Objective: Frequent readmissions for acute exacerbations of COPD (AECOPD) are an independent risk factor for increased mortality and use of health-care resources. Disease severity and C-reactive protein (CRP) level are validated predictors of long-term prognosis in such patients. This study investigated the utility of combining serum CRP level with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) exacerbation risk classification for predicting readmission for AECOPD. Methods: This was a prospective observational study of consecutive patients hospitalized for AECOPD at Peking University Third Hospital, in Beijing, China. We assessed patient age; gender; smoking status and history (pack-years); lung function; AECOPD frequency during the last year; quality of life; GOLD risk category (A-D; D indicating the greatest risk); and serum level of high-sensitivity CRP at discharge (hsCRP-D). Results: The final sample comprised 135 patients. Of those, 71 (52.6%) were readmitted at least once during the 12-month follow-up period. The median (interquartile) time to readmission was 78 days (42-178 days). Multivariate analysis revealed that serum hsCRP-D ≥ 3 mg/L and GOLD category D were independent predictors of readmission (hazard ratio = 3.486; 95% CI: 1.968-6.175; p < 0.001 and hazard ratio = 2.201; 95% CI: 1.342-3.610; p = 0.002, respectively). The ordering of the factor combinations by cumulative readmission risk, from highest to lowest, was as follows: hsCRP-D ≥ 3 mg/L and GOLD category D; hsCRP-D ≥ 3 mg/L and GOLD categories A-C; hsCRP-D < 3 mg/L and GOLD category D; hsCRP-D < 3 mg/L and GOLD categories A-C. Conclusions: Serum hsCRP-D and GOLD classification are independent predictors of readmission for AECOPD, and their predictive value increases when they are used in combination.

Keywords: Pulmonary disease, chronic obstructive/epidemiology; Acute disease; Acute-phase proteins; Hospitalization; Patient readmission; Inflammation.

We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.

Keywords: Empyema, pleural; Pneumonia, pneumococcal; Pneumococcal infections.

Objective: To assess ICU patients with COPD, in terms of in-hospital characteristics, two-year mortality and two-year functional status of survivors. Methods: A prospective cohort study involving patients with acute exacerbation of COPD admitted to the ICUs of two hospitals in the city of Porto Alegre, Brazil, between July of 2005 and July of 2006. At two years after discharge, survivors were interviewed by telephone in order to determine Karnofsky scores and scores on a scale regarding activities of daily living (ADL). Results: The sample comprised 231 patients. In-hospital mortality was 37.7%, and two-year post-discharge mortality was 30.3%. Of the 74 survivors, 66 were interviewed (89%). The mean age at ICU admission was 74 ± 10 years, and the mean Acute Physiology and Chronic Health Evaluation II score was 18 ± 7. Two or more comorbidities were present in 87.8% of the patients. Of the 66 interviewees, 57 (86.3%) lived at home, 58 (87.8%) were self-sufficient, 12 (18.1%) required oxygen therapy, and 4 (6.1%) still required ventilatory support. There was a significant reduction in the quality of life and autonomy of the survivors, as evidenced by the Karnofsky scores (85 ± 9 vs. 79 ± 11, p = 0.03) and ADL scale scores (29 ± 5 vs. 25 ± 7; p = 0.01), respectively. Conclusions: In this patient sample, two-year mortality was quite high. Although there was a noticeable reduction in the functional status of the survivors, they remained self-sufficient.

Keywords: Pulmonary disease, chronic obstructive/mortality; Quality of life; Intensive care units.

Objective: To evaluate the diagnostic performance of the rapid shallow breathing index (RSBI) in predicting extubation failure among adult patients in the intensive care unit and to determine the appropriateness of the classical RSBI cut-off value. Methods: This was a prospective study conducted in the adult intensive care unit of the Botucatu School of Medicine Hospital das Clínicas. The RSBI was evaluated in 73 consecutive patients considered clinically ready for extubation. Results: The classical RSBI cut-off value (105 breaths/min/L) presented a sensitivity of 20% and a specificity of 95% (sum = 115%). Analysis of the receiver operator characteristic (ROC) curve revealed a better cut-off value (76.5 breaths/min/L), which presented a sensitivity of 66% and a specificity of 74% (sum = 140%). The area under the ROC curve for the RSBI was 0.78. Conclusions: The classical RSBI cut-off value proved inappropriate, predicting only 20% of the cases of extubation failure in our sample. The new cut-off value provided substantial improvement in sensitivity, with an acceptable loss of specificity. The area under the ROC curve indicated that the discriminative power of the RSBI is satisfactory, which justifies the validation of this index for use.

