RU2599349C1 - Method for prediction of progression of chronic obstructive pulmonary disease (copd) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to diagnostics, and can be used for prediction of progression of COPD. Forced expiratory volume is measured for 1 second in %. Amount of CD8⁺ soluble membrane antigen molecules is determined by formula. If the amount of CD8⁺ soluble membrane antigen molecules is less than 351 unfavourable progressive course of COPD is determined.

EFFECT: method allows to reduce the time of examination, simplify the method for estimating the patient state and provide the possibility of express diagnostics due to determination of amount of CD8⁺ soluble membrane antigen molecules by formula.

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Description

            The present invention relates to medicine, namely to diagnosis, as well as to the study of biological fluids using physical and chemical methods and can be used in pulmonology to predict the adverse course of chronic obstructive pulmonary disease (COPD) and timely adjustment of treatment.

Leading pulmonologists of the world talk about the relevance of this topic. Already today there are 210 million patients with COPD in the world, and this figure is constantly increasing. At present, COPD is the fourth leading cause of death in the world. If you do not pay the closest attention to the prevention and treatment of the disease, then, according to WHO forecasts, by 2020, COPD may take third place in this sad list. Russia is no exception to global statistics. In our country, the problem of COPD is particularly acute, due to the widespread smoking, adverse environmental conditions, climatic factors and untimely diagnosis of the disease. So, already in 2007, 2.4 million patients with diagnosed COPD were registered in Russia. In total, it is estimated that COPD affects about 11 million people - almost 10% of the population. Such a noticeable difference in numbers is explained by the fact that, as a rule, the disease is diagnosed in the late stages, when the steadily progressing pathological process is no longer treatable. This explains the high mortality among patients. Moreover, this trend is characteristic not only for Russia. According to the European Respiratory Society, only 25% of cases are diagnosed in a timely manner. Mortality among patients with COPD after discharge from hospital is 43% for one year and 49% for two years.

The strategy and tactics of managing a patient with COPD is determined by the clinical situation, including numerous factors, the consideration of which is necessary for the rational management of the patient and involves the use of both drug and non-drug methods. Early diagnosis of COPD is extremely difficult, since this pathology is characterized by slow progression and a long asymptomatic period. In a situation where a typical clinical picture develops, indicating that the patient has irreversible changes in the bronchopulmonary apparatus, the diagnosis of COPD is reduced to determining changes in the function of external respiration, the presence or absence of an inflammatory component, as well as conducting stress tests. Thus, at present, the issues of diagnosis and prognosis for COPD are among the most relevant.

The well-known "Method for predicting the course of non-specific lung diseases" (US Pat. RU No. 2121675 from 10.11.1998). Examine bronchial secretions and / or sputum using microbiological methods. The number of conditionally pathogenic bacteria, pathogenic bacteria and fungi of the genus Candida is determined, evaluating each indicator in points. With a score of 0-2, remission of non-specific lung diseases is predicted, with 3-5, pneumonia worsens with a favorable course, with 6-8 points - chronic pneumonia with bronchiectasis and abscess formation, or chronic pneumonia with a unfavorable course, with 9-12 points - severe immunodeficiency and the presence of malignant neoplasms in the lungs.

According to the authors, the known method increases the possibility and accuracy of predicting the course of inflammatory lung diseases.

The disadvantages of this method include the need to examine the bronchial secret obtained by bronchoscopy, which is a complex expensive procedure, traumatic for the patient, requiring special preparation and finding the patient in a hospital.

For the prototype of the invention, a well-known method for predicting the progression of chronic obstructive pulmonary disease (COPD) is selected, including measuring the volume of forced expiration in 1 s (FEV1,%). (Marina Saetta et all CD8 + T-Lymphocytes in Peripheral Airways of Smokers with Chronic Obstructive Pulmonary Disease / American Journal of Respiratory and Critical Care Medicine, Vol. 157, (1998), p. 822-826)

The known method includes:

- determination of FEV1 for 1 s (in individuals with FEV1 <80% of the due, a bronchodilation test was performed - repeated examination of FEV1 15 minutes after inhalation of 200 μg of salbutamol),

- determination of forced vital capacity of the lungs (FVC),

- histological, morphometric and immunohistochemical analyzes of the surgical material (peripheral airways) obtained from 16 smokers who underwent lung resection for localized cancer. Nine of the examined patients had symptoms of chronic bronchitis and chronic limitation of air flow rate, seven - asymptomatic course with normal lung function. In this case, the morphometric analysis included the measurement of the internal diameter and size of the wall of the respiratory tract and the area of smooth muscles. In the peripheral airways obtained by resection of the lungs, the content of neutrophils, macrophages, CD4 + and CD8 +, T-lymphocytes infiltrating the wall of the airways was evaluated.

