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9
BtCHMK Украгнськог' медичног' стоматологгчног академгг
УДК 616. 24 - 002 - 07
NEW APPROACH TO A PROBLEM OF DIAGNOSTICS OF PULMONARY HYPERTENSION AT PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Boyko D.M., Boyko M.G.
High state educational institution of Ukraine «Ukrainian medical stomatological academy»
Chronic obstructive pulmonary disease (COPD) is one of the major problems of up-to-date health care, thus such tendency is typical for many developed countries in the world due to its non-stop growth, its prevalence and its mortality rate. The purpose of our research was to carry out the comparative analysis of Doppler echocardiography diagnostics of increased pressure in a pulmonary artery (PA) and radiographic signs of pulmonary hypertension (PH) on the basis of spiral computer tomography in patients with COPD of 2nd stage in combination with mild essential hypertension and presence of PH of the 1st degree. It is necessary to notice that the value of correlation between PA diameter and the A diameter (index of PA/A) under SPAP 41--50 mmHg was likely (р<0,01) high er when compared in patients who had a level of SPAP 40 mmHg. SPAP indexes in patients with 2nd stage COPD corresponded to the 1st stage of PH, and the correlation between PA diameter and A diameter grew with the increase of SPAP and had a stable character.
Key words: COPD, pulmonary hypertension.
Chronic obstructive pulmonary disease (COPD) is one of the major problems of modern health care, thus such tendency is characteristic for many developed countries of the world in connection with permanent growth of its prevalence and lethal finals' quantity, caused by the disease [11]. Almost at 32 % patients the combination of hypertensive disease and COPD is marked. And also very serious complication of COPD, requiring individual approach in diagnostics and treatment, is the development of pulmonary hypertension (PH) [5, 6, 11].
The purpose of our research was to conduct the comparative analysis of Doppler echocardiography diagnostics of increased pressure in a pulmonary artery (PA) and radiographic attributes of PH, on the basis of spiral computer tomography, at patients with COPD of 2nd stage in combination with soft essential hypertensy and presence of PH of the 1st stage.
Methods
The research was carried out with the participation of 83 patients, among them 40 men and 43 women (about (48,9±9) years old). Three experimental groups were formed. First, control group, included 29 patients which had no COPD and didn't have combination with cardiovascular diseases. The second group was formed of 27 patients with COPD of 2nd stage and 1st stage pulmonary hypertension (PH). 27 patients entered into the third group, they had COPD of 2nd stage in combination with soft 1st stage essential hypertension (EH) and 1st stage PH [6, 7, 10]. There were investigated the group of patients with 2nd stage COPD in combination with EH and PH conducted in the period of remission of COPD and in the rest. Patients which were included into our research had EH, which arose up 3-6 years prior to appearing of COPD symptomes; and the presence of exacerbation of COPD for a patient did not cause the increase of
pressure in the systemic and pulmonary circulations. To all of patients was conducted Doppler echocardiography and determination of systolic pulmonary artery pressure. Spiral computer tomography (SCT) of thorax organs (at the beginning of research, prior to anti-hypertensive preparations' application), and the intention of diameters of the ascending aorta (A) (at its ostium level) and of the main pulmonary artery (PA) as well was performed. Special attention was paid to the presence of emphysema characteristic for COPD [4, 15].
Doppler echocardiography was conducted to all the patients and determination of systolic pulmonary artery pressure (SPAP) was performed according to the method of Isobe (1986) [13] and the registration of the maximal rate of a stream of tricuspid regurgitation, which could be determined from the 4-chamber apex or subcostal acoustic access [2]. Also there was conducted spirometry and pulse oximetry. Spiral computer tomography of organs of thorax was conducted on CT/e Dual GE Medical Systems, the USA.
The statistical processing of the obtained data was conducted with the use of non-parametric methods as Mann-Whitney U test and the Spearman grade correlation coefficient. The calculation of diagnostic sensitivity and specificity of the prognostic value of positive and negative result, and relation to plausibility for a positive result was carried out as well.