Keywords: Adult; Intensive care; ROC curve; Ventilator weaning; Diagnosis; Respiration, artificial.

Objective: To determine whether serum selenium levels are associated with the conversion of bacteriological tests in patients diagnosed with active pulmonary tuberculosis after eight weeks of standard treatment. Methods: We evaluated 35 healthy male controls and 35 male patients with pulmonary tuberculosis, the latter being evaluated at baseline, as well as at 30 and 60 days of antituberculosis treatment. For all participants, we measured anthropometric indices, as well as determining serum levels of albumin, C-reactive protein (CRP) and selenium. Because there are no reference values for the Brazilian population, we used the median of the serum selenium level of the controls as the cut-off point. At 30 and 60 days of antituberculosis treatment, we repeated the biochemical tests, as well as collecting sputum for smear microscopy and culture from the patients. Results: The mean age of the patients was 38.4  11.4 years. Of the 35 patients, 25 (71%) described themselves as alcoholic; 20 (57.0%) were smokers; and 21 (60.0%) and 32 (91.4%) presented with muscle mass depletion as determined by measuring the triceps skinfold thickness and arm muscle area, respectively. Of 24 patients, 12 (39.2%) were classified as moderately or severely emaciated, and 15 (62.5%) had lost > 10% of their body weight by six months before diagnosis. At baseline, the tuberculosis group had lower serum selenium levels than did the control group. The conversion of bacteriological tests was associated with the CRP/albumin ratio and serum selenium levels 60 days after treatment initiation. Conclusions: Higher serum selenium levels after 60 days of treatment were associated with the conversion of bacteriological tests in pulmonary tuberculosis patients.

Keywords: Selenium; Nutritional status; Tuberculosis; Immunity.

Objective: To evaluate the value of soluble urokinase-type plasminogen activator receptor (suPAR) in the diagnosis of acute exacerbation of COPD (AECOPD) and in monitoring treatment response, analyzing the relationship between suPAR and fibrinogen in AECOPD. AECOPD leads to increased airway inflammation, contributing to an exaggerated release of inflammatory mediators. Methods: We recruited 45 patients with AECOPD and 20 healthy control subjects. Medical histories were taken, and all subjects underwent clinical examination, chest X-ray, pulmonary function tests, and blood gas analysis. On day 1 (treatment initiation for the AECOPD patients) and day 14 (end of treatment), blood samples were collected for the determination of serum suPAR and plasma fibrinogen. Results: Serum levels of suPAR were significantly higher in the AECOPD group than in the control group. In the AECOPD patients, there was a significant post-treatment decrease in the mean serum suPAR level. The sensitivity, specificity, and accuracy of suPAR were 95.6%, 80.0%, and 93.0%, respectively. The Global Initiative for Chronic Obstructive Lung Disease stage (i.e., COPD severity) correlated positively and significantly with serum levels of suPAR and plasma levels of fibrinogen. Conclusions: Monitoring the serum suPAR level can be helpful in the evaluation of the COPD treatment response and might be a valuable biomarker for determining the prognosis of AECOPD. Because serum suPAR correlated with plasma fibrinogen, both markers could be predictive of AECOPD.

Keywords: Pulmonary disease, chronic obstructive/complications; Pulmonary disease, chronic obstructive/diagnosis; Receptors, urokinase plasminogen activator; Fibrinogen.

