Background - The critical donor shortage in pediatric pulmonary transplantation has prompted lobar transplantation from living-related. However, in the case of great size discrepancy between the adult donor and the small child recipient, a pulmonary segment or medium lobe represents grafts with restricted vascular bed. The authors hypothesized that this type of graft may develop pulmonary hypertension in the recipient by the end of the growth period. Methods - This hypothesis was investigated in a porcine survival model of lung transplantation in piglets. There were three groups for comparison purposes: I (n = 4) - transplantation of the upper lobe from an adult donor, graft being proportional to the recipient but irrigated by two arterial rami only; II (n = 5) - transplantation of the lower lobe from an adult donor, graft being oversized to the recipient and having adequate vascular bed; III (n = 6) - transplantation of immature lung, from matched-sized donor. Graft function was studied three months after the transplantation, when the growth period was completed. Results - The pulmonary artery pressure of grafts in group I (51.8 ± 2.1 mmHg) was increased compared to that of group II (40.4 ± 2.5 mmHg) and of group III (34.8 ± 1.5 mmHg), reaching statistical significance (p = 0.0003). Conclusions - The lobar graft proportional to the recipient, with restricted vascular bed, had hampered hemodynamic performance in the growing animal. These results suggest that graft proportionality should be secondary to an adequate vascular bed.

Keywords: Lung transplantation. Lobar transplantation, experimental. Swine.

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 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.

Objective: To analyze the rate at which lungs available for transplantation in the state of São Paulo in 2006 were utilized and to determine the lung donor profile in the same period. Methods: A retrospective study of 497 clinical charts of lung tissue donors from January to December of 2006. Results: According to the clinical charts, lungs were not offered for transplant in 149 cases (30%), which were therefore excluded from the study. Among the 348 lung donors eligible for inclusion in the study, the mean age was 37.4 ± 16.1 years, and 56.9% were males. The main causes of brain death among the donors were stroke (in 40.5%), skull-brain trauma (in 34.2%) and subarachnoid hemorrhage (in 10.9%). The great majority of these lung donors (90.5%) received vasoactive agents, and 13.5% presented cardiopulmonary arrest. The mean donor leukocyte count was 15,008 ± 6,467 cells/mm3, 67.8% of the donors received anti-bacterial agents, and 26.1% presented lung infection. Nearly 40% of the lung donors presented chest X-ray abnormalities. Only 4.9% of the lung donors were accepted, representing 28 lungs (allograft utilization rate of 4%). The causes for donor exclusion were gas exchange alterations (in 30.1%), infection (in 23.7%) and distance (in 10.9%). Conclusions: The lung utilization rate in the state of São Paulo is low when compared to mean rates worldwide. In addition, more than half of the donor pool was excluded due to altered gas exchange or pulmonary infection. The combination of better care of the potential donor and more flexible selection criteria could increase allograft utilization.

Keywords: Lung transplantation; Donor selection; Tissue donors.

Bronchial healing remains one of the dominant issues in lung transplantation. Among other factors, the quality of airway protection during procurement may contribute to improve bronchial healing. In most centers lung preservation is performed using the pulmonary artery (PA) flush perfusion (FP). The present study was performed to investigate the influence of different routes of perfusion on the distribution of Euro-Collins solution (EUC) in lung parenchyma and upper airways in swine. The animals were divided into 4 groups, 1 without FP; Control (n=6), and the others with EUC delivery via: pulmonary artery (PA) (n=6); pulmonary and bronchial arteries simultaneously (PA+BA) (n=8), and pulmonary veins (PV). Lungs and airways were assessed by the following methods: dye-labeled microspheres for total and regional perfusion, tissue water content, and lung temperature. There was no significant difference in total lung flow between PA+BA and PA, both superior to the PV group. Flow in the proximal and distal trachea were significantly increased: PA+BA (0.970 ± 0.4 and 0.380 ± 0.2 mL/min/g, respectively); PA ( 0.023 ± 0.007 and 0.024 ± 0.07 mL/min/g, respectively); PV (0.009 ± 0.003 and 0.021 ± 0.006 mL/min/g respectively) and Control experiments (0.125 ± 0.0018 and 0.105 ±0.012 mL/min/g, respectively). The highest flow rates in the right main bronchus were achieved by PA+BA (1.04 ± 0.4 mL/min/g) as comparison to Control, PA, and PV groups (0.11 ± 0.03, 0.033 ± 0.008, and 0.019 ± 0.005 mL/min/g, respectively). Flows in the left main bronchus were significantly increased by PA+BA (0.97 ± 0.3 mL/min/g), as comparison to control, PA and PV groups (0.09 ± 0.02, 0.045 ± 0.012, and 0.027 ± 0.006 mL/min/g, respectively). In conclusion, these data showed that the distribution of EUC in airways of swine is significantly improved by PA+BA perfusion.

