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Pereira CAC, Cordero S, Resende AC. Progressive fibrotic interstitial lung disease. J Bras Pneumol 2023; 49:e20230098. [PMID: 37610955 PMCID: PMC10578905 DOI: 10.36416/1806-3756/e20230098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 06/24/2023] [Indexed: 08/25/2023] Open
Abstract
Many interstitial lung diseases (ILDs) share mechanisms that result in a progressive fibrosing phenotype. In Brazil, the most common progressive fibrosing interstitial lung diseases (PF-ILDs) are chronic hypersensitivity pneumonitis, idiopathic pulmonary fibrosis, unclassified ILD, and connective tissue diseases. PF-ILD is seen in approximately 30% of patients with ILD. Because PF-ILD is characterized by disease progression after initiation of appropriate treatment, a diagnosis of the disease resulting in fibrosis is critical. Different criteria have been proposed to define progressive disease, including worsening respiratory symptoms, lung function decline, and radiological evidence of disease progression. Although the time elapsed between diagnosis and progression varies, progression can occur at any time after diagnosis. Several factors indicate an increased risk of progression and death. In the last few years, antifibrotic drugs used in patients with idiopathic pulmonary fibrosis have been tested in patients with PF-ILD. The effects of nintedanib and placebo have been compared in patients with PF-ILD, a mean difference of 107.0 mL/year being observed, favoring nintedanib. The U.S. Food and Drug Administration and the Brazilian Health Regulatory Agency have approved the use of nintedanib in such patients on the basis of this finding. Pirfenidone has been evaluated in patients with unclassified ILD and in patients with other ILDs, the results being similar to those for nintedanib. More studies are needed in order to identify markers of increased risk of progression in patients with ILD and determine the likelihood of response to treatment with standard or new drugs.
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Affiliation(s)
- Carlos A C Pereira
- . Programa de Assistência e Pesquisa em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Soraya Cordero
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
| | - Ana Carolina Resende
- . Programa de Pós-Graduação em Doenças Pulmonares Intersticiais, Departamento de Clínica Médica, Serviço de Pneumologia, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:e97-e156. [PMID: 33861992 DOI: 10.1016/j.chest.2021.03.066] [Citation(s) in RCA: 79] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/07/2021] [Accepted: 03/22/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The purpose of this analysis is to provide evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion, and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. A diagnostic algorithm is provided, using supporting data from the recommendations where possible, along with expert consensus to help physicians gauge the probability of HP. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Criteria are presented to facilitate diagnosis of HP. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
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Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, UK
| | | | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
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Fernández Pérez ER, Travis WD, Lynch DA, Brown KK, Johannson KA, Selman M, Ryu JH, Wells AU, Tony Huang YC, Pereira CAC, Scholand MB, Villar A, Inase N, Evans RB, Mette SA, Frazer-Green L. Executive Summary: Diagnosis and Evaluation of Hypersensitivity Pneumonitis: CHEST Guideline and Expert Panel Report. Chest 2021; 160:595-615. [PMID: 33865835 DOI: 10.1016/j.chest.2021.03.067] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 03/25/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The purpose of this summary is to provide a synopsis of evidence-based and consensus-derived guidance for clinicians to improve individual diagnostic decision-making for hypersensitivity pneumonitis (HP) and decrease diagnostic practice variability. STUDY DESIGN AND METHODS Approved panelists developed key questions regarding the diagnosis of HP using the PICO (Population, Intervention, Comparator, and Outcome) format. MEDLINE (via PubMed) and the Cochrane Library were systematically searched for relevant literature, which was supplemented by manual searches. References were screened for inclusion and vetted evaluation tools were used to assess the quality of included studies, to extract data, and to grade the level of evidence supporting each recommendation or statement. The quality of the evidence was assessed using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Graded recommendations and ungraded consensus-based statements were drafted and voted on using a modified Delphi technique to achieve consensus. RESULTS The systematic review of the literature based on 14 PICO questions resulted in 14 key action statements: 12 evidence-based, graded recommendations, and 2 ungraded consensus-based statements. All evidence was of very low quality. INTERPRETATION Diagnosis of HP should employ a patient-centered approach and include a multidisciplinary assessment that incorporates the environmental and occupational exposure history and CT pattern to establish diagnostic confidence prior to considering BAL and/or lung biopsy. Additional research is needed on the performance characteristics and generalizability of exposure assessment tools and traditional and new diagnostic tests in modifying clinical decision-making for HP, particularly among those with a provisional diagnosis.
