Objective: To describe the prevalence and severity of sleep disorders and circadian alterations in COVID-19 patients four months after the acute phase of the disease. Methods: This was a cross-sectional observational prospective study of patients with mild COVID-19, moderate COVID-19 (requiring hospitalization but no mechanical ventilation), or severe COVID-19 (with ARDS) four months after the acute phase of the disease. All patients underwent a home sleep apnea test and seven-day wrist actigraphy, as well as completing questionnaires to assess sleep quality and mental health. Differences among the three groups of patients were evaluated by ANOVA and the chi-square test. Results: A total of 60 patients were included in the study. Of those, 17 were in the mild COVID-19 group, 18 were in the moderate COVID-19 group, and 25 were in the severe COVID-19 group. Sleep quality, as assessed by satisfaction, alertness, timing, efficiency, and duration scale scores, was found to be impaired in all three groups, which also had a high prevalence of unhealthy sleep, as assessed by the Pittsburgh Sleep Quality Index. The prevalence of insomnia was increased in all three groups, as assessed by the Insomnia Severity Index. The home sleep apnea test showed that the overall prevalence of obstructive sleep apnea was 60%, and seven-day wrist actigraphy showed that total sleep time was < 7 h in all three groups. Changes in quality of life and in the circadian rest-activity pattern were observed in all three groups. Conclusions: Sleep-related symptoms, changes in the circadian rest-activity pattern, and impaired mental health appear to be common in COVID-19 patients four months after the acute phase of the disease, severe COVID-19 being associated with a higher prevalence of obstructive sleep apnea.

Keywords: Sleep apnea, obstructive; Sleep disorders, circadian rhythm; COVID-19.

Objectives: To describe persistent symptoms and lung function in mild cases of COVID-19 six months after infection. Methods: Data collection was performed through a semi-structured questionnaire containing information on the participants' demographic and anthropometric data, the disease in the acute phase, and persistent symptoms six months after COVID-19 using spirometry and manovacuometry. Results: A total of 136 participants were evaluated, of whom 64% were male, with a mean age of 38.17 ± 14.08 years and a body mass index (BMI) of 29.71 ± 17.48 kg/m2. The main persistent symptoms reported were dyspnea on exertion (39.7%), memory loss (38.2%), and anxiety (48.5%). Considering lung function, the participants reached 88.87 ± 17.20% of the predicted forced vital capacity (FVC), 86.03 ± 22.01% of the forced expiratory volume in one second (FEV1), and 62.71 ± 25.04% of peak expiratory flow (PEF). Upon manovacuometry, 97.41 ± 34.67% of the predicted inspiratory force (Pimax) and 66.86 ± 22.97% of the predicted expiratory force (Pemax) were observed. Conclusions: Six months after COVID-19 infection, a reduction in PEF and MEP was observed. Among the most commonly reported persistent symptoms were fatigue, tiredness with the slightest exertion, anxiety and depression, memory loss, and deficits in concentration.

Keywords: Post-acute COVID-19 Syndrome, Respiratory Function Tests, Dyspnea.

Objective: There are few studies on chronic obstructive pulmonary disease (COPD) establishing differences between the functional parameters of the disease and variants of sleep. The aim of the authors is to describe the sleep patterns of these patients and to investigate possible correlations among spirometric, gasometric, and polysomnographic variants. Methods: Transversal study using patients with COPD, submitted to spirometry, arterial gasometry, and polysomnography. Results: 21 male patients were studied with average age = 67 ± 9, 7 ± 4 average points in the Epworth sleep scale, average FEV1/FVC% = 54 ± 13.0, average PaO2 = 68 ± 11 mmHg, average PaCO2 = 37 ± 6 mmHg. Sleep efficiency decreased (65 ± 16%) with the decrease in slow wave sleep (8 ± 9%) and in rapid eye movement (REM) sleep (15 ± 8%). Average T90 = 43 ± 41%. Average apnea-hypopnea index (AHI) = 3 ± 5/h, two patients (9.5%) presented overlap syndrome. In the correlation analysis a correlation was observed between PaO2 and T90 (p < 0.01), PaCO2 and T90 (p < 0.05), and AHI and the cardiac rate in REM (p < 0.01). There was no correlation between spirometric and polysomnographic variants. Conclusion: The low sleep efficiency, the high number of awakenings, and shift in stages show the low quality of sleep. There were no linear correlations between the spirometric and polysomnographic variants.

