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14DOI: 10.24411/2181-0443/2021-10008 РЕНТГЕНОЛОГИЧЕСКИЕ ОСОБЕННОСТИ ТЕЧЕНИЯ ХРОНИЧЕСКОЙ ОБСТРУКТИВНОЙ БОЛЕЗНИ ЛЕГКИХ В СОЧЕТАНИИ С САХАРНЫМ ДИАБЕТОМ
Турдуматов Жамшед Анварович Мардиева Гульшод Маматмурадовна Сайфиев Фаррух Дильшод угли Солеева Нигина Ботур кизи
Самаркандский государственный медицинский институт Самарканд, Узбекистан
Изучены особенности течения ХОБЛ в сочетании с сахарным диабетом методами рентгенографии и МСКТ. Выделены легочный компонент и системные проявления, усугубляющие болезнь. В основе проявлений сахарного диабета лежат микро- и макроангиопатии, влияющие на легочную микроциркуляцию. Стандартная рентгенография выраженные различия между обследуемыми группами больных с ХОБЛ не выявила. Диагностически значимыми для ХОБЛ при проведении МСКТ является симптом экспираторной «воздушной ловушки», в сочетании с расширением и деформацией бронхов, вплоть до бронхиолоэктазов. Патогномичны изменения, характеризующие микроангиопатию: расширенные сосуды паренхимы, очаговоподобные тени сосудистого генеза, четкообразная форма сосудов, которые рассматриваются как следствие специфической микроангиопатии и фиброзных изменений при ХОБЛ.
Ключевые слова: ХОБЛ, сахарный диабет, рентгенография, МСКТ.
X-RAY PECULIARITIES OF THE COURSE OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE IN COMBINATION WITH DIABETES MELLITUS
The features of the course of COPD in combination with diabetes mellitus were studied using X-ray and MSCT methods. The pulmonary component and systemic manifestations that aggravate the disease have been identified. The manifestations of diabetes mellitus are based on micro- and macroangiopathies that affect pulmonary microcirculation. Standard radiography did not reveal significant differences between the examined groups of patients with COPD. Diagnostically significant for COPD during MSCT is a symptom of an expiratory "air trap", in combination with expansion and deformation of the bronchi, up to bronchioectasis. Changes characterizing microangiopathy are pathognomic: dilated parenchymal vessels, focal-like shadows of vascular genesis, a distinct shape of vessels, which are considered as a consequence of specific microangiopathy and fibrotic changes in COPD.
Key words: chronic obstructive pulmonary disease, diabetes mellitus, X-ray, MSCT.
ЦАНДЛИ ДИАБЕТ БИЛАН КЕЧАДИГАН СУРУНКАЛИ ОБСТРУКТИВ УПКА КАСАЛЛИГИНИНГ УЗИГА ХОС РЕНТГЕНОЛОГИК ХУСУСИЯТЛАРИ
УСОК (упканинг сурункали обструктив касаллиги)нинг Цандли диабет билан биргаликда кечиш хусусиятлари рентгенография ва МСКТ усуллари ёрдамида урганилди.Касалликни кучайтирадиган упка компоненти ва тизимли куринишлари ажратилди.Цандли диабетнинг намоён булиши асосида упка микроциркуляциясига таъсир курсатадиган микро ва макроангиопатиялар ётади. Стандарт рентгенография УСОК билан касалланган беморларнинг текширилган гурухлари уртасида сезиларли фарЦларни аниЦламади. УСОК билан касалланганларда МСКТ утказиш учун диагностик ахамиятга эга булган белги бу бронхиоэктазгача бронхлар кенгайиши ва деформацияси билан биргаликда кечадиган экспиратор "Хаво ушлагичи симптомидир. Микроангиопатияни тавсифловчи патогномик узгаришлар:томирлар соясининг учоЦсимон кенгайиши, Цон томир генезли учоЦЦа ухшаш соялари, УСОКда узига хос микроангиопатия ва фиброз узгаришларнинг натижасида юзага келувчи Цон томирларнинг аниЦ шакли.
Калит сузлар: УСОК, Цандли диабет, рентгенография, МСКТ.
Introduction. One of the primary problems of medicine today is chronic obstructive pulmonary disease (COPD). COPD is a systemic disease and as the pathopulmonological process progresses, along with lung damage, pulmonary hypertension, chronic pulmonary heart and significant systemic effects develop cachexia, skeletal muscle atrophy, osteoporosis, anemia, and an increased risk of cardiovascular diseases [11,12].
According to the definition of COPD included in the main document on COPD management [8], the huge role of concomitant diseases in increasing the severity of COPD, affecting the quality of life, prognosis and survival is emphasized. It should be noted that COPD patients have significant comorbidity. In modern clinical practice, it is increasingly possible to meet patients who have a combination of type 2 diabetes, coronary heart disease, arterial hypertension and COPD [7].