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Affiliation(s)
- Evans R Fernández Pérez
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO.
| | - William D Travis
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David A Lynch
- Department of Radiology, National Jewish Health, Denver, CO
| | - Kevin K Brown
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, Denver, CO
| | - Kerri A Johannson
- Departments of Medicine and Community Health Science, University of Calgary, Calgary, AB, Canada
| | - Moisés Selman
- Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, México City, México
| | - Jay H Ryu
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Athol U Wells
- Department of Medicine, Royal Brompton Hospital, Imperial College London, London, England
| | - Yuh-Chin Tony Huang
- Department of Environmental and Occupational Medicine, Duke University Medical Center, Durham, NC
| | - Carlos A C Pereira
- Department of Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Ana Villar
- Respiratory Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Naohiko Inase
- Department of Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | | | - Stephen A Mette
- Department of Medicine, University of Arkansas for Medical Sciences, AR
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Costa CM, Neder JA, Verrastro CG, Paula-Ribeiro M, Ramos R, Ferreira EM, Nery LE, O'Donnell DE, Pereira CAC, Ota-Arakaki J. Uncovering the mechanisms of exertional dyspnoea in combined pulmonary fibrosis and emphysema. Eur Respir J 2019; 55:13993003.01319-2019. [PMID: 31649067 DOI: 10.1183/13993003.01319-2019] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 10/12/2019] [Indexed: 01/19/2023]
Abstract
The prevailing view is that exertional dyspnoea in patients with combined idiopathic pulmonary fibrosis (IPF) and emphysema (CPFE) can be largely explained by severe hypoxaemia. However, there is little evidence to support these assumptions.We prospectively contrasted the sensory and physiological responses to exercise in 42 CPFE and 16 IPF patients matched by the severity of exertional hypoxaemia. Emphysema and pulmonary fibrosis were quantified using computed tomography. Inspiratory constraints were assessed in a constant work rate test: capillary blood gases were obtained in a subset of patients.CPFE patients had lower exercise capacity despite less extensive fibrosis compared to IPF (p=0.004 and 0.02, respectively). Exertional dyspnoea was the key limiting symptom in 24 CPFE patients who showed significantly lower transfer factor, arterial carbon dioxide tension and ventilatory efficiency (higher minute ventilation (V'E)/carbon dioxide output (V'CO2 ) ratio) compared to those with less dyspnoea. However, there were no between-group differences in the likelihood of pulmonary hypertension by echocardiography (p=0.44). High dead space/tidal volume ratio, low capillary carbon dioxide tension emphysema severity (including admixed emphysema) and traction bronchiectasis were related to a high V'E/V'CO2 ratio in the more dyspnoeic group. V'E/V'CO2 nadir >50 (OR 9.43, 95% CI 5.28-13.6; p=0.0001) and total emphysema extent >15% (2.25, 1.28-3.54; p=0.01) predicted a high dyspnoea burden associated with severely reduced exercise capacity in CPFEContrary to current understanding, hypoxaemia per se is not the main determinant of exertional dyspnoea in CPFE. Poor ventilatory efficiency due to increased "wasted" ventilation in emphysematous areas and hyperventilation holds a key mechanistic role that deserves therapeutic attention.
