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Sarmet M, Maldaner V, Zeredo JLL. Videofluoroscopy: A Promising Tool for Assessing Upper Airway Dysfunction During Mechanical Insufflation-Exsufflation. Chest 2024; 165:e128-e130. [PMID: 38599759 DOI: 10.1016/j.chest.2023.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 11/21/2023] [Indexed: 04/12/2024] Open
Affiliation(s)
- Max Sarmet
- Graduate Program in Health Science and Technology, University of Brasilia, Brasilia, Brazil.
| | - Vinicius Maldaner
- Graduate Program in Health Science and Technology, University of Brasilia, Brasilia, Brazil
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Ntoumenopoulos G, Andersen T, Hardingham NM. Upper airway assessment and its implications for interventions by respiratory physiotherapists. Physiother Theory Pract 2024; 40:184-189. [PMID: 35904123 DOI: 10.1080/09593985.2022.2106916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/16/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND When noninvasive interventions such as chest physiotherapy fail, then more aggressive interventions for airway secretion clearance with nasotracheal airway suctioning may be required. Clinicians however have to insert the nasotracheal suction catheter "blindly" and the success of being able to trigger a cough and pass through the vocal folds with a suction catheter is low. CASE DESCRIPTION The patient, a 48-year-old male underwent a heart and lung transplant. Following extubation, the patient developed secretion retention with a weak ineffective cough and swallow and required physiotherapy interventions with frequent "blind" passes of nasotracheal suctioning. OUTCOMES The patient required nasotracheal suction with frequent multiple failed attempts before successful passage of the suction catheter to trigger a cough reflex and clear secretions. A combined physiotherapist and speech and language therapist intervention during fiberoptic endoscopic evaluation of swallow (FEES) was recorded to both evaluate swallow and passage of the suction catheter. The video illustrated the successful passage of a suctioning catheter through the vocal folds leading to an effective cough and airway clearance. DISCUSSION We present a case report demonstrating that it is feasible to visualize the upper airways during nasotracheal suctioning as an objective means to guide the more accurate successful insertion of the suction catheter past the vocal folds. Rather than "blind" placement of nasotracheal suction catheters visualization using transnasal laryngoscopy should be useful to increase chances of passing through the vocal folds.
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Affiliation(s)
| | - Tiina Andersen
- Norwegian Centre of Excellence for Home Mechanical Ventilation, Thoracic Department, Haukeland University Hospital, Bergen, Norway
| | - Nicola M Hardingham
- Speech Pathology Department, St Vincent's Hospital, Sydney, Australia
- School of Health and Rehabilitation Sciences, University of Queensland, St Lucia, Australia
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Dorça A, Vergara J, Skoretz SA, Brenner MJ, Diniz DS, Zeredo JL, Sarmet M. Respiratory support effect on pharyngeal area in patients with amyotrophic lateral sclerosis: A fluoroscopic comparison of NIV, helmet/CPAP, and high-flow nasal cannula. Respir Med Case Rep 2023; 46:101958. [PMID: 38187117 PMCID: PMC10770539 DOI: 10.1016/j.rmcr.2023.101958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 11/17/2023] [Accepted: 12/05/2023] [Indexed: 01/09/2024] Open
Abstract
The global use of noninvasive respiratory support provided by different supportive ventilation delivery methods (SVDMs) has increased, but the impact of these devices on the upper airway structures of patients with amyotrophic lateral sclerosis (ALS) is not known. We aimed to compare the pharyngeal cross-sectional area during spontaneous breathing with four different SVDMs: intranasal masks, oronasal masks, high-flow nasal cannula (HFNC), and helmet in patients with ALS. We compared measures of the pharyngeal area during spontaneous breathing and SVDM use. The greatest increase was observed with intranasal mask use, followed by HFNC, oronasal mask, and helmet respectively. In conclusion, upper airway opening in patients with ALS is enhanced by positive pressure with intranasal masks and HFNC, showing promise for increasing pharyngeal patency. Future studies should explore its applicability and effectiveness in maintaining long-term pharyngeal patency, especially in this population with bulbar weakness.
