A Bronquiolite Obliterante pós-infecciosa (BO) é conseqüência de agressão ao epitélio do trato respiratório inferior que se caracteriza por obstrução da via aérea distal. Autores ressaltam que além do diagnóstico oportuno da BO, do tratamento agressivo das infecções e da oxigenoterapia, é importante um plano nutricional adequado para evolução clínica favorável desta enfermidade. O objetivo do presente estudo é avaliar o estado nutricional de crianças e adolescentes portadores de BO, e, analisar a associação com aspectos clínicos e nutricionais. Para tanto, foi realizado estudo transversal em crianças (<10 anos) e adolescentes (10-18 anos), com diagnóstico clínico/tomográfico de BO, em acompanhamento ambulatorial. Para a determinação do estado nutricional nas crianças foram analisados os escores-Z de peso por idade (ZPI), estatura por idade (ZEI) e peso por estatura (ZPE), e nos adolescentes analisou-se o ZEI e a distribuição dos percentis do Índice de Massa Corporal (IMC). Entre os ≤ 5 anos, os índices foram avaliados com base no padrão da Organização Mundial da Saúde (WHO, 2006), e, a partir dos cinco anos adotou-se a referência do Centers for Disease Control (CDC, 2000). Na avaliação da composição corporal, adotou-se a referência de Frisancho, 1990, foram analisadas as dobras cutâneas tricipital (DCT) e subescapular (DCS) e a soma das duas (SDCTS) para reserva de gordura e a circunferência muscular do braço (CMB) para determinar reserva muscular. O consumo alimentar foi identificado pelo recordatório alimentar de 24 horas (RA24H). A função pulmonar foi avaliada, em pacientes maiores de oito anos, onde se realizou a espirometria e o teste de caminhada de 6 minutos (TC6). Na avaliação do estado nutricional, destaca-se o alto percentual de indivíduos com desnutrição e/ou risco para desnutrição 21,7% e 17,5% respectivamente. Encontrou-se um percentual de pacientes com 8,8% de sobrepeso e 10,5% de obesidade. Quando estratificados por faixa etária, observou-se nas crianças, que o PI e o EI apresentaram maior percentual de desnutrição 21,6% e 16,2%, respectivamente, enquanto que o PE subestimou o diagnóstico de desnutrição. Entre os adolescentes, a aplicação do IMC demonstrou um alto percentual de pacientes com desnutrição (25%) e risco para desnutrição (20%). Quanto a composição corporal, 51% dos indivíduos apresentaram desnutrição por baixa reserva muscular estimada pela CMB, e a maioria dos pacientes apresentou reserva de gordura dentro dos valores de normalidade, quando avaliada por DCT, DCS e SDCTS (68,4%, 64,9% e 63,2%, respectivamente). No que se refere ao consumo alimentar, a metade dos pacientes relataram apresentar ingestão energética abaixo do recomendado. Na avaliação da função pulmonar, observou-se alto percentual de distúrbio obstrutivo moderado (53,5%) e grave (28,5%) (Espirometria VEF1%), e, no desempenho ao exercício (TC6) a maioria dos pacientes (59,2%) apresentou resultados inferiores aos valores de referência. O prejuízo da função pulmonar indicado pelo VEF1% se associou com menor desempenho ao exercício indicado pelo TC6 (r=0,434; p=0,024). O diagnóstico de desnutrição e/ou risco nutricional, e também a baixa reserva muscular apresentaram associação significativa com o TC6 (p=0,032; p=0,030). Não se observou associação entre a função pulmonar, avaliada pelo VEF1%, com as variáveis nutricionais (estado nutricional, composição corporal, ingestão alimentar). Estes resultados sugerem a necessidade de intervenção nutricional, e também, observou-se que, além da utilização dos indicadores de peso e estatura faz-se necessária à associação da análise da composição corporal, com isso, um número maior de pacientes com desnutrição e/ou com risco aumentado de desenvolvê-la seriam identificados e adequadamente manejados. / Post-infectious