Results and discussion
Taking into account that chronic hypoxia is the key factor of PH origin at COPD [8], the analysis of basic parameters of the external breathing function (EBF) and saturation in pulsating arterial vessels (Sp O2) is conducted. The level of systolic arterial pressure (SAP), diastolic arterial pressure (DAP) and SPAP is also investigated (table 1).
* This research was done in the network of theme: "Develop a rational scheme of treatment of patients with pulmonary tuberculosis in combination with chronic obstructive pulmonary disease", state registration number 0107U001213.
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Table 1
Description of the basic parameters of researching subjects depending on division into groups.
PARAMETERS CONTROL GROUP (N=29) PATIENTS WITH 2nd STAGE COPD AND PH (N=27) PATIENTS WITH 2nd STAGE COPD, EH AND PH (N=27)
AGE (YEARS) 46±8,5 51±9 52±11
SEX (M/F)* 13/14 12/15 11/18
SP O2 (%) 97±2 93±1** 92±2**
FEV1(%) 91±11 66±11** 62±5,5**
FEV1/FVC (%) 82±12 68±9,5J 68±3,5**
SAP (MMHG) 125±6 130±4 145±3,5**#
DAP (MMHG) 85±5 80±5 90±5,5**#
SPAP (MMHG) 18±3 36±5,2** 37±4,7**
Notes: 1. * - M.- male; . F - female; 2. $ - p<0,05 when compared to a control group; 3. ** - p<0,01 when compared to a control group, 4. # - p<0,01 at comparison between patients with 2n stage COPD combined with PH and patients with 2n stage CoPd, essential and pulmonary hypertensie.
Table 2
The results of findings testify to the decline of respiratory function of lungs and, accordingly, - decline of blood oxigenation, that was expressed in the perceptible (p<0,01) diminishing of Sp O2 to 93% at patients with 2nd stage COPD combined with 1st degree PH, and to 92% - at presence of 2nd stage COPD and soft essential hypertensie and 1st degree pulmonary hypertensie combination (in comparison with the control group). Level of SAP and DAP at patients with 2nd stage COPD at presence of EH fitted to the 1st degree AH. and was considerably (p<0,01) higher in comparison with the groups, which did not have such combination.
Indexes of SPAP in groups with 2nd stage COPD in combination with PH and at presence of combination EH and PH, did not differ between themselves, but they had perceptible (p<0,01) differences with a control group. The inspection of patients was conducted in the condition of rest and during the remission of COPD, that increase of SPAP at the patients was of a proof character and, that's why, it was impossible to exclude the second hurt of vascular bed of pulmonary circulation circle [1, 5]. For the determination of pulmonary artery and aorta diameter, depending on constitutional features, the calculation of the area of the body surface was conducted in all patients by Mosteller's formula (1987) [12].
The calculation of the required diameters of PA and A is conducted in all of the probed groups depending on the area of body surface, and it is known that one square meter of body surface area fits to 2 cm2 of pulmonary artery's area above the valve [9, 14]. Required diameter of aorta of human upwards 40-ty years was calculate by formula: 1,92 + (0,74 x S of body surface (m2)) [3]. On the basis of the results of spiral computer tomography of thorax organs at patients with 2nd stage COPD and at patients of control group, the diameter of pulmonary artery and aorta was determined, and the index which characterizes correlation between the diameter of pulmonary and he diameter of aorta (index of PA/A) was also estimated, and it could be expressed by the formula: PA / A, where PA is a diameter of pulmonary artery in mm., and A is a diameter of aorta in mm. Analysis of the got data is resulted in a (table 2).
Comparative analysis of the required and actual sizes of pulmonary artery and its attitude toward the diameter of aorta, depending on constitutional features, at patients with the 2nd stage COPD and at patients of control group.