Keywords: Lung transplantation. Flush perfusion. Bronchial circulation. Bronchial complications.

Objective: To use an experimental model to evaluate the effect of heart failure on oxidative stress in the rat diaphragm. Methods: The model of myocardial infarction was developed through left coronary artery ligation. On day 42 after coronary artery ligation, the animals were killed, after which the diaphragms were collected and homogenized. Oxidative stress was evaluated in diaphragm homogenates through measurement of lipid peroxidation and assays of the activity of antioxidant enzymes, including catalase and glutathione peroxidase (enzymes that reduce hydrogen peroxide to water), as well as superoxide dismutase (an antioxidant enzyme that reduces superoxide anions to hydrogen peroxide). Results: The coronary artery ligation model was found to be effective in causing heart failure. In the animals submitted to coronary artery ligation, the mean infarcted area of the left ventricle was 39%. Lipid peroxidation was 217% greater in the diaphragms of ligated animals than in those of controls. The activity of catalase and glutathione peroxidase was 77% and 20% lower, respectively, in study rats than in control rats. Infarction did not modify superoxide dismutase activity. Conclusion: The results suggest that left coronary artery ligation results in oxidative stress in the diaphragm.

Keywords: Myocardial infarction; Oxidative stress; Congestive heart failure; Antioxidants; Diaphragm; Rats

Congenital lobar emphysema is a disease in which symptoms often begin during the first six months of age. In this report, the authors present the case of a twenty-year-old woman whose symptoms started when she had a spontaneous pneumothorax, an exceptional occurrence. The possible etiologies for that congenital lung malformation and the reasons for the performance of a conservative treatment are discussed.

Keywords: Pulmonary emphysema. Pneumothorax. Abnormalities.

Objective: To evaluate post-operative complications in living lobar lung transplant donors. Methods: Between September of 1999 and May of 2005, lobectomies were performed in 32 healthy lung transplant donors for 16 recipients. The medical charts of these donors were retrospectively analyzed in order to determine the incidence of post-operative complications and alterations in pulmonary function after lobectomy. Results: Twenty-two donors (68.75%) presented no complications. Among the 10 donors presenting complications, the most frequently observed complication was pleural effusion, which occurred in 5 donors (15.6% of the sample). Red blood cell transfusion was necessary in 3 donors (9.3%), and 2 donors underwent a second surgical procedure due to hemothorax. One donor presented pneumothorax after chest tube removal, and one developed respiratory infection. There were two intra-operative complications (6.25%): one donor required bronchoplasty of the middle lobe; and another required lingular resection. No intra-operative mortality was observed. Post-operative pulmonary function tests demonstrated an average reduction of 20% in forced expiratory volume in one second (p < 000.1) compared to pre-operative values. Conclusions: Lobectomy in living lung transplant donors presents high risk of post-operative complications and irreversible impairment of pulmonary function. Careful pre-operative evaluation is necessary in order to reduce the incidence of complications in living lobar lung transplant donors.

Keywords: Lung transplantation; Living donors; Pneumonectomy; Postoperative complications.

To review the cases of patients with congenital lobar emphysema (CLE) submitted to surgical treatment at two university hospitals over a 30-year period. Methods: We reviewed the medical records of children with CLE undergoing surgical treatment between 1979 and 2009 at the Botucatu School of Medicine Hospital das Clínicas or the Mogi das Cruzes University Hospital. We analyzed data regarding symptoms, physical examination, radiographic findings, diagnosis, surgical treatment, and postoperative follow-up. Results: During the period studied, 20 children with CLE underwent surgery. The mean age at the time of surgery was 6.9 months (range, 9 days to 4 years). All of the cases presented with symptoms at birth or during the first months of life. In all cases, chest X-rays were useful in defining the diagnosis. In cases of moderate respiratory distress, chest CT facilitated the diagnosis. One patient with severe respiratory distress was misdiagnosed with hypertensive pneumothorax and underwent chest tube drainage. Only patients with moderate respiratory distress were submitted to bronchoscopy, which revealed no tracheobronchial abnormalities. The surgical approach was lateral muscle-sparing thoracotomy. The left upper and middle lobes were the most often affected, followed by the right upper lobe. Lobectomy was performed in 18 cases, whereas bilobectomy was performed in 2 (together with bronchogenic cyst resection in 1 of those). No postoperative complications were observed. Postoperative follow-up time was at least 24 months (mean, 60 months), and no late complications were observed. Conclusions: Although CLE is an uncommon, still neglected disease of uncertain etiology, the radiological diagnosis is easily made and surgical treatment is effective.