bronchiolitis obliterans (BO) is the result of aggression suffered by the epithelium of the lower respiratory tract and which obstructs the distal airways. Authors state that, in addition to early diagnosis of BO, aggressive treatment of infections and oxygen therapy, an appropriate nutritional plan is also important to favorable clinical evolution in this disease. The objective of the present study was to assess the nutritional status of children and adolescents with BO and to analyze associations with clinical and nutritional factors. A cross-sectional study was carried out of children (<10 years) and adolescents (10-18 years) in outpatients follow-up with a clinical/tomographic diagnosis of BO. The nutritional status of the children was determined using z scores for weight for age (ZWA), height for age (ZHA) and weight for height (ZWH), and for the adolescents, ZHA was analyzed together with the distribution of Body Mass Index (BMI) percentiles. For those aged ≤ 5 years, indices were assessed on the basis of the World Health Organization reference standards (WHO, 2006), and, from 5 years onwards, the Centers for Disease Control references were adopted (CDC, 2000). Body composition was evaluated according to the references published in Frisancho, 1990, where tricipital skinfolds (TSF), subscapular skinfolds (SSF) and the sum of the two (STSSF) were used to gauge body fat reserves and the muscular circumference of the arm (MCA) was used to gauge muscle reserves. Dietary intake was identified using a 24-hour dietary recall (24HDR). Pulmonary function was evaluated in patients over 8 years old, using spirometry and a 6-minute walking test (6WT). Of note in the nutritional status assessment was the high percentage of individuals with malnutrition and/or at risk of malnutrition, 21.7% and 17.5% respectively. The percentage of overweight patients was 8.8% and the percentage of obesity was 10.5%. When broken down by age group, it was observed that among the children WA and HA detected higher percentages of malnutrition, 21.6% and 16.2% respectively, while WH underestimated malnutrition diagnoses. Among the adolescents, application of the BMI demonstrated a high percentage of patients with malnutrition (25%) and at risk from malnutrition (20%). With relation to body composition, 51% of the individuals exhibited malnutrition in terms of low muscle reserves, estimated using the MCA, and the majority of patients exhibited fat reserves within the limits of normality, when assessed according to TSF, SSF and STSSF (68.4%, 64.9% and 63.2%, respectively). With relation to nutritional intake, half of the patients reported an energy intake below the recommended level. The pulmonary function assessment revealed a high percentage of moderate (53.5%) and severe (28.5%) obstructive disorders (Spirometry VEF1%), and, the majority of patients (59.2%) had worse performance at the exercise test (6WT) than the reference figures. The compromised pulmonary function indicated by the VEF1% was associated with weaker performance at exercise, as indicated by the 6WT (r=0.434; p=0.024). Diagnoses of malnutrition and/or nutritional risk, and also low muscle reserves, exhibited significant associations with the 6WT results (p=0.032; p=0.030). No association was observed between pulmonary function, assessed by VEF1%, and nutritional variables (nutritional status, body composition, nutritional intake). These results suggest the need for nutritional intervention, and it can also be observed that, in addition to using weight and height indices, it is necessary to combine these with an analysis of body composition, so that a larger number of patients with malnutrition and/or at an increased risk of developing malnutrition may be identified and correctly managed.