PARAMETERS CONTROL GROUP (N=29) PATIENTS WITH COPD OF 2nd STAGE AND PH (N=27) PATIENTS WITH 2nd STAGE COPD, EH AND PH (N=27)
REQUIRED DIAMETER OF PA (MM) 21±3 22±2 21±2
ACTUAL DIAMETER OF PA (MM) 20±3 36±5**t 38±7**t
REQUIRED DIAMETER OF A (MM) 32,1±2,9 33,2±2,4 33,6±3,1
ACTUAL DIAMETER OF A (MM) 30±4 29±6,5 28,5±5,5
PA/A 0,69±0,135 0,92±0,11** 1,0±0,08**
S OF BODY SURFACE (M2) 1,86±0,405 1,92±0,44 1,9±0,24
Notes: 1. ** - p<0,01 when compared to a control group;
2. f - p<0,05 at comparison of actual and required diameters of pulmonary artery (PA).
3. $ - p<0,05 at comparison of actual and required diameters of aorta (A).
4. ^ - p<0,05 at comparison of required diameters of pulmonary artery (PA).
5. -f - p<0,05 at comparison of required diameters of aorta (A).
Required diameters of PA, A and of body surface area in all groups had no statistical deviations. In the case of patients with 2nd stage COPD in combination with PH and at patients with 2nd stage COPD in combination with EH and PH, there were revealed perceptible (p<0,01) differences of actual diameters of PA in comparison with a control group. Actual diameters of PA, in fact, were (p<0,05) higher than any required ones in both groups with COPD of 2nd stage, combined with PH or with EH and PH, but without any differences between each other. The analysis of correlation connection according to Spearman between the level of SPAP and the index PA/A was carried out (figure 1).
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■ Patients with 2nd stage COPD and pulmonary hypertension (n=27)
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Systolic pulmonary artery pressure (mmHg)
Figure 1. The correlation between the level of systolic pulmonary artery pressure and the index of the relation of pulmonary artery diameter to the diameter of aorta.
In this group of patients there is strong bilateral (after Spearman) correlation (p<0,01) between the index of PA/A and level of SPAP. The coefficient of correlation made up r=0,838. In addition, this cross-correlation connection is positive, and it means that with the increase of SPAP in patients with 2nd stage COPD in combination with PH or EH and PH is fixed the increase of the parameters of the PA/A index. The higher are the indexes of SPAP - the higher are the values of the index of PA/A; patients were up-diffused into the proper groups [table3].
Table 3
Parameters of index of PA/A in the dependence on the level of SPAP and degrees of PH
SPAP (MMHG) N* DEGREE OF PH INDEX OF PA/A
<30 29 0 0,69±0,135
31-40 29 I 0,92±0,14t
41-50 25 I 1,08±0,07tfl
Notes: 1. * number of patients in each of the groups under the supervision;
2. J - p<0,01 when compared to patients which have a level of SPAP <30 mmHg;
3. fl - p<0,01 at comparison between patients which have the level of SPAP 31-40 mmHg and ones with the level of SPAP 41-50 mmHg
In all of probed patients, with diagnosed PH, the level of SPAP did not exceed 50 mmHg, that fits to the PH of the 1st degree. Patients with the level of SPAP »30 mmHg (Control group) (n=29) was had index of PA/A 0,69±0,135, diagnostic sensitiveness 89%, specificity 96%, and the prognostic value of positive result 89%, prognostic value of negative result 5%, and relation to plausibility for a positive result 9,9 (clinical example 1).
Clinical case 1.
The patient P., 49; suffers from chronic bronchitis. Complains of the protracting cough for a day. Objectively: the hard breathing auscultatively, mostly in the lower departments of lungs. An arteriotony is 100/80 mmHg, pulse - 80 b. /min., breathing frequency 18 per 1 min., the parafunctions of breathing were not discovered from the data of spirogra-phy. FEV1 is 93% and FEV1/FVC - 76% from required. SpO2 about 97%. At dopplerocardiography research of right chambers of heart - the systole pressure in a pulmonary artery was 17 mmHg. Spiral computer tomography find out no changes of lungs' structure, the diameter of aorta is 25mm. and the diameter of the pulmonary artery is 17 mm. The area of the body surface is 1,47 m2. The required diameter of pulmonary artery is 19 mm. Index PA/A - 0,68.