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Affiliation(s)
- Camila M Costa
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - J Alberto Neder
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | | | - Marcelle Paula-Ribeiro
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Roberta Ramos
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Eloara M Ferreira
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Luiz E Nery
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Denis E O'Donnell
- Laboratory of Clinical Exercise Physiology and Respiratory Investigation Unit, Queen's University and Kingston General Hospital, Kingston, ON, Canada
| | - Carlos A C Pereira
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
| | - Jaquelina Ota-Arakaki
- Pulmonary Vascular Disease and Interstitial Lung Disease Services, Division of Respirology, Federal University of Sao Paulo, Sao Paulo, Brazil
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Oliveira RKF, Ota-Arakaki JS, Gomes PS, Gimenez A, Messina CMS, Ramos RP, Ferreira EVM, Systrom DM, Pereira CAC. Pulmonary haemodynamics and mortality in chronic hypersensitivity pneumonitis. Eur Respir J 2018; 51:13993003.00430-2018. [PMID: 29622570 DOI: 10.1183/13993003.00430-2018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 03/25/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Rudolf K F Oliveira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Paula S Gomes
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Andrea Gimenez
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Carolina M S Messina
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Roberta P Ramos
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
| | - David M Systrom
- Division of Pulmonary and Critical Care Medicine, Dept of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Carlos A C Pereira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (Unifesp), São Paulo, Brazil
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Gimenez A, Storrer K, Kuranishi L, Soares MR, Ferreira RG, Pereira CAC. Change in FVC and survival in chronic fibrotic hypersensitivity pneumonitis. Thorax 2017; 73:391-392. [PMID: 28883091 DOI: 10.1136/thoraxjnl-2017-210035] [Citation(s) in RCA: 100] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/03/2017] [Accepted: 07/14/2017] [Indexed: 11/03/2022]
Abstract
The predictive value of the decline in FVC by ≥10% on survival in patients with fibrotic hypersensitivity pneumonitis is unknown. Of 112 patients included, 66 (59%) had surgical lung biopsies. Patients with ≥10% decline in predicted FVC after 6-12 months had a significantly increased risk of all-cause mortality (median survival 53 months, 95% CI 37 to 69 vs 139 months, 95% CI 66 to 212 months, p=0.007). On multivariate analysis remained associated with increasing mortality: decline in FVC by ≥10% (HR 4.13, 95% CI 1.96 to 8.70, p=0.005), lower FVC% (HR 1.03, 95% CI 1.01 to 1.05, p=0.003) and with decreasing mortality improvement with antigen avoidance (HR 0.18, 95% CI 0.04 to 0.77, p=0.021).
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Affiliation(s)
- Andrea Gimenez
- Interstitial Lung Diseases Program, Federal University of São Paulo, São Paulo, Brazil
| | - Karin Storrer
- Interstitial Lung Diseases Program, Federal University of São Paulo, São Paulo, Brazil
| | - Lilian Kuranishi
- Interstitial Lung Diseases Program, Federal University of São Paulo, São Paulo, Brazil
| | - Maria Raquel Soares
- Interstitial Lung Diseases Program, Federal University of São Paulo, São Paulo, Brazil
| | | | - Carlos A C Pereira
- Interstitial Lung Diseases Program, Federal University of São Paulo, São Paulo, Brazil
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Larsen BT, Smith ML, Elicker BM, Fernandez JM, de Morvil GAAO, Pereira CAC, Leslie KO. Diagnostic Approach to Advanced Fibrotic Interstitial Lung Disease: Bringing Together Clinical, Radiologic, and Histologic Clues. Arch Pathol Lab Med 2016; 141:901-915. [DOI: 10.5858/arpa.2016-0299-sa] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—
Idiopathic pulmonary fibrosis (IPF) is a distinctive clinicopathologic entity and the most common form of progressive diffuse lung scarring in older adults. Idiopathic pulmonary fibrosis manifests histopathologically as the usual interstitial pneumonia pattern. The usual interstitial pneumonia pattern is distinguished by geographically and temporally heterogeneous fibrosis that is peripherally accentuated, often with honeycombing and traction bronchiectasis. Idiopathic pulmonary fibrosis is not the only disease that leads to end-stage lung fibrosis, however, and several other entities may also cause advanced fibrosis. Surgical lung biopsies often present a diagnostic dilemma when they show clear evidence of advanced fibrosis, but the clinical, imaging, and/or histopathologic subcharacteristics suggest something other than IPF.
Objective.—
To address this dilemma, we review several other fibrotic lung diseases, including connective tissue disease–associated interstitial lung disease, chronic hypersensitivity pneumonitis, advanced pulmonary Langerhans cell histiocytosis, end-stage pulmonary sarcoidosis, Erdheim-Chester disease, Hermansky-Pudlak syndrome, and others, detailing their clinical, radiologic, and histopathologic attributes and emphasizing similarities to and differences from IPF.
Data Sources.—
Data sources comprised published peer-reviewed literature and personal experience of the authors.
Conclusions.—
Often, clues in the lung biopsy may offer the first suggestion of a fibrotic lung disease other than IPF, and accurate classification is important for prognosis, treatment, and the development of future therapies.