A Bronquiolite Obliterante pós-infecciosa (BO) é conseqüência de agressão ao epitélio do trato respiratório inferior que se caracteriza por obstrução da via aérea distal. Autores ressaltam que além do diagnóstico oportuno da BO, do tratamento agressivo das infecções e da oxigenoterapia, é importante um plano nutricional adequado para evolução clínica favorável desta enfermidade. O objetivo do presente estudo é avaliar o estado nutricional de crianças e adolescentes portadores de BO, e, analisar a associação com aspectos clínicos e nutricionais. Para tanto, foi realizado estudo transversal em crianças (<10 anos) e adolescentes (10-18 anos), com diagnóstico clínico/tomográfico de BO, em acompanhamento ambulatorial. Para a determinação do estado nutricional nas crianças foram analisados os escores-Z de peso por idade (ZPI), estatura por idade (ZEI) e peso por estatura (ZPE), e nos adolescentes analisou-se o ZEI e a distribuição dos percentis do Índice de Massa Corporal (IMC). Entre os ≤ 5 anos, os índices foram avaliados com base no padrão da Organização Mundial da Saúde (WHO, 2006), e, a partir dos cinco anos adotou-se a referência do Centers for Disease Control (CDC, 2000). Na avaliação da composição corporal, adotou-se a referência de Frisancho, 1990, foram analisadas as dobras cutâneas tricipital (DCT) e subescapular (DCS) e a soma das duas (SDCTS) para reserva de gordura e a circunferência muscular do braço (CMB) para determinar reserva muscular. O consumo alimentar foi identificado pelo recordatório alimentar de 24 horas (RA24H). A função pulmonar foi avaliada, em pacientes maiores de oito anos, onde se realizou a espirometria e o teste de caminhada de 6 minutos (TC6). Na avaliação do estado nutricional, destaca-se o alto percentual de indivíduos com desnutrição e/ou risco para desnutrição 21,7% e 17,5% respectivamente. Encontrou-se um percentual de pacientes com 8,8% de sobrepeso e 10,5% de obesidade. Quando estratificados por faixa etária, observou-se nas crianças, que o PI e o EI apresentaram maior percentual de desnutrição 21,6% e 16,2%, respectivamente, enquanto que o PE subestimou o diagnóstico de desnutrição. Entre os adolescentes, a aplicação do IMC demonstrou um alto percentual de pacientes com desnutrição (25%) e risco para desnutrição (20%). Quanto a composição corporal, 51% dos indivíduos apresentaram desnutrição por baixa reserva muscular estimada pela CMB, e a maioria dos pacientes apresentou reserva de gordura dentro dos valores de normalidade, quando avaliada por DCT, DCS e SDCTS (68,4%, 64,9% e 63,2%, respectivamente). No que se refere ao consumo alimentar, a metade dos pacientes relataram apresentar ingestão energética abaixo do recomendado. Na avaliação da função pulmonar, observou-se alto percentual de distúrbio obstrutivo moderado (53,5%) e grave (28,5%) (Espirometria VEF1%), e, no desempenho ao exercício (TC6) a maioria dos pacientes (59,2%) apresentou resultados inferiores aos valores de referência. O prejuízo da função pulmonar indicado pelo VEF1% se associou com menor desempenho ao exercício indicado pelo TC6 (r=0,434; p=0,024). O diagnóstico de desnutrição e/ou risco nutricional, e também a baixa reserva muscular apresentaram associação significativa com o TC6 (p=0,032; p=0,030). Não se observou associação entre a função pulmonar, avaliada pelo VEF1%, com as variáveis nutricionais (estado nutricional, composição corporal, ingestão alimentar). Estes resultados sugerem a necessidade de intervenção nutricional, e também, observou-se que, além da utilização dos indicadores de peso e estatura faz-se necessária à associação da análise da composição corporal, com isso, um número maior de pacientes com desnutrição e/ou com risco aumentado de desenvolvê-la seriam identificados e adequadamente manejados. / Post-infectious bronchiolitis obliterans (BO) is the result of aggression suffered by the epithelium of the lower respiratory tract and which obstructs the distal airways. Authors state that, in addition to early diagnosis of BO, aggressive treatment of infections and oxygen therapy, an appropriate nutritional plan is also important to favorable clinical evolution in this disease. The objective of the present study was to assess the nutritional status of children and adolescents with BO and to analyze associations with clinical and nutritional factors. A cross-sectional study was carried out of children (<10 years) and adolescents (10-18 years) in outpatients follow-up with a clinical/tomographic diagnosis of BO. The nutritional status of the children was determined using z scores for weight for age (ZWA), height for age (ZHA) and weight for height (ZWH), and for the adolescents, ZHA was analyzed together with the distribution of Body Mass Index (BMI) percentiles. For those aged ≤ 5 years, indices were assessed on the basis of the World Health Organization reference standards (WHO, 2006), and, from 5 years onwards, the Centers for Disease Control references were adopted (CDC, 2000). Body composition was evaluated according to the references published in Frisancho, 1990, where tricipital skinfolds (TSF), subscapular skinfolds (SSF) and the sum of the two (STSSF) were used to gauge body fat reserves and the muscular circumference of the arm (MCA) was used to gauge muscle reserves. Dietary intake was identified using a 24-hour dietary recall (24HDR). Pulmonary function was evaluated in patients over 8 years old, using spirometry and a 