Objective: To evaluate a 24-month supervised, community-based maintenance exercise program after 3 months of pulmonary rehabilitation (PR) in comparison with a 27-month physical activity counseling program, in terms of the effects on maximal muscle strength, muscle power output, and exercise capacity, in individuals with COPD. Methods: Sixty-three men with moderate-to-severe COPD were recruited from two previous studies. Of those 63 participants, 31 were offered 3 months of PR followed by a 24-month supervised maintenance exercise program (24MME group) and 32 were offered a 27-month physical activity counseling program (27MPAC group). Measurements at 3 months and at the end of the study period included maximal strength of the upper and lower limbs, power output of the lower limbs, six-minute walk distance (6MWD), and quality of life. Results: At 27 months, the improvements in maximal strength of the upper and lower limbs were greater in the 24MME group than in the 27MPAC group (37.6 ± 28.3% and 28.4 ± 13.3%, respectively, vs. 8.8 ± 16% and 13.6 ± 16.4%, respectively; p < 0.05), as was the improvement in power output of the lower limbs (24.6 ± 18.4% vs. −2.3 ± 28.5%; p < 0.01). The increase in the 6MWD after 3 months was also greater in the 24MME group than in the 27MPAC group (33.2 ± 36.6 m vs. 2.9 ± 34.7 m; p < 0.05), although there were no differences between the two groups in terms of the Δ6MWD at 27 months (vs. baseline). Conclusions: A supervised, community-based maintenance program is a successful long-term strategy to preserve the benefits of PR on peripheral muscle function and exercise capacity in individuals with COPD. However, physical activity counseling can maintain maximal muscle strength and exercise capacity in such individuals.

Keywords: Pulmonary disease, chronic obstructive; Muscle strength; Leg/physiology, Muscle, skeletal/physiology; Physical fitness; Exercise therapy/methods.

Objective: Respiratory syncytial virus (RSV) is a major cause of severe respiratory infections in older adults, particularly those with comorbidities. Despite its clinical impact, RSV remains underdiagnosed and underreported. We sought to assess the burden of RSV in older adults (= 60 years of age) in Brazil using national surveillance data for the 2022-2023 period. Methods: We analyzed RSV cases reported in the Sistema de Informação de Vigilância Epidemiológica, identifying them among reported cases of SARS. Cases were examined by demographic characteristics, seasonal trends, and clinical outcomes. RSV cases were compared across defined etiologies. Results: Among 355,230 reported cases of SARS in older adults, 201,965 (56.8%) had a defined etiology, and 1,465 (0.7%) were confirmed as RSV cases. Cases peaked in the second quarter of each year, with the highest incidence in the southern and southeastern regions. Despite a low hospitalization rate (2.3 per 100,000 population), severe outcomes were common: 30.4% required ICU admission, and 24.9% resulted in death, with mortality being highest in those = 90 years of age. Conclusions: RSV-related hospitalizations in Brazil appear underestimated, with reported cases likely representing the most severe spectrum due to underreporting and diagnostic limitations. Seasonal patterns peaked in April-May, and regional differences highlight a higher incidence in the southern and southeastern regions, likely due to epidemiological factors and diagnostic disparities. Although the recent approval of RSV vaccines offers an opportunity to reduce disease burden, successful implementation requires broader access and inclusion in the Brazilian National Immunization Program. Strengthening surveillance, diagnostic capacity, and reporting processes is critical for better disease assessment and public health planning.

Keywords: Respiratory syncytial virus infections; Severe acute respiratory syndrome; Hospitalization; Epidemiology; Aged; Surveillance.

