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9ISSN 2223-4047
BecmnuK Maeucmpamypu. 2022. № 2-2 (125)
N.B. Soleeva, F.D. Sayfiev, J.A. Turdumatov, D.N. Mansurov
COMPUTED TOMOGRAPHY CAPABILITIES IN THE DIAGNOSIS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Chronic obstructive pulmonary disease ranks fourth among the causes of death - after cardiovascular, cancer and cerebrovascular diseases - and is a frequent cause of temporary disability). Unfortunately, the timely diagnosis of COPD occurs in only 25% of cases, despite the high prevalence of the disease. This adversely affects the quality of treatment, as therapy is particularly effective in the early stages of bronchial obstruction. This situation is due to the late seeking of medical care and the low accuracy of diagnosis in the early stages. The diagnosis of COPD, according to GOLD requirements, is based on data from the assessment of external respiratory function. The diagnosis is made when the Tiffno index is below a threshold of 0.7. However, the early stages are characterised by isolated obstruction of the small bronchi and bronchioles, which is not detectable by spirometry. Computed tomography (CT) is the most accurate method of diagnosing subtle morphological changes associated with COPD.
Key words: Chronic obstructive pulmonary disease, computed tomography.
Introduction: Currently, researchers are trying to expand the criteria for COPD diagnosis and relate the flow, with clinical data, as well as to study the features of the course of the disease functional disorders that characterize air limitation in different groups of COPD patients. This approach has been called phenotyping of COPD patients. It is worth noting that the division of COPD patients into phenotypes is not only a theoretical issue of disease pathogenesis, but also affects the efficiency of response to the ongoing therapy with different drugs and, consequently, determines the quality of life of patients. COPD as a result of its pathogenesis leads to the development of various complications, including cardiac complications that can be detected by echocardiography. One of the most dangerous complications is chronic pulmonary remodelling. Identifying and predicting chronic pulmonary heart disease is an urgent issue in the comprehensive evaluation of a patient with COPD. The examination of COPD patients makes extensive use of:
- specialised clinical applications for post-processing analysis of CT scans, which provide objective numerical indicators. The radiologist can rely on these indicators in assessing the extent of emphysema as well as in determining the progression of the disease at follow-up.
Existing systems have a number of disadvantages, such as the inability to install on a personal computer, incomplete compatibility of data obtained from different tomographs, high cost, lack of a Russian-language interface and lack of unification of functions.
According to the 2011 GOLD revision, a diagnosis of COPD should be suspected in all patients with dyspnoea, chronic cough or sputum production and/or with a history of exposure to disease-specific risk factors. Separately, it is indicated that the diagnosis should be confirmed by spirometry (GOLD, 2011). Until recently, spirometry data were the only factors determining the stage of COPD. It is now increasingly clear that spirometry measures such as SPH1 or Tiffno index, for example, do not fully reflect the complexity of the clinical manifestations of COPD. Emphysema and hyperinflation, severe dyspnoea, reduced nutritional status, and peripheral muscle dysfunction are independent predictors of COPD progression. Patients' gender and comorbidities are also important phenotypic characteristics of COPD, which do not correlate with SPH1. For COPD staging, GOLD-2011 recommends the use of a modified British Medical Research Council (mMRC) questionnaire in addition to SPH1. Despite these facts, the diagnosis and staging of COPD today is overwhelmingly based on spirometry results (GOLD, 2011). In the assessment of external respiratory function (RBF), the presence of bronchial obstruction is judged by the forced vital capacity (FVC) and the volume of forced exhalation in the first second (FEF1). The FEL is the volume of air a patient exhales during the fastest, forced exhalation. In bronchial obstruction, a significant decrease is detected. The second measure of bronchial obstruction, SPE1, is used both alone and to calculate the Tiffno index using the formula SPE1/FEL. Normally, the Tiffno index varies between 75-83%.
