that has been made in this area, even in a short period of time. Tobacco dependence is increasingly acknowledged as a chronic condition that can require multiple interventions. In addition, recent evidence supports the critical role of counseling, in individual and group interventions, as well as in conjunction with pharmacological treatment.The evidence-based selection method was applied in order to identify appropriate references in the specialized litera- IntroductionThis update represents the strong commitment of the Brazilian Thoracic Association to smoking cessation. It provides health professionals with a comprehensive instrument to deal with the principal aspects of tobacco dependence. It includes new and effective clinical treatments and highlights changes in procedures in certain situations.The comparison between this content and that of the previous guidelines shows the significant scientific progress The use of the strength of recommendation associated with the bibliographic citations in the text has as the following principal objectives: to clarify the information source; to stimulate the search for stronger scientific evidence; and to introduce a didactic and simple way to aid in the critical evaluation on the part of the reader, who is the one responsible for making the decisions concerning the patient being treated. Diagnostic approach Clinical evaluationThe smoker should be submitted to clinical evaluation upon admission to the smoking cessation program. The objective is to identify functional alterations in the lungs, the existence of smoking related diseases (SRDs), possible contraindications and drug interactions during the pharmacological treatment of the dependence. The profile of the smoker, the level of nicotine dependence and the motivation to stop smoking are also evaluated at this time.This evaluation (Chart 1) should include accurate clinical history, complete physical examination, and some complementary tests, depending on local diagnostic resources.Chest X-ray is an essential tool during the treatment. A good physician-patient relationship, together with professional sensitivity and observation skills, will indicate the most appropriate time. Some people are afraid of what they might find, avoiding treatment so that they do not have to face the situation. ture. This was followed by critical review by pairs, who ultimately presented their recommendations.The decision to adopt any of these guidelines should be made by the professional, taking into consideration the resources available in the locale and the specific circumstances of the patient. Although this document describes the principal recommendations in each situation, there is limited space for publishing. Therefore, additional references are provided to those interested in broadening their scientific knowledge on this subject.These guidelines are an up-to-date and comprehensive tool to aid health professionals in treating smokers, in public or private health care clinics. This is the role of the government and the public poli...

Exhaled nitric oxide (ENO) is used increasingly as a surrogate marker of airway inflammation in research protocols that may incorporate standard efficacy measures, such as spirometry before and after bronchodilator, which could affect ENO measurements. In seven healthy volunteers and 11 mild asthmatic subjects, we measured ENO before and serially for 1 h after spirometry. On two additional days in the subjects with asthma, we reexamined the effect of spirometry as before, followed by the serial measurement of ENO for 1 h after two puffs of salbutamol (100 microgram/puff) by metered-dose inhaler or matching placebo. As early as 1 min after spirometry, ENO fell by 13% and 10% in the normal and asthmatic subjects, respectively. In both groups, ENO returned to baseline over 1 h. In the asthmatic subjects, salbutamol caused a significant mean increase of the order of 10 parts per billion in ENO (p < 0.001) for 1 h as compared with placebo inhaler. We conclude that spirometry and beta2-agonist may perturb ENO values and recommend that studies control for these factors.

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by successive episodes of cessation or decrease in respiratory airflow, in which obesity is an important risk factor. The prevalence of the disease in morbidly obese patients is approximately 70%. Treatment is based on the use of continuous positive airway pressure (CPAP) and weight loss in obese patients. Weight loss by dieting often produces unsatisfactory results, and the use of CPAP does not show good adherence because of being long-term and uncomfortable. Bariatric surgery has emerged as the treatment for morbid obesity and various associated co-morbidities. This article reviews the principal studies that evaluate the modifications in obstructive sleep apnea after bariatric surgery, showing that surgery is an effective treatment for the management of OSAHS in morbidly obese patients.