According to various authors, diabetes mellitus is combined with COPD from 2 to 16% [4]. Pathogenetic mechanisms underlying the high frequency of combined COPD and type 2 diabetes are being actively studied. Potential mechanisms include: chronic systemic inflammation, oxidative stress, and chronic hyperglycemia [1,6]. Special attention is paid to the combination of COPD and type 2 diabetes mellitus, since both diseases belong to the second half of life, and according to a number of authors, diabetes mellitus is combined with COPD in 2.0-16.0% of cases [3,4,5]. Concomitant diabetes accelerates the progression of ventilation, disorders and worsens the prognosis, increasing the risk of death from COPD [2,9,10]
Taking into account the above, the purpose of our study is to determine the
Nosological and gi
radiological features of COPD in diabetes mellitus, and the possibility of predicting its development.
Material and methods of research. The
object of the study was 75 patients. A random sample was made from an array of patients with established diagnoses of "Chronic obstructive pulmonary disease and "diabetes Mellitus". The inclusion criteria were the presence of chronic obstructive pulmonary disease in accordance with GOLD, as well as the presence of diabetes mellitus in accordance with the algorithms of specialized medical care for patients with diabetes.
The control group was represented by 12 healthy individuals who did not have lung diseases and diabetes at the age of 20 - 40 years: men - 6, women - 4.
To study the features of COPD in combination with diabetes, all patients were divided into 3 groups. The main group I consisted of patients with COPD combined with diabetes. To compare the results, we examined patients with COPD who made up group II and patients with diabetes who made up group III (table 1).
The study of patients with COPD was conducted upon admission to the clinic after stabilization of the condition. Patients with diabetes were examined at admission to the Department or on an outpatient basis. Among the examined patients with COPD and diabetes, there were 46 men and 29 women. The comparison groups I and II were dominated by men, which is typical for patients with COPD. Group III was dominated by women. The age of patients in the main group varied from 25 to 70 years. Patients aged 50 to 65 years prevailed.
Table 1.
characteristics of patients
Groups patients Type of diseases Abs. number %
I COPD in combination with 40 53.7
diabetes
II COPD 20 26.7
III SD 15 20.0
Total 75 100.0
Patients of the main group were more likely to have concomitant diseases of the circulatory system. Arterial hypertension and coronary disease prevailed in patients with COPD in combination with diabetes mellitus.
Traditional radiography and multispiral computer tomography (MSCT), which was performed on a Light Speed 16 tomograph (General Electric Medical Systems) using highresolution computer tomography (KTBP) parameters, were used as x-ray morphological methods. The scanning step is 1.3 mm, with reconstruction of sections with a thickness of 1 mm or less.
The results of the study. All the examined patients of groups I and II had various degrees of severity of leading complaints of COPD patients (shortness of breath, cough, sputum discharge). The frequency of COPD exacerbations 3 or more times a year in group I was observed in 16 (40.0%), in group II - in 3 (15.0%) patients. That is, more frequent exacerbations of COPD were observed in the COPD group with concomitant diabetes. It should be noted that the increased purulent
nature of sputum was one of the signs of severity of exacerbation. In the examined patients, we detected a mild severity of COPD exacerbation in 8 (20.0%) patients of the main group, and in 5 (25.0%) patients of group II. The average severity of COPD exacerbation was detected in 27 (67.5%) patients of the main group and in 13 (65.0%) patients from group II. Severe severity of COPD exacerbation was determined in 5 patients (12.5%) in group I, and in group II - in 2 (10.0%) patients.
If the severity of COPD is comparable in these groups, we can assume an adverse effect of diabetes on the development of COPD. Especially, considering that diabetes mellitus preceded COPD or was detected simultaneously with COPD in 14 (35%) patients of the main group. This suggests the possibility of an adverse interaction between diabetes and COPD.
Evaluation of the results of x-ray examination did not reveal significant differences in the assessment of lung parenchyma in groups I and II of the examined patients (table 2).
Table 2.