Bronchial obstruction can be assessed using peak flowmetry on a portable device, which is easier to use than spirometry on a fixed device. Only peak expiratory flow (PEF) is assessed with this technique. However,
© N.B. Soleeva, F.D. Sayfiev, J.A. Turdumatov, D.N. Mansurov, 2022.
studies have shown that PSR alone often underestimates the severity of bronchial obstruction. To make a diagnosis of COPD, the Tiffno index after bronchodilator testing should be less than a threshold value of 0.7. It has been noted that using a well-defined OEF1/EFEL ratio (Tiffno index) to determine airflow limitation leads to overdiagnosis of COPD in the elderly and under-45s, especially in the early stage of the diseas Традиционно для оценки степени тяжести заболевания выделяют классы по тяжести ограничения скорости воздушного потока: GOLD 1 (ОФВ1 80%), GOLD 2 (ОФВ 1=50-80%), GOLD 3 (30-50%) и GOLD 4 (ОФВ1 30%) (GOLD, 2011). In recent years, studies have used an integral scheme, including the degree of airflow limitation, British Medical Research Council questionnaire data to assess the severity of dyspnoea and the number of exacerbations, to assess the patient's condition and risk of exacerbations in a comprehensive way. As a result, patients are divided into 4 groups: A (low risk, few symptoms), B (low risk, many symptoms), C (high risk, few symptoms) and D (high risk, many symptoms). The defined classes have been shown to correlate with disease progression and a worsening of the patient's condition. It is a proven fact that spirometry data do not fully assess the respiratory status of COPD patients. Firstly, spirometry is ineffective in detecting obstruction of the distal airways, which are affected by COPD. Second, the resistance of the respiratory bronchioles to airflow is much lower than the total resistance of the lungs. The total cross-sectional area of the terminal respiratory tract is much greater than that of the trachea and large bronchi, but only 20% of the resistance comes from the bronchioles. Therefore, the bronchioles may be asymptomatic and may not show changes in spirometry. Often, symptoms of small bronchial involvement are an incidental finding on CT scanning. Thus, it can be concluded that, although spirometry is mandatory in suspected COPD, it should not be the only method of diagnosis and staging of COPD. There is a trend towards supplementing spirometry data with different data for a comprehensive assessment of the patient's condition. It is worth noting separately that bronchial changes with a diameter of less than 2-3 mm are not detected spirometrically, and it is at this level that pathological changes occur in the early stages of disease development.
Clinical indications for CTBP in chronic obstructive pulmonary disease are:
1. Identification and determination of the stage of COPD, taking into account the history of the disease (smoking history, occupational inhalation effects on the lungs, frequent pneumonia in childhood)
2. Diagnosis of possible lung complications, in particular pneumonia, spontaneous pneumothorax, various lung tumours, etc.
3. In the planning of thoracic surgery, including lung transplantation.
Computed tomography in patients with COPD allows the structure of the lung tissue and the condition of the small bronchi to be assessed. For this purpose, CTBT is used, which can be a variant of stepwise scanning or performed in spiral mode on MSCT machines [15, 38]. CTVR can serve as a non-invasive method of detecting morphological changes in the lungs in the early stages of COPD, which enables to prescribe adequate treatment in time and to judge the effectiveness of the therapy. According to the results obtained, X-ray revealed no lung changes in almost half of the examined patients with COPD (43.8%), while sensitivity, specificity, and prognostic indexes of CTBP study are significantly higher than those of conventional lung X-ray, which suggests that CTBP is a more informative technique for detection and differential diagnosis of COPD, especially in early stages of the disease. The sensitivity of CTVR is 88.7% and the specificity is 95.4%, which is significantly higher than that of conventional radiography (11.3% and 65.5%, respectively). The sensitivity of CT scan in the diagnosis of COPD is 90.3% and that of CTVR is 95.2%. The specificity is 84.3% and 89.5%, and the accuracy is 87.5% and 94.9%, respectively. However, a number of authors have noted the disadvantages of CTVR in the diagnosis of COPD. For example, a study by K. Kurashima et al. (2005) showed that CTBP has a rather high sensitivity and low specificity in the diagnosis of COPD. Pulmonary emphysema was not detected by CTVR in 18.6% of patients with COPD . CTVR clarifies the localisation of the most airy areas in the lungs. The densitometric density of normal lung tissue ranges from -600 to -900 Ni. In