Insomnia and excessive sleepiness are common in the investigation of sleep-disordered breathing. Circadian rhythm sleep disorders are perhaps the most often overlooked conditions in the differential diagnosis of these symptoms. Circadian rhythm sleep disorders manifest as misalignment between the sleep period and the physical/social 24-h environmental cycle. The two most prevalent circadian rhythm sleep disorders are delayed sleep phase (common in adolescents) and advanced sleep phase (common in the elderly), situations in which the sleep period is displaced to a later or earlier time, respectively. It is important to keep these two disorders in mind, since they can be confused with insomnia and excessive sleepiness. However, there are nine possible diagnoses, and all nine are of clinical interest. Since light is the principal cue used in synchronizing the biological clock, blind individuals and night-shift/swing-shift workers are more prone to develop circadian rhythm sleep disorders. In this article, the new international classification of circadian rhythm sleep disorders is reviewed.

Keywords: Circadian rhythm; Sleep disorders; Sleep initiation and maintenance disorders; Sleep stages; Sleep apnea syndromes.

Objective: To evaluate the combined impact of videofluoroscopic swallow study (VFSS) and therapeutic feeding and swallowing interventions on clinical outcomes in children with oropharyngeal dysphagia (OPD). Methods: This was an uncontrolled longitudinal analytical study in which OPD patients were evaluated before and after VFSS. Children = 24 months of age diagnosed with OPD in a clinical setting and undergoing VFSS for investigation and management of OPD were included in the study. The study participants received therapeutic feeding and swallowing interventions after having undergone VFSS, being followed at an outpatient clinic for pediatric dysphagia in order to monitor feeding and swallowing difficulties. Respiratory and feeding outcomes were compared before and after VFSS. Results: Penetration/aspiration events were observed in 61% of the VFSSs (n = 72), and therapeutic feeding and swallowing interventions were recommended for 97% of the study participants. After the VFSS, there was a reduction in the odds of receiving antibiotic therapy (OR = 0.007) and in the duration of antibiotic therapy (p = 0.014), as well as in the odds of being admitted to hospital (p = 0.024) and in the length of hospital stay (p = 0.025). A combination of oral and enteral feeding became more common than oral or enteral feeding alone (p = 0.002). Conclusions: A high proportion of participants exhibited penetration/aspiration on VFSS. Therapeutic feeding and swallowing interventions following a VFSS appear to be associated with reduced respiratory morbidity in this population.

Keywords: Fluoroscopy; Deglutition disorders; Respiratory tract diseases; Pneumonia, aspiration; Nutritional support.

Objective: To evaluate breathing pattern and thoracoabdominal motion during breathing exercises. Methods: Twenty-four patients with class II or III obesity (18 women; 6 men) were studied on the second postoperative day after gastroplasty. The mean age was 37 ± 11 years, and the mean BMI was 44 ± 3 kg/m2. Diaphragmatic breathing, incentive spirometry with a flow-oriented device and incentive spirometry with a volume-oriented device were performed in random order. Respiratory inductive plethysmography was used in order to measure respiratory variables and thoracoabdominal motion. Results: Comparisons among the three exercises showed significant differences: tidal volume was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing; the respiratory rate was lower during incentive spirometry with the volume-oriented device than during incentive spirometry with the flow-oriented device; and minute ventilation was higher during incentive spirometry (with the flow-oriented device or with the volume-oriented device) than during diaphragmatic breathing. Rib cage motion did not vary during breathing exercises, although there was an increase in thoracoabdominal asynchrony, especially during incentive spirometry with the flow-oriented device. Conclusions: Among the breathing exercises evaluated, incentive spirometry with the volume-oriented device provided the best results, because it allowed slower, deeper inhalation.

Keywords: Breathing exercises; Physical therapy (Specialty); Bariatric surgery; Obesity, morbid.

Objective: To estimate the rates of recurrence, cure, and treatment abandonment in patients with pulmonary tuberculosis treated with a four-drug fixed-dose combination (FDC) regimen, as well as to evaluate possible associated factors. Methods: This was a retrospective observational study involving 208 patients with a confirmed diagnosis of pulmonary tuberculosis enrolled in the Hospital Tuberculosis Control Program at the Institute for Thoracic Diseases, located in the city of Rio de Janeiro, Brazil. Between January of 2007 and October of 2010, the patients were treated with the rifampin-isoniazid-pyrazinamide (RHZ) regimen, whereas, between November of 2010 and June of 2013, the patients were treated with the rifampin-isoniazid-pyrazinamide-ethambutol FDC (RHZE/FDC) regimen. Data regarding tuberculosis recurrence and mortality in the patients studied were retrieved from the Brazilian Case Registry Database and the Brazilian Mortality Database, respectively. The follow-up period comprised two years after treatment completion. Results: The rates of cure, treatment abandonment, and death were 90.4%, 4.8%, and 4.8%, respectively. There were 7 cases of recurrence during the follow-up period. No significant differences in the recurrence rate were found between the RHZ and RHZE/FDC regimen groups (p = 0.13). We identified no factors associated with the occurrence of recurrence; nor were there any statistically significant differences between the treatment groups regarding adverse effects or rates of cure, treatment abandonment, or death. Conclusions: The adoption of the RHZE/FDC regimen produced no statistically significant differences in the rates of recurrence, cure, or treatment abandonment; nor did it have any effect on the occurrence of adverse effects, in comparison with the use of the RHZ regimen.

