Abstract Objective: To determine the prevalence of gastroesophageal reflux disease (GERD) and to evaluate the esophageal motor profile of patients with respiratory symptoms referred to a digestive motility referral center for esophageal function testing. Methods: The results of esophageal manometry and 24-h esophageal pH-metry were analyzed. The inclusion criterion was presenting respiratory symptoms, with or without accompanying digestive symptoms. Results: Of the 1,170 patients included in the study, 602 (51.5%) reported having digestive and respiratory symptoms (DRS group), and 568 (48.5%) reported having only respiratory symptoms (RS group). Asthma was diagnosed in 142 patients in the RS group (RS-A subgroup) and in 201 of those in the DRS group (DRS-A subgroup). Of the 346 cases of esophageal dysmotility, hypomotility was found in 175 (14.3% and 15.6% in the DRS and RS groups, respectively), and lower esophageal sphincter (LES) hypotonia was found in 411 (40.3% and 30.2%, respectively). Hypotonia correlated with GERD. Exposure of the distal esophagus to acid was markedly abnormal in the supine position. The prevalence of GERD in the sample as a whole, the RS-A/DRS-A subgroups and the RS-A subgroup alone was 39.8%, 44.0% and 35.2%, respectively. Conclusions: Hypotonic LES was the most common abnormality and correlated with GERD. Although GERD was more evident in the DRS group, approximately one third of the patients in the RS group also presented GERD (silent GERD). The findings suggest that GERD can be an extrapulmonary cause of chronic respiratory symptoms unresponsive to conventional therapy.

Keywords: Gastroesophageal reflux; Signs and symptoms, respiratory; Asthma; Esophageal pH monitoring; Manometry.

Background: The relationship between asthma and gastroesophageal reflux is, as yet, not completely understood. Among the mechanisms thought to be responsible for gastroesophageal reflux-related worsening of asthma symptoms are the vagovagal reflex and microaspiration. Objective: To assess forced expiratory volume in one second after acid infusion. Method: This study investigated the effect of acid infusion in 13 volunteers with moderate asthma and gastroesophageal reflux. Spirometry was performed before and after insertion of an 8F nasogastric tube and a pH meter. After 15 minutes of saline solution infusion into the midpoint between the upper esophageal sphincter and lower esophageal sphincter, and again after 15 minutes of esophageal acidification (with hydrochloric acid) of the same area, forced expiratory volume in one second was reassessed. Acidification was repeated every 5 minutes until forced expiratory volume in one second values stabilized (variation: < 5%). Results: Mean forced expiratory volume in one second values remained stable during the tube insertion, saline infusion, initial hydrochloric acid infusion and subsequent hydrochloric acid infusion procedures (p = 0.72). Lower forced expiratory volume in one second values were seen resulting from the tube insertion in two patients (drops of 11% and 22%, respectively), after saline infusion in another two (drops of 13% and 14%) and after acid infusion in 1 (a drop of 22%). Conclusion: Esophageal acidification over short periods does not lead to spirometric alterations in a group of asthmatics with gastroesophageal reflux. However, in some cases, simple esophageal procedures or infusions result in bronchospasm.

Keywords: Key words: Asthma. Gastroesophageal reflux. Respiratory function tests. Endoscopy/methods.

Objective: To evaluate the impact of asthma, by gender, in a population sample of asthma patients in Brazil. Methods: We conducted face-to-face interviews with 400 subjects (> 12 years of age) included in a national probability telephone sample of asthma patients in the Brazilian state capitals of São Paulo, Rio de Janeiro, Curitiba, and Salvador. Each of those 400 subjects completed a 53-item questionnaire that addressed five asthma domains: symptoms; impact of asthma on quality of life; perception of asthma control; exacerbations; and treatment/medication. Results: Of the 400 patients interviewed, 272 (68%) were female. In relation to respiratory symptoms, the proportion of women reporting extremely bothersome symptoms (cough with sputum, tightness in the chest, cough/shortness of breath/tightness in the chest during exercise, nocturnal shortness of breath, and nocturnal cough) was greater than was that of men. Daytime symptoms, such as cough, shortness of breath, wheezing, and tightness in the chest, were more common among women than among men. Women also more often reported that their asthma interfered with normal physical exertion, social activities, sleep, and life in general. Regarding the impact of asthma on quality of life, the proportion of subjects who reported that asthma caused them to feel that they had no control over their lives and affected the way that they felt about themselves was also greater among women than among men. Conclusions: Among women, asthma tends to be more symptomatic, as well as having a more pronounced effect on activities of daily living and on quality of life.