Objective: Respiratory muscle weakness is a functional repercussion of chronic lung disease (CLD). The objective of this study was to assess the effects of home-based respiratory muscle training (RMT) in children and adolescents with CLD or neuromuscular disease (NMD). Methods: This was a quasi-experimental study involving children and adolescents with CLD or NMD. Before and after 6 months of home-based RMT, we measured respiratory muscle strength (MIP and MEP), PEF, and peak cough flow (PCF). We made statistical comparisons between the pre-RMT and post-RMT values, as well as evaluating the correlation between the duration and effect of RMT. Results: The study included 29 patients, with a mean age of 12 years (range, 5-17 years), of whom 18 (62.1%) were male. The CLD group comprised 11 patients (37.9%), and the NMD group comprised 18 (62.1%). The mean duration of the RMT was 60 weeks (range, 46-90 weeks) in the CLD group and 39 weeks (range, 24-89 weeks) in the NMD group. In comparison with the pre-RMT values, the post-RMT values for MIP and MEP were significantly higher in both groups, whereas those for PEF and PCF were significantly higher only in the NMD group. We found no correlation between the duration and the effect of RMT. Conclusions: Home-based RMT appears to be an effective strategy for increasing respiratory muscle strength in children and adolescents with CLD or NMD, although it increased the ability to cough effectively only in those with NMD.

Keywords: Breathing exercises; Cystic fibrosis; Bronchiolitis obliterans; Neuromuscular diseases; Cough.

Objective: COPD is one of the major causes of morbidity and mortality worldwide. Health care providers should counsel their smoking patients with COPD to quit smoking as the first treatment step. However, in countries with high prevalences of smoking, health care workers may also be smokers. The aim of this study was to determine the frequency and severity of COPD in health care workers who smoke. Methods: This was a cross-sectional study. All health care workers who smoke, from nine health care centers in Serbia, were invited to participate in the study and perform spirometry. The diagnosis of COPD was based on a post-bronchodilator FEV1/FVC ratio of < 0.70. All patients completed the COPD Assessment Test and the Fagerström Test for Nicotine Dependence. Results: The study involved 305 subjects, and 47 (15.4%) were male. The mean age of the participants was 49.0 ± 6.5 years. Spirometry revealed obstructive ventilatory defect in 33 subjects (10.8%); restrictive ventilatory defect, in 5 (1.6%); and small airway disease, in 96 (31.5%). A diagnosis of COPD was made in 29 patients (9.5%), 25 (86.2%) of whom were newly diagnosed. On the basis of the Global Initiative for COPD guidelines, most COPD patients belonged to groups A or B (n = 14; 48.2%, for both); 1 belonged to group D (3.6%); and none, to group C. Very high nicotine dependence was more common in those with COPD than in those without it (20.7% vs. 5.4%, p = 0.01). Conclusions: In this sample of health care workers, the frequency of COPD was comparable with that in the general population. The presence of COPD in health care workers who smoke was associated with higher nicotine dependence.

Keywords: Pulmonary disease, chronic obstructive/prevention & control; Smoking; Health personnel.

Objective: To compare a once-daily long-acting β2 agonist (indacaterol 150 µg) with a once-daily long-acting anticholinergic (tiotropium 5 µg) in terms of their effects on exercise endurance (limit of tolerance, Tlim) in patients with moderate COPD. Secondary endpoints were their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Methods: This was a randomized, single-blind, crossover pilot study involving 20 patients (mean age, 60.9 ± 10.0 years; mean FEV1, 69 ± 7% of predicted). Spirometric parameters, Transition Dyspnea Index scores, Tlim, and exertional dyspnea were compared after three weeks of each treatment (with a one-week washout period between treatments). Results: Nineteen patients completed the study (one having been excluded because of COPD exacerbation). Improvement in Tlim from baseline tended to be greater after treatment with tiotropium than after treatment with indacaterol (96 ± 163 s vs. 8 ± 82 s; p = 0.06). Tlim significantly improved from baseline after treatment with tiotropium (having increased from 396 ± 319 s to 493 ± 347 s; p = 0.010) but not after treatment with indacaterol (having increased from 393 ± 246 to 401 ± 254 s; p = 0.678). There were no differences between the two treatments regarding improvements in Borg dyspnea scores and lung hyperinflation at "isotime" and peak exercise. There were also no significant differences between treatments regarding Transition Dyspnea Index scores (1.5 ± 2.1 vs. 0.9 ± 2.3; p = 0.39). Conclusions: In patients with moderate COPD, tiotropium tends to improve Tlim in comparison with indacaterol. No significant differences were observed between the two treatments regarding their effects on lung hyperinflation, exercise-related dyspnea, and daily-life dyspnea. Future studies, including a larger number of patients, are required in order to confirm our findings and explore mechanistic explanations. (ClinicalTrials.gov identifier: NCT01693003 [http://www.clinicaltrials.gov/])

Keywords: Pulmonary disease, chronic obstructive; Exercise; Bronchodilator agents.