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Affiliation(s)
- Alessandra Dorça
- Department of Health Sciences, Universidade Federal de Goiás (UFG), Goiânia, Brazil
| | - José Vergara
- Department of Surgery, University of Campinas, Campinas, Brazil
| | - Stacey A. Skoretz
- School of Audiology & Speech Sciences, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
- Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
- Centre for Heart Lung Innovation, St. Paul's Hospital, Vancouver, BC, Canada
| | - Michael J. Brenner
- Department of Otolaryngology-Head and Neck Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Jorge L. Zeredo
- Graduate Department of Health Science and Technology, University of Brasília, Brasília, Brazil
| | - Max Sarmet
- Graduate Department of Health Science and Technology, University of Brasília, Brasília, Brazil
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Carlucci A, Patout M, Winck JC. Does one size fit all? An update on chronic ventilatory support in different respiratory illnesses. Breathe (Sheff) 2023; 19:230046. [PMID: 37492344 PMCID: PMC10365079 DOI: 10.1183/20734735.0046-2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 05/15/2023] [Indexed: 07/27/2023] Open
Abstract
Home noninvasive ventilation (HNIV) improves outcomes in different disease categories. In this article, we discuss indications for when and how to initiate HNIV in COPD, obesity hypoventilation syndrome (OHS) and neuromuscular disorders (NMD). While in COPD, significant diurnal hypercapnia and high-intensity HNIV are essential ingredients for success, in NMD and OHS, early respiratory changes are best detected during sleep through oxy-capnography associated (or not) with respiratory polygraphy. In COPD and OHS, it is crucial to consider the coexistence of obstructive sleep apnoea because treatment with continuous positive airway pressure may be the simplest and most effective treatment that should be proposed even in hypercapnic patients as first-line therapy. In NMD, the need for continuous HNIV and eventual switching to tracheostomy ventilation makes this group's management more challenging. Achieving successful HNIV by improving quality of sleep, quality of life and keeping a good adherence to the therapy is a challenge, above all in COPD patients. In OHS patients, on top of HNIV, initiation of other interventions such as weight loss management is crucial. More resources should be invested in improving all these aspects. Telemonitoring represents a promising method to improve titration and follow-up of HNIV.
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Affiliation(s)
- Annalisa Carlucci
- Dipartimento di Medicina e Chirurgia Malattie dell'Apparato Respiratorio, Università degli Studi dell'Insubria, Varese, Italy
- U.O. di Pneumologia Riabilitativa, Istituti Clinici Scientifici Maugeri, IRCCS Pavia, Pavia, Italy
| | - Maxime Patout
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service des Pathologies du Sommeil (Département R3S), Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - João Carlos Winck
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro de Reabilitação do Norte, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
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Proesmans M, Vermeulen F, Boon M. Understanding and managing respiratory infections in children and young adults with neurological impairment. Expert Rev Respir Med 2023; 17:203-211. [PMID: 36932917 DOI: 10.1080/17476348.2023.2192483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Patients with neurocognitive impairment (NI) have multiple medical needs, with respiratory problems leading to an important reduction in quality of life and life expectancy. We aimed to explain that the origin of chronic respiratory symptoms in patients with NI is multifactorial. AREAS COVERED In people with NI there is a high prevalence of swallowing dysfunction and hypersalivation inducing aspiration; cough efficacy is decreased resulting in chronic lung infection; sleep-disordered breathing is frequent and muscle mass is abnormal due to malnutrition. Technical investigations are not always specific and sensitive enough to better diagnose the causes of the respiratory symptoms; moreover, they can sometimes be difficult to perform in this vulnerable patient population. We provide a clinical pathway to adopt to identify, prevent, and treat respiratory complications in children and young adults with NI. A holistic approach in discussion with all care providers and the parents is highly recommended. EXPERT OPINION The care for people with NI and chronic respiratory problems is challenging. The interplay between several causative factors may be difficult to entangle. Well-performed clinical research in this field is largely missing and should be encouraged. Only then, evidence-based clinical care will become possible for this vulnerable patient group.
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Affiliation(s)
- Marijke Proesmans
- KU Leuven, Department of Development and Regeneration, Woman and Child Unit, CF Research Lab, Leuven, Belgium
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
| | - Francois Vermeulen
- KU Leuven, Department of Development and Regeneration, Woman and Child Unit, CF Research Lab, Leuven, Belgium
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
| | - Mieke Boon
- KU Leuven, Department of Development and Regeneration, Woman and Child Unit, CF Research Lab, Leuven, Belgium
- Department of Pediatrics, Pediatric Pulmonology, University Hospital Leuven, Leuven, Belgium
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Pierucci P, Portacci A, Carpagnano GE, Banfi P, Crimi C, Misseri G, Gregoretti C. The right interface for the right patient in noninvasive ventilation: a systematic review. Expert Rev Respir Med 2022; 16:931-944. [PMID: 36093799 DOI: 10.1080/17476348.2022.2121706] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Research in the field of noninvasive ventilation (NIV) has contributed to the development of new NIV interfaces. However, interface tolerance plays a crucial role in determining the beneficial effects of NIV therapy. AREAS COVERED This systematic review explores the most significant scientific research on NIV interfaces, with a focus on the potential impact that their design might have on treatment adherence and clinical outcomes. The rationale on the choice of the right interface among the wide variety of devices that are currently available is discussed here. EXPERT OPINION The paradigm "The right mask for the right patient" seems to be difficult to achieve in real life. Ranging from acute to chronic settings, the gold standard should include the tailoring of NIV interfaces to patients' needs and preferences. However, such customization may be hampered by issues of economic nature. High production costs and the increasing demand represent consistent burdens and have to be considered when dealing with patient-tailored NIV interfaces. New research focusing on developing advanced and tailored NIV masks should be prioritized; indeed, interfaces should be designed according to the specific patient and clinical setting where they need to be used.