Keywords: Asthma/diagnosis; Asthma/prevention & control; Quality of life.

Abstract Objective: To determine the levels of alpha-1 antitrypsin (AAT) and the presence of S and Z alleles in patients with chronic respiratory symptoms. Methods: Patients with chronic cough and dyspnea were submitted to clinical evaluation, pulmonary function tests, high-resolution computed tomography, nephelometric determination of AAT and determination of S and Z alleles by polymerase chain reaction. Smoking and AAT levels were considered the dependent variables. Results: Of the 89 patients included in the study, 44 were female. The mean age was 51.3 ± 18.2 years. The S and Z alleles were detected in 33.3% and 5.7%, respectively, and the gene frequency was 0.16 and 0.028, respectively. Two patients were SZ heterozygotes (AAT levels ≤ 89 mg/dL). The patients were divided into groups based on AAT level: ≤ 89 mg/­dL (deficiency, no group); 90-140 mg/dL (intermediate, Group 1, n = 30); and ≥ 141 mg/dL (normal, Group 2, n = 57). The frequency of smokers was the same in both groups, although tobacco intake was greater in Group 2. The S allele was present in 13 and 14 patients in Groups 1 and 2, respectively, whereas the Z allele was present in 2 and 1 patient in the same groups. There was no difference in the results of pulmonary function tests or in the frequency of bronchiectasis or emphysema between the two groups. Spirometric values and AAT levels were similar in smokers and nonsmokers. Bronchiectasis was more common in nonsmokers, and emphysema was more common in smokers. Conclusions: Thirty patients presented AAT levels lower than the mean values found in patients with the MM or MS genotype, and this fact could not be explained by an increased frequency of S and Z alleles.

Keywords: Alpha 1-antitrypsin; Emphysema: Lung diseases; Alleles.

Objective: To describe and analyze clinical symptoms and spirometric alterations of patients with chronic obstructive pulmonary disease (COPD) and history of exposure to wood and tobacco smoke. Methods: We retrospectively evaluated data related to 170 patients distributed into 3 groups: 34 exposed only to wood smoke, 59 patients exposed only to tobacco smoke and 77 patients exposed to both. Results: The groups did not differ significantly in terms of age (p = 0.225) or degree of exposure, considering each type of exposure in isolation or in combination (p = 0.164 and p = 0.220, respectively). Females predominated in the group exposed to wood smoke. There were no differences among the groups regarding respiratory symptoms (p > 0.05), and moderate dyspnea predominated in the three groups (p = 0.141). The group exposed to wood smoke presented higher percentages of forced expiratory volume in one second/forced vital capacity ratio and of forced expiratory volume in one second (p < 0.05). Positive results on bronchodilator testing occurred more frequently in the group exposed to tobacco smoke. The percentage of severe and extremely severe obstruction was significantly higher in the group exposed to tobacco smoke (44.1%) than in that exposed to wood smoke (11.8%; p = 0.006). Conclusions: Respiratory symptoms and pulmonary function alterations consistent with COPD were observed in the groups of patients exposed to wood smoke. However, those alterations were not as significant as the alterations observed in the groups exposed to tobacco smoke. This study emphasizes the importance of prospective studies in evaluating the risk of wood-smoke-related COPD in Brazil, as well as the need for preventive measures in this area.

Keywords: Pulmonary disease, chronic obstructive; Smoking; Air pollution, indoor; Smoke.

Objective: To identify symptoms of dysphagia in individuals with COPD, based on their responses on a self-perception questionnaire. Methods: The study comprised 35 individuals with COPD and 35 healthy individuals, matched for age and gender. The study group was assessed regarding COPD severity; sensation of dyspnea; body mass index (BMI); and symptoms of dysphagia. The control group was assessed regarding BMI and symptoms of dysphagia. Results: The most common symptoms of dysphagia in the study group were pharyngeal symptoms/airway protection (p < 0.001); esophageal symptoms/history of pneumonia (p < 0.001); and nutritional symptoms (p < 0.001). Positive correlations were found between the following pairs of variables: FEV1 and BMI (r = 0.567; p < 0.001); pharyngeal symptoms/airway protection and dyspnea (r = 0.408; p = 0.015); and esophageal symptoms/history of pneumonia and pharyngeal symptoms/airway protection (r = 0.531; p = 0.001). There was a negative correlation between nutritional symptoms and BMI (r = −0.046; p < 0.008). Conclusions: Our results show that the individuals with COPD presented with symptoms of dysphagia that were associated with the pharyngeal and esophageal phases of swallowing, as well as with the mechanism of airway protection, a history of pneumonia, and nutritional symptoms.

