Currently, chronic obstasctive pulmonary disease (COPD)
takes a leading place in the stascture of morbidity, disability and mortality in
patients with pathology of the respiratory system [1].
The clinical picture of chronic obstasctive pulmonary disease
major sign of disease is bronchial obstasction of varying degrees of severity
related, including violations of the kinetics of the bronchi and
mucociliary clearance. Features of mucociliary transport in patients with COPD
the subject of many studies [2], but issues related to state
bronhokineticheskoy functions still remain largely unresolved.
necessity of differentiating the various options violation bronhokinetiki
dictated by the importance of developing methods for the verification of these disorders.
leading methods of diagnosis of chronic obstasctive pulmonary disease
are: functional (evaluation of respiratory function), bronchoscopic,
radiology and laboratory research methods. These methods in
largely represent morphological characteristics
severity of the pathological process, nature and stage of inflammation, as well as mucociliary clearance
in chronic obstasctive pulmonary disease. However,
not take into account the state of the motor function of the bronchi (bronhokinez) and
its role in the tactics of these patients. To evaluate the perfusion of lung function
method of isotope perfusion scintigraphy of the lungs. However, this method
only indirectly may indicate a violation of ventilatory function
lung-related pathology bronhokinetiki and does not reflect the state of
mucociliary clearance.
Since 1986 our country and abroad has been proposed technique
inhalation delivery of the radiopharmaceutical (RP) in the bronchi [3, 4]. As the RFP
used an isotope of technetium 99mTc associated with albumin [5]. Given the likelihood
bronchoobstasctive reactions to inhalation carrier,
large size of aerosol particles and the high cost of complex albumin-the RFP, we
was developed a modified method of inhalation bronhostsintigrafii with
isotope 99mTc without a carrier. The purpose of this study was a comparative assessment of
bronhokinetiki by inhalation
bronhostsintigrafii patients without respiratory pathology and patients with COPD
varying degrees of severity.
Material and methods
were examined 17 patients (11 men and 6 women) aged 23 to 73
years who were hospitalized in the medical unit number 1, "ZIL". 5 patients did not
revealed pathology of the respiratory system (control group). In 12 patients had been diagnosed with COPD
: a 7 - chronic obstasctive bronchitis (COB)
moderate / severe and 5 - chronic bronchitis with a minor
degree of obstasction. All patients were satisfied clinical blood tests and
sputum, chest X-ray, an electrocardiogram, a study of external respiration
(LF) using the apparatus of "Asthma Monitor AM-1" and bronchoscopic
study. According to spirometry in the control group were noted
signs of airflow obstasction. In patients with chronic obstasctive bronchitis moderate / severe
4 patients revealed mild bronchial obstasction: the volume
forced expiratory volume in 1 second (FEV1) was 60,2 ± 6,4% of the proper quantities and at 3
patients - a significant expression obstasction (FEV1 35,4 ± 7,3% of the proper values),
including one patient with severe COPD, and innate
bullous emphysema with repeated episodes of spontaneous pneumothorax on the left . At 5
patients with chronic bronchitis, bronchial obstasction was observed minor (FEV1
70,4 ± 5,2% of the proper values).
In carrying out bronchoscopy in patients with the control group were observed
pathology of the bronchial tree. Patients with chronic bronchitis with a minor
obstasction had evidence of endobronchitis I level, and in patients with chronic obstasctive bronchitis was found
tracheobronchial dyskinesia varying degrees of severity and effects
endobronchitis II-III degree.
Research accumulation of radiotracer in the lungs and the dynamics of its removal was performed using
radiodiagnostic system MV9100_9191 / A (Hungary), which includes
gamma camera and a PC with the software "Gold Rada +
3.0" (Russia) . Inhalation of radiopharmaceutical produced by the nebulizer Pari LC (Pari,
Germany) for 10 minutes at a speed of air flow 10 l / min. For the protection of
gammaizlucheniya exhalation the patient was carried out in a special ventilation
camera. 99mTs_pertehnetata activity was 300 MBq. The study was conducted in a room
radioisotope laboratory, air-conditioned, with
temperature of 21 ± 1 ° C and relative humidity of 55-65%. Activity
gammaizlucheniya after inhalation of radiopharmaceutical was recorded for 30 min in
mode of 1 frame per 2 minutes. The results obtained are processed by methods of variational statistics
.
Results and discussion
Inhalation bronhostsintigrafiya included determination of the accumulation of radiotracer in the lung tissue
(static bronhostsintigrafiya) and study of clearance of the radiopharmaceutical
(dynamic bronhostsintigrafiya). With static bronhostsintigrafii
estimated accumulation of radiotracer (in%) in different parts of the lungs, allowing
visualize anatomical divisions with reduced ventilatory capacity.
volume inhaled RFP and the area of its distribution in the lung was taken for
100%.
results of static (left column) and dynamic (right column
) bronhostsintigrafii. Explanation in the text. Along the horizontal axis - time.
total distribution of radiotracer in healthy subjects was in the right lung 52,7 ±
3,1%, in the left - 47, 3 ± 2,3%. A minor part of the RFP was delayed in the oral cavity
by inhalation, swallowing saliva and was determined in the form of tags
glow in the stomach. 30 min after inhalation in the RFP completely
bronchial secretions is displayed in the gastrointestinal tract. Figure (a, b)
bronhostsintigrammy presented in both static and dynamic modes patient
without pathology of the respiratory system. The static distribution bronhostsintigramme
radiopharmaceutical in both lungs in the zones is uniform, part of the RFP is visualized in the stomach.