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Affiliation(s)
| | | | | | | | | | | | - Kevin O. Leslie
- From the Department of Laboratory Medicine & Pathology (Drs Larsen, Smith, and Leslie), Mayo Clinic, Scottsdale, Arizona; the Department of Radiology (Dr Elicker), University of California, San Francisco; Juan Max Boettner Hospital (Drs Fernandez and Arbo-Oze de Morvil), Asunción, Paraguay; and the Department of Medicine (Dr Pereira), Federal University of São Paulo, São Paulo, Brazil
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Oliveira RKF, Pereira CAC, Ramos RP, Ferreira EVM, Messina CMS, Kuranishi LT, Gimenez A, Campos O, Silva CMC, Ota-Arakaki JS. A haemodynamic study of pulmonary hypertension in chronic hypersensitivity pneumonitis. Eur Respir J 2014; 44:415-24. [PMID: 24743965 DOI: 10.1183/09031936.00010414] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic hypersensitivity pneumonitis is a common fibrotic interstitial lung disease. The prevalence of pulmonary hypertension diagnosed by right heart catheterisation and its cardiopulmonary function findings in patients with chronic hypersensitivity pneumonitis are unknown. Consecutive symptomatic patients with chronic hypersensitivity pneumonitis were prospectively evaluated. All patients were submitted to right heart catheterisation, pulmonary function testing, a 6-min walk test, echocardiography, blood gas determination and N-terminal pro-brain natriuretic peptide analyses. Nonhypoxaemic patients also underwent incremental cardiopulmonary exercise testing. 50 patients underwent right heart catheterisation; 25 (50%) of these had pulmonary hypertension and 22 (44%) had a pre-capillary haemodynamic pattern. The patients with pre-capillary pulmonary hypertension had lower forced vital capacity (mean ± sd 50 ± 17% versus 69 ± 22% predicted, p<0.01), carbon monoxide diffusing capacity (37 ± 12% versus 47 ± 14% predicted, p<0.01), arterial oxygen tension (median (interquartile range) 59.0 (47.8-69.3) versus 73.0 (62.2-78.5) mmHg, p<0.01) and saturation after the 6-min walk test (78 ± 8% versus 86 ± 7%, p<0.01). In pre-capillary pulmonary hypertension, oxygen uptake was also lower at the anaerobic threshold (41 ± 11% versus 50 ± 8% predicted, p=0.04) and at peak exercise (12.8 ± 1.6 versus 15.0 ± 2.5 mL · kg(-1) · min(-1), p=0.02). Pre-capillary pulmonary hypertension is common in symptomatic chronic hypersensitivity pneumonitis and is related to interstitial lung disease severity. Additionally, pulmonary hypertension is more prevalent in hypoxaemic patients with impaired lung function and exercise capacity.
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Affiliation(s)
- Rudolf K F Oliveira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Carlos A C Pereira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil,
| | - Roberta P Ramos
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Eloara V M Ferreira
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Carolina M S Messina
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Lilian T Kuranishi
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Andrea Gimenez
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
| | - Orlando Campos
- Division of Cardiology, Dept of Medicine, UNIFESP, Brazil
| | | | - Jaquelina S Ota-Arakaki
- Division of Respiratory Diseases, Dept of Medicine, Federal University of São Paulo (UNIFESP), Brazil
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Burity EF, Pereira CAC, Rizzo JA, Brito MCA, Sarinho ESC. Reference values for spirometry in preschool children. J Pediatr (Rio J) 2013; 89:374-80. [PMID: 23791023 DOI: 10.1016/j.jped.2013.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 01/09/2013] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Reference values for lung function tests differ in samples from different countries, including values for preschoolers. The main objective of this study was to derive reference values in this population. METHODS A prospective study was conducted through a questionnaire applied to 425 preschool children aged 3 to 6 years, from schools and day-care centers in a metropolitan city in Brazil. Children were selected by simple random sampling from the aforementioned schools. Peak expiratory flow (PEF), forced vital capacity (FVC), forced expiratory volumes (FEV1, FEV0.50), forced expiratory flow (FEF25-75) and FEV1/FVC, FEV0.5/FVC and FEF25-75/FVC ratios were evaluated. RESULTS Of the 425 children enrolled, 321 (75.6%) underwent the tests. Of these, 135 (42.0%) showed acceptable results with full expiratory curves and thus were included in the regression analysis to define the reference values. Height and gender significantly influenced FVC values through linear and logarithmic regression analysis. In males, R(2) increased with the logarithmic model for FVC and FEV1, but the linear model was retained for its simplicity. The lower limits were calculated by measuring the fifth percentile residues. CONCLUSION Full expiratory curves are more difficult to obtain in preschoolers. In addition to height, gender also influences the measures of FVC and FEV1. Reference values were defined for spirometry in preschool children in this population, which are applicable to similar populations.