Keywords: Tuberculosis, pulmonary, Drug combinations; Recurrence.

Objective: To assess the influence of the COVID-19 pandemic on hospital admissions (HA), intra-hospital deaths (HD), and intra-hospital lethality rates (HL) related to respiratory diseases (RD) other than COVID-19 in Brazil. Methods: This observational time-series study was conducted through comparative analyses of the HA, HD, and HL related to non-COVID-19 RD registered between March and December 2020 by the Brazilian Unified Public Health System on the DataSUS Tabnet platform, using as reference the values recorded in the same period of 2019 and those projected by linear regression methods for 2020, considering the period from 2015 to 2019. The adopted statistical significance level was 5% (p < 0.05). Results: Compared to 2019, in 2020, there was a 42% decrease in HA and a 7.4% decrease in total HD related to non-COVID-19 RD, followed by a 60% increase in HL associated with this group of diseases. The HA and HL registered in 2020 differed significantly from the projected trend for that year by linear regression (p < 0.05). Of note, a significant reduction in hospitalizations due to asthma (-46%), chronic obstructive pulmonary disease (-45%), bronchiectasis (-54%), pneumonia (-46%), and acute bronchitis (-73%) was observed. Conclusions: During the first 8 months of the pandemic, there was a decline in HA and an increase in HL related to non-COVID-19 RD in Brazil, which can hypothetically reflect logistical challenges and delays in the management of this group of diseases.

Keywords: Pulmonary disease, COVID-19, non-COVID-19, Hospitalization, Mortality.

Objective: To analyze the effectiveness of the Tuberculosis Control Program, in conjunction with the recently incorporated Family Health Program, in the city of Cáceres, Brazil, between 1999 and 2004. Methods: This was a descriptive epidemiological study, based on the registry of tuberculosis cases diagnosed and treated in Cáceres, according to the characteristics of the cases diagnosed, whether or not the protocol for diagnosis, treatment, and monitoring of patients was followed, as well as the type of health care facility involved. Results: The incidence of tuberculosis was reduced from 99.4 to 49.8 (per 100,000 inhabitants) between 1999 and 2004. The patients presented characteristics similar to those of patients from other regions of Brazil, with a predominance of males during their most economically productive years. Among the patients presenting pulmonary forms and treated via the Family Health Program, there was a reduction in the number of sputum smear microscopies performed at the moment of diagnosis (OR = 0.33; 95%CI: 0.16-0.66) and prior to discharge (OR = 0.32; 95%CI: 0.18‑0.59). The patients monitored via the Family Health Program presented a 16.4% lower cure rate than did those treated at the referral center, as well as being more likely to abandon treatment (OR = 2.93; 95%CI: 1.15-7.46) and to die (OR = 5.71; 95%CI: 1.85‑18.1). Conclusion: The decentralization of the treatment services to the family health clinics did not improve the treatment or monitoring of tuberculosis cases in the city of Cáceres.

Keywords: Tuberculosis/epidemiology; Community Health Services; Health care reform/Brazil.

Objective: To evaluate clinical predictors of poor sleep quality in COPD patients with and without obstructive sleep apnea (OSA). Methods: Consecutive stable patients with COPD were evaluated for OSA by means of overnight polysomnography; for sleep quality by means of the Pittsburgh Sleep Quality Index (PSQI); and for disease impact by means of the COPD Assessment Test. COPD severity was graded in accordance with the 2020 GOLD guidelines. Predictors of poor sleep quality were evaluated by multivariate logistic regression analysis. Results: We studied 51 patients with COPD alone and 51 patients with COPD and OSA. Both groups had similar age (66.2 ± 9.2 years vs. 69.6 ± 10.7, p = 0.09) and airflow limitation (p = 0.37). Poor sleep quality was present in 74.8% of the study participants, with no significant difference between COPD patients with and without OSA regarding PSQI scores (p = 0.73). Polysomnography showed increased stage 1 non-rapid eye movement sleep and arousal index, as well as reduced sleep efficiency and stage 3 non-rapid eye movement sleep, in the group of patients with COPD and OSA (p < 0.05). Independent predictors of poor sleep quality were GOLD grade C/D COPD (OR = 6.4; 95% CI, 1.79-23.3; p < 0.01), a COPD Assessment Test score = 10 (OR = 12.3; 95% CI, 4.1-36.5; p < 0.01), and lowest SaO2 < 80% (p < 0.0001). Conclusions: Poor sleep quality is quite common in patients with COPD and is associated with severe COPD and poor health status, having a negative impact on overall quality of life. Despite changes in polysomnography, OSA appears to have no impact on subjective sleep quality in COPD patients.

