Introduction: The use of inhaled drugs through metered-dose inhaler has been advocated for years. Nonetheless, a small number of patients are routinely treated by this technique. Prescriptions of inhaled drugs by healthcare providers are not frequent, usually because they anticipate patients will not be able to perform the technique correctly. In addition, healthcare providers do not usually take their time to appropriately teach patients how to use metered-dose inhalers correctly. Objective: To evaluate the percentage of uninstructed patients that learn how to use a metered-dose inhaler correctly after being taught by a pneumologist. Patients and methods: One hundred and nineteen patients from a private clinic were prospectively studied in São Paulo, southeastern Brazil. Patients were exhaustively taught how to use the metered-dose inhaler at the first consultation and were told to return after 10 days, when they were asked to perform the technique exactly the way they were doing it at home. Their performance was classified as correct, slightly incorrect, intermediately incorrect, and totally incorrect. Results: Twenty-six patients were excluded for not coming to the second appointment. The final sample comprised 93 patients. Age ranged from 9 to 81 years (mean age 42.6 ± 21); 59.2% of the patients were male and 40.8% female. Considering all patients, only 16.25 of them used the metered-dose inhaler totally incorrectly and 19.3% performed the technique intermediately incorrectly. The most frequent mistakes were: metered-dose inhaler device was placed inside the mouth; inspiration before jet was activated; fast aspiration; inspiration through the nose. Thirty-three percent of patients who were under 15 and over 75 years performed the technique correctly. Conclusion: This study has demonstrated that the majority of the patients learned how to use the metered-dose inhaler correctly after being properly and extensively taught.

Keywords: Nebulizers and vaporizers. Inhalation administration. Learning.

Objective: Inhaler technique comprises a set of procedures for drug delivery to the respiratory system. The oral inhalation of medications is the first-line treatment for lung diseases. Using the proper inhaler technique ensures sufficient drug deposition in the distal airways, optimizing therapeutic effects and reducing side effects. The purposes of this study were to assess inhaler technique in pediatric and adult patients with asthma; to determine the most common errors in each group of patients; and to compare the results between the two groups. Methods: This was a descriptive cross-sectional study. Using a ten-step protocol, we assessed inhaler technique in 135 pediatric asthma patients and 128 adult asthma patients. Results: The most common error among the pediatric patients was failing to execute a 10-s breath-hold after inhalation, whereas the most common error among the adult patients was failing to exhale fully before using the inhaler. Conclusions: Pediatric asthma patients appear to perform most of the inhaler technique steps correctly. However, the same does not seem to be true for adult patients.

Keywords: Administration, inhalation; Aerosols/administration & dosage; Asthma/prevention & control.

Background: Short-acting b2 agonists delivered by metered-dose inhaler (MDIs) are the drugs usually used for the reversal of methacholine-induced bronchoconstriction. The b2 agonists that are delivered by dry-powder inhaler (DPI) can be an efficacious option. Objective: To evaluate the effectiveness and speed of action of salbutamol delivered by DPI (Pulvinal; Butoventâ), in comparison to salbutamol delivered by MDI, in reversing methacholine-induced bronchoconstriction. Method: Sixty successive methacholine-induced bronchoconstriction patients who presented a decrease of at least 20% in forced expiratory volume (FEV1) were evaluated prospectively. Of these 60 patients, we randomized 30 (first group) to receive 200 mcg of salbutamol by MDI and 30 (second group) to receive 200 mcg of salbutamol by DPI (Pulvinal). Both drugs were administered with the objective of reversing bronchoconstriction during the final phase of a bronchoprovocation test. The FEV1 values obtained at 1 and 5 minutes after bronchodilator administration were evaluated. Results: The groups were comparable in gender distribution, age, weight, dose level provoking a 20% drop in FEV1 (first group: 1.3 mg; second group: 1.19 mg; p = 0.79) and post-methacholine FEV1 (first group: 2.03 l; second group: 1.99 l; p = 0.87), with no statistically significant differences between the two groups. In the first group (MDI), the mean increase in FEV1 was 16.2% (at 1 minute) and 22.2% (at 5 minutes), and in the second group (DPI) it was 17% (at 1 minute) and 23.6% (at 5 minutes). There was no statistically significant difference between the groups (p = 0.8). Conclusion: The b2-agonists delivered by DPI (Pulvinal) present the same bronchodilator efficacy and speed of action as do those delivered by the more traditional MDI method.