6-minute walking test (6WT). Of note in the nutritional status assessment was the high percentage of individuals with malnutrition and/or at risk of malnutrition, 21.7% and 17.5% respectively. The percentage of overweight patients was 8.8% and the percentage of obesity was 10.5%. When broken down by age group, it was observed that among the children WA and HA detected higher percentages of malnutrition, 21.6% and 16.2% respectively, while WH underestimated malnutrition diagnoses. Among the adolescents, application of the BMI demonstrated a high percentage of patients with malnutrition (25%) and at risk from malnutrition (20%). With relation to body composition, 51% of the individuals exhibited malnutrition in terms of low muscle reserves, estimated using the MCA, and the majority of patients exhibited fat reserves within the limits of normality, when assessed according to TSF, SSF and STSSF (68.4%, 64.9% and 63.2%, respectively). With relation to nutritional intake, half of the patients reported an energy intake below the recommended level. The pulmonary function assessment revealed a high percentage of moderate (53.5%) and severe (28.5%) obstructive disorders (Spirometry VEF1%), and, the majority of patients (59.2%) had worse performance at the exercise test (6WT) than the reference figures. The compromised pulmonary function indicated by the VEF1% was associated with weaker performance at exercise, as indicated by the 6WT (r=0.434; p=0.024). Diagnoses of malnutrition and/or nutritional risk, and also low muscle reserves, exhibited significant associations with the 6WT results (p=0.032; p=0.030). No association was observed between pulmonary function, assessed by VEF1%, and nutritional variables (nutritional status, body composition, nutritional intake). These results suggest the need for nutritional intervention, and it can also be observed that, in addition to using weight and height indices, it is necessary to combine these with an analysis of body composition, so that a larger number of patients with malnutrition and/or at an increased risk of developing malnutrition may be identified and correctly managed.

The inhalation lesion is one of the biggest mortality causes in fire exposed patients at closed places. Medium and long follow-up respiratory consequences are still rarely reported at world literature. Alveolar-capillary membrane commitment caused by inhaled particles can persist during several years and progress to bronchiolitis obliterans. Thereby, the objective of this work was to evaluate the Diffusing Capacity for Carbon Monoxide (DLCO) lung test, at patients that inhaled toxic smoke at a fire in the nightclub Kiss at January 2013, in Santa Maria, parallel 29°, south Brazil, after first year follow-up. Were included 64 patients that were submited to DLCO and 6-minutes Walk Test (WT6) measurements. Dates were obtained by standard formularies including demographic characteristics, respiratory symptoms and inhalatory medication use. DLCO average was 63% (20,95 mL/mmHg/min) from predict and WT6 distance was 505,55 meters. At studied sample, 21,8% were asthmatics and when compared to no-asthmatics, they had better DLCO (p = 0,017). There was no statistical significance when compared other variables how: tracheal intubation, dyspnea, tabagism, dessaturation at WT6, smoke exposure time and intubation duration to DLCO results. Studied patients had a DLCO reduction greater than current literature. Development of chronic pulmonary complications, especially bronchiolitis obliterans, is a concrete possibility and must be better clarified and adequate screened. Late development of this kind of complication makes a prolonged ambulatorial follow-up indispensable. / A lesão inalatória é uma das grandes causas de mortalidade em pacientes expostos a incêndios fechados. As consequências respiratórias a médio e longo prazo nos sobreviventes ainda é pouco relatada na literatura mundial. O comprometimento da membrana alvéolo capilar pelas partículas inaladas pode persistir ao longo dos anos e progredir para bronquiolite obliterante. Desta forma, o objetivo deste trabalho foi avaliar o teste de difusão do monóxido de carbono (DLCO), nos pacientes que inalaram fumaça tóxica no incêndio ocorrido na Boate Kiss em Janeiro de 2013, em Santa Maria, paralelo 29°, no Sul do Brasil, após o primeiro ano do incêndio. Ao todo foram incluídos 64 pacientes, os quais foram submetidos à medida da DLCO e ao teste de caminhada de seis minutos (TC6). Os dados foram obtidos através de questionário contendo informações que incluíam características dos pacientes, sintomas respiratórios e uso de medicação inalatória. A DLCO média foi 63% do previsto (20,95 mL/mmHg/min) e a média da distancia no TC6 foi 505,5 metros. Na amostra estudada, 21,8% eram asmáticos e quando comparados a não asmáticos, possuíam melhor DLCO com p 0,017. Não houve significância estatística quando comparados outras variáveis como: intubação orotraqueal, dispneia, tabagismo, dessaturação no TC6, tempo de exposição, dias de intubação ao resultado da DLCO. Os pacientes estudados apresentaram redução na DLCO maior que a encontrada na literatura. O desenvolvimento de complicações pulmonares crônicas, em especial, bronquiolite obliterante, é uma possibilidade concreta e deve ser esclarecida e adequadamente rastreada. A característica tardia dessas complicações torna o seguimento ambulatorial prolongado imprescindível.