The number of CD8 + T-lymphocytes and the volume of smooth muscles were increased in smokers with symptoms of chronic bronchitis and chronic bronchial obstruction compared with asymptomatic smokers with normal lung function, while the number of neutrophils, macrophages and CD4 + T-lymphocytes were the same in both groups of subjects persons.

The authors of the study concluded that smokers who develop symptoms of chronic bronchitis and chronic airflow restriction have an increased number of CD8 + T cells and a smooth muscle area in the peripheral airways compared with asymptomatic smokers with normal lung function, which , according to the authors of the prototype method, indicates the important role of CD8 + T-lymphocytes and remodeling of the respiratory tract in the pathogenesis of chronic obstructive pulmonary disease.

However, the known method was developed for research purposes to study whether the inflammatory process in the peripheral airways of smokers who develop symptoms of chronic bronchitis and chronic airflow restriction is different from asymptomatic smokers who do not develop a chronic restriction of airflow rate. The method is based on the study of lung tissue obtained during surgery for lung cancer, which makes it impossible for its widespread use in clinical practice, since it requires surgical intervention. The authors of the present invention came to the conclusion that excessive secretion of CD8 ^{+ by} T-lymphocytes can occur in response to repeated viral infections, which makes the known method insufficiently accurate. It should be noted that for this category of patients the prediction of COPD is not significant, since their life prognosis is subsequently determined by the course of oncopathology.

The disadvantages of the prototype method include the following:

- invasive (surgical) receiving the test material, which is inaccessible in clinical practice and traumatic for the patient,

- insufficient accuracy of the forecast, since the study of CD8 ⁺ was conducted in patients operated on for lung tumors,

- for this category of patients, the course of the underlying disease (oncopathology), and not chronic obstructive pulmonary disease, is significant

- the implementation of the method takes a lot of time and does not provide the possibility of express prediction of severe turning of COPD, as well as to carry out the correction of the treatment

The task of the invention is to provide a method for predicting the progression of chronic obstructive pulmonary disease, devoid of the disadvantages of the prototype.

The technical result of the proposed method is to increase the accuracy of prediction of COPD progression, the exclusion of invasive intervention, providing the possibility of express prediction of severe COPD, reducing the time of the study. The method is non-invasive, since the content of soluble molecules of the membrane antigen CD8 ^{+ is} carried out without blood sampling from the patient only on the basis of FEV1 data, which greatly simplifies and cheapens the cost of the study. The method can be used as a screening for predicting the progression of COPD to optimize treatment. The application of the method facilitates a control study of the value of soluble molecules of the membrane antigen CD8 ⁺ during treatment, having only repeated studies of FEV1, which also allows you to control the effectiveness of immunomodulating therapy.

The technical result is achieved by the fact that in the known method for predicting the progression of chronic obstructive pulmonary disease (COPD), including measuring the volume of forced expiration in 1 s (AF1,%), the content of soluble molecules of the membrane antigen CD8 ^{+ is} determined by the formula:

the content of soluble molecules of the membrane antigen CD8 ⁺ = a + b * FEV1:

where a is a constant equal to 231.94;

b - non-standardized coefficient equal to 2,0012,

and when the content of soluble molecules of the membrane antigen CD8 ^{+ is} less than 351, an unfavorable progressive course of COPD is determined.

The present invention meets the criterion of "novelty", since when conducting patent information research, no sources were found that discredited the novelty of the proposed method.

The present invention meets the criterion of "inventive step", as in the available scientific, medical and patent literature there are no technical solutions with essential features of the proposed method.

Today it is known that immunocompetent cells involved in chronic inflammation in COPD carry membrane antigens on their surface that characterize the direction of their differentiation (Mail D. Immunology: Transl. From English / - M .: Logosphere, 2007. - 568 from.). Differentiation molecules can have soluble forms that are found in blood serum, and on the one hand reflect the level of membrane expression of antigen, on the other hand, they are capable of modulating the immune response (Novikov V.V. Soluble forms of membrane proteins of cells of the immune system / V.V. Novikov , A.V. Karaulov, A.Yu. Baryshnikov. - M: MIA, 2008 .-- 249 p.). A CD8 ⁺ molecule is present on the membrane of cytotoxic T lymphocytes and part of natural killer cells. This antigen is a co-receptor of the T-cell receptor and provides recognition of antigens presented with the participation of class I HLA molecules. On the one hand, soluble CD8 ^{+ is} produced by activated cytotoxic T cells and serves as a marker for their activation. On the other hand, interacting with HLA I, sCD8 ⁺ inhibits the cytotoxic effect of cells, inhibits their activation and proliferation, which makes it possible to consider soluble CDS ^{+ as an} immune response suppressor (Meseguer, M.A. Microbiological diagnosis of bacterial lower respiratory tract infections / MA Meseguer [et al.] // Enferm Infecc Microbiol Clin. - 2008 (Aug-Sep.). - Vol. 26, N 7. - P. 430-6; Morgan, CL Soluble CD8 stabilizes the HLA class I molecule by promoting beta2M exchange: analysis in real-time / CL Morgan [et al] // Hum Immunol. - 1999 (May). - Vol. 60, N 5. - P. 442-9).