Keywords: Asthma. Bronchodilator agents/administration & dosage. Albuterol/administration & dosage. Methacholine chloride/administration & dosage. Respiratory therapy/methods. Administration, inhalation/methods. Prospective studies.

Objective: To identify incorrect inhaler techniques employed by patients with respiratory diseases in southern Brazil and to profile the individuals who make such errors. Methods: This was a population-based, cross-sectional study involving subjects ≥ 10 years of age using metered dose inhalers (MDIs) or dry powder inhalers (DPIs) in 1,722 households in the city of Pelotas, Brazil. Results: We included 110 subjects, who collectively used 94 MDIs and 49 DPIs. The most common errors in the use of MDIs and DPIs were not exhaling prior to inhalation (66% and 47%, respectively), not performing a breath-hold after inhalation (29% and 25%), and not shaking the MDI prior to use (21%). Individuals ≥ 60 years of age more often made such errors. Among the demonstrations of the use of MDIs and DPIs, at least one error was made in 72% and 51%, respectively. Overall, there were errors made in all steps in 11% of the demonstrations, whereas there were no errors made in 13%.Among the individuals who made at least one error, the proportion of those with a low level of education was significantly greater than was that of those with a higher level of education, for MDIs (85% vs. 60%; p = 0.018) and for DPIs (81% vs. 35%; p = 0.010).Conclusions: In this sample, the most common errors in the use of inhalers were not exhaling prior to inhalation, not performing a breath-hold after inhalation, and not shaking the MDI prior to use. Special attention should be given to education regarding inhaler techniques for patients of lower socioeconomic status and with less formal education, as well as for those of advanced age, because those populations are at a greater risk of committing errors in their use of inhalers.

Keywords: Asthma; Pulmonary disease, chronic obstructive; Dry powder inhalers; Metered dose inhalers.

Objective: To evaluate the effect of the association of the breath stacking (BS) technique associated with routine physiotherapy on pulmonary function, lung volumes, maximum respiratory pressures, vital signs, peripheral oxygenation, thoracoabdominal mobility, and pain in the surgical incision in patients submitted to upper abdominal surgery during the postoperative period, as well as to analyze BS safety. Methods: This was a randomized clinical trial involving 34 patients divided into a control group (CG; n = 16), who underwent conventional physiotherapy only, and the BS group (BSG; n = 18), who underwent conventional physiotherapy and BS. Both groups performed two daily sessions from postoperative day 2 until hospital discharge. The primary outcomes were FVC and Vt. The safety of BS was assessed by the incidence of gastrointestinal, hemodynamic, and respiratory repercussions. Results: Although FVC significantly increased at hospital discharge in both groups, the effect was greater on the BSG. Significant increases in FEV1, FEV1/FVC ratio, PEF, and FEF25-75% occurred only in the BSG. There were also significant increases in Ve and Vt in the BSG, but not when compared with the CG values at discharge. MIP and MEP significantly increased in both groups, with a greater effect on the BSG. There was a significant decrease in RR, as well as a significant increase in SpO2 only in the BSG. SpO2 acutely increased after BS; however, no changes were observed in the degree of dyspnea, vital signs, or signs of respiratory distress, and no gastrointestinal and hemodynamic repercussions were observed. Conclusions: BS has proven to be safe and effective for recovering pulmonary function; improving lung volumes, maximum respiratory pressures, and peripheral oxygenation; and reducing respiratory work during the postoperative period after upper abdominal surgery.