Dynamic bronhostsintigramma (figure, b) estimated by the curve inference
isotope with bronchial secretion of bronchial tree in 30 minutes.
Period (T 1 / 2) RFP made in patients without pathology of respiratory organs: for
right lung - 20,6 ± 4,2 min, for the left lung - 28,3 ± 3,8 min,
corresponds to the topography of the bronchial tree. In patients with chronic obstasctive bronchitis
and signs of moderate or severe bronchial obstasction much determined
zone to reduce the accumulation of radiotracer in the different anatomical parts of the lungs that
evidence of violation of the kinetics of the bronchi, ventilating
corresponding zone of the lungs. Figure (c, d) are static and dynamic
bronhostsintigrammy patient F., age 70, with severe COPD in the background
karnifitsirovannoy lower lobe of the left lung, FEV1 32% of the proper values. When
static bronhostsintigrafii (Figure, B) revealed a significant redistribution of
inhaled radiotracer between the zones of the right and left lung with
account anatomo_funktsionalnogo damaged segments of the left lung (
accumulation of radiotracer in the right lung - 70.2% in the left lung - 29.8%). The dynamic
bronhostsintigramme (Fig. i) revealed a significant reduction in the amplitude and
flattening of the curve tracer washout from the bronchi of the left lung. T1 / 2 for the right
lung was 37 min for the left - 41 min.
Based on these results we can conclude that in this case
have expressed a violation bronhokinetiki and mucociliary failure
predominantly in the bronchi of the left lung. Figure (e, f) presented
static and dynamic bronhostsintigrammy sick Ya, 55 years old, with severe COPD
and congenital bullous emphysema with repeated episodes of spontaneous pneumothorax
left. Patient was surgically treated
pneumothorax, and according to the conclusion there were signs of radiological
straightening kollabirovannogo lung. However, during the inhalation
bronhostsintigrafii noted the almost complete absence of accumulation of radiotracer in the bronchi
left lung (the accumulation of radiotracer in the right lung - 93.1%, in the left lung - 6,9%,
figure, q). The dynamic bronhostsintigramme (Fig. e) tracer washout from
bronchi of the left lung were observed, which was reflected in a straight line on
scintigrams. Tracer washout from the bronchi of the right lung was satisfactory,
T1 / 2 was 22 min. Based on these results we can conclude that in
this case there is discrepancy between radiographic and
bronhostsintigraficheskih data. The latter, in our opinion,moreaccurately reflect
severity of COPD and low efficiency of the operation.
Figure (g, h) are presented bronhostsintigrammy patient Z., 1971, from
severe COPD in acute phase with severe bronchial obstasction and
tracheobronchial dyskinesia. When static study (Figure, F)
mentioned uniform bilateral reduction in accumulation of radiotracer in the distal
bronchial tree, while the bulk of the radiopharmaceutical accumulated in the trachea and main bronchi
. Dynamic bronhostsintigramma (Fig. h) revealed a decrease in
T1 / 2 to 12 min, and the zonal characteristic curves of tracer washout was
low-amplitude and flattened. Based on these results, we can
conclude that in this case there is a significant expression
bronchoobstasctive syndrome on the background of tracheobronchial dyskinesia. Under
patients with chronic bronchitis with a slightly pronounced bronchial obstasction
no significant violations in the accumulation of radiotracer in the zones
lungs, but the dynamic bronhostsintigrafii observed lengthening of the time
tracer washout from both lungs.
half-life was significantly lengthened the RFP: up to 27,3 ± 2,4 min from the right
lung (p <0.05) and up to 32,4 ± 2,8 min of left lung (p <0,05) compared
with those of patients without disease of the respiratory system.
Thus, inhalation bronhostsintigrafiya can detect violations
bronchial obstasction and kinetics according to the static study and
also in the form of the curve and the time of tracer washout from the bronchial tree in
dynamic study. Indications for this diagnostic procedure
are:
1) COPD - to clarify the degree of severity;
2) diagnosis of tracheobronchial dyskinesia;
3) assessment of lung ventilation in kollabirovannom;
4) assessment of mucociliary clearance in patients with obstasctive and nonobstasctive disease
bronchi.
Conclusion
Numerous clinical experience demonstrates the safety and effectiveness of inhaled
bronhostsintigrafii [3-7]. Using isotope 99mTc
without a carrier can reduce the size of aerosol particles and increase the penetration
radiopharmaceutical in the generation of small bronchi, which gives amorecomplete picture of
bronchial obstasction in different parts of the bronchial tree
. Another advantage of the modified our method is
significant cheapening the cost of the study. The results of this work
allow us to recommend the method of inhalation bronhostsintigrafii isotope 99mTc
without a carrier as an additional objective criterion for the diagnosis and
assessment of the severity of COPD.
List of literature
1. Chuchalin AG Pulmonology in Russia and ways of its development: Current issues
Pulmonology, Ed. Chuchalin AG M., 2000. P. 15.
2. Solopov VN / / Ter. arch. 1989. T. 61. ¹ 3. S. 1958.
3. Gerasin VA et al Ter. arch. 1989. T. 61. ¹ 3. P. 62.
4. Kosuda S. et al. / / J. Nucl. Med. 1986. V. 27. ¹ 9. P. 1397.
5. Ingels K. et al. / / Eur. Arch. Otorhinolaryngol. 1995. V. 252. ¹ 6. P.
340.
6. Scheuch G. et al. / / Pneumologie. 1999. V. 53. ¹ 7. P. 329.
7. Groth S. et al. / / Thorax. 1988. V. 43. ¹ 5. P. 360.