Ce travail portant sur l’imagerie tomodensitométrique double énergie de la ventilation a permis d’établir les points suivants :• L’irradiation d’un examen thoracique acquis en double énergie peut être abaissée à celle d’un examen acquis en simple énergie, grâce à l’utilisation de la reconstruction itérative.• L’analyse qualitative du parenchyme pulmonaire en imagerie double énergie doit se faire sur les reconstructions monochromatiques 50-55keV.• L’atténuation théorique maximale du Krypton dosé à 80% est modérément inférieure à celle du Xénon dosé à 30%.• La décomposition des matériaux en tomodensitométrie double énergie simple source est possible sur le Xénon et le Krypton.• L’utilisation d’un produit de contraste gazeux n’a pas d’impact significatif sur le Workflow en routine clinique.• Le Krypton est cliniquement sûr à la dose de 80%.• La technique ne permet pas de détecter le Krypton au-delà de la carène de manière satisfaisante, probablement en raison d’une concentration en gaz atteinte insuffisante.• Le recalage élastique augmente les performances diagnostiques de détection de la bronchiolite oblitérante par rapport à une simple analyse visuelle. / This work on dual energy CT ventilation imaging has established the following:• The radiation dose of a dual energy chest CT can be reduced to that of a single energy examination through the use of iterative reconstruction.• The qualitative analysis of the lung parenchyma should be made on the 50-55keV monochromatic reconstructions.• The maximum theoretical attenuation obtained with 80% Krypton is moderately inferior to that of 30% Xenon.• Dual energy material decomposition of Xenon and Krypton is efficient with a single source technique.• The use of a gaseous contrast agent has no significant impact on the workflow in the clinical setting.• The Krypton is safe at 80% concentration.• The technique does not satisfactorily detect Krypton beyond the carina, probably due to insufficient gas concentration.• The elastic registration increases the diagnostic performance of bronchiolitis obliterans syndrome detection, compared to a simple visual analysis.