Frequency of detection of various radiological signs of damage in COPD
Radiological changes Patient groups
group I group II
abs. % abs. %
Emphysema 12 30.0 8 40.0
Strengthening and deformation of the pulmonary pattern by type of pneumosclerosis 16 40.0 7 35.0
Thickening of the bronchial walls 34 85.0 18 90.0
Indistinct contours of blood vessels, bronchi 16 40.0 7 35.0
and lung roots
"Sabre-like" shape of the trachea 7 17,5 3 15,0
Perivascular and peribronchial "couplings" around vessels and bronchi 5 12,5 3 15,0
Flattening of the diaphragm domes and smoothness of the pleural sinuses 6 15.0 3 15.0
Thickening of the interlobular pleura 6 15.0 2 10.0
Curley Lines 2 5.0 1 5.0
Calcinates 5 12.5 3 15.0
All X-rays of the lungs were performed at the height of inspiration, with delayed breathing. The most characteristic radiological signs of obstruction in the lungs were: increased airiness of the lung tissue in the exhalation phase due to
excessive air content in the respiratory parts of the lungs (in group I 30%, in group II 40%); flattening of the diaphragm domes and smoothness of the pleural sinuses (15% in both groups); vertical position of the heart axis on the
chest x-ray in a direct projection (a "small" heart shadow or a so-called "drip" heart); the" sabre-shaped " shape of the trachea is the predominance of the sagittal (anteroposterior) size of the trachea, determined by the lateral radiograph, over the transverse size, measured by the radiograph in direct projection (17.5% and 15%, respectively).
In addition, when the review radiography of the chest in patients with COPD were identified: strengthening and deformation of lung pattern in hilar and nudepregnancy lung type pulmonary fibrosis (40% and 35% respectively); the thickening of the walls of lobar and segmental bronchi (85% and 90%, respectively); blurring of blood vessels, bronchi, and the "blurred" structure of the roots of the lungs.
Assessment of the mediastinal shadow during radiography in patients with COPD revealed its own characteristics. Due to right ventricular overload in COPD, the examined patients showed some changes in the configuration of the mediastinal shadow on the x-ray. Due to increased pressure in the small circle of blood circulation, large branches and the main trunk of the pulmonary artery expand, respectively, the second arc of the left contour of the cardiovascular shadow lengthens and becomes more convex. As the load increases, the right ventricle expands, so the lower arc of the right contour shifts to the right, and the atriovasal angle moves up. Changes in the heart caused by a chronic pulmonary process in the lungs, as is known, received the General name "pulmonary heart". In patients with COPD, included in groups I and II, the prevailing percentage of our observations showed the configuration of the "pulmonary heart" ("cor pulmonalis").
Similar clinical symptoms in patients with various pathological changes in the lungs created significant difficulties in differential diagnosis of COPD with chronic bronchitis and emphysema, as well as in assessing the severity of COPD. This circumstance served as the basis for the study of additional possibilities of computed tomography (CT) in the diagnosis of COPD in
order to improve the effectiveness of radiation research methods.
The results of a detailed analysis of X-ray morphological changes in patients with COPD and diabetes mellitus using multispiral computed tomography are presented in tables 9 and 10. All analyzed data was divided into two groups. The changes included in group 1 included signs that were characteristic of COPD and the transferred inflammatory process in the lungs: thickened and deformed bronchi, emphysema, bronchiectasis, thickening of the pleura and pleural adhesions, intrapulmonary calcifications. The changes included in group 2 included signs of microangiopathy: expanded parenchymal vessels, including focal shadows of vascular origin, 2-5 mm in size; clear-cut vasodilation.
MSCT of the lungs using functional respiratory tests (inhalation phase and exhalation phase) allowed detecting early signs of COPD development already at the preclinical stage of the disease, even if the external respiratory function indicators were normal. When using CT in the expiratory phase, the predominant number of patients with COPD in groups I and II revealed the presence of air "traps" in the lungs, the "tree with kidneys" symptom, indicating pathological changes at the level of small bronchi.
Emphysema and bronchiectasis were found in groups I and II and were absent in group III patients (table 3). Pleural thickening, pleural adhesions, and calcifications were detected in all three groups. Thickened and deformed bronchi were detected in 30 (75.0%) patients of the main group and 18 (90.0%) patients of group II. In group III, thickening and deformity of the bronchi occurred in 2 (13.3%) patients, which was significantly less common in comparison with groups I and II. Therefore, this trait was typical for COPD patients with and without diabetes mellitus. CT-symptoms of changes in the pulmonary parenchyma, such as expiratory air "trap", "ring" symptom (presence of bronchiectasis), "tree with kidneys" symptom (bronchioles lesion) they were pathognomic for patients with COPD from groups I and II.
Table 3.
CT-symptoms characteristic of COPD and previous pneumonia
Signs Of group Patients with
I II III
abs. % abs. % abs. %
thickened and deformed bronchi 30 75.0 19 95.0 2 13.3
Emphysema 38 95.0 20 100 0 0.0
Bronchiectasis 28 70.0 1 75.0 0 0,0
Pleural thickening and pleural adhesions 22 55.0 11 55.0 3 20.0
Calcinates 24 60.0 10 50.0 5 33.3
Expiratory air "trap" 37 92.5 17 85.0 - -
ring" Symptom (presence of broichoectasis) 12 30.0 7 35.0 - -
Symptom of " tree with kidneys "(bronchioles) 29 72.5 13 65.0 - -
Expanded parenchymal vessels and focal shadows of vascular origin with a diameter of 25 mm were equally common in all compared groups (table 4). However, in patients with COPD, these signs were combined with thickening and deformity of the bronchi,
bronchiectasis, emphysema and were a consequence of COPD and the transferred inflammatory process. In group III patients, thickened and deformed bronchi, emphysema, and bronchiectasis were not found.
