RU2593229C2 - Method of diagnosing and monitoring clinical course of lung diseases accompanied by accumulation of protein and lipid substances in alveoli - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to pulmonology and endoscopy, and can be used for examination of lungs in diseases, accompanied by accumulation of protein and/or lipid substances in alveoli. High resolution lungs computed tomography (HRCT) is conducted. Segments are identified with changes of pulmonary parenchyma and without changes. In addition, airways laser confocal endo microscopy (CLEM) is conducted using mini-probe with laser beam with wave length of 488 nm. Presence of protein and/or lipid substances is identified. CLEM is carried out simultaneously with repeated HRCT of two segments with parenchyma changes with pitch of 0.5-1 mm and two segments without changes according to first conducted HRCT.

EFFECT: method enables stating presence of pulmonary pathology without tissue biopsy, assessment degree of alveoli filling with substances, containing proteins and lipids, control of pulmonary lavage efficiency.

1 cl, 4 dwg, 1 ex

Description

The invention relates to methods for establishing the presence and severity of accumulation in the lumen of the pulmonary alveoli of substances containing proteins and lipids, and can be used in pulmonology and endoscopy for the diagnosis and assessment of the course of lung diseases.

It is known to use confocal laser endomicroscopy (CLEM) to determine the presence of intra-alveolar accumulation of substances [Salatin M, Roussel F, Hauss PA, et al. In vivo imaging of pulmonary alveolar proteinosis using confocal endomicroscopy. J Eur Respir. 2010; 36: 451]. The use of the KLEM method allows visualization of intra-alveolar substances of a protein-lipid nature, however, due to the lack of the ability to control the distal part of the mini-probe, it is carried out to the respiratory parts of the respiratory system blindly, along the path of least resistance, and therefore it is impossible to establish the final location of its tip in advance segment, which does not allow to get a complete picture of the distribution of intraluminal substances. Also known is the high-resolution computed tomography (CT) method, which allows you to assess the condition of the entire pulmonary parenchyma by identifying affected areas and is the “gold standard” method in pulmonology. Similar radiological symptoms in addition to diseases accompanied by the accumulation of protein and lipid substances in the alveoli, such as alveolar proteinosis, lipoid pneumonia, Gaucher disease, alveolar microlithiasis and others [Borie R, Danel C, Debray MP, et al. Pulmonary alveolar proteinosis. Eur Respir Rev. 2011, 20: 98-107; Seymour JF, Preseneill JJ. Pulmonary alveolar proteinosis: progress in the first 44 years. Am J Respir Crit Care Med. 2002, 166: 215-235], also occurs with exogenous allergic alveolitis, pulmonary adenocarcinoma, pneumocystis pneumonia and others. In this regard, to confirm the presence of diseases accompanied by the accumulation of protein and lipid substances in the alveoli, additional diagnostic methods, such as lung tissue biopsy, are required.

The objective of this invention was to create a method that allows you to more efficiently detect the presence of diseases accompanied by the accumulation of protein and lipid substances in the alveoli, as well as in some cases (with alveolar proteinosis) to confirm the diagnosis without biopsy of the lung tissue.

This problem is solved by first performing CTEC and then CLEM of the respiratory tract in all accessible segments and sub-segments of the lungs on both sides using a mini-probe with a laser beam with a wavelength of 488 nm and estimating the number of floating intraalveolar protein and lipid substances on a 5-point scale, where 0 points means the absence of a sign, and 5 points - maximum severity, and the subsequent simultaneous conduct of KLEM and CTEC in two or more segments of the lung with changes detected in CTEC and in two or more lung segments - without change, according to HRCT, when stepping playback (step every 0.5-1 mm) the totality of the selected scans of the chest.