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Affiliation(s)
- Edjane F Burity
- Pós-graduação em Saúde da Criança e do Adolescente, Universidade Federal de Pernambuco, Recife, PE, Brazil.
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Curimbaba J, Pimenta J, Moreira JM, Carla Sousa Rodrigues U, Coletta ENA, Pereira CAC. Sarcoidosis Masquerading as Atrial Fibrillation: Interesting Case Discussion as Well as Recent Advances in Diagnosis and Management of Cardiac Sarcoidosis. J Atr Fibrillation 2012; 5:533. [PMID: 28496787 DOI: 10.4022/jafib.533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2012] [Revised: 04/10/2012] [Accepted: 08/18/2012] [Indexed: 11/10/2022]
Abstract
This report presents a case of cardiac sarcoidosis initially manifested with atrial fibrillation. This behavior is very uncommon in spite of the fact that the disease is multisystemic, affecting predominantly the lungs. It is emphasized that the diagnosis of the cardiac involvement is difficult, and when this occurs, can lead to conducting system disturbances, heart failure or sudden death (SD). The diagnosis can be made by evaluating the clinical manifestations, the noninvasive tests like ECG, Holter monitoring, chest radiography, thoracic computed tomography, magnetic resonance image and positron emission tomography. In general, sarcoidosis is treated with steroid compounds with good outcome, mainly when performed in the initial phases of the disease. Other cardiac manifestations, such as arrhythmias, atrioventricular block or heart failure, are managed similar to other cardiomyopathies.
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Affiliation(s)
- Jefferson Curimbaba
- Coordinator of the Cardiology Clinic, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
| | - João Pimenta
- Director of the Cardiology Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil
| | - José Marcos Moreira
- Coordinator of the Holter Section, Cardiology Service, Hospital do Servidor Públicoo Estadual, São Paulo, SP, Brazil
| | | | | | - Carlos A C Pereira
- Director of the Pneumology Service, Hospital do Servidor Público Estadual, São Paulo, SP, Brazil, From the Cardiology and Pneumology Services, Hospital do Servidor Publico Estadual, São Paulo, SP, Brazil
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11
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Kawano-Dourado LB, Carvalho CRR, Santos UP, Canzian M, Coletta ENA, Pereira CAC, Kairalla RA. Tunnel excavation triggering pulmonary sarcoidosis. Am J Ind Med 2012; 55:390-4. [PMID: 22113960 DOI: 10.1002/ajim.21030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2011] [Indexed: 11/10/2022]
Abstract
CONTEXT A definite cause of sarcoidosis has not been identified, however past research suggests that environmental factors may be triggers of the granulomatous response in genetically susceptible individuals. CASE PRESENTATION A 22-year-old male non-smoker, presented with progressive exertional dyspnea and cough of 3 months duration. One year before, when he started working in tunnel excavation, he had a normal chest radiograph. Chest imaging revealed bilateral nodules and masses of peribronchovascular distribution plus mediastinal lymphadenomegaly. Histologic lymph node analysis revealed non-caseating confluent granulomas. Sarcoidosis was diagnosed. The patient was treated with corticosteroids and advised to change jobs. Complete remission of the disease was achieved and persisted for at least one year without steroid treatment. DISCUSSION Sarcoidosis is believed to have environmental triggers. The timing of the onset of sarcoidosis in this patient following intensive exposure to tunnel dust suggests an environmental contribution. The recognition that sarcoidosis may have occupational triggers have medical, employment, and legal implications.
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Affiliation(s)
- L B Kawano-Dourado
- Pulmonary Division, Heart Institute (InCor), Medical School of the University of São Paulo, São Paulo, Brazil.