At patients which had the level of SPAP 31 - 40 mmHg (n=29) the value of the index of PA/A was (0,92±0,14), diagnostic sensitivity - 39%, specificity was 93%, prognostic value of the positive result -91%, prognostic value of the negative result - 55% and relation to the plausibility for a positive result -5,57 (clinical example 2). A research group included 14 patients with COPD of the 2nd stage, that had it in the combination with PH, and 15 patients with EH and PH.
Clinical case 2.
Patient A. at her 60-s suffers from the chronic obstructive pulmonary disease (COPD) 2nd stage in the state of remission, she has soft essential hyper-tensie and pulmonary hypertensie of 1st degrees as well. Complains of slight cough and moderate shortness of breath at walking. She had hypertensive illness about 6 years. The diagnosis of COPD was set about 15 years ago. At work she contacted
Актуальт проблемы сучасноТ медицины
with an organic dust. Objectively: the percussive sound has "in-box" tint; auscultatively hard breathing, dry whistling wheezes. An arteriotony is 155/90 mmHg, pulse - 76 b./min., breathing rate 19 per 1 min. From data of spirography FEV1 is 72% and FEV1/FVC - 79% from the required level. SpO2 -about 92 %. During the performing test with the broncholithic preparation (salbutamol - 400 mcg) noticed an increase of the Ofv1 - 13% from the required level. Doppler echocardiography research of right departments of the heart found out the increase of systole pressure in the pulmonary artery to 34 mmHg Spiral computer tomography found the centrylobullar emphysema of lungs, the diameter of the aorta is 28 mm. and the diameter of the pulmonary artery - 26mm. Episodically uses beta-2-antagonists of short action (salbutamol) and uses salmeterol in a dose 25 mcg twice a day, as antihypertensive preparations she uses adelphani un-constantly. The area of the body surface is 2.12 m2. Required diameter of pulmonary artery - 23 mm. Index PA/A - 0,92.
25 tested patients, among them 12 - have 2nd stage COPD in combination with PH, 13 patients have EH and PH, and have level of SPAP from 41 to 50 mmHg, index of PA/A - (1,08±0,07), diagnostic sensitiveness - 46%, specificity - 96%, prognostic value of the positive result - 96%, prognostic value of the negative result - 51%, and relation to plausibility for the positive a result 11,5 (clinical example 3).
Clinical case 3.
Patient D., 52 years old, suffers from the chronic obstructive pulmonary disease (COPD) of the 2nd stage in remission state, and from soft essential hypertensie and pulmonary hypertensie of the 1st degree. He complains of a shortness of breath, which disturbs at getting upstairs to a 2nd floor, and at walking. He's suffered from the hypertensive illness about 7 years. The diagnosis of COPD was made about 6 years ago. Objectively: the percussive sound has "in-box" tint; auscultatively hard breathing and dry whistling wheezes. An arteriotony is 148/99 mmHg, pulse - 80 b./min., breathing frequency 19 per 1 min.. Data of spirography shows, that FEV1 is 64% and FEV1/FVC - 72% from required level. SpO2 - about 93 %. During the carrying out the test with broncholithic preparation (salbutamol - 400 mcg) was noticed an increase of the Ofv1 - to 10% from required level. Doppler echo-cardiography research of right departments of heart found out the increase of systole pressure in a pulmonary artery to 44 mmHg Spiral computer tomography found the emphysema bules of II-III types, diameter of aorta - to 31 mm. and pulmonary artery - 34 mm. Episodically uses ipratropium bromide (20 mcg) / fenoterol hydrobromide (50 mcg) - 2-3 inhalations per day. The area of body surface is 2,04 m2.The required diameter of pulmonary artery is 22mm. Index PA/A - 1,09.