The proposed method is as follows. At the first stage, the patient undergoes primary CTEC, according to the results of which it can be assumed that there is a lung disease, accompanied by the accumulation of protein and / or lipid substances in the alveoli. At the second stage, such a patient undergoes endoscopic examination using KLEM. Airway KLEM is performed under local or general anesthesia using a standard flexible bronchoscope through which a mini-probe is carried out through the instrument channel. For KLEM, a mini-probe with a laser beam with a wavelength of 488 nm is used, which excites the natural fluorescence of the structures of the distal airways, allowing real-time video recording. The mini-probe is carried out in the distal direction until the alveolar passages and sacs are visualized. All available lung segments and sub-segments on both sides are analyzed. The number of floating intraalveolar protein and lipid substances is estimated on a 5-point scale, where 0 points mean the absence of a sign, and 5 points mean maximum severity. The total number of segments and sub-segments in which fluorescent intraluminal complexes are determined is calculated, and their number is scored. The third and most important stage of the examination is the simultaneous use of KLEM and CTEC in the examination of four (two with changes and two without changes) or more known areas of the lungs. The number of the latter should be as small as possible, due to compliance with the principles of safe examination with moderate radiation exposure. First, a mini-probe is inserted through the instrument channel of the endoscope to visualize the alveolar passages and endomicroscopic images of the distal airways are recorded, during which selective scanning of the selected lung section using CTEC is performed. As a result of the simultaneous use of KLEM and CTEC in the lung area without changes on the CT scan, the presence of protein-lipid substances with a severity of 1-4 points was established, while in the lung zone with characteristic CTEC symptoms for these diseases, the expression of protein-lipid substances was 4-5 points . Thus, the simultaneous use of KLEM and CTEC not only confirms the diagnosis of a disease characterized by accumulation of protein and / or lipid substances in the alveoli, but, providing double control of the methods, allows comprehensively assessing the severity of the pathological process in two (or more if necessary) pulmonary segments.

The invention is illustrated by the following figures:

Figure 1. KLEM in vivo in a patient with accumulation in the lumen of the alveoli of the protein-fat substance before (A) and 2 days after (B) lavage of the whole lung.

Figure 2. Semi-quantitative assessment of the number of floating intra-alveolar complexes: A - no complexes (0 points), B - single complexes (1 point), C - less than half of the field of view is filled (2 points), D - half of the field of view is filled (3 points) , E - more than half of the field of view is filled (4 points), F - field of view is completely filled (5 points).

Figure 3. Correspondence between CTEC and CLEM images. The last scan (A) of the 8th segment on the right, where the mini-probe (arrow) is still visible and the first next 1-mm scan without a mini-probe (arrow) (B), showing typical CTVR symptoms for a disease accompanied by the accumulation of protein-lipid substances in the lumen of the alveoli. KLEM (C) shows a large number of floating floating alveolar complexes (2-5 points on a rating scale).

Figure 4. Correspondence between CTEC and CLEM images. The last scan (A) of the 4th segment on the right, where the mini-probe (arrow) is still visible and the first next 1-mm scan without a mini-probe (arrow) (B), showing the absence of CTEC symptoms of the disease. KLEM (C) shows floating intraalveolar complexes against the background of a preserved alveolar structure, less pronounced (0-3 points on an assessment scale) than in the presence of CTEC signs of pathology.

The invention is illustrated by the following clinical example.

Example

Patient G., 34 years old, in 2012 was admitted for examination and treatment for progressive dyspnea during physical exertion and productive cough. Smoking experience 27 pack-years.

First of all, chest CTVR was performed, in which a focal lesion of the lung parenchyma was revealed in the form of radiological symptoms of “frosted glass” and “cobblestone bridge” with primary localization in the 2nd, 3rd, 5th, 8th and 9th segments on the right and in the 4th, 5th, 6th and 10th segments on the left. The 4th, 6th and 10th segments on the right and the 8th and 9th segments on the left were completely free from changes. The remaining pulmonary segments were partially affected.

Then, distal airway CLEM was performed (alveoscopy) under local anesthesia with lidocaine at the end of routine bronchoscopy using a flexible bronchoscope with a diameter of 5.9 mm (EB-530T model; Fujinon, Japan). To study the bronchopulmonary system, the Alveoflex mini-probe of the Cellvizio apparatus (Mauna Kea Technologies, France) with a diameter of 1.4 mm is used, the resolution of which is 3.5 μm, the diameter of the optical field is 600 μm, the depth of study is 0-50 μm, with fixation 12 images per second. A mini-probe was inserted into the instrumental channel of the bronchoscope, carefully guided forward to visualize the alveolar sacs and passages. All available segments and sub-segments of both lungs were sequentially analyzed. The video sequence was analyzed using the system software (Cellvizio viewer, version 1.6.0; Mauna Kea Technologies).