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Rodrigues SCS, Rocha NAS, Lima MS, Arakaki JSO, Coletta ENA, Ferreira RG, Gonzaga LR, Pereira CAC. Factor analysis of sarcoidosis phenotypes at two referral centers in Brazil. Sarcoidosis Vasc Diffuse Lung Dis 2011; 28:34-43. [PMID: 21796889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND In sarcoidosis, clinical presentations and outcomes vary widely. OBJECTIVE To characterize the clinical phenotypes of sarcoidosis, by factor analysis, in a series of cases with long-term follow-up. METHODS We conducted a retrospective study involving 137 patients with biopsy-confirmed sarcoidosis, recruited from two referral centers in São Paulo, Brazil. Organ involvement was evaluated in accordance with a previously established protocol. Sarcoidosis phenotypes were characterized by factor analysis. RESULTS Follow-up ranged from 6 to 144 months. Four factors (phenotypes) were identified: relevant residual pulmonary fibrosis; relapse; residual airflow limitation; and acute disease. The four factors collectively accounted for 66% of the total variance. Patients with relevant residual pulmonary fibrosis were older and presented with the following: greater symptom duration; skin involvement; low forced vital capacity; low forced expiratory volume in one second/forced vital capacity ratio; and more advanced radiographic stages at baseline. The relapse phenotype was associated with chronic disease, greater dyspnea severity, neurologic involvement, and cardiac involvement. Patients with residual airflow limitation more often had airflow obstruction at baseline, chronic disease, and relevant residual pulmonary fibrosis. Acute disease was associated with being younger, weight loss, scoring lower for dyspnea, and having extensive involvement. Abnormal calcium metabolism was associated with acute disease and with relapse. CONCLUSIONS Sarcoidosis can be categorized into four different clinical phenotypes: three that are chronic; and one that is acute and self-limiting. In many cases, these phenotypes can be easily recognized.
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Affiliation(s)
- S C S Rodrigues
- Paulista School of Medicine, Federal University of São Paulo, São Paulo, Brazil.
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Lima MS, Coletta ENAM, Ferreira RG, Jasinowodolinski D, Arakaki JSO, Rodrigues SCS, Rocha NANS, Pereira CAC. Subacute and chronic hypersensitivity pneumonitis: histopathological patterns and survival. Respir Med 2010; 103:508-15. [PMID: 19179061 DOI: 10.1016/j.rmed.2008.12.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2008] [Revised: 12/09/2008] [Accepted: 12/22/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND In hypersensitivity pneumonitis (HP), survival can be predicted on the basis of the severity of fibrosis in surgical lung biopsy, but few data are available on the influence of clinical, functional, tomographic and histologic findings on prognosis. OBJECTIVES To describe the impact on survival of clinical data, histological patterns, and HRCT findings in subacute/chronic HP. METHODS A retrospective analysis of 103 patients diagnosed with HP submitted to surgical lung biopsy. Chronic HP was characterized by HRCT findings indicative of fibrosis (n=76). RESULTS The most relevant exposures were to molds and birds. Lung biopsies revealed typical HP with granulomas in 46 patients, bronchiolocentric interstitial pneumonia in 27, and non-specific interstitial pneumonia (NSIP) in 16. By univariate analysis, several findings were predictors of mortality: older age, male sex, velcro crackles, higher FEV(1)/FVC ratio, lower oxygen saturation during exercise, and absence of mosaic pattern/air trapping and presence of fibrosis on HRCT. By multivariate analysis, remained significant: age (p=0.007), oxygen saturation during exercise (p=0.003), and mosaic pattern/air trapping on HRCT (p=0.004). Patients with NSIP had a greater survival than did those with typical histology and those with bronchiolocentric pneumonia (p=0.033). CONCLUSIONS A wide range of histological features are found in HP. Typical findings are seen in 45% of cases. Other common patterns are NSIP and centriacinar lesions. Survival is better in patients with NSIP and worse in those with older age, desaturation during exercise, and absence of mosaic pattern/air trapping on HRCT.
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Affiliation(s)
- Mariana S Lima
- Division of Respiratory Diseases, Department of Medicine, Universidade Federal de São Paulo - Escola Paulista de Medicina, São Paulo, Brazil.