Keywords: Deglutition disorders; Pulmonary disease, chronic obstructive; Pathological conditions, signs and symptoms.

The prevalence of respiratory symptoms in populations at risk or in populations not at risk is an indirect indicator of acute and chronic respiratory diseases, with a high grade of confidence from an epidemiological point of view. In order to contribute to this, the authors carried out a prevalence study among workers with occupational exposure to silica dust in a marble plant. The authors selected workers who worked with hard granite stone, slate and marble. Workers were submitted to a standardized questionnaire and 84 people were studied. All were male, mean age was (± SD) 26.2 (± 7.4 years), and had had short time of exposure to dust (52 workers worked less than 5 years in the marble industry). Thirty-four were smokers (10.0 (± 2.3) pack years), 9 former smokers, and 41 non-smokers. Twenty-four had cough, 30 sputum, 1 dyspnea grade III, 5 wheezing. Thirty-eight presented at least one of the studied respiratory symptoms and 9 presented chronic bronchitis. The lung function evaluated in 82 workers through spirometry was normal in 78 of the cases and an obstructive pattern was detected in 4 of them. A significant statistical association between chronic bronchitis and exposure time to stone dust was found (OR = 5.37; 95% CI = 1.01-28.74). However, that association was lost after other factors, such as cigarette smoking and age, were evaluated (OR = 1.21; 95% CI = 0.12-11.93). The association between smoking and bronchitis (OR = 14.18; 95% CI = 1.80-111.62) remained marginally significant even after controlling exposure time to stone dust and age (OR = 6.34; 95% CI = 0.76-52.94). Results suggest that among the marble industry workers studied, the prevalence of chronic bronchitis is more strongly associated to smoking to with exposure time to stone dust.

Objective: To evaluate clinical features of malformations of lung and mediastinum. Methods: Retrospective analysis of 51 patients with malformations identified in the author's division between 1982 and 1997. They verified the clinical manifestations, diagnostic procedures, and treatment. Results: The most frequent anomaly was esophageal atresia/tracheoesophageal fistula (12), followed by vascular ring (11), congenital lobar emphysema (7), diaphragmatic hernia/eventration (7), bronchogenic cyst (5), pulmonary hypoplasia (4), pulmonary sequestration (3), and arterial-venous fistula (2). Age at diagnosis varied from birth to 10 years. Most of them exhibited symptoms at first month, some even at birth. The main respiratory symptoms were tachypnea, coughing, retractions, dyspnea, wheezing, pneumonia and rales. Chest X-rays with barium swallow were most important for diagnosis. When chest radiology was inconclusive, CT scans were next in achieving diagnosis. Surgical intervention was the effective treatment in 86% of cases. Conclusions: Lung and mediastinal congenital malformations with respiratory symptoms require adequate diagnostic evaluation and immediate intervention. The most frequent respiratory symptoms were coughing and tachypnea and chest X-rays with barium swallow was the main diagnostic method. Survival is good and mortality is secondary to associated malformations.

Keywords: Bronchopulmonary malformations. Respiratory distress. Retrospective studies.

Background: Nasal and pharyngeal symptoms are common in patients with obstructive sleep apnoea (OSA) treated with nasal continuous positive airway pressure (CPAP). However, these symptoms are common in OSA patients even before the treatment. Objectives: Determine the impact of nasal CPAP on nasal and pharyngeal symptoms in OSA patients. Method: Thirty-five adult patients (28 males), age 54±10 years old, with OSA diagnosed by polissonography. All patients answered to a questionnaire about the presence and quantification of sneezing, rhinorrhea, nasal pruritus, obstruction and bleeding, nasal and pharyngeal dryness. The questionnaire was answered before and after at least three months of CPAP therapy. Results: The apnea-hypopnea index was 50±25 events per hour. Twenty six patients (74%) presented at least one naso-pharingeal symptom before treatment. Nasal obstruction was the most common symptom, being referred by 18 patients (51%). Among the patients that were initially assymptomatic (n=9), 78% developed adverse nasal reactions to CPAP. In contrast, among the patients that presented nasal symptoms before treatment, there was a significant reduction in nasal obstruction, nasal and throat dryness scores as well as nasal bleeding after CPAP therapy. Conclusions: Nasal na pharyngeal symptoms are frequent in OSAS patients. CPAP therapy may originate nasal symptoms in patients previously assymptomatic, as well as reduce the intensity of these symptoms in patients that are previously symptomatic.