Histopathological studies have shown an increase in the content of T-lymphocytes, especially CD8 ⁺ cells (cytotoxic) in all parts of the lungs with COPD. In the studies of domestic authors, an increase in CD8 ⁺ cells in the induced sputum of patients with COPD was found in direct proportion to the severity of the disease.

In the available literature, we have not found methods for predicting the progression of COPD, based on the study of the content of a soluble molecule of the membrane antigen CD8 ⁺ , obtained indirectly, without immunological studies, based on the data of forced expiratory volume for 1 sec.

There is evidence of close correlations between the serum CD8 ⁺ content and the FEV1 value (Pazych S.A. Markers of activation and cell death of induced sputum in bronchial asthma and chronic obstructive pulmonary disease: abstract of dissertation ... candidate of medical sciences: 14.00. 43 / Svetlana Anatolyevna Pazych. - Vladivostok, 2005 .- 23 p.).

The method is as follows.

When a patient is admitted to the hospital after a standard clinical examination of the patient, an FVD study is conducted with measurement of forced expiratory volume for 1 s (FEV1,%). Next, determine the content of soluble molecules of the membrane antigen CD8 ⁺ by the formula:

the content of soluble molecules of the membrane antigen CD8 ⁺ = a + b * FEV1:

where a is a constant equal to 231.94;

b - non-standardized coefficient equal to 2,0012,

and when the value of the content of soluble molecules of the membrane antigen CD8 ⁺ less than 351 determine the unfavorable progressive course of COPD

The technical result of the invention is confirmed by clinical trials: 50 COPD patients in the acute stage were examined at the age of 35 to 79 years (average age 60 ± 10), of which 36 men (72%) and 14 women (28%). The duration of the disease in the examined patients ranged from 1 year to 40 years (15 [7; 20]), a history of smoking from 1 year to 66 years. During the examination, a complex of clinical-functional, laboratory and instrumental studies was used. The patient specified the duration of smoking and the frequency of exacerbation of the disease over a period of 12 months. When assessing the serum level of soluble differentiating molecules of the cells of the immune system, blood was taken from the cubital vein (in the morning on an empty stomach). Determination of the level of soluble forms of membrane molecules was carried out using enzyme immunoassay using polyclonal antibodies specific for membrane antigens of mononuclear cells of human blood and monoclonal antibodies (MCA) of the ICO series. The concentration of soluble forms of membrane antigens was determined using an STAT-FAX-2100 enzyme-linked immunosorbent assay device with a wavelength of 450 and 630 nm, the data obtained were expressed in arbitrary units (U / ml). When assessing the serum level of soluble differentiating molecules of the cells of the immune system, the blood serum samples of patients were compared with the results of the examination of the control group, which included 30 healthy donors, the control group, persons without COPD, comparable in gender and age.

The study of the function of external respiration was carried out using a pneumotachometric sensor that records the volumetric rate of air flow. The subsequent automatic computer analysis of the inspiratory and expiratory parts of the flow-volume loop was performed using the Flow screen apparatus (JAEGER, Germany). The proper values were calculated automatically taking into account the gender, age, height and weight of each patient. The following indicators were evaluated: vital lung capacity (VC); forced expiratory volume in 1 second (FEV1); maximum expiratory flow at the level of 50% and 25% FVC (MOS 50 and MOS 25), reflecting patency at the level of medium and small bronchi. Indicators were considered reduced if their value was less than 80% of the proper value. The results are entered in Excel spreadsheets.