Keywords: Respiratory system abnormalities; Congenital abnormalities; Pulmonary surgical procedures; Pulmonary emphysema.

Objective: To describe orofacial muscle function in patients with severe asthma. Methods: This was a descriptive study comparing patients with severe controlled asthma (SCA) and severe uncontrolled asthma (SUA). We selected 160 patients, who completed a sociodemographic questionnaire and the 6-item Asthma Control Questionnaire (ACQ-6), as well as undergoing evaluation of orofacial muscle function. Results: Of the 160 patients evaluated, 126 (78.8%) and 34 (21.2%) presented with SCA and SUA, respectively, as defined by the Global Initiative for Asthma criteria. Regardless of the level of asthma control, the most frequent changes found after evaluation of muscle function were difficulty in chewing, oronasal breathing pattern, below-average or poor dental arch condition, and difficulty in swallowing. When the sample was stratified by FEV1 (% of predicted), was significantly higher proportions of SUA group patients, compared with SCA group patients, showed habitual open-mouth chewing (24.8% vs. 7.7%; p < 0.02), difficulty in swallowing water (33.7% vs. 17.3%; p < 0.04), and voice problems (81.2% vs. 51.9%; p < 0.01). When the sample was stratified by ACQ-6 score, the proportion of patients showing difficulty in swallowing bread was significantly higher in the SUA group than in the SCA group (66.6% vs. 26.6%; p < 0.01). Conclusions: The prevalence of changes in the stomatognathic system appears to be high among adults with severe asthma, regardless of the level of asthma control. We found that some such changes were significantly more common in patients with SUA than in those with SCA.

Keywords: Speech/physiology; Stomatognathic system/physiopathology; Asthma/complications; Deglutition disorders; Mastication/physiology.

Diabetes mellitus is an endocrine/metabolic disorder characterized by hyperglycemia. Its impact on the respiratory system is characterized by functional changes and alterations in gas exchange. The objective of this study was to evaluate the increase in oxidative stress and the potential damages to the lung structure in an experimental model of streptozotocin-induced diabetes. We conducted histological, biochemical and blood gas analyses in the lungs of diabetic rats. We concluded that the effects of experimental diabetes mellitus include oxidative stress, structural changes in the lung tissue and altered gas exchange.

Keywords: Lung; Diabetes mellitus; Oxidative stress; Diabetes mellitus, experimental; Free radicals.

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 evaluate different weight loss (WL) cut-off points as prognostic markers of 3-month survival after diagnosis of stage IV non-small cell lung cancer (NSCLC). Methods: This was a prospective study involving 104 patients with metastatic (stage IV) NSCLC who were admitted to a cancer treatment center in southern Brazil between January of 2014 and November of 2016. We evaluated total WL and WL per month, as well as WL and WL per month in the 6 months preceding the diagnosis. The patients were followed for 3 months after diagnosis. A Cox proportional hazards regression model and Kaplan-Meier curves were used in order to evaluate 3-month survival. Results: The median WL in the 6 months preceding the diagnosis was 6% (interquartile range, 0.0- 12.9%). Patients with WL ≥ 5% had a median survival of 78 days, compared with 85 days for those with WL < 5% (p = 0.047). Survival at 3 months was 72% for the patients with WL ≥ 5% (p = 0.047), 61% for those with WL ≥ 10% (p < 0.001), and 45% for those with WL ≥ 15% (p < 0.001). In the multivariate analysis, the hazard ratio for risk of death was 4.51 (95% CI: 1.32-15.39) for the patients with WL ≥ 5%, 6.34 (95% CI: 2.31-17.40) for those with WL ≥ 10%, and 14.17 (95% CI: 5.06-39.65) for those with WL ≥ 15%. Conclusions: WL in the 6 months preceding the diagnosis of NSCLC is a relevant prognostic factor and appears to be directly proportional to the rate of survival at 3 months.

Keywords: Weight loss; Carcinoma, non-small-cell lung; Prognosis.