Objective: To validate the Pulmonary Embolism Severity Index (PESI), which was developed for risk stratification after acute pulmonary embolism (PE), for use in Brazil. Methods: This was a single-center retrospective study involving patients admitted to the emergency department with acute PE. The original and simplified versions of the PESI were calculated using hospital admission data from medical records. The outcome measure was the overall 30-day mortality rate. Results: We included 123 patients. The mean age was 57 ± 17 years, and there was a predominance of females, who accounted for 60% of the cohort. There were 28 deaths, translating to an overall 30-day mortality rate of 23%. In the cluster analysis by risk class, overall 30-day mortality was 2.40% for classes I-II, compared with 20.00% for classes III-IV-V (relative risk [RR] = 5.9; 95% CI: 1.88-18.51; p = 0.0002). When we calculated overall 30-day mortality using the simplified version (0 points vs. ≥ 1 point), we found it to be 3.25% for 0 points and 19.51% for ≥ 1 point (RR = 2.38; 95% CI: 0.89-6.38; p = 0.06). Using the original version, a survival analysis showed that risk classes I and II presented similar Kaplan-Meier curves (p = 0.59), as did risk classes III, IV, and V (p = 0.25). However, the curve of the clusters based on the original version, showed significantly higher mortality in the III-IV-V classes than in the I-II classes (RR = 7.63; 95% CI: 2.29-25.21; p = 0.0001). The cluster analysis based on the original version showed a greater area under the ROC curve than did the analysis based on the simplified version (0.70; 95% CI: 0.62-0.77 vs. 0.60; 95% CI: 0.51-0.67; p = 0.05). Conclusions: The PESI adequately predicted the prognosis after acute PE in this sample of the population of Brazil. The cluster analysis based on the original version is the most appropriate analysis in this setting.

Keywords: Pulmonary embolism; Severity of illness index; Risk assessment.

Objective: To determine whether a restrictive pattern on spirometry is associated with the level of physical activity in daily life (PADL), as well as with cardiovascular disease (CVD) risk factors, in asymptomatic adults. Methods: A total of 374 participants (mean age, 41 ± 14 years) underwent spirometry, which included the determination of FVC and FEV1. A restrictive pattern on spirometry was defined as an FEV1/FVC ratio > 0.7 and an FVC < 80% of the predicted value. After conducting demographic, anthropometric, and CVD risk assessments, we evaluated body composition, muscle function, and postural balance, as well as performing cardiopulmonary exercise testing and administering the six-minute walk test. The PADL was quantified with a triaxial accelerometer. Results: A restrictive pattern on spirometry was found in 10% of the subjects. After multivariate logistic regression, adjusted for confounders (PADL and cardiorespiratory fitness), the following variables retained significance (OR; 95% CI) as predictors of a restrictive pattern: systemic arterial hypertension (17.5; 1.65-184.8), smoking (11.6; 1.56-87.5), physical inactivity (8.1; 1.43-46.4), larger center-of-pressure area while standing on a force platform (1.34; 1.05-1.71); and dyslipidemia (1.89; 1.12-1.98). Conclusions: A restrictive pattern on spirometry appears to be common in asymptomatic adults. We found that CVD risk factors, especially systemic arterial hypertension, smoking, and physical inactivity, were directly associated with a restrictive pattern, even when the analysis was adjusted for PADL and cardiorespiratory fitness. Longitudinal studies are needed in order to improve understanding of the etiology of a restrictive pattern as well as to aid in the design of preventive strategies.

Keywords: Spirometry; Hypertension; Motor activity; Sedentary lifestyle; Smoking.

Objective: A substantial number of people with COPD suffer from exacerbations, which are defined as an acute worsening of respiratory symptoms. To minimize exacerbations, telehealth has emerged as an alternative to improve clinical management, access to health care, and support for self-management. Our objective was to map the evidence of telehealth/telemedicine for the monitoring of adult COPD patients after hospitalization due to an exacerbation. Methods: Bibliographic search was carried in PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Scopus, Biblioteca Virtual de Saúde/LILACS and Cochrane Library databases to identify articles describing telehealth and telemonitoring strategies in Portuguese, English, or Spanish published by December of 2021. Results: Thirty-nine articles, using the following concepts (number of articles), were included in this review: telehealth (21); telemonitoring (20); telemedicine (17); teleconsultation (5); teleassistance (4); telehomecare and telerehabilitation (3 each); telecommunication and mobile health (2 each); and e-health management, e-coach, telehome, telehealth care and televideo consultation (1 each). All these concepts describe strategies which use telephone and/or video calls for coaching, data monitoring, and health education leading to self-management or self-care, focusing on providing remote integrated home care with or without telemetry devices. Conclusions: This review demonstrated that telehealth/telemedicine in combination with telemonitoring can be an interesting strategy to benefit COPD patients after discharge from hospitalization for an exacerbation, by improving their quality of life and reducing re-hospitalizations, admissions to emergency services, hospital length of stay, and health care costs.