Keywords: Pulmonary disease, chronic obstructive; Sleep Quality; Sleep apnea, obstructive; Health status.

Many patients hospitalized with COVID-19 were unable to return to work or their return was delayed due to their health condition. The aim of this observational study was to evaluate the impact of moderate-to-severe and critical COVID-19 infection on persistence of symptoms and return to work after hospital discharge. In this study, two thirds of hospitalized patients with pulmonary involvement reported persistence of symptoms six months after COVID-19 infection, such as memory loss (45.5%), myalgia (43.9%), fatigue (39.4%), and dyspnea (25.8%), and 50% slowly returned to work, with repercussions due to fatigue and/or loss of energy.

Keywords: COVID-19/complications; COVID-19/rehabilitation; Return to work; Hospitalization; Survivors.

Objective: To evaluate symptoms, lung function, and quality of life of a cohort of patients hospitalized for severe COVID-19 12 months after hospital admission. Methods: This was a cross-sectional study. We included severe COVID-19 survivors hospitalized in one of three tertiary referral hospitals for COVID-19 in the city of Belo Horizonte, Brazil. Participants were submitted to lung function and six-minute walk tests and completed the EQ-5D-3L questionnaire. Results: The whole sample comprised 189 COVID-19 survivors (mean age = 59.6 ± 13.4 years) who had been admitted to a ward only (n = 96; 50.8%) or to an ICU (n = 93; 49.2%). At 12 months of follow-up, 43% of patients presented with dyspnea, 27% of whom had a restrictive ventilatory disorder and 18% of whom presented with impaired DLCO. There were no significant differences in FVC, FEV1, and TLC between the survivors with or without dyspnea. However, those who still had dyspnea had significantly more impaired DLCO (14.9% vs. 22.4%; p < 0.020) and poorer quality of life. Conclusions: After one year, survivors of severe COVID-19 in a middle-income country still present with high symptom burden, restrictive ventilatory changes, and loss of quality of life. Ongoing follow-up is needed to characterize long COVID-19 and identify strategies to mitigate its consequences.

Objective: To evaluate COVID-19 knowledge, attitudes, and practices among health care workers (HCWs) practicing in Latin American countries during the first surge of the COVID-19 pandemic. Methods: This was a multinational cross-sectional survey study, using an online self-administered questionnaire. The final version of the questionnaire comprised 40 questions, organized in five sections: demographic and professional characteristics; COVID-19 knowledge; attitudes toward COVID-19; COVID-19 practices; and institutional resources. Results: The study involved 251 HCWs from 19 Latin American countries who agreed to participate. In our sample, 77% of HCWs participated in some sort of institutional training on COVID-19, and 43% had a low COVID-19 knowledge score. COVID-19 knowledge was associated with the type of health center (public/private), availability of institutional training, and sources of information about COVID-19. Concerns about not providing adequate care were reported by 60% of the participants. The most commonly used ventilatory strategies were protective mechanical ventilation, alveolar recruitment maneuvers, and prone positioning, and the use of drugs to treat COVID-19 was mainly based on institutional protocols. Conclusions: In this multinational study in Latin America, almost half of HCWs had a low COVID-19 knowledge score, and the level of knowledge was associated with the type of institution, participation in institutional training, and information sources. HCWs considered that COVID-19 was very relevant, and more than half were concerned about not providing adequate care to patients.

Keywords: COVID-19; Health knowledge, attitude, practice; Health personnel; Latin America.

Cystic adenomatoid malformation of the lung is a rare form of congenital pulmonary disease. It has been found in all lobes, it is rarely bilateral, and is associated to hydramnion, placental edema, and fetal hydrops. It is divided into three types, with different clinical and histologic characteristics. Intrauterine diagnosis is possible by means of ultrasound examination, and the treatment of choice is lobectomy. The authors describe four cases seen at their hospital and review the literature.

Keywords: Cystic adenomatoid malformation. Congenital malformation. Lung.