emphysema, this figure rises to -900l-1000 Ni. In addition, comparison of the densitometric values of adjacent parts of the lung during inspiration and exhalation helps to identify not only overinflated but also poorly ventilated parts of the lung. Importantly, a CT scan also shows the extent to which any part of the lung is collapsed. The changes between inspiration and exhalation serve as an index of regional ventilation. Using a series of slices, the condition of all parts of the bronchial tree is determined, peri-ribronchial infiltrates, broncho- and bronchioloectasis, vasoconstriction in oligemic areas are revealed. Peripheral parts of the lung fields deserve special attention. In case of pathological changes of small bronchi and transition of process to bronchioles, small striations and branching structures, tubular shadows, small foci are detected here. In some cases the expiratory obstruction syndrome (so called "air traps") is detected, when the area of swollen lung does not disappear or reduce its density on exhalation. In the preclinical stage (risk of disease onset), CT scan reveals thickening of the walls of the bronchi and bronchioles, sometimes widening of their lumen (broncho- and bronchiectasis), often local, not sharply pronounced signs of expiratory trapping (mainly during exhalation studies). The CT scan provides an opportunity to assess functional features not only of lobules and segments, but also of individual lobules of the lung CT scan allows to differentiate degrees of severity of COPD, but not the initial
manifestations of the disease. In areas of impaired bronchial patency, equal in volume to individual lobules, sometimes segments and even lobes, the study reveals areas of increased airiness - "air traps" (aAgarrA) on exhalation. "Air trapping" is the retention of stored gas in any part of the lungs during the exhalation phase. On high-resolution computed tomograms, air-trap regions appear as areas of lower density than normal parenchyma and are usually localised within a secondary lobule, segment, lobe or the whole lung, being more clearly visualised on exhalation. The 'air trap' symptom is seen on an expiratory CT scan in cases where the patency of the small bronchi is compromised. This is more characteristic of obstructive changes in general and is not specific for COPD. Emphysema is characterised by a pathological enlargement of the air-containing spaces distal to the terminal bronchioles in the absence of overt fibrosis in the lung tissue. Emphysema is usually classified into three main types according to the predominant localisation of areas of destruction: centrilobular, panlobular and paraseptal. In the early stages of development, these forms of emphysema can be distinguished with confidence by CTVR. In the final stage of the disease it is difficult or impossible to distinguish them not only on CT scan, but also on morphological examination.
The detection of signs of emphysema on CTVR and the exclusion of symptoms of interstitial lung disease complete the diagnostic process. Crucially, it is not necessary to perform a lung biopsy in these cases. Appearance of small foci inside secondary lobules on a background of some intralobular interstitial pattern enhancement is called in scientific literature as symptoms of "tree with swollen kidneys" or "toy men" and morphologically correspond to manifestations of obliterating bronchiolitis of various etiology.
Conclusions: Thus, among modern methods of radiological diagnostics of COPD a special place belongs to CT scanning, especially when using its functional (aspiratory-expiratory) modification.
The symptom of expiratory "air trap" in combination with dilation and deformation of bronchi of various calibers up to broncho- and bronchiolectasis are diagnostically significant for COPD at high resolution computed tomography. High resolution computed tomography is a non-invasive and highly informative method of radiological diagnostics of COPD, as well as an effective method of assessing the stage and prognosis of the disease and determining the further treatment strategy. High resolution computed tomography should be an integral part of complex clinical and radiological examination of patients with COPD.
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SOLEEVA NIGINA BOTUR KIZI - master's resident of the department of radiation diagnostics and therapy, Samarkand State Medical Institute.
FARRUKHDILSHOD UGLISAIFIEV- magistrate resident, department of radiation diagnostics and therapy, Samarkand State Medical Institute.
ISSN 2223-4047
BecmnuK Maeucmpamypu. 2022. № 2-2 (125)
JAMSHID ANVAROVICH TURDUMATOV - Assistant of Department of Radiation Diagnostics and Therapy, Samarkand State Medical Institute.
MANSUROV DILMUROD NORIMOVICH - resident of MA course at the Department of Internal Diseases, Samarkand State Medical Institute.