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Affiliation(s)
- Paola Pierucci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Andrea Portacci
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Giovanna Elisiana Carpagnano
- A. Cardiothoracic Department, Respiratory and Critical care Unit Bari Policlinic University Hospital, B. Section of Respiratory Diseases, Dept. of Basic Medical Science Neuroscience and Sense Organs, University of Bari 'Aldo Moro'
| | - Paolo Banfi
- IRCCS Fondazione Don Carlo Gnocchi, Milano,Italy
| | - Claudia Crimi
- Respiratory Medicine Unit, "Policlinico-Vittorio Emanuele San Marco" University Hospital, Catania, Italy
| | | | - Cesare Gregoretti
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Italy and Fondazione Istituto "G.Giglio" Cefalù', Palermo, Italy
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Sarmet M, Mangilli LD, Costa GP, Paes JPRS, Codeço VM, Million JL, Maldaner V. The relationship between pulmonary and swallowing functions in patients with neuromuscular diseases followed up by a tertiary referral center: a cross-sectional study. LOGOP PHONIATR VOCO 2021; 47:117-124. [PMID: 33586591 DOI: 10.1080/14015439.2021.1879254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Respiratory muscle weakness is common in patients with neuromuscular diseases (NMD). This puts them at risk for dysphagia and other pulmonary complications. OBJECTIVES To investigate the relationship between pulmonary function and swallowing in NMD. MATERIALS AND METHODS In this cross-sectional study, medical records of patients undergoing treatment at the Tertiary Referral Center for Neuromuscular Diseases of Hospital de Apoio de Brasília, Brazil, were reviewed. Respiratory function was assessed through spirometry (FVC and FEV1 measured) and swallowing assessed by the Dysphagia Risk Evaluation Protocol and the Functional Oral Intake Scale. RESULTS Two hundred and twenty-two patients were included. Dysphagia was present in 46.8% of patients and impairment of pulmonary function in 64.0%. The mean FVC observed was 66.9% and FEV1 was 66.0%, indicating restrictive lung disease. A correlation between the decline of pulmonary and swallowing functions was observed in patients with NMDs (FVC vs. DREP, R = 0.46; FVC vs. FOIS, R = 0.42; FEV1 vs. DREP, R = 0.42; FEV1 vs. FOIS, R = 0.40, p<.01). FVC and FEV1 values tend to be lower in patients with dysphagia in the context of NMD. CONCLUSIONS A positive correlation between pulmonary function and swallowing outcomes was observed in patients with NMD. Despite respiratory and swallowing impairment being widely present in the population with NMD, they require different treatments according to the disease's pathophysiology. Future studies should be conducted to explore the disease-specific relationship between pulmonary function and swallowing in patients with NMD.
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Affiliation(s)
- Max Sarmet
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Graduate Department of Health Sciences and Technologies, University of Brasília (UnB), Brasília, Brazil
| | | | - Geovanna Pereira Costa
- Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
| | | | - Vitor Martins Codeço
- Department of Thoracic Diseases, Hospital Regional da Asa Norte, Brasília, Brazil
| | - Janae Lyon Million
- Department of Human Biology, University of California, Santa Cruz, CA, USA
| | - Vinicius Maldaner
- Departments of Speech Therapy and Physical Therapy, Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil.,Undergraduate Program, College of Medicine, Escola Superior de Ciências da Saúde, Brasília, Brazil
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Dorça A, Sarmet M, Maldaner V. The influence of the non-invasive ventilation mask interface on the upper airway of patients with amyotrophic lateral sclerosis. Pulmonology 2021; 27:359-361. [PMID: 33408044 DOI: 10.1016/j.pulmoe.2020.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/05/2020] [Accepted: 12/06/2020] [Indexed: 02/03/2023] Open
Affiliation(s)
- Alessandra Dorça
- Universidade Federal de Goiás, Department of Health Sciences, Goiânia, Brazil
| | - Max Sarmet
- Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil; University of Brasília (UnB), Graduate Department of Health Sciences and Technologies, Brasília, Brazil.