Keywords: Abdomen/surgery; Pulmonary ventilation; Physical therapy modalities. (ClinicalTrials.gov identifier: NCT 04418700 [http://www.clinicaltrials.gov/])

Requesting passive cooperation from the patient and supplying new parameters for the analysis of the ventilatory mechanics, the forced oscillations technique (FOT) has complementary characteristics to the classical methods of lung evaluation. In this work, a review of the principles of this technique is initially presented together with a discussion about its advantages and present limitations. The performance of the technique is compared to classical methods in the detection of breathing disorders. The main clinical applications reported previously in the literature, including the evaluation of the ventilatory mechanics in children, studies in neonates, monitoring of patients under mechanical ventilation, occupational medicine, and evaluation of respiratory sleep disturbances are reviewed and discussed. Based on this review and on the results obtained in studies made in their laboratory, the authors concluded that FOT could render a more detailed examination and facilitate the accomplishment of lung function tests under conditions in which traditional techniques are not appropriate.

Keywords: respiratory mechanics, oscillometry, respiratory function tests

Objective: To evaluate how pulmonologists view the impact that asthma and COPD has on their patients, as well as how they treat these diseases. Methods: Survey including 227 pulmonologists participating in the VI Brazilian Congress on Asthma, II Brazilian Congress on COPD and II Brazilian Congress on Smoking, all of which were held in 2007. Results: According to the answers given by the pulmonologists, COPD is a public health problem of equal or greater importance than asthma, and COPD causes various disruptions in the lives of patients and their family members. When prescribing an inhalation device, pulmonologists feel that simplicity of use is more important than is the cost. There was a slight preference for the Aeroliser® and Diskus® systems. The budesonide-formoterol combination was the therapeutic regimen most often cited for the continued treatment of symptomatic asthma, whereas tiotropium bromide was the most often cited medication for the treatment of COPD. Selection of the therapeutic regimen for asthma and COPD is primarily influenced by the results of therapeutic trials published in the literature. Conclusions: The opinions of pulmonologists on the topics under study are in concordance with data in the specialized literature.

Keywords: Questionnaires; Asthma; Pulmonary disease, chronic obstructive; Physician's practice patterns; Brazil.

Recurrent pleural effusion, which is commonly seen in clinical practice, compromises patient quality of life, especially in patients with advanced malignant disease. The therapeutic approach to the pleural space involves a wide range of techniques, including aggressive procedures such as pleurectomy. Among such techniques, pleurodesis is the most frequently used. Pleurodesis can be induced through the insertion of pleural catheters, as well as through major surgical procedures (such as thoracotomy). There are various recommended sclerosing agents, including talc (which is the most widely used), silver nitrate and, recently, proliferative cytokines. This article summarizes the principal approaches to the treatment of recurrent pleural effusion, pleurodesis in particular, addressing the indications for, as well as the advantages and disadvantages of, their application in daily pulmonology practice.

Keywords: Pleural effusion, malignant/prevention & control; Pleural neoplasms; Pleura/surgery; Pleurodesis/methods; Silver nitrate; Talc; Recurrence

Objective: To identify the risk factors for pulmonary complications after thoracotomy for the resection of pulmonary nodules in patients with sarcoma. Methods: A retrospective cohort study involving 68 consecutive patients diagnosed with sarcoma and submitted to a total of 174 thoracotomies for the resection of pulmonary nodules. The dependent variable was defined as the occurrence of any postoperative pulmonary complications. The independent variables were related to the patient, underlying diagnosis, and type of surgical procedure. We analyzed the data using a multivariate generalized estimating equations model with logistic link function and a symmetric correlation structure. Results: Complications were observed in 24 patients (13.8%, 95% CI: 9.0-19.8), and there was one death. The mean length of hospital stay was twice as long in the patients with postoperative complications as in those without (18.8 ± 10.0 days vs. 8.6 ± 6.0 days; p < 0.05). The variables that correlated with the outcome measure were the type of resection (wedge vs. anatomic; OR = 3.6; 95% CI: 1.5-8.8), the need for blood transfusion (OR = 9.8; 95% CI: 1.6-60.1), and the number of nodules resected (OR = 1.1; 95% CI: 1.0-1.1). The multivariate model showed an area under the ROC curve of 0.75 (95% CI: 0.65-0.85). Conclusions: Postoperative pulmonary complications were common after pulmonary nodule resection in patients with sarcoma, occurring in approximately 10% of the procedures. The occurrence of such complications can be expected when techniques other than wedge resection are employed, when blood transfusion is required, and when a great number of nodules are resected. Therefore, it is possible to identify patients at risk for pulmonary complications, who should be closely monitored in the immediate postoperative period. In such patients, all preventive measures should be taken.