Table 4.
CT-symptoms characteristic of microangiopathy
Patients with
Signs of group II I] [I
abs. % abs. % abs. %
The dilated vessels of the 38 95.0 14 70.0 14 93.3
parenchyma
Hearth-like shadows (2- 28 70.0 12 60.0 13 86.7
5mm)
Clear shape of vessels 38 95.0 8 40.0 14 93.3
Consequently, in patients with diabetes mellitus, dilation of parenchymal vessels and vascular foci-like shadows of small diameter can be considered as a manifestation of diabetic angiopathy. In patients with COPD, this sign is due to the development of fibrosis.
Clear-cut vascular shape was detected in 38 (95.0%) patients of group I and 8 (40.0%) patients of group II. In group III, this sign was detected in 14 (93.3%) patients, which was
53.3% more often than in group II. Consequently, the clear shape of the vessels was characteristic of COPD patients in combination with diabetes mellitus and diabetic patients.
As you can see, the clear shape of blood vessels is more common in patients with COPD in combination with diabetes in comparison with patients with COPD, which indicates an adverse effect of diabetes on the state of microcirculation in COPD.
In general, studying the main manifestations of respiratory failure in patients of the main (I) and II groups, we found that the frequency of cyanosis did not differ in group I and II. Participation in breathing of auxiliary muscles was more often observed in the main group. Respiratory failure depending on Ra02 was detected in 39 (97.5%) patients of the main group and 15 (75%) patients of group II. Dyspnea in patients of the main group was more pronounced than in the comparison group.
Consequently, in general, respiratory failure detected by clinical and laboratory -instrumental methods was more pronounced in the main group than in the second group. The severity of dyspnea did not depend on the stage of COPD and prevailed in the main group.
As can be seen, when managing patients with COPD in combination with diabetes mellitus, attention should be paid to more pronounced clinical manifestations of respiratory failure (shortness of breath, participation in breathing of auxiliary muscles, hypoxemia), especially in patients with stage III COPD.
Summarizing our discussion, we can say that in the structure of COPD, there is a pulmonary component and systemic manifestations that can aggravate the disease. Extrapulmonary effects of COPD include diabetes mellitus. The manifestations of diabetes mellitus are based on micro-and macroangiopathies that affect the pulmonary microcirculation.
Standard X-ray examination revealed no significant differences between the examined groups of patients with COPD. The variety of different bronchopulmonary diseases with similar clinical symptoms makes it extremely difficult to conduct a differential diagnosis of COPD. In this regard, there is a need to identify objective diagnostic criteria that can be obtained using x-ray and computed tomography studies.
COPD is formed as a result of damage to the small bronchi, which determines the
complex, and makes it possible to differentiate this disease with emphysema and chronic bronchitis. To diagnose microvessel damage in patients with COPD and diabetes mellitus, to predict the course of non-specific lung diseases, based on the specific results of the study, it is advisable to conduct multispiral computed tomography with the detection of expanded parenchymal vessels, foci-like shadows of vascular Genesis with a diameter of 2-5 mm, and a clear shape of the vessels. Signs of the development of macro - and microangiopathy in patients with COPD in combination with diabetes mellitus are hypoxemia. Microangiopathy of the lungs probably plays a crucial role in unfavorable course of COPD in patients with diabetes mellitus.
Conclusions. Patients with COPD in combination with diabetes mellitus are characterized by more pronounced respiratory failure and chronic pulmonary heart disease, frequent exacerbations and more pronounced hypoxemia in comparison with patients with COPD. Assessment of the degree of ventilation in the lungs in patients with COPD should be carried out in the conditions of CT performed in the inhalation and exhalation phases. Diagnostically significant for COPD during computed tomography is the symptom of an expiratory "air trap", combined with the expansion and deformation of the bronchi of various calibers, up to broncho - and bronchioloectasis.
MSCT in patients with COPD and diabetes mellitus pathognomic changes that characterize microangiopathy in: expanded parenchymal vessels, focal shadows of vascular Genesis with a diameter of 2-5 mm, a clear shape of the vessels. These changes can be considered as a consequence of specific microangiopathy and fibrotic changes characteristic of COPD. The clear shape of microvessels is a specific x-ray morphological feature in patients with COPD in combination with diabetes mellitus and diabetes mellitus itself.
characteristic clinical and radiological symptom
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