Contexte : La survie à long terme après la transplantation pulmonaire est compromise par le rejet chronique (chronic lung allograft dysfunction (CLAD)), une complication qui touche 50% des patients à 5 ans post-greffe. Le CLAD regroupe quatre phénotypes distincts caractérisés par une atteinte pulmonaire obstructive (Bronchiolitis obliterans syndrome (BOS)) ou restrictive (Restrictive allograft syndrome (RAS)), ou une combinaison des deux (phénotypes mixte et non défini). L’obésité est associée à une diminution de la fonction pulmonaire en raison de facteurs mécaniques, métaboliques et inflammatoires qui lui sont associés. Le gain de poids suite à la greffe pulmonaire est fréquent et parfois considérable, ce qui peut compromettre la fonction pulmonaire. Or, le lien entre le gain de poids post-greffe et la survenue des phénotypes du CLAD demeure inconnu. Objectifs : 1) Décrire les trajectoires pondérales post-greffe pulmonaire des patients ayant développé ou non l’un des quatre phénotypes du CLAD; 2) Déterminer si le statut pondéral à la greffe et la variation de poids et d’IMC après la greffe sont associés à la survenue des phénotypes du CLAD; 3) Examiner si les phénotypes du CLAD influencent la survie post-greffe. Méthodologie : Étude rétrospective des dossiers médicaux de patients ayant reçu une transplantation pulmonaire bilatérale au CHUM entre 2000 et 2020. En utilisant la classification de l’International Society for Heart and Lung Transplantation, les patients ont été classés parmi les cinq catégories suivantes : Absence ou présence de l’un des quatre phénotypes du CLAD. Résultats : Parmi les 579 patients inclus; 412 (71.1%) n’ont pas développé de CLAD, et 81 (14.0%), 20 (3.5%), 59 (10.2%) and 7 (1.2%) ont respectivement développé les phénotypes BOS, RAS, mixte et non-défini. Les trajectoires post-greffe de poids des patients qui développent une restriction pulmonaire (RAS, mixte et non-défini) se distinguent par des gains de poids plus importants. Une augmentation du poids (kg) (Hazard ratio [HR] : 1,04, IC 95% [1,01-1,08]; P = 0,008) et de l’IMC (kg/m2) (HR : 1,13, IC 95% [1,03-1,23]; P = 0,008) en post-greffe sont associés à une augmentation du risque de RAS. La survie post-greffe (années) est plus faible chez les patients ayant développé les phénotypes RAS (9,07 [IC 95% 7,43-10,70]), mixte (8,41 [IC 95% 6,56-10,25]) et non défini (9,99 [IC 95% 4,67-15,31]; p<0,001). Conclusion : Les liens entre le gain de poids post-greffe et la survenue des phénotypes restrictifs du CLAD doivent être clarifiées pour déterminer si une gestion optimale du poids préviendrait leur développement. / Background: Chronic lung allograft dysfunction (CLAD) is a common complication after lung transplant (LTx), affecting 50% of patients by five years post-LTx. It is associated with poor survival, limited to 1 to 5 years after CLAD diagnosis. Four CLAD clinical phenotypes have been defined: Bronchiolitis Obliterans Syndrome (BOS), Restrictive allograft syndrome (RAS), mixed and undefined phenotypes. Weight gain is commonly observed after LTx and may negatively impact lung function and post-LTx survival. Yet, the association between post-LTx weight gain and the development of CLAD and its phenotypes remains to be explored. Objectives: 1) To describe post-LTx weight trajectories of CLAD-free patients and patients who developed the various CLAD phenotypes; 2) To determine the associations between BMI at transplant, post-LTx variation of weight and BMI, and the risk of developing the various CLAD phenotypes and; 3) To examine whether the development of the CLAD phenotypes impacted post-LTx survival. Methods: This is a retrospective cohort study of patients who received a first bilateral LTx at the CHUM between 2000 and 2020. We extracted demographic, anthropometric, and clinical data from medical charts. Using the 2019 International Society for Heart and Lung Transplantation classification, patients were categorized among these five categories: CLAD-free or presence of one of the four CLAD phenotypes. Results: Our sample consisted of 579 patients; 412 (71.1%) remained CLAD-free, and 81 (14.0%), 20 (3.5%), 59 (10.2%), and 7 (1.2%) developed BOS, RAS, the mixed and the undefined phenotype, respectively. Weight trajectories showed that patients who developed restrictive CLAD (RAS, mixed and undefined) experienced weight gains of greater amplitude within the first five years post-LTx than CLAD-free patients and patients with BOS. An increase in weight (kg) (Hazard ratio [HR]: 1.04, 95% CI [1.01- 1.08]; P = 0.008) and BMI (kg/m2 ) (HR: 1.13, 95% CI [1.03-1.23]; P = 0.008) during post-LTx follow-up was associated with a greater risk of RAS. Worse survival (years) was seen in patients who developed the RAS (9.07 [95% CI 7.43-10.70]), mixed (8.41 [95% CI 6.56-10.25]), and undefined (9.99 [95% CI 4.67-15.31]; p<0.001) phenotypes. Conclusion: Future studies must clarify the associations between post-LTx weight gain and the onset of restrictive CLAD and whether it could be prevented with appropriate weight management strategies.