Keywords: Pulmonary disease, chronic obstructive; Symptom flare up; Telemedicine; Patient discharge.

Objective: Acute exacerbations of COPD (AECOPD) are common causes of hospitalization. Various scoring systems have been proposed to classify the risk of clinical deterioration or mortality in hospitalized patients with AECOPD. We sought to investigate whether clinical deterioration and mortality scores at admission can predict adverse events occurring during hospitalization and after discharge of patients with AECOPD. Methods: We performed a retrospective study of patients admitted with AECOPD. The National Early Warning Score 2 (NEWS2), the NEWS288-92%, the Dyspnea, Eosinopenia, Consolidation, Acidemia, and atrial Fibrillation (DECAF) score, and the modified DECAF (mDECAF) score were calculated at admission. We assessed the sensitivity, specificity, and overall performance of the scores for the following outcomes: in-hospital mortality; need for invasive mechanical ventilation or noninvasive ventilation (NIV); long hospital stays; hospital readmissions; and future AECOPD. Results: We included 119 patients admitted with AECOPD. The median age was 75 years, and 87.9% were male. The NEWS288-92% was associated with an 8.9% reduction in the number of individuals classified as requiring close, continuous observation, without an increased risk of death in the group of individuals classified as being low-risk patients. The NEWS288-92% and NEWS2 scores were found to be adequate in predicting the need for acute NIV and longer hospital stays. The DECAF and mDECAF scores were found to be better at predicting in-hospital mortality than the NEWS2 and NEWS288-92%. Conclusions: The NEWS288-92% safely reduces the need for clinical monitoring in patients with AECOPD when compared with the NEWS2. The NEWS2 and NEWS288-92% appear to be good predictors of the length of hospital stay and need for NIV, but they do not replace the DECAF and mDECAF scores as predictors of mortality.

Keywords: Pulmonary disease, chronic obstructive/mortality; Symptom flare up; Early warning score; Length of stay; Patient readmission.

Objective: To describe the clinical results and the degree of satisfaction of patients submitted to thoracic sympathectomy at the level of the fourth and fifth ribs (R4-R5) for the treatment of axillary hyperhidrosis. Methods: We included 118 patients diagnosed with axillary hyperhidrosis and having undergone axillary sympathectomy at the R4-R5 level between March of 2003 and December of 2007 at the Paraná Federal University Hospital de Clínicas, located in the city of Curitiba, Brazil. All procedures were carried out by the same surgeon. Data regarding the resolution of axillary hyperhidrosis and the degree of patient satisfaction with the surgical outcome, as well as compensatory hyperhidrosis in the early and late postoperative periods (after 7 days and after 12 months, respectively), were collected. Results: Of the 118 patients evaluated, 99 (83.9%) and 81 (68.6%) showed complete resolution of the symptoms in the early and late postoperative periods, respectively. Compensatory hyperhidrosis occurred in 49 patients (41.5%) in the early postoperative period and in 77 (65.2%) in the late postoperative period. Of those 77, 55 (71.4%) categorized the compensatory hyperhidrosis as mild. In the early postoperative period, 110 patients (93.2%) were satisfied with the surgical results, and 104 (88.1%) remained so in the late postoperative period. Conclusions: Sympathectomy at the R4-R5 level is efficient in the resolution of primary axillary hyperhidrosis. The degree of patient satisfaction with the long-term surgical results is high. Mild compensatory hyperhidrosis is the main side effect associated with this technique.