Keywords: Sarcoma; Neoplasm metastasis; Risk; Thoracotomy; Thoracic surgery.

Background: The six minutes walk test has been increasingly utilized to assess the effectiveness of different clinical and surgical treatment options in pulmonary diseases. However lack of standardization for their performance may influence measurements and jeopardize assessment of the functional capacity of patients with cardiopulmonary disease. Objective: To determine the possible effects of learning on the distance covered during the six minute walk test for bearers of chronic obstructive pulmonary disease. Method: A retrospective analysis of 35 medical records of COPD patients referred to the Pulmonary Rehabilitation Program of the University Hospital of Brasília was carried out. On alternate days these patients had performed two six minutes walk tests, spirometry and arterial blood gas analysis. Clinical and functional diagnosis was based upon the history of exposure to risk factors, mucus production, dyspnea and spirometric dysfunction after use of bronchodilators. The Student test was used for the comparison of results that were different. Results: The distances covered in the second six-minute walk test (515 ± 82 meters) were greater than those covered in the first six-minute walk test (480 ± 85 metros), with statistically significant differences (p<0.05). However measurements of the muscular effort and perception of dyspnea (Borg scale), peripheral blood oxygen saturation (SpO2), respiratory and heart rates did not disclose any statistically significant differences between the two tests (p<0.05). Conclusion: The present study suggests that in order to standardize the six minutes walk test, the procedure should be performed at least twice to better assess the functional capacity of patients, bearers of chronic obstructive pulmonary disease.

Keywords: Walking. Effectiveness. Lung diseases, obstrutive.

Objective: To predict COVID-19 in hospitalized patients with SARS in a city in southern Brazil by using machine learning algorithms. Methods: The study sample consisted of patients = 18 years of age admitted to the emergency department with SARS and hospitalized in the Hospital Escola - Universidade Federal de Pelotas between March and December of 2020. Epidemiological, clinical, and laboratory data were processed by machine learning algorithms in order to identify patterns. Mean AUC values were calculated for each combination of model and oversampling/undersampling techniques during cross-validation. Results: Of a total of 100 hospitalized patients with SARS, 78 had information for RT-PCR testing for SARS-CoV-2 infection and were therefore included in the analysis. Most (58%) of the patients were female, and the mean age was 61.4 ± 15.8 years. Regarding the machine learning models, the random forest model had a slightly higher median performance when compared with the other models tested and was therefore adopted. The most important features to diagnose COVID-19 were leukocyte count, PaCO2, troponin levels, duration of symptoms in days, platelet count, multimorbidity, presence of band forms, urea levels, age, and D-dimer levels, with an AUC of 87%. Conclusions: Artificial intelligence techniques represent an efficient strategy to identify patients with high clinical suspicion, particularly in situations in which health care systems face intense strain, such as in the COVID-19 pandemic.

Keywords: COVID-19/diagnosis; Artificial intelligence; Machine learning.