Objective: To evaluate the magnitude of diurnal changes in the parameters of pulmonary function and respiratory muscle strength/endurance in a sample of patients with COPD. Methods: A group of 7 patients underwent spirometry, together with determination of MIP and MEP, at two distinct times (between 8:00 and 8:30 a.m. and between 4:30 and 5:00 p.m.) on a single day. Between assessments, the patients remained at rest in the laboratory. Results: In accordance with the Global Initiative for Chronic Obstructive Pulmonary Disease staging system, COPD was classified as moderate, severe, and very severe in 1, 3, and 3 of the patients, respectively. From the first to the second assessment, there were significant decreases in FVC, FEV1, and MEP (of 13%, 15%, and 10%, respectively), as well as (less than significant) decreases in PEF, MIP, and maximal voluntary ventilation (of 9%, 3%, and 11%, respectively). Conclusions: In this sample of COPD patients, there were diurnal variations in the parameters of pulmonary function and respiratory muscle strength. The values of FEV1, FVC, and MEP were significantly lower in the afternoon than in the morning.

Keywords: Pulmonary disease, chronic obstructive; Respiratory function tests; Respiratory muscles.

Objective: To investigate the histological subtypes and mutational profiles of non-small cell lung cancer in Brazil, looking for correlations among histological subtypes, expression of anaplastic lymphoma kinase (ALK), EGFR mutation status, and programmed death-ligand 1 (PD-L1) expression. Methods: We evaluated 173 specimens obtained from patients with lung adenocarcinoma in northeastern Brazil. Expression of PD-L1 and ALK was evaluated by immunohistochemistry; EGFR mutation status was evaluated by sequencing. We categorized the histological subtypes in accordance with the International Association for the Study of Lung Cancer/American Thoracic Society/European Respiratory Society classification. Results: The most common histological subtypes of lung adenocarcinoma were solid predominant (in 46.8%), acinar predominant (in 37.0%), and lepidic predominant (in 9.8%). ALK expression was detected in 10.4% of the samples, and 22.0% of the tumors harbored EGFR mutations. The most common EGFR mutation was an exon 21 L858R point mutation (in 45.5%), followed by an exon 19 deletion (in 36.3%). The tumor proportion score for PD-L1 expression was ≥ 50% in 18.2% of the samples, 1-49% in 32.7%, and 0% in 49.5%. The solid predominant subtype was significantly associated with wild-type EGFR status (p = 0.047). Positivity for PD-L1 expression was not found to be significantly associated with ALK expression or EGFR mutation status. Conclusions: Our results suggest that the molecular profile of non-small cell lung cancer in northeastern Brazil differs from those of populations in other regions of the country, with ALK positivity being higher than the other biomarkers. Further studies including clinical and genetic information are required to confirm these differences, as well as studies focusing on populations living in different areas of the country.

Keywords: Anaplastic lymphoma kinase; ErbB receptors; B7-H1 antigen; Carcinoma, non-small-cell lung; Brazil.

Objective: To evaluate the use of video lessons on the topic of COPD as a training tool for a multidisciplinary team working in the primary health care sector. Methods: This was a quasi-experimental study involving a multidisciplinary team working at a primary health care clinic. The level of knowledge about COPD was measured by applying a specific, 16-item questionnaire - before, immediately after, and three months after the video lessons. In a set of six structured video lessons, the training focused on the prevention, case-finding, treatment, and monitoring of cases of COPD. The data were analyzed with the Friedman test, the Kruskal-Wallis test, Tukey's post hoc test, Dunnett's test, and the Bonferroni test. Results: There was a significant difference between the periods before and immediately after the training in terms of the scores on 15 of the 16 items on the questionnaire regarding the level of knowledge about COPD. The median total score of the participants increased significantly, from 60 points before the training to 77 points immediately thereafter and 3 months thereafter (p < 0.001 for both). Before the training, 23 (63.9%) and 13 (36.1%) of the members of the multidisciplinary team presented strong and very strong levels of agreement, respectively, among the 16 questionnaire items. After the training, 100% of the individuals presented a very strong degree of agreement. Conclusions: Multidisciplinary education through video lessons increased the knowledge of COPD on the part of a primary health care team, and the knowledge acquired was retained for at least three months after the intervention.