Keywords: Hyperhidrosis; Axilla; Sympathectomy; Thoracic surgery, video-assisted.

Objective: To evaluate the pattern of pro-inflammatory cytokines, anti-inflammatory cytokines and the acute phase response (APR) as markers of the response to treatment of pulmonary tuberculosis. Methods: Twenty-eight patients with pulmonary tuberculosis were evaluated at three time points: pretreatment (T0), treatment month 3 (T3) and treatment month 6 (T6). Levels of interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), interleukine-10 (IL-10) and transforming growth factor-beta (TGF-β) were determined using ELISA in the supernatant of peripheral blood mononuclear cell and monocyte culture. Levels of total protein, albumin, globulins, C-reactive protein (CRP), alpha-1-acid glycoprotein (AAG) and erythrocyte sedimentation rate (ESR) were also determined. All of these parameters were also evaluated, only once, in a group of healthy controls. Results: In relation to controls, patients presented cytokine levels and APR that were higher at T0, lower at T3 and either lower (TNF-α, IL-10, TGF-β, AAG and ESR) or normal (IFN-γ and CRP) at T6. Conclusions: For individuals with negative smear sputum microscopy, CRP, AAG and ESR are potential markers of pulmonary tuberculosis and of the need for treatment; CRP (T0 > T3 > T6 = reference) can also be a marker of treatment response. In the patients, the Th0 profile (IFN-γ, IL-10, TNF-α and TGF-β), inducer of and protector against inflammation, predominated at T0, whereas the Th2 profile (IL-10, TNF-α and TGF-β), protecting against the harmful pro-inflammatory effect of the remaining TNF-α, predominated at T6. The behavior of IFN-γ (T0 > T3 > T6 = controls) suggests its use as a marker of treatment response.

Keywords: Acute-phase proteins; Cytokines; Mycobacterium tuberculosis; Tuberculosis/therapy.

Objective: To evaluate characteristics of physical activities in daily life in COPD patients in Brazil, correlating those characteristics with physiological variables. Methods: Physical activities in daily life were evaluated in 40 COPD patients (18 males; 66 ± 8 years of age; FEV1 = 46 ± 16 % of predicted; body mass index = 27 ± 6 kg/m2) and 30 healthy age- and gender-matched subjects, using a multiaxial accelerometer-based sensor for 12 h/day on two consecutive days. We also assessed maximal and functional exercise capacity, using the incremental exercise test and the six-minute walk test (6MWT), respectively; MIP and MEP; peripheral muscle force, using the one-repetition maximum test and the handgrip test; quality of life, using the Saint George's Respiratory Questionnaire (SGRQ); functional status, using the London Chest Activity of Daily Living questionnaire; and dyspnea sensation, using the Medical Research Council (MRC) scale. Results: Mean walking time/day was shorter for COPD patients than for the controls (55 ± 33 vs. 80 ± 28 min/day; p = 0.001), as movement intensity was lower (1.9 ± 0.4 vs. 2.3 ± 0.6 m/s2; p = 0.004). The COPD patients also tended to spend more time seated (294 ± 114 vs. 246 ± 122 min/day, p = 0.08). Walking time/day correlated with the 6MWT (r = 0.42; p = 0.007) and maximal workload (r = 0.41; p = 0.009), as well as with age, MRC scale score and SGRQ activity domain score (−0.31 ≤ r ≤ −0.43; p ≤ 0.05 for all). Conclusions: This sample of Brazilian patients with COPD, although more active than those evaluated in studies conducted in Europe, were less active than were the controls. Walking time/day correlated only moderately with maximal and functional exercise capacity.

Keywords: Pulmonary disease, chronic obstructive; Motor activity; Exercise tolerance.