Autores e colaboradores Diretrizes para Cessação do Tabagismo Número de substâncias identificadas em 15 funções químicas existentes no fumo Funções Número de químicas substâncias Amidas, imidas 237 Ácidos carboxílicos 227 Lactonas 150 Ésteres 474 Aldeídos 108 Cetonas 521 Álcoois 379 Fenóis 282 Aminas 196 N-eterocíclicos 921 Hidrocarbonetos 755 Nitrilas 106 Éteres 311 Carboidratos 42 Anidridos 11 Total 4.720

Exhaled nitric oxide (ENO) has been suggested as a marker of airway inflammation. This study aimed to evaluate the role of ENO in the investigation of chronic cough. We measured ENO in 38 adult patients reporting chronic cough, in 23 healthy control subjects, and in 44 asthmatics. In addition to the regular investigation, ENO was measured by a chemiluminescent analyzer using the restricted breath technique. In the chronic cough group, 30 were considered as nonasthmatic, whereas asthma was diagnosed in eight by a positive methacholine challenge. ENO values were significantly higher in patients with chronic cough attributable to asthma as compared with those with chronic cough not attributable to asthma and to healthy volunteers (75.0 ppb; 16.7 ppb; and 28.3 ppb, respectively). The sensitivity and specificity of ENO for detecting asthma, using 30 ppb as the ENO cutoff point, were 75 and 87%, respectively. The positive and negative predictive values were 60 and 93%, and the positive and negative likelihood ratios were 5.8 and 0.3, respectively. We conclude that ENO may have a role in the evaluation of chronic cough. In this group of patients, low ENO suggested little likelihood of asthma. The patients with chronic cough not attributable to asthma showed a low ENO value as compared with healthy volunteers and asthmatics.

Nasal nitric oxide measurement may be a surrogate marker of upper airway inflammation. There is, however, no standardized measurement technique; and this led us to examine measurement techniques for acceptability and reproducibility. In five subjects we examined the flow dependence of nasal NO. In 13 healthy volunteers, nasal NO was measured on-line by five methods: 1) Tidal nasal and oral breathing: NO sampling during exclusive nasal followed by exclusive oral tidal breathing; 2) Fixed flow exhalation: NO sampling during exclusive nasal followed by exclusive oral exhalation at 100 mL/second from total lung capacity; 3) Nasal-oral aspiration: air aspirated from the mouth via both nares at 100 mL/second with glottis closure; 4) Aspiration from one nares: air aspirated from one nares at 3.3 mL/second using nitric oxide analyzer sample line with velum closure; 5) Nasal Insufflation: NO sampled at one nares as air insufflated into the other nares at a flow of 100 mL/second with velum closure. Acceptability of all methods was assessed by subjects and technicians. Nasal NO concentration showed a significant inverse correlation with transnasal flow rate. All methods showed excellent reproducibility as assessed by the intraclass correlation coefficient except tidal breathing, which showed highly variable breath-to-breath NO levels, although mean breath values were reproducible. Mean nasal NO concentrations with methods 1, 2, 3, 4, and 5 were 32.1, 50.2, 62.8, 1381, and 60.0 ppb, respectively. Velum closure was not always achieved in methods 4 and 5, whereas methods 1 and 2 required separate nasal and oral procedures. Method 5 had reduced acceptability. NO concentrations were similar with methods that used the same airflow (2, 3, and 5). Nasal NO can be sampled in different ways with excellent reproducibility. In view of the flow dependence of nasal NO, it is vital to use a constant flow rate, and lower airway NO contribution must be excluded or subtracted. The fixed flow exhalation appears to be the preferred method as it is highly reproducible and acceptable.

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The aim of this study was to evaluate adherence to treatment in persistent asthma in Brazil to determine the factors associated with non-adherence and to measure the efficacy of telephone calls in enhancing adherence. In a prospective, multicenter, interventional clinical trial with parallel groups, asthmatics were randomized into an intervention group or a control group. Asthmatics included in the intervention group received an initial telephone call to record demographic information and asthma characterization. After that, biweekly telephone calls were made to promote treatment adherence. Asthmatics included in the control group received only the initial and final telephone calls. Both groups received three packages of salmeterol/fluticasone for 3 months. The main outcome measure was the percentage of participants who took the prescribed doses of the drug. A total of 271 patients were included. The overall adherence rate was 51.9% for the control group and 74.3% for the intervention group. This meant a reduction of relative risk (RRR) of 47% (p < 0.001). The number needed to treat (NNT) was 4.5. The only variable associated with better adherence was severe persistent asthma. A low-cost easily implemented intervention, tailored to each individual, enhanced the adherence rate among Brazilian asthmatic patients.