RU2388405C1 - Method of evaluating degree of severity of trophologic insufficiency in patients with chronic obstructive lung disease - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine: pulmonology, general therapy, in particular to methods of evaluating trophologic status in patients with chronic obstructive lung disease (COLD). Determined are index of factual body weight and analysis of absorption of 131I-trioleate-glycerin, determined is total index of excreted with feces radioactivity R and by formula CFBbw=W/R, where W - body weight, in kg, R - total index of excreted with feces radioactivity, in %, coefficient of fat balance of body weight (CFBbw) is calculated, and if coefficient value equals from 20 to 23 absence of trophologic insufficiency is diagnosed, if coefficient equals from 16 to 17 moderate degree of trophologic insufficiency is diagnosed, if coefficient equals from 9 to 10 and lower expressed degree of trophologic insufficiency is diagnosed. ^ EFFECT: increase of accuracy and clinical self-descriptiveness. ^ 1 tbl, 3 ex

Description

The invention relates to medicine, pulmonology, general therapy, and specifically to methods for assessing the severity of trophological insufficiency in patients with chronic obstructive pulmonary disease (COPD).

Recent studies have shown that COPD is characterized not only by a pathological bronchopulmonary process, but also by significant systemic manifestations, aggravating the course and prognosis of the disease [1, 2]. A decrease in nutritional status (trophological insufficiency) of COPD patients is one of the main systemic manifestations of this pathology [3, 4] and is assessed as an unfavorable prognostic factor independent of other markers of COPD severity, such as FEV ₁ or PaO ₂ [5, 6]. The trophological status reflects the amount of body mass and structure, as well as the totality of metabolic processes that ensure sustainable homeostasis.

A known method for assessing the state of trophological status, which consists in determining somatometric indicators, which include: determining body weight (kg), body length (cm), shoulder circumference, skin-fat folds of the triceps at the level of its middle third [7, 8]. Body mass (MT) is not only one of the most important indicators of trophological status [8, 9], but is also characterized as an integral concept that includes a number of important components of the body structure. Deficiency of body weight can be due to any component of the body structure, the leading ones of which are fat and protein components. Therefore, more accurate quantitative indicators are needed to determine the deficit of a component of the body mass structure that determines the severity of trophological insufficiency. In this regard, it is relevant to diagnose through methods that evaluate the absorption function of the small intestine, determine the provision of the body with essential (irreplaceable) nutrients - proteins, fats, carbohydrates, which participate in all vital processes of the body and maintain proper metabolic homeostasis.

Closest to the proposed is a method for assessing trophological status by determining body mass index (BMI), which is calculated as the ratio of body mass index (MT in kg) to height (in meters) squared: BMI = MT / Height ² (kg / m ² ). BMI values are interpreted according to classification criteria for this Kaplan-Meier indicator [10].

The normal BMI value is determined in the range from 20 to 24 kg / m ² . The trophological insufficiency is judged by a decrease in BMI below 20 kg / m ² , with an increase in BMI of more than 24 kg / m ^2, overweight is diagnosed and when a value above 29 kg / m ^{2 is} diagnosed with obesity [10].

The known method is not sufficiently informative from a clinical point of view with respect to assessing the severity of the development of trophological insufficiency, since there are no clearly established criteria characterizing this condition. The known method is also not informative for establishing the nature of the deficiency of the structural component of body weight, in particular, the depletion of adipose tissue. Fats are the most effective substrate for reactions that occur with the formation of energy. Therefore, not only the state of metabolic homeostasis as a whole, but also the state of energy metabolism in the body will depend on the effectiveness of intestinal lipolysis and absorption of fat.

A new technical task is to increase the accuracy and clinical informativeness of the method for assessing the severity of trophological insufficiency in patients with chronic obstructive pulmonary disease.

To solve the problem in a method for assessing the severity of trophological insufficiency in patients with chronic obstructive pulmonary disease (COPD), which consists in determining the actual body weight, an additional study of the absorption of ¹³¹ I-trioleate-glycerol is carried out, and the total indicator of radioactivity P excreted with feces is determined and according to the formula:

KZhb mt = M / R, where

M - body weight, in kg,

P is the total indicator of radioactivity excreted with feces, in%, the coefficient of the fat balance of body mass (CJB mt) is calculated and, with its value from 20 to 23, the absence of trophological insufficiency is diagnosed, with its value from 16 to 17, a moderate degree of trophological insufficiency is diagnosed, and with its value from 9 to 10 and below diagnose a pronounced degree of trophological insufficiency.