Objective: This paper is a continuation of the study on the validity of equations of predicted value (PV) for the Brazilian population. A comparison was made between the equations proposed by Mallozi and by Polgar for the Brazilian population, which are mainly used in the United States and Europe. Methods: PVs of 185 patients of both sexes (89 boys and 96 girls), ages between 6 and 17 years, were analyzed. For each subject, the PVs for forced vital capacity (FVC), forced expiratory volume at 1 sec. (FEV1), and the medium expiratory flow (MEF) were calculated according to the equations proposed by Mallozi and Polgar. Results were compared. Diagnoses were made according to the Brazilian Consensus of Spirometry. Results: The PV-M for FVC is 0.38% higher for boys and 2.19% higher for girls than that determined by Polgar. The PV-P for FEV1 is 6.67% (p < 0.05) lower for girls, suggesting an underassessment of the obstructive impairment. For boys, a mean lower value of 7.26% as compared to the VT-M is at the limit of significance (0.05 < p < 0.01). No significant difference between the two equations analyzed was found for MEF. Conclusions: The PVs for CVF and VEF1 for Brazilian children, according to Mallozzi, are significantly different when compared to those published by authors like Polgar. As a result, the authors found that Mallozzi's equations are more likely to detect obstructive impairment and less likely to diagnose restrictive ventilatory insufficiency.

Keywords: Spirometry. Vital capacity. Forced expiratory volume. Maximal medium expiratory flow rate. Case-control studies

Objective: To compare the efficacy, safety, and tolerability of azithromycin and amoxicillin in the treatment of patients with infectious exacerbation of chronic obstructive pulmonary disease. Methods: This study was conducted at six medical centers across Brazil and included 109 patients from 33 to 82 years of age. Of those, 102 were randomized to receive either azithromycin (500 mg/day for three days, n = 49) or amoxicillin (500 mg every eight hours for ten days, n = 53). The patients were evaluated at the study outset, on day ten, and at one month. Based on the clinical evaluation of the signs and symptoms present on day ten and at one month, the outcomes were classified as cure, improvement, or treatment failure. The microbiological evaluation was made through the culture of sputum samples that were considered appropriate samples only after leukocyte counts and Gram staining. Secondary efficacy evaluations were made in order to analyze symptoms (cough, dyspnea, and expectoration) and pulmonary function. Results: There were no differences between the groups treated with azithromycin or amoxicillin in terms of the percentages of cases in which the outcomes were classified as cure or improvement: 85% vs. 78% (p = 0.368) on day ten; and 83% vs. 78% (p = 0.571) at one month. Similarly, there were no significant differences between the two groups in the secondary efficacy variables or the incidence of adverse effects. Conclusion: Azithromycin and amoxicillin present similar efficacy and tolerability in the treatment of acute exacerbation of chronic obstructive pulmonary disease.

Keywords: Amoxicillin/therapeutic use; Azithromycin/therapeutic use; Bronchitis, chronic/drug therapy;

Objective: Wood smoke exposure is a risk factor for COPD. For a given degree of airway obstruction, the reduction in DLCO is smaller in individuals with wood smoke-related COPD than in those with smoking-related COPD, suggesting that there is less emphysema in the former. The objective of this study was to compare HRCT findings between women with wood smoke-related COPD and women with smoking-related COPD. Methods:áTwenty-two women with severe COPD (FEV1/FVC ratio < 70% and FEV1 < 50%) were divided into two groups: those with wood smoke-related COPD (n = 12) and those with smoking-related COPD (n = 10). The two groups were compared regarding emphysema scores and airway involvement (as determined by HRCT); and functional abnormalities-spirometry results, DLCO, alveolar volume (VA), the DLCO/VA ratio, lung volumes, and specific airway resistance (sRaw). Results: There were no significant differences between the two groups in terms of FEV1, sRaw, or lung hyperinflation. Decreases in DLCO and in the DLCO/VA ratio were greater in the smoking-related COPD group subjects, who also had higher emphysema scores, in comparison with the wood smoke-related COPD group subjects. In the wood smoke-related COPD group, HRCT scans showed no significant emphysema, the main findings being peribronchial thickening, bronchial dilation, and subsegmental atelectasis. Conclusions: Female patients with severe wood smoke-related COPD do not appear to develop emphysema, although they do show severe airway involvement. The reduction in DLCO and VA, with a normal DLCO/VA ratio, is probably due to severe bronchial obstruction and incomplete mixing of inspired gas during the determination of single-breath DLCO.