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 profile the characteristics of adult patients with bronchiectasis, drawing comparisons between cystic fibrosis (CF) patients and those with bronchiectasis from other causes in order to determine whether it is rational to extrapolate the bronchiectasis treatment given to CF patients to those with bronchiectasis from other causes. Methods: A retrospective analysis of the medical charts of 87 patients diagnosed with bronchiectasis and under follow-up treatment at our outpatient clinic. Patients who had tuberculosis (current or previous) were excluded. We evaluated the clinical, functional, and treatment data of the patients. Results: Of the 87 patients with bronchiectasis, 38 (43.7%) had been diagnosed with CF, through determination of sweat sodium and chloride concentrations or through genetic analysis, whereas the disease was due to another etiology in 49 (56.3%), of whom 34 (39.0%) had been diagnosed with idiopathic bronchiectasis. The mean age at diagnosis was lower in the patients with CF than in those without (14.2 vs. 24.2 years; p < 0.05). The prevalence of symptoms (cough, expectoration, hemoptysis, and wheezing) was similar between the groups. Colonization by Pseudomonas aeruginosa or Staphylococcus aureus was more common in the CF patients (82.4 vs. 29.7% and 64.7 vs. 5.4%, respectively). Conclusions: The causes and clinical manifestations of bronchiectasis are heterogeneous, and it is important to identify the differences. It is crucial that these differences be recognized so that new strategies for the management of patients with bronchiectasis can be developed.

Keywords: Cystic fibrosis; Bronchiectasis/diagnosis; Bronchiectasis/therapy; Respiratory function tests.

Since they were first established, ex vivo models of lung reconditioning have been evaluated extensively. When rejected donor lungs are used, the great variability among the cases can hinder the progress of such studies. In order to avoid this problem, we developed a technique that consists of separating the lung block into right and left blocks and subsequently reconnecting those two blocks. This technique allows us to have one study lung and one control lung.

Keywords: Lung transplantation; Transplantation conditioning; Organ preservation; Organ preservation solutions.

Climate change is a huge and present threat to human health. This article aims to deepen the knowledge about the environmental impact of inhaler devices on their carbon footprint for patients and health professionals, providing information that allows a better choice of the type of device to be prescribed for the treatment of asthma and COPD. This narrative and nonsystematic review was carried out by searching databases (PubMed, Google Scholar, SciELO, and EMBASE) for articles published between 2017 and 2022, written in Portuguese or in English, using the search words "inhalation device" OR "environmental." The review showed that global warming cannot be addressed by focusing only on inhaler devices. However, the devices that we use to treat respiratory diseases such as asthma and COPD, which are diseases that are aggravated by climate change, are also causing that change. Therefore, health professionals, patient organizations, and industries should take a lead in health policies to offer affordable alternatives to inhalers containing hydrofluoroalkane.

Keywords: Asthma; Pulmonary disease, chronic obstructive; Environmental health; Nebulizers and vaporizers.

Objectives: This study explores the relationship between inhaler visual identification, naming, and adherence outcomes, and evaluates the potential of combining these factors into a screening tool for identifying poor adherence. Methods: This observational, prospective study included adult patients with COPD, asthma, or asthma+COPD who had been on chronic inhalation therapy for at least the past year. Data were collected through patient interviews and medical records. Adherence was assessed using the Test of Adherence to Inhalers (TAI) questionnaire and prescription records, calculated as the Proportion of Days Covered (PDC). The patients completed a questionnaire to evaluate their ability to visually identify and name their inhalers. Results: Among the 196 participants, significant differences in adherence levels were observed across the COPD, asthma, and asthma+COPD groups, with COPD patients demonstrating higher adherence rates (p=0.001). Concordance between TAI and PDC was highest in the COPD group (75.0%), compared to the asthma (51.3%) and asthma+COPD (55.5%) groups. Correct naming of inhalers was not significantly correlated with adherence. However, correct inhaler visual identification was associated with better adherence. Incorrect visual identification showed low sensitivity (15.9%) but high specificity (92.6%) for detecting poorly adherent patients. Conclusions: The ability to visually identify inhalers was associated with better adherence, while the ability to name inhalers was not. Although incorrect visual identification has limited utility as a screening tool, it may still serve as a rapid and practical method for identifying poorly adherent patients in clinical practice.

Keywords: COPD, asthma, inhalers, therapeutic adherence, visual perception.