Conclusion
It is necessary to notice that value of index of PA/A at SPAP 41-50 mmHg was certainly (p<0,01) higher when compared with patients which have a level of SPAP 40 mmHg Indexes of SPAP at patients with 2nd stage COPD fit to the 1st stage of PH, and the attitude of PA diameter toward the diameter of A (index of PA/A) grows with the increase of SPAP and has stable character.
References
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BtCHMK Украгнськог' медичног' стоматологгчног академгг
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Реферат
HOBE ВИР1ШЕННЯ ПРОБЛЕМИ Д1АГНОСТИКИ ЛЕГЕНЕВ01' Г1ПЕРТЕНЗИ У ХВОРИХ НА ХРОН1ЧНЕ
ОБСТРУКТИВНЕ ЗАХВОРЮВАННЯ ЛЕГЕНЬ
БойкоД.М., БойкоМ.Г.
Ключов1 слова: ХОЗЛ, легенева ппертензт.
Хрон1чне обструктивне захворювання легень (ХОЗЛ) - одна з найважлив1ших проблем сучасно!' охо-рони здоров'я, причому така тенденц1я характерна для багатьох розвинутих краш св1ту у зв'язку з по-стшним зростанням розповсюдженост1 та смертносп вщ цього захворювання. Метою нашого досл1-дження було провести пор1вняльний анал1з м1ж доплерокардюграф1чною д1агностикою пщвищеного тиску в легеневш apTepiï (ПА) та рентгенолопчними ознаками лeгeнeвoï ппертензп (ЛГ) на ochobî cni-рально'Г кoмп'ютepнoï тoмoгpaфiï, у хворих на ХОЗЛ II ст. в поеднанш з м'якою ессенц1альною пперте-нз1ею та наявн1стю ЛГ I ступеня. Потр1бно зауважити, що значения ¡ндексу в1дношення лeгeнeвoï арте-piï до аорти (¡ндекс ЛА/А) при СТЛА 41-50 мм рт. ст. було в1рог1дно (р<0,01) вищим при пор1внянн1 з пац1ентами, як1 мають р1вень СТЛА <40 мм рт. ст. Показники СТЛА у хворих на ХОЗЛ II ст. вщповща-ють I ступеню ЛГ, а вщношення д1аметра ЛА до д1аметра А зростае ¡з п1двищенням СТЛА та мае стш-кий характер.
Реферат
НОВОЕ РЕШЕНИЕ ПРОБЛЕМЫ ДИАГНОСТИКИ ЛЕГОЧНОЙ ГИПЕРТЕНЗИИ У БОЛЬНЫХ С ХРОНИЧЕСКИМ ОБСТРУКТИВНЫМ ЗАБОЛЕВАНИЕМ ЛЕГКИХ Бойко Д.Н., Бойко Н.Г.
Хроническое обструктивное заболевание легких (ХОЗЛ) - одна из важнейших проблем современной охраны здоровья, при этом такая тенденция характерна для многих развитых странах мира в связи с постоянным возрастанием распространенности и смертности от этого заболевания. Целью нашей работы было провести сравнительный анализ между доплерокардиографической диагностикой повышенного давления в легочной артерии (ЛА) и рентгенологическими признаками легочной гипертензии (ЛГ), на основе спиральной компьютерной томографии, у больных с ХОЗЛ II ст. в сочетании с мягкой эссенциальной гипертензией и наличием ЛГ I степени. Нужно заметить, что значение индекса отношения легочной артерии к аорте (индекс ЛА/А) при СТЛА 41-50 мм рт. ст. был вероятно (р<0,01) выше при сравнении с пациентами, у которых уровень СТЛА <40 мм рт. ст. Показатели СТЛА у больных с ХОЗЛ II ст. соответствуют ЛГ I степени, а отношение диаметра ЛА к диаметру А возрастает с повышением СТЛА и имеет стойкий характер.