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Ribeiro M, Pereira CAC, Nery LE, Beppu OS, Silva COS. Methacholine vs adenosine on intra and extrathoracic airway hyperresponsiveness in patients with cough variant asthma. Allergy 2008; 63:527-32. [PMID: 18394126 DOI: 10.1111/j.1398-9995.2007.01589.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Airway hyperresponsiveness (AHR) can be studied by bronchoprovocation test (BPT) using direct (methacholine - MCh) or indirect (adenosine 5'-monophosphate - AMP) stimuli. These two substances have not been compared in cough variant asthma (CVA). OBJECTIVE We designed a randomized, single-blind, cross-over study to compare AMP and MCh in the detection of CVA. Additionally, we examined whether assessment of extrathoracic airway hyperresponsiveness (EAHR) during MCh and AMP helped in the evaluation of CVA. METHODS Patients with CVA with previous positive MCh BPT performed challenges with AMP and MCh. The variables were: (i) a provocative dose producing a 20% fall in forced expiratory volume in 1 s (FEV(1)) value (PD(20)MCh); (ii) a provocative dose producing a 25% fall in the maximal mid-inspiratory flow (FIF(50)) from baseline (PD(25)MCh) for MCh; (iii) a provocative concentration producing a 20% fall in FEV(1) value (PC(20)AMP) and (iv) a provocative concentration producing a 25% fall in the FIF(50) from baseline (PC(25)AMP) for AMP. RESULTS All 113 patients with CVA responded to PD(20)MCh and 96% and 69% responded to PC(20)AMP, if we used PC(20) </= 200 mg/ml or PC(20) </= 100 mg/ml, respectively, with an excellent correlation between these two tests (r = 0.87 and 0.76, respectively). Extrathoracic AHR associated with AHR was found in 10% in MCh challenge and in 11% with AMP challenge and no patients had EAHR alone. CONCLUSION Adenosine challenges correlate well with MCh in patients with CVA. A minority (c. 10%) of CVA patients have EAHR as measured by these tests, while most had AHR as assessed with each of the challenge agents.
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Affiliation(s)
- M Ribeiro
- Respiratory Division, Department of Medicine, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
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Pereira CAC, Malheiros T, Coletta EM, Ferreira RG, Rubin AS, Otta JS, Rocha NS. Survival in idiopathic pulmonary fibrosis-cytotoxic agents compared to corticosteroids. Respir Med 2005; 100:340-7. [PMID: 16002271 DOI: 10.1016/j.rmed.2005.05.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2004] [Accepted: 05/02/2005] [Indexed: 02/06/2023]
Abstract
STUDY OBJECTIVE To compare the survival of patients with IPF treated retrospectively with corticosteroids alone, to survival of patients treated with immunosuppressive and corticosteroids combined. DESIGN Non-randomized retrospective cohort study. SETTING Three tertiary centers in Brazil. PATIENTS Eighty-two IPF patients were included. The diagnosis was confirmed by open lung biopsy in 48. Patients received either corticosteroids alone (group I) or cytotoxic agents in addition to corticosteroids (group II). MEASUREMENTS AND RESULTS The primary end-point was mortality. Secondary outcome included longitudinal changes in FVC. Mean age was 66+/-8 years. FVC was 71+/-17% of predicted. There were 48 deaths during the study period (59%), 44 secondary to respiratory causes. From preliminary univariate analysis, for the group as a whole, worse survival was found to be associated with FVC% <70% of predicted (P=0.004), evidence of disease progression by follow-up FVC measurements (P=0.01), and pharmacologic treatment (P=0.014). Median survival was 25 months for the group I, and 45 months for the group II (Log-Rank=6.45, P=0.01). After adjusting for FVC > or =70% and<70% of predicted, there was evidence to indicate that survival was associated with recommended pharmacologic treatment only in patients with FVC> or =70% (Log Rank=6.84, P=0.009). CONCLUSIONS The combination of immunosuppressive agents and prednisone results in better survival when compared to prednisone alone in patients with IPF. The benefit seems to occur only in patients with less severe disease, as reflected by FVC> or =70%.
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Affiliation(s)
- Carlos A C Pereira
- Department of Pulmonology, Paulista School of Medicine, Federal University of Sao Paulo, Av Iraí 393 conj 34, Moema 04082 001, Sao Paulo, SP, Brazil.