The method is as follows: for a patient diagnosed with COPD, the standard examination program includes determining the somatometric indicator - body weight (in kg), by weighing on a medical balance, and assigning an absorption study with ¹³¹ I-trioleate-glycerol [11], which is taken orally on an empty stomach at a dose of 10 μCi with 30 ml of olive oil 30 minutes before breakfast. Feces are collected daily from the day of taking a test breakfast until the complete disappearance of radioactivity. The amount of radioactivity excreted in feces is expressed as a percentage of the dose taken, and after the total radioactivity excreted with feces ¹³¹ I-trioleate-glycerol is obtained, the coefficient of body fat balance (CJB mt) is calculated as the ratio of body weight to the total indicator P of excreted ¹³¹ I-trioleate -glycerol with feces:

KZhb mt = M / R, where M is body weight (in kg);

P is the total excretion rate of ¹³¹ I-trioleate glycerol with feces (in%) and

when the coefficient value is from 20 to 23, the absence of trophological insufficiency is diagnosed (a sample average body mass in kg of 70 is divided by the total rate of isolated trioleate glycerol with feces - 3.29 ± 0.07%),

when the coefficient value is from 16 to 17, a moderate degree of trophological insufficiency is diagnosed,

with a coefficient value of 9 to 10 and lower, a pronounced degree of trophological insufficiency is diagnosed.

Extrapulmonary manifestations of COPD, including weight loss, are very important for assessing the severity of the disease [12]. In this context, BRCelli et al. [13] showed that a comprehensive scoring taking into account various COPD syndromes: FEV ₁ , body weight, and ability to exercise is much more predictive in relation to the treatment program for patients with COPD compared to isolated use of FEV ₁ .

Thus, the assessment of trophological status in patients with COPD, in particular the ratio of body mass to fat absorption, which assesses the degree of fat supply to the body, is a fairly relevant method for examining these patients. In the case of trophological insufficiency identified in this way, due to depletion of adipose tissue, the doctor will be able to apply the correction technique for the corresponding deficient state in order to maintain a stable metabolic homeostasis.

Example 1

Patient Novikov AM, 46 years old, was admitted to the pulmonology department of the city hospital No. 3 with a diagnosis of COPD stage I in the acute phase.

Upon receipt, in addition to complaints and clinical examination data characterizing the phase of exacerbation of COPD, no other pathology was determined. During a physical examination, no visual signs of trophological insufficiency were detected. The standard examination plan, in addition to general clinical, laboratory studies and other indicators characterizing the phase of the disease exacerbation, the severity of its course, included a study according to the proposed method - determining the actual body weight by weighing the patient on a medical scale, and a radionuclide study of the absorption function of the small intestine with I ¹³¹ trioleate-glycerol, followed by determination of the coefficient of fat balance of body weight (KZht mt).

The results of the studies showed that the patient has positive indicators of the phase of exacerbation of COPD. The body weight is 76 kg, an additional study was carried out according to the proposed method — the total release rate of I ¹³¹ trioleate-glycerol is 3.29%, the value of CJB mt is 23. Thus, the patient has a trophological status of COPD, the somatic pool of fat in relation to body weight is not reduced. Based on the results of the studies, recommendations were made for the treatment of the patient, consisting in the fact that the program of treatment of COPD included only groups of medications aimed at stopping the phase of the exacerbation of the disease without medical correction of trophological status. The patient is recommended for further observation in the clinical examination mode and control of CFL mt once a year.

Example 2

Patient V. Potapov, 44 years old, was admitted to the therapeutic department of the city hospital No. 3 with a diagnosis of COPD stage II in the acute phase.

Upon receipt, in addition to complaints and clinical data characterizing the phase of exacerbation of COPD, complaints were made of general weakness, rapid fatigue during physical exertion. A physical examination revealed some signs of trophological insufficiency - dry skin, moderate depletion of subcutaneous fat.

In addition to studies: general clinical, laboratory, and other indicators characterizing the phase of exacerbation of COPD, the severity of its course, the study according to the proposed method — determining the actual body weight by weighing the patient on a medical scale and a radionuclide study of thin intestines I ^{131 with} trioleate-glycerol, followed by determination of the coefficient of fat balance of body weight (CJB MT).