Keywords: Instructional films and videos; Pulmonary disease, chronic obstructive; Inservice training; Primary health care; Education, medical.

Objective: To investigate the effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of adult patients with asthma. Methods: This study comprised 24 healthy controls and 69 patients with asthma, all of whom were nonsmokers. The patients were divided into three groups according to the severity of airway obstruction (mild, moderate or severe). Each of the three groups was divided into two subgroups according to the bronchodilator response (BR): positive (BR+) or negative (BR−). These measurements were conducted before and after albuterol use (300 µg). Airway obstruction was determined by means of spirometry, and the resistive and elastic properties were determined by means of the forced oscillation technique. Results: The resistance at the intercept (R0) presented greater reductions in the groups with higher obstruction. This reduction was more evident in the BR+ subgroups than in the BR− subgroups (p < 0.02 and p < 0.03, respectively). There was a significant difference between the control group and the BR+ subgroup with severe obstruction (p < 0.002). The reductions in dynamic elastance (Edyn) were significantly greater in proportion to the degree of obstruction, in the BR− subgroups (p < 0.03), and in the BR+ subgroups (p < 0.003). The reductions in Edyn were significantly greater in the BR− subgroup with moderate obstruction (p < 0.008) and in the BR+ subgroup with severe obstruction (p < 0.0005) than in the control group. Conclusions: In patients with asthma, increased airway obstruction results in greater reductions in R0 and Edyn after albuterol use. These reductions are greater among BR+ patients than among BR− patients.

Keywords: Asthma; Bronchodilator agents; Respiratory mechanics; Spirometry; Albuterol.

Objective: To compare the expiratory flow increase technique (EFIT) and vibration accompanied by postural drainage (PD) in terms of their effects on the heart rate (HR), respiratory rate (RR) and SpO2 of infants with acute viral bronchiolitis (AVB). Methods: Infants with clinical and radiological diagnosis of AVB were analyzed. The HR, RR and SpO2 were registered at four time points: prior to the procedure; and at 10, 30 and 60 min after the procedure. The patients were divided into three groups: submitted to the EFIT; submitted to vibration/PD; and control. Results: We included 81 infants, 27 per group, with a mean age of 4.52 years and a mean weight of 6.56 kg. Using ANOVA, we found that the EFIT and vibration/PD groups presented no significant differences in relation to the control group in terms of the mean values for HR, RR or SpO2 (p > 0.05). Considering only the four time points evaluated, the mean RR was significantly lower in the EFIT and vibration/PD groups than in the control group (p < 0.05). Conclusions: In terms of overall improvement of cardiorespiratory parameters, neither the EFIT nor vibration/PD provided any benefit to infants with BVA. However, over time, respiratory physical therapy seems to contribute to decreasing the RR in these patients.

Keywords: Bronchiolitis, viral; Physical therapy modalities; Infant.

Objective: To determine the efficacy of chest compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation, in comparison with that of aspiration alone, in removing secretions, normalizing hemodynamics, and improving respiratory mechanics in patients on mechanical ventilation. Methods: This was a randomized crossover clinical trial involving patients on mechanical ventilation for more than 48 h in the ICU of the Porto Alegre Hospital de Clínicas, in the city of Porto Alegre, Brazil. Patients were randomized to receive aspiration alone (control group) or compression accompanied by a 10-cmH2O increase in baseline inspiratory pressure on pressure support ventilation (intervention group). We measured hemodynamic parameters, respiratory mechanics parameters, and the amount of secretions collected. Results: We included 34 patients. The mean age was 64.2  14.6 years. In comparison with the control group, the intervention group showed a higher median amount of secretions collected (1.9 g vs. 2.3 g; p = 0.004), a greater increase in mean expiratory tidal volume (16  69 mL vs. 56  69 mL; p = 0.018), and a greater increase in mean dynamic compliance (0.1  4.9 cmH2O vs. 2.8  4.5 cmH2O; p = 0.005). Conclusions: In this sample, chest compression accompanied by an increase in pressure support significantly increased the amount of secretions removed, the expiratory tidal volume, and dynamic compliance. (ClinicalTrials.gov Identifier:NCT01155648 [http://www.clinicaltrials.gov/])

Keywords: Physical therapy modalities; Respiration, Artificial; Intensive care units; Respiratory therapy.