| | - Vinicius Maldaner
- Hospital de Apoio de Brasília, Tertiary Referral Center of Neuromuscular Diseases, Brasília, Brazil; Centro Universitário UniEvangélica, Graduate Department of Human Movement and Rehabilitation Program, Anápolis, Brazil
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Janssens JP, Michel F, Schwarz EI, Prella M, Bloch K, Adler D, Brill AK, Geenens A, Karrer W, Ogna A, Ott S, Rüdiger J, Schoch OD, Soler M, Strobel W, Uldry C, Gex G. Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology. Respiration 2020; 99:1-36. [PMID: 33302274 DOI: 10.1159/000510086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022] Open
Abstract
Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland,
| | - Franz Michel
- Klinik für Neurorehabilitation und Paraplegiologie, Basel, Switzerland
| | - Esther Irene Schwarz
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Maura Prella
- Division of Pulmonary Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Konrad Bloch
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Dan Adler
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
| | | | - Aurore Geenens
- Pulmonary League of the Canton of Vaud, Lausanne, Switzerland
| | | | - Adam Ogna
- Respiratory Medicine Service, Locarno Regional Hospital, Locarno, Switzerland
| | - Sebastien Ott
- Universitätsklinik für Pneumologie, Universitätsspital (Inselspital) und Universität, Bern, Switzerland
- Division of Pulmonary Diseases, St. Claraspital, Basel, Switzerland
| | - Jochen Rüdiger
- Division of Pulmonary and Sleep Medicine, Medizin Stollturm, Münchenstein, Switzerland
| | - Otto D Schoch
- Division of Pulmonary Diseases, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Markus Soler
- Division of Pulmonary Diseases, St. Claraspital, Basel, Switzerland
| | - Werner Strobel
- Division of Pulmonary Diseases, Universitätsspital Basel, Basel, Switzerland
| | - Christophe Uldry
- Division of Pulmonary Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Grégoire Gex
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Pulmonary Diseases, Hôpital du Valais, Sion, Switzerland
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Freitas C, Martins N, Novais-Bastos H, Morais A, Fernandes G, Magalhães A. The role of interventional bronchoscopy in the management of post-intubation tracheal stenosis: A 20-year experience. Pulmonology 2019; 27:296-304. [PMID: 31901372 DOI: 10.1016/j.pulmoe.2019.12.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/27/2019] [Accepted: 12/10/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Benign tracheal stenosis management is still controversial, and there is no international consensus on the best treatment option. Thus, we aimed to look into the history of PITS and the different strategies used in its treatment. The importance of bronchoscopic treatment was also defined, and its effectiveness and safety were assessed. METHODS Retrospective study of patients diagnosed with PITS, who were referred to the Bronchology Department between January 1996 and December 2016. RESULTS Of 115 patients enrolled (mean age 48.5±17.6 years, 53% males), 66.1% had complex stenosis. The most common causes of intubation were respiratory (29.9%), neurological (26.8%) and surgical (19.6%). Complex stenosis was caused by longer intubation, and was more frequent among previously tracheostomized patients. The most common location was the upper third of trachea (60.9%). Most cases were initially treated by interventional bronchoscopy, and although serial dilations were effective in some complex PITS, a higher proportion of simple stenosis was successfully managed with this treatment option. Long-term recurrence after serial dilation was observed in 25.0% of cases. Stent placement was required (19.1%) only for complex PITS. Stent-related complications were frequent (61.9%) and linked to the stenting time (p<0.001). Overall, there were no procedure-related complications. Surgical intervention was also performed (30.0%), always with complex PITS. Post-surgical recurrences were observed in 24.2% of cases. CONCLUSIONS Interventional bronchoscopy is an efficient and safe modality in PITS management. Further studies are needed for better classification and improved knowledge of PITS pathogenesis, and to achieve international consensus of definition to guide clinicians in their practice.
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Affiliation(s)
- C Freitas
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal.
| | - N Martins
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Rua Alfredo Allen, 208, 4200-136 Porto, Portugal
| | - H Novais-Bastos
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Institute for Research and Innovation in Health, University of Porto, Rua Alfredo Allen, 208, 4200-136 Porto, Portugal
| | - A Morais
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal
| | - G Fernandes
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal; Faculty of Medicine, University of Porto, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal
| | - A Magalhães
- Department of Pulmonology, Centro Hospitalar e Universitário São João, Alameda Prof. Hernani Monteiro, 4200-319 Porto, Portugal
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