Keywords: Obstructive sleep apnea syndrome. Nasal obstruction. Continuous positive airway pressure, compliance.

Objective: To determine whether respiratory symptoms and chronic bronchitis are associated with the use of biomass fuels (BMFs) among women residing in rural areas of the Ekiti State, in southwestern Nigeria. Methods: From January to June of 2009, we carried out a cross-sectional study including 269 adult women. To collect data on sociodemographic status, type of fuel used for cooking in the household, respiratory symptoms, and smoking history, we used a questionnaire adapted from the European Community Respiratory Health Survey. All of the participants were invited to undergo spirometry. Results: Of the 269 women in the study, 161 (59.9%) used BMFs for cooking. The proportion of women who reported respiratory symptoms was greater among those using BMFs than among those using a non-BMF-cough (13.7% vs. 3.7%); wheezing (8.7% vs. 2.8%); chest pain (7.5% vs. 1.9%); breathlessness (11.8% vs. 6.5%); nasal symptoms (9.3% vs. 4.6%); and chronic bronchitis (10.6% vs. 2.8%). Multivariate logistic regression analysis revealed that the use of BMFs was associated with the following variables: cough (OR = 4.82; p = 0.01); chronic bronchitis (OR = 3.75; p = 0.04); wheezing (OR = 2.22; p = 0.23); chest pain (OR = 3.82; p = 0.09); breathlessness (OR = 1.54; p = 0.35); and nasal symptoms (OR = 2.32; p = 0.20). All of the spirometric parameters evaluated (FEV1, FVC, FEV1/FVC ratio, and PEF) were lower in the women using BMFs than in those using a non-BMF. Conclusions: Our results underscore the need for women using BMFs in their households to replace them with a nontoxic type of fuel, such as electricity or gas.

Keywords: Signs and symptoms, respiratory; Biofuels; Bronchitis, chronic; Air pollution, indoor.

Objective: To describe lung function findings in overweight children and adolescents without respiratory disease. Methods: This was a cross-sectional study involving male and female overweight children and adolescents in the 8-18 year age bracket, without respiratory disease. All of the participants underwent anthropometric assessment, chest X-ray, pulse oximetry, spirometry, and lung volume measurements. Individuals with respiratory disease were excluded, as were those who were smokers, those with abnormal chest X-rays, and those with an SpO2 ≤ 92%. Waist circumference was measured in centimeters. The body mass index-for-age Z score for boys and girls was used in order to classify the individuals as overweight, obese, or severely obese. Lung function variables were expressed in percentage of the predicted value and were correlated with the anthropometric indices. Results: We included 59 individuals (30 males and 29 females). The mean age was 11.7 ± 2.7 years. Lung function was normal in 21 individuals (35.6%). Of the 38 remaining individuals, 19 (32.2%), 15 (25.4%), and 4 (6.7%) presented with obstructive, restrictive, and mixed ventilatory disorder, respectively. The bronchodilator response was positive in 15 individuals (25.4%), and TLC measurements revealed that all of the individuals with reduced VC had restrictive ventilatory disorder. There were significant negative correlations between the anthropometric indices and the Tiffeneau index in the individuals with mixed ventilatory disorder. Conclusions: Lung function was abnormal in approximately 65% of the individuals evaluated here, all of whom were overweight. Obstructive ventilatory disorder and positive bronchodilator response predominated.

Keywords: Obesity/complications; Respiratory function tests; Lung diseases/etiology.

Objective: To identify respiratory symptoms and evaluate lung function in mine workers. Methods: This was a cross-sectional observational study involving production sector workers of a pyrochlore mining company. The subjects completed the British Medical Research Council questionnaire, which is designed to evaluate respiratory symptoms, occupational exposure factors, and smoking status. In addition, they underwent pulmonary function tests with a portable spirometer. Results: The study involved 147 workers (all male). The mean age was 41.37 ± 8.71 years, and the mean duration of occupational exposure was 12.26 ± 7.09 years. We found that 33 (22.44%) of the workers had respiratory symptoms and that 26 (17.69%) showed abnormalities in the spirometry results. However, we found that the spirometry results did not correlate significantly with the presence of respiratory symptoms or with the duration of occupational exposure. Conclusions: The frequencies of respiratory symptoms and spirometric changes were low when compared with those reported in other studies involving occupational exposure to dust. No significant associations were observed between respiratory symptoms and spirometry results.