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Souza ACTG, Pereira CAC. [Bronchial provocation tests using methacholine, cycle ergometer exercise and free running in children with intermittent asthma]. J Pediatr (Rio J) 2005; 81:65-72. [PMID: 15742089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2023] Open
Abstract
OBJECTIVE To compare airway responsiveness to methacholine, cycle ergometer exercise and free running in children with intermittent asthma. METHODS A randomized study was conducted with 30 children of both genders with intermittent asthma. Each child was submitted to challenge testing on three separate days, in random order: a) Methacholine challenge using a dosimeter; b) Exercise challenge testing -- free running along a 50-meter-long corridor; c) Dry-air exercise challenge on a cycle ergometer. Target heart rate during exercise was 80 to 90% of the maximum predicted value. Spirometry was performed 3, 6,10,15,20 and 30 minutes after exercise. Exercise-induced bronchospasm was defined as a decrease in FEV1 of > or = 10% in comparison to pretest values. RESULTS Mean age was 11+/-3 years. FEV1 and FEV1/FVC ratios were normal and similar before all provocation tests. The maximum heart rate was 178+/-7 bpm during cycling and 181+/-6 bpm during the free running test (p > 0.05). Significant bronchospasm was observed with methacholine in 23 cases, after free running in 19 and after cycling in 14 children (p < 0.05, methacholine vs exercise tests). Taking all FEV1 measurements after exercise into account, the free running test resulted in greater exercise-induced bronchospasm in comparison with exercise made on a cycle ergometer (p = 0.003, chi2 = 8.948). There was a significant, but poor, correlation between the maximum percentage decrease in FEV1 after free running and cycling (r = 0.46, p < 0.01). CONCLUSIONS Methacholine challenge identifies a greater number of asthmatics in comparison to exercise tests. When bronchial provocation test with methacholine is not available, free running should be the test of choice due to its simplicity and greater ability to induce bronchospasm.
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Affiliation(s)
- Ana C T G Souza
- Hospital do Servidor Público Estadual Francisco Morato de Oliveira, São Paulo, SP.
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Barros WGP, Neder JA, Pereira CAC, Nery LE. Clinical, Radiographic and Functional Predictors of Pulmonary Gas Exchange Impairment at Moderate Exercise in Patients with Sarcoidosis. Respiration 2004; 71:367-73. [PMID: 15316210 DOI: 10.1159/000079641] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2003] [Accepted: 02/02/2004] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pulmonary gas exchange impairment (GEI) is a common consequence of intrathoracic sarcoidosis presenting with important therapeutic and prognostic implications. OBJECTIVE To determine the role of clinical, radiographic and functional variables in predicting GEI during moderate exercise at the estimated lactate threshold (theta(L)) in patients with sarcoidosis. METHODS Fifty-four outpatients (29 females) with biopsy-proven sarcoidosis had clinical evaluation (baseline dyspnea index), lung function tests and an incremental cardiopulmonary exercise test with theta(L) estimation. On a separate day, patients underwent a constant work rate test at theta(L) with assessment of arterial blood gas tensions. RESULTS There was no evidence of GEI [DeltaP (A - a) O(2)/VO(2) >20 mm Hg.l. min(-1)] in patients with radiographic stages 0-I (n = 13). In the remaining 41 patients, GEI was associated with more extensive radiographic involvement and reduced diffusing capacity of the lung for carbon monoxide (DL(CO)), forced expiratory volume in 1 s, total lung capacity and forced vital capacity (% predicted;p < 0.05); baseline dyspnea index and resting arterial blood gas tensions, in contrast, were not significantly related to GEI. DL(CO) correlated best with GEI. The negative predictive value of DL(CO) >70% predicted (absent-to-mild impairment) was 91.3% (sensitivity = 81.8%) and the positive predictive value of DL(CO) </=50% predicted (severe impairment) was 83.3% (specificity = 96.6%, likelihood ratio = 13.35). There was no improvement in diagnostic accuracy when other physiological tests were added to DL(CO). These results were consistent with those found in a multiple logistic regression analysis with GEI as the dependent variable (p < 0.01). CONCLUSIONS Conventional chest radiography and DL(CO) measurements suffice to estimate the individual risk of GEI at moderate exercise in patients with sarcoidosis.
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Affiliation(s)
- Walder G P Barros
- Pulmonary Function and Clinical Exercise Physiology Unit, Respiratory Division, Department of Medicine, Federal University of São Paulo, Paulista School of Medicine, São Paulo, Brazil
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