Objective: Because pulmonary embolism (PE) and COPD exacerbation have similar presentations and symptoms, PE can be overlooked in COPD patients. Our objective was to determine the prevalence of PE during COPD exacerbation and to describe the clinical aspects in COPD patients diagnosed with PE. Methods: This was a prospective study conducted at a university hospital in the city of Ankara, Turkey. We included all COPD patients who were hospitalized due to acute exacerbation of COPD between May of 2011 and May of 2013. All patients underwent clinical risk assessment, arterial blood gas analysis, chest CT angiography, and Doppler ultrasonography of the lower extremities. In addition, we measured D-dimer levels and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels. Results: We included 172 patients with COPD. The prevalence of PE was 29.1%. The patients with pleuritic chest pain, lower limb asymmetry, and high NT-pro-BNP levels were more likely to develop PE, as were those who were obese or immobile. Obesity and lower limb asymmetry were independent predictors of PE during COPD exacerbation (OR = 4.97; 95% CI, 1.775-13.931 and OR = 2.329; 95% CI, 1.127-7.105, respectively). Conclusions: The prevalence of PE in patients with COPD exacerbation was higher than expected. The association between PE and COPD exacerbation should be considered, especially in patients who are immobile or obese.

Keywords: Pulmonary disease, chronic obstructive; Pulmonary embolism; Risk factors.

Objective: To cross-culturally adapt the Duke Activity Status Index (DASI) for use in Brazil and evaluate the reproducibility of the new (Brazilian Portuguese-language) version. Methods: We selected stable patients with clinical and spirometric diagnosis of COPD. Initially, the DASI was translated into Brazilian Portuguese, and the cross-cultural adaptation was performed by an expert committee. Subsequently, 12 patients completed the questionnaire, so that their questions and difficulties could be identified and adjustments could be made. An independent translator back-translated the final version into English, which was then submitted to and approved by the original author. The final Brazilian Portuguese-language version of the DASI was applied to 50 patients at three distinct times. For the assessment of interobserver reproducibility, it was applied twice within a 30-min interval by two different interviewers. For the assessment of intraobserver reproducibility, it was applied again 15 days later by one of the interviewers. Results: The mean age of the patients was 62.3 ± 10.0 years, the mean FEV1 was 45.2 ± 14.7% of the predicted value, and the mean body mass index was 26.8 ± 5.8 kg/m2. The intraclass correlation coefficients for intraobserver and interobserver reproducibility were 0.95 and 0.90, respectively. The correlations between the DASI and the Saint George's Respiratory Questionnaire (SGRQ) domains were all negative and statistically significant. The DASI correlated best with the SGRQ activity domain (r = −0.70), the total SGRQ score (r = −0.66), and the six-minute walk distance (r = 0.55). Conclusions: The Brazilian Portuguese-language version of the DASI is reproducible, fast, and simple, correlating well with the SGRQ.

Keywords: Activities of daily living; Pulmonary disease, chronic obstructive; Reproducibility of results.

Objective: The use of the rapid shallow breathing index (RSBI) is recommended in ICUs, where it is used as a predictor of mechanical ventilation (MV) weaning success. The aim of this study was to compare the performance of the RSBI calculated by the traditional method (described in 1991) with that of the RSBI calculated directly from MV parameters. Methods: This was a prospective observational study involving patients who had been on MV for more than 24 h and were candidates for weaning. The RSBI was obtained by the same examiner using the two different methods (employing a spirometer and the parameters from the ventilator display) at random. In comparing the values obtained with the two methods, we used the Mann-Whitney test, Pearson's linear correlation test, and Bland-Altman plots. The performance of the methods was compared by evaluation of the areas under the ROC curves. Results: Of the 109 selected patients (60 males; mean age, 62 ± 20 years), 65 were successfully weaned, and 36 died. There were statistically significant differences between the two methods for respiratory rate, tidal volume, and RSBI (p < 0.001 for all). However, when the two methods were compared, the concordance and the intra-observer variation coefficient were 0.94 (0.92-0.96) and 11.16%, respectively. The area under the ROC curve was similar for both methods (0.81 ± 0.04 vs. 0.82 ± 0.04; p = 0.935), which is relevant in the context of this study. Conclusions: The satisfactory performance of the RSBI as a predictor of weaning success, regardless of the method employed, demonstrates the utility of the method using the mechanical ventilator.

Keywords: Respiration, artificial; Ventilator weaning; Spirometry.