The results of the studies showed that the patient has positive indicators characterizing the phase of exacerbation of COPD, body weight is 70 kg, the total excretion rate of I ¹³¹ trioleate glycerol is 4.29%, the value of CJB mt is 16. Thus, the patient with COPD has objective data diagnosing moderate trophological insufficiency, characterizing a decrease in the somatic pool of adipose tissue in relation to body weight. Based on the results of the studies, recommendations were made for the treatment of the patient, consisting in the fact that the COPD treatment program included groups of medications aimed at both stopping the phase of exacerbation of COPD and drug correction of the revealed moderate trophological insufficiency. The patient was prescribed multicomponent enzyme preparations that restore digestion and absorption of fats. In this case, the absorption function of the small intestine was reduced, and therefore, the intake of fat in the body was insufficient, which was manifested by a decrease in the coefficient of fat balance of body weight, diagnosing moderate trophological insufficiency. The patient underwent prolonged therapy, for 2 months, with multicomponent enzyme preparations, followed by a control study of the trophological status according to the calculation of CJB mt. The results of the control study showed that the body weight of the patient with COPD increased to 72 kg, the total indicator of radioactivity I ^{131 of} troleate glycerol excreted with feces is 3.29%, the value of CFL mt is 21. Thus, the patient has returned to trophological status. Observation in the dispensary mode is recommended.

Example 3

Patient Syutkin AF, 50 years old, was admitted to the pulmonology department of the city hospital No. 3 with a diagnosis of COPD stage III in the acute phase. Sick for 26 years. Upon receipt, in addition to complaints and clinical data characterizing the phase of exacerbation of COPD, complaints were made of general weakness, decreased performance, and rapid fatigue. During the physical examination of the patient, the state of low nutrition, muscle exhaustion, and depletion of subcutaneous fat paid attention.

In addition to the general clinical laboratory study and other indicators characterizing the acute phase of COPD and the severity of the disease, the standard examination plan included a study according to the proposed method, which consists in determining the actual body weight by weighing on a medical balance, and a study with ¹³¹ I-trioleate glycerol at a dose of 10 μCi, taken orally with 30 ml of olive oil, 30 minutes before breakfast. Feces were collected daily from the day the test breakfast was taken until radioactivity disappeared completely. The amount of radioactivity excreted in the feces was expressed as a percentage of the dose taken.

The results of the studies confirmed the phase of exacerbation of COPD in the patient, body weight was 68 kg, fat loss with feces according to the total radioactivity of ¹³¹ I-trioleate-glycerol was 7.28%, the value of CJB mt was 9.3, which corresponds to severe trophological insufficiency. Fat loss associated with impaired digestion and absorption led to the depletion of body fat, according to the value of body fat, and the development of a severe degree of trophological insufficiency.

Based on the results of the studies, recommendations were made on the treatment of the patient, consisting in the fact that the COPD treatment program included not only groups of medications aimed at stopping the phase of exacerbation of COPD, but also medical correction of trophological insufficiency. The treatment program also includes: multicomponent enzyme preparations in a regimen of 2 capsules 3 times a day during main meals.

Underestimation of clinical data characterizing the severity of trophological insufficiency can contribute to the progression of the underlying disease. Given the low level of CJB mt, the doctor prescribed the patient prolonged therapy with multicomponent enzyme preparations, which the patient should take after hospital treatment, followed by monitoring of the CJB mt parameter. The results of the study, conducted after 6 months, showed that the patient’s body weight increased to 70 kg, the total excretion rate of ¹³¹ I-trioleate-glycerol with feces is 4.02%, the value of CFL mt is 17.4. Thus, a clinical observation showed that the patient’s severe trophological insufficiency was converted to a moderate degree of severity, the general condition of the patient in terms of tolerance of physical exertion improved. The patient is recommended to constantly take maintenance therapy with multicomponent enzyme preparations and once a year to control the index of CFL mt.

The proposed criteria for assessing trophological insufficiency in patients with COPD are selected based on the interpretation of clinical observations.

Initially, normative indicators were established for the allocation of ¹³¹ I-trioleate-glycerol (neutral fat) [10] with feces in a healthy category of people - the control group (n-10). The indicator was characterized by a sample mean value of 3.30 ± 0.23% (Table 1). The result obtained is consistent with the literature [10, 14].

When making a diagnosis of COPD and randomizing patients into groups depending on the stage of the disease, we were guided by the main provisions of the GOLD 2006 program (level of forced expiratory volume reduction in 1 second - FEV ₁ ) [15]. Clinically, patients were in a stable phase of the disease. The study did not include patients with stage IV of COPD - a very severe course, patients with decompensation of the pulmonary heart (the function of the right ventricle was evaluated by ultrasound dopplerography), with concomitant diseases that interfere with digestion and absorption.