Further, KLEM was performed simultaneously with chest CTVR, which made it possible to determine the position of the distal end of the mini-probe at each moment of the study. CTEC images, confirming the positioning of the mini-probe during the KLEM study in the area of pathological changes, were performed for two pulmonary segments with changes revealed by CTEC, which were diffuse areas of “frosted glass” with thickening of the interlobular septa in the form of a “cobblestone bridge”. These were the 8th segment on the right and the 6th segment on the left. The 4th segment on the right and the 9th segment on the left were taken as segments with the parenchyma unchanged during CTEC. The following protocol was used: the patient is lying on his back; the thickness of the sections was 0.5-1 mm; the principle of selective (cluster) scanning of zones of interest was used to reduce radiation exposure; scanning was carried out at the end of a deep breath. In order to exclude the possibility of taking any anatomical structure (for example, a vessel) for the probe tip, the principle of tracking a mini probe on a series of successive scans with a measurement of its density was applied. Due to the metal content in the probe tip, it is about 3000 HU, so that the distal part of the mini-probe can be easily distinguished from lung structures.

The number of floating intraalveolar protein and lipid substances was evaluated using a 5-point scale, where 0 points mean the absence of a sign, and 5 points mean maximum severity. Figure 2 reflects a semi-quantitative estimate of the number of floating intraalveolar complexes: A - no complexes (0 points), B - single complexes (1 point), C - less than half the field of view (2 points), D - half the field of view (3 points) , E - more than half of the field of view is filled (4 points), F - field of view is completely filled (5 points).

The results of the KLEM examination showed the presence in the distal airways of the patient in 18 of the 20 alveolar regions (10 segments on each side) of pathological changes. In 15 of them, fluorescent intra-alveolar complexes were visualized (3-5 points according to the previous scale) against the background of unchanged alveolar structures, in the rest - clusters of alveolar macrophages glued together by a moderately fluorescent liquid (1-3 points) or moderately fluorescent liquid (1 point ) without any additional elements. In addition, a similar fluid that is not found in CLEM of the normal distal airways was noted not only in the lumen of the alveoli, but also in the distal bronchioles. No changes were detected in 2 of the 20 alveolar regions; only single alveolar macrophages (0 points) were recorded on alveoscopic images, which, as you know, are well visualized by CLEAM in current and former smokers due to the accumulation of tobacco tar in them.

Figure 3 illustrates the results obtained using the survey method with the simultaneous use of KLEM and CTEC. The last scan (A) of the 8th pulmonary segment on the right, where the mini-probe (arrow) is still visible, and the first next 1-mm scan without a mini-probe (arrow) (B) show the position of the probe and typical CTVR symptoms for the disease, accompanied by the accumulation of protein-lipid substances in the lumen of the alveoli. KLEM (C) shows a large number of floating floating alveolar complexes (2-5 points on an assessment scale) in the same pulmonary segment.

Figure 4 reflects the presence of floating intraalveolar complexes in the 4th pulmonary segment on the right, where there are no symptoms of the disease on CTEC, while the changes according to CLEM are less pronounced (0-3 points on the rating scale) than in segments with CTEC signs of pathology.

According to a survey with the simultaneous use of KLEM and CTEC, the patient was diagnosed with autoimmune alveolar proteinosis. A pulmonary tissue biopsy was performed to confirm the diagnosis.

A patient underwent bilateral total brochoalveolar lavage for therapeutic purposes. The tactics of conducting therapeutic bronchoalveolar lavage (total rather than segmental lavage of the lung) were selected on the basis of the detection of changes characteristic of alveolar proteinosis in 18 of the 20 alveolar regions, in 75% of which fluorescent intraalveolar complexes were visualized on each side (3-5 points according to the previously given scale). On the 2nd day after lavage, the patient was examined according to the method described above. A significant (up to 0–2 points) decrease in the number of floating intraalveolar fluorescence complexes was found in 73% of the alveolar regions filled with them before treatment, when comparing identical zones. Figure 1 reflects the results of in vivo CLEM in a patient with accumulation of protein-fat substance in the lumen of the alveoli before and 2 days after lavage of the whole lung.

Thus, the proposed method allows to obtain a more accurate picture of diseases accompanied by the accumulation of protein and lipid substances in the alveoli, as well as confirm the diagnosis without biopsy of the lung tissue.

Claims (1)

A method for the study of lungs in diseases accompanied by the accumulation of protein and / or lipid substances in the alveoli, including high-resolution computed tomography (CTEC) of the lungs and identification of segments with changes in the lung parenchyma and without changes, characterized in that they additionally carry out confocal laser endomicroscopy (CLEM) airways using a mini-probe with a laser beam with a wavelength of 488 nm, detecting the presence of protein and / or lipid substances, and KLEM is carried out simultaneously with repeated K BP 0.5-1 mm increments with two segments and two changes in parenchymal segments unchanged data originally held HRCT.

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