Objective: To estimate the prevalence of undiagnosed COPD among individuals with risk factors for the disease treated at primary health care clinics (PHCCs) in the city of Aparecida de Goiânia, Brazil. Methods: Inclusion criteria were being ≥ 40 years of age, having a > 20 pack-year history of smoking or a > 80 hour-year history of exposure to biomass smoke, and seeking medical attention at one of the selected PHCCs. All subjects included in the study underwent spirometry for the diagnosis of COPD. Results: We successfully evaluated 200 individuals, mostly males. The mean age was 65.9 ± 10.5 years. The diagnosis of COPD was confirmed in 63 individuals, only 18 of whom had been previously diagnosed with COPD (underdiagnosis rate, 71.4%). There were no significant differences between the subgroups with and without a previous diagnosis of COPD in relation to demographics and risk factors. However, there were significant differences between these subgroups for the presence of expectoration, wheezing, and dyspnea (p = 0.047; p = 0.005; and p = 0.047, respectively). The FEV1 and FEV1/FVC ratio, expressed as percentages of the predicted values, were significantly lower in the subjects with a previous diagnosis of COPD, which was predominantly mild or moderate in both subgroups. Conclusions: The rate of underdiagnosis of COPD was high at the PHCCs studied. One third of the patients with risk factors for COPD met the clinical and functional criteria for the disease. It seems that spirometry is underutilized at such facilities.

Keywords: Pulmonary disease, chronic obstructive/diagnosis; Primary health care; Spirometry.

Objective: To evaluate the prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients, describing the major clinical syndromes diagnosed and the outcomes of the patients. Methods: A cross-sectional study conducted in the emergency room of a tertiary care university hospital. Between November of 2008 and November of 2009, we reviewed the total number of emergency room visits per day. Children and adults who presented with at least one respiratory symptom were included in the study. The electronic medical records were reviewed, and the major characteristics of the patients were recorded. Results: During the study period, there were 37,059 emergency room visits, of which 11,953 (32.3%) were motivated by respiratory symptoms. The prevalence of emergency room visits due to respiratory symptoms was 28.7% and 38.9% among adults and children, respectively. In adults, the rates of hospitalization and mortality were 21.2% and 2.7%, respectively, compared with 11.9% and 0.3%, respectively, in children. Among the adults, the time from symptom onset to emergency room visit correlated positively with the need for hospitalization (p < 0.0001), the length of the hospital stay (p < 0.0001), and the mortality rate (p = 0.028). Conclusions: We found a high prevalence of respiratory symptoms as the motive for emergency room visits by adult and pediatric patients. Our results could inform decisions regarding the planning of prevention measures. Further epidemiological studies are needed in order to clarify the risk factors for severe respiratory symptoms.

Objective: Manually assisted coughing (MAC) consists of a vigorous thrust applied to the chest at the beginning of a spontaneous expiration or of the expiratory phase of mechanical ventilation. Due to routine use of MAC in intensive care units, the objective of this study was to assess the effects of MAC on respiratory system mechanics in patients requiring full ventilatory support. Methods: We assessed 16 sedated patients on full ventilatory support (no active participation in ventilation). Respiratory system mechanics and oxyhemoglobin saturation were measured before and after MAC, as well as after endotracheal aspiration. Bilateral MAC was performed ten times on each patient, with three respiratory cycle intervals between each application. Results: Data analysis demonstrated a decrease in resistive pressure and respiratory system resistance, together with an increase in oxyhemoglobin saturation, after MAC combined with endotracheal aspiration. No evidence of alterations in peak pressures, plateau pressures or respiratory system compliance change was observed after MAC. Conclusions: The use of MAC alters respiratory system mechanics, increasing resistive forces by removing secretions. The technique is considered safe and efficacious for postoperative patients. Using MAC in conjunction with endotracheal aspiration provided benefits, achieving the proposed objective: the displacement and removal of airway secretions.

Keywords: Cough; Sputum; Respiratory mechanics; Respiration, artificial.