Keywords: Spirometry; Mining; Niobium; Occupational exposure.

Objective: Discomfort and noncompliance with noninvasive ventilation (NIV) interfaces are obstacles to NIV success. Total face masks (TFMs) are considered to be a very comfortable NIV interface. However, due to their large internal volume and consequent increased CO2 rebreathing, their orifices allow proximal leaks to enhance CO2 elimination. The ventilators used in the ICU might not adequately compensate for such leakage. In this study, we attempted to determine whether ICU ventilators in NIV mode are suitable for use with a leaky TFM. Methods: This was a bench study carried out in a university research laboratory. Eight ICU ventilators equipped with NIV mode and one NIV ventilator were connected to a TFM with major leaks. All were tested at two positive end-expiratory pressure (PEEP) levels and three pressure support levels. The variables analyzed were ventilation trigger, cycling off, total leak, and pressurization. Results: Of the eight ICU ventilators tested, four did not work (autotriggering or inappropriate turning off due to misdetection of disconnection); three worked with some problems (low PEEP or high cycling delay); and one worked properly. Conclusions: The majority of the ICU ventilators tested were not suitable for NIV with a leaky TFM.

Keywords: Ventilators, mechanical; Positive-pressure Respiration; Noninvasive ventilation; Equipment safety; Equipment failure; Masks.

Objective: To evaluate the effect that seasonality has on the occurrence of respiratory symptoms in a Brazilian city with a tropical climate. Methods: This was a cross-sectional study, in which data related to subjects who sought outpatient treatment at a primary health care clinic in the city of Goiânia, Brazil, were correlated with daily meteorological data. Over a one-year period, all the patients who met the inclusion criteria were interviewed on 44 distinct, randomly selected days (11 days per season). We used ANOVA in order to compare the means of the dependent variables by season. Correlations were drawn between each dependent variable and each meteorological variable. The effects of the meteorological variables were analyzed with an AutoRegressive Moving Average with eXogenous input (ARMAX) model. Results: Of the 3,354 participants, 494 (14.6%) had respiratory symptoms. Although temperature variation alone had no effect on the number of individuals with respiratory symptoms, the low levels of humidity during winter resulted in a statistically significant difference among the seasons (p < 0.01). The mean minimum relative humidity on the three days prior to the interviews correlated negatively with the number of subjects with respiratory symptoms (p = 0.04). An ARMAX model including the same variable showed a statistically significant coefficient (p < 0.0001). Conclusions: In this sample, the number of subjects with respiratory symptoms increased significantly when the relative humidity dropped, and this increase could be predicted using meteorological data.

Keywords: Seasons; Tropical climate/adverse effects; Signs and symptoms, respiratory; Logistic models.

Objective: To investigate the extent to which exercise is associated with symptoms in patients with severe obstructive sleep apnea (OSA). Methods: We included subjects with an apnea-hypopnea index (AHI) > 30 events/h who completed validated sleep and exercise questionnaires. We compared symptom frequency/scores between exercisers and nonexercisers, adjusting for the usual confounders. Results: The sample included 907 nonexercisers and 488 exercisers (mean age, 49 ± 14 years; mean AHI, 53 ± 20 events/h; 81% men). Nonexercisers and exercisers differed significantly in terms of obesity (72% vs. 54%), the mean proportion of sleep in non-rapid eye movement stage 3 sleep (9 ± 8% vs. 11 ± 6%), and tiredness (78% vs. 68%). Nonexercisers had a higher symptom frequency/scores and poorer sleep quality. Adjustment for exercise weakened the associations between individual symptoms and the AHI, indicating that exercise has a mitigating effect. In binary logistic models, exercise was associated with approximately 30% lower adjusted questionnaire1 score > 2, tiredness; poor-quality sleep, unrefreshing sleep, and negative mood on awakening. Although the odds of an Epworth Sleepiness Scale score > 10 were lower in exercisers, that association did not withstand adjustment for confounders. Conclusions: Exercise is associated with lower frequency/intensity of symptoms in patients with severe OSA. Because up to one third of patients with severe OSA might exercise regularly and therefore be mildly symptomatic, it is important not to rule out a diagnosis of OSA in such patients.

Keywords: Sleep apnea syndromes; Exercise; Sleepiness; Polysomnography.

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.