The absorption of ¹³¹ I-trioleate-glycerol was studied in 93 patients with COPD aged 42-71 years (65 men, 28 women), disease duration from 8 to 35 years. At the same time, in 22 patients with COPD, according to clinical and functional data, I stage was diagnosed - mild (FEV) / FVC <70%, FEV ₁ ≥80% of the due) - 1 group; 36 patients had stage II - moderate course (FEV ₁ / FVC <70%, 50% ≤EV ₁ <80% of the due) - group II; in 35 patients, stage III of COPD was determined - severe (FEV ₁ / FVC <70%, 30% ≤EV ₁ <50% of the due) - group III.

In 39 patients with COPD, a correlation analysis was performed using a paired correlation coefficient between body weight deficiency and excretion rates of ¹³¹ I-trioleate glycerol.

Statistical processing of the research results was carried out using standard application software packages. The results are presented in the form M ± m, where M is the arithmetic mean, m is the arithmetic mean error. The critical level of significance (p) when testing statistical hypotheses in our studies was assumed to be 0.05 or less.

The absorption indices of ¹³¹ I-trioleate glycerol analyzed in this study in patients with COPD, depending on the stage of the disease, are presented in Table 1.

In the first group of patients, the excretion rates of ¹³¹ I-trioleate-glycerol did not have a statistically significant difference from the control group. In the moderate stage (group II), in comparison with the control group and the patient group I, the quantitative excretion of fat by ¹³¹ I-trioleate-glycerol increased by an average of 1.3 times (p = 0.012) or by 30%.

An analysis of the results showed that in patients with COPD in a moderate stage, fat digestion is disturbed (according to the test with ¹³¹ I-trioleate-glycerol) and its absorption is reduced.

In the severe stage of COPD (group III), in comparison with the control group and group I patients, the excretion of ¹³¹ I-trioleate-glycerol increased on average 2.2 times (p = 0.001) or 120%. These studies have shown that in the severe stage of COPD, impaired intestinal digestion of fat and its absorption are significantly more significant. The established violations of the absorption of the small intestine in relation to fats in COPD are secondary in origin due to the fact that they are not detected in the mild stage and are mediated by the peculiarities of the pathophysiological mechanisms of COPD, which are more manifested in the moderate and severe stages of the disease.

Thus, in the mild stage of COPD, the coefficient of fat balance of body weight, defined as the ratio of body weight (in kg) to the total rate of excreted ¹³¹ I-trioleate glycerol with feces: KZhB mt = M / P was determined in the range from 20 to 23, which did not characterize the development of trophological insufficiency. In patients with COPD of moderate stage CJB, mt is from 16 to 17, which characterized the development of a moderate degree of trophological insufficiency.

In patients with severe COPD of severe stage of CFJ, mt was determined in the range from 9 to 10, which characterized the development of a pronounced degree of trophological insufficiency, mediated by impaired digestion and absorption of fat.

A study of the correlation between the body mass deficit of patients with COPD and excretion rates of ¹³¹ I-trioleate-glycerol revealed that the paired correlation coefficient is: r = 0.72 ± 0.04, (p = 0.001), which means a high degree of tightness of the relationship between two signs. The analysis showed that the lack of body weight of patients with COPD is associated with impaired absorption of fat.

Thus, evaluating the trophological status in patients with COPD, it can be concluded that one of the mechanisms of fatty tissue depletion, as one of the leading components of body weight, is a decrease in fat absorption and increased loss of it with feces, and this relationship has a high degree of close connection.

Thus, the proposed method for assessing the degree of trophological insufficiency of patients with COPD using the calculation of CJB mt allows us to more accurately assess the depletion of adipose tissue associated with impaired digestion and absorption, as one of the leading components of body weight balance. Direct correlations of a high degree of tightness between the deficit of body weight of patients with COPD and a decrease in fat absorption r = 0.72 were found.

Assessing the severity of trophological insufficiency in patients with COPD by the value of CJB mt allows you to determine the amount of therapy for its correction, including it in the standard treatment plan, in order to reduce the severity of this negative risk factor and improve the quality of life of patients.

Literature

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Claims (1)

A method for assessing the severity of trophological insufficiency in patients with chronic obstructive pulmonary disease (COPD), which consists in determining the actual body mass index, characterized in that they additionally study the absorption of ¹³¹ I-trioleate glycerol, and determine the total indicator of radioactivity P excreted with feces and according to the formula:
KZhb mt = M / R, where M is body weight, kg; P is the total indicator of radioactivity excreted with feces,%, the coefficient of the fat balance of body mass (CJB mt) is calculated and when the coefficient value is from 20 to 23, the absence of trophological insufficiency is diagnosed, when the coefficient value is from 16 to 17, a moderate degree is diagnosed trophological insufficiency, with a coefficient value of 9 to 10 or lower, a pronounced degree of trophological insufficiency is diagnosed.