PTE was considered the effective cause of death. Clinic suspicion was present in 5 (16.6%) patients; in 25 (83.4%) patients, there were only postmortem findings. Conclusion: PTE rates in autopsies were similar to those found in international literature. The rates of clinical suspicion were half of the ones mentioned in school hospitals in the United States and Europe. PTE was subsuspected in life in patients hospitalized at HCPA.

Keywords: Venous thromboembolism. Deep venous thrombosis. Pulmonary artery. Pulmonary infarction.

Pulmonary thromboembolism is a common condition. Its diagnosis usually requires pulmonary scintigraphy, computed angiotomography, pulmonary arteriography and, in order to rule out other diagnoses, the measurement of D-dimer levels. Due to the fact that these diagnostic methods are not available in most Brazilian hospitals, the validation of other diagnostic techniques is of fundamental importance. We describe a case of a woman with chronic pulmonary hypertension who experienced a pulmonary thromboembolism event. Pulmonary scintigraphy, computed angiotomography and pulmonary arteriography were used in the diagnosis. The D-dimer test result was positive. Volumetric capnography was performed at admission and after treatment. The values obtained were compared with the imaging test results.

Keywords: Thromboembolism; Hypertension, pulmonary; Capnography; Schistosomiasis.

Objective: To determine the prevalence of alternative diagnoses based on chest CT angiography (CTA) in patients with suspected pulmonary thromboembolism (PTE) who tested negative for PTE, as well as whether those alternative diagnoses had been considered prior to the CTA. Methods: This was a cross-sectional, retrospective study involving 191 adult patients undergoing CTA for suspected PTE between September of 2009 and May of 2012. Chest X-rays and CTAs were reviewed to determine whether the findings suggested an alternative diagnosis in the cases not diagnosed as PTE. Data on symptoms, risk factors, comorbidities, length of hospital stay, and mortality were collected. Results: On the basis of the CTA findings, PTE was diagnosed in 47 cases (24.6%). Among the 144 patients not diagnosed with PTE via CTA, the findings were abnormal in 120 (83.3%). Such findings were consistent with an alternative diagnosis that explained the symptoms in 75 patients (39.3%). Among those 75 cases, there were only 39 (20.4%) in which the same alterations had not been previously detected on chest X-rays. The most common alternative diagnosis, made solely on the basis of the CTA findings, was pneumonia (identified in 20 cases). Symptoms, risk factors, comorbidities, and the in-hospital mortality rate did not differ significantly between the patients with and without PTE. However, the median hospital stay was significantly longer in the patients with PTE than in those without (18.0 and 9.5 days, respectively; p = 0.001). Conclusions: Our results indicate that chest CTA is useful in cases of suspected PTE, because it can confirm the diagnosis and reveal findings consistent with an alternative diagnosis in a significant number of patients.

Keywords: Pulmonary embolism/diagnosis; Pulmonary embolism/epidemiology; Angiography.

Objective: To analyze the clinicopathological aspects of bronchioloalveolar carcinoma (BAC) and the survival in a sample of patients at clinical stage I. Methods: A retrospective study involving 26 patients diagnosed with clinical stage I BAC and undergoing surgery at the Thoracic Diseases Institute of the Federal University of Rio de Janeiro, in the city of Rio de Janeiro, Brazil, between 1987 and 2007. We analyzed clinicopathological and radiological aspects, as well as mortality and survival. The data, which were collected from the medical charts of the patients, were statistically analyzed. Results: Females predominated (n = 16). The mean age at diagnosis was 68.5 years. Most patients were active smokers (69.2%). The most common forms of presentation of BAC were the asymptomatic form (84.6%) and the nodular form (88.5%). Involvement of the upper lobes predominated (57.7%). Stage IB was the most common pathological stage, followed by stages IA and IIB (46.2%, 38.4% and 15.4%, respectively). There was no in-hospital mortality. Four patients died during the postoperative follow-up, with a mean disease-free survival time of 21.3 months. The overall five-year survival rate was 83%. The probability of survival for the patients diagnosed after 1999 showed a trend toward an increase when compared with that for those diagnosed up through 1999 (three-year survival rate: 92% vs. 68%; p = 0.07). Conclusions: The clinicopathological aspects of this study sample were similar to those of patients with BAC evaluated in previous studies.

Keywords: Adenocarcinoma, bronchiolo-alveolar; Carcinoma, non-small-cell lung; Lung; Smoking.

Objective: To correlate tomographic findings with pulmonary function parameters in patients with idiopathic pulmonary fibrosis (IPF). Methods: A cross-sectional study was carried out, in which 30 nonsmoking patients with IPF were evaluated. Using a semiquantitative scoring system, the following high-resolution computerized tomography (HRCT) findings were quantified: total interstitial disease (TID), reticular abnormality/honeycombing, and ground-glass opacity (GGO). The functional variables were measured by spirometry, forced oscillation technique (FOT), helium dilution method, as well as the single-breath method of measuring diffusion capacity of the lung for carbon monoxide (DLCO). Results: Of the 30 patients studied, 18 were female, and 12 were male, with a mean age of 70.9 years. We found that TID and reticular abnormality and honeycombing correlated significantly (negative correlations) with the measurements of forced vital capacity (FVC), total lung capacity (TLC), DLCO, and dynamic respiratory compliance were found, as well as that GGO correlated significantly (and positively) with residual volume/TLC. The ratio of forced expiratory flow between 25 and 75% of FVC to FVC (FEF25-75%/FVC) correlated positively with TID, reticular abnormality/honeycombing, and GGO. Conclusion: In IPF patients, the measurements of volume, diffusion, and dynamic compliance are the physiological variables which best reflect the extent of the interstitial disease on HRCT scans.

Keywords: Lung diseases, interstitial; Pulmonary fibrosis; Tomography, X-ray computed; Respiratory function tests.

Objective: To evaluate HRCT scans of the chest in 22 patients with cocaine-induced pulmonary disease. Methods: We included patients between 19 and 52 years of age. The HRCT scans were evaluated by two radiologists independently, discordant results being resolved by consensus. The inclusion criterion was an HRCT scan showing abnormalities that were temporally related to cocaine use, with no other apparent causal factors. Results: In 8 patients (36.4%), the clinical and tomographic findings were consistent with "crack lung", those cases being studied separately. The major HRCT findings in that subgroup of patients included ground-glass opacities, in 100% of the cases; consolidations, in 50%; and the halo sign, in 25%. In 12.5% of the cases, smooth septal thickening, paraseptal emphysema, centrilobular nodules, and the tree-in-bud pattern were identified. Among the remaining 14 patients (63.6%), barotrauma was identified in 3 cases, presenting as pneumomediastinum, pneumothorax, and hemopneumothorax, respectively. Talcosis, characterized as perihilar conglomerate masses, architectural distortion, and emphysema, was diagnosed in 3 patients. Other patterns were found less frequently: organizing pneumonia and bullous emphysema, in 2 patients each; and pulmonary infarction, septic embolism, eosinophilic pneumonia, and cardiogenic pulmonary edema, in 1 patient each. Conclusions: Pulmonary changes induced by cocaine use are varied and nonspecific. The diagnostic suspicion of cocaine-induced pulmonary disease depends, in most of the cases, on a careful drawing of correlations between clinical and radiological findings.

Keywords: Cocaine, Cocaine-related disorders; Tomography, X-ray computed; Lung diseases.