Statistical analysis was performed using the program "STATISTICA 6.0". The nature of the data distribution was evaluated by the Kolmogorov-Smirnov and Shapiro-Wilks criteria. If the distribution of the attribute was assumed to be approximately normal, the results were presented in the form M ± σ, where M is the average; σ is the standard deviation; for the analysis, parametric criteria were used. When the distribution of the results was different from normal, the data were provided in the form of a median and 25 and 75 percentiles (Me [25p; 75p]), the analysis was carried out using nonparametric statistics methods. To assess the analytical dependence of signs (models), the method of simple regression analysis was used. The value of p <0.05 was taken as the level of statistical significance. (Rebrova O.Yu. Statistical analysis of medical data. Application of the STATISTICA application package / O.Yu. Rebrova. - M .: MediaSfera, 2006. - 312 p.).

When examining the function of external respiration in patients with COPD, bronchial obstruction was revealed: moderately severe in moderate and severe in severe disease (table 1).

During the study, the authors of the present invention studied the serum content of the soluble form of sCD8 ⁺ depending on the severity of the COPD, determined taking into account the "Global" strategy for the diagnosis, treatment and prevention of chronic obstructive pulmonary disease (2008 revision) / Per. from English under the editorship of Belevsky A.S. - M.: Atmosphere Publishing Holding, 2009. - 100 p. (table 2).

As can be seen from table 2, the content of the tested molecules at different stages of COPD did not differ, but significant differences were obtained compared with the control group.

A more detailed analysis of the data obtained in patients with COPD revealed fluctuations in the serum level of soluble membrane molecules: in 40% of patients, the indicators were increased or tended to increase (1 subgroup), in 60% (2 subgroup), they were significantly reduced in comparison with donors ( table 3).

A reduced level of the soluble CD membrane antigen molecule of ⁸ patients with COPD 2 subgroups may reflect a decrease in the membrane expression of these molecules and inhibition of the cytotoxic immunity, while patients of subgroup 1 tended to increase the soluble sCD8 ⁺ molecule, which indicates the activation of cytotoxic sCD8 ⁺ cells in this category sick.

A direct correlation was found between bronchial patency (FEV1) and the content of soluble CD8 ⁺ membrane antigen molecules (r = 0.57, p = 0.03).

Based on a simple linear regression analysis (statistica 6.0 program), we established not only the fact of the relationship between FEV1 and CD8 ⁺ , but also an analytical relationship between FEV1 and the level of soluble molecules of the CD8 ⁺ membrane antigen. The analytical equation was presented as:

soluble molecules of the membrane antigen CD8 ⁺ = a + b * FEV1 (in% of the proper values):

where CD8 ⁺ is the level of the soluble molecule of the membrane antigen CD8 ⁺ ;

a is a constant reflecting the degree of deviation of the regression line from the origin (standard error = 39.18, p = 0.00001);

b - non-standardized coefficient b (standard error = 0.54, p = 0.001), which is a measure of the relationship between the analyzed characters and shows the degree of variation between the average values of the dependent trait (sCD8 ⁺ ) with each unit of the independent trait (FEV1).

FEV1 - forced expiratory volume for 1 sec (% of the required values)

a = 231.94, b = 2.0012

sCD8 ⁺ = 231.94 + 2.0012 × FEV1%.

The standard error of model estimation was 64.49 at p = 0.002, which testified to the adequacy of this analytical model.

The data obtained by us on the relationship between the two signs allows, in practice, taking into account the FEV1 value, to determine the level of soluble sCD8 ⁺ membrane antigen molecule level, a reduced level of which indicates an increase in the severity and progression of COPD.

Examples of specific performance are given in the form of extracts from medical records.

Clinical example 1: patient T., 68 years old, was sent to the pulmonology department of hospital No. 10. Diagnosis at admission: Chronic obstructive pulmonary disease of the III degree, severe course, phenotope with frequent exacerbations, in the phase of exacerbation, DN II Art. IHD: stable angina pectoris II KFK, NK I. Hypertension III tbsp. AH degree 2 risk 4. Upon receipt of a complaint of shortness of breath with slight exertion and at rest, cough with hard-to-distinguish sputum of yellow-green color, fever up to 38.0 ° С. From the anamnesis it is known that he suffers from chronic bronchitis for about 30 years. The smoking index is 40 packs / year. Inpatient treatment for exacerbations 2 times a year.

Outpatient receives "Seritid" 250/25 mcg in 1 breath - 2 ing. 2 times a day, "Spiriva" 18 mcg 1 ing. day, "Berodual" - as needed, theopec 300 mg 2 times a day, veropamil at a dose of 80 mg 3 times a day. Deterioration of about 10 days, due to the inefficiency of outpatient treatment sent to the hospital. Objectively: the patient’s state of moderate severity, proper physique, increased nutrition, cyanosis of the lips, face, barrel-shaped chest, percussion sound box, in the lungs in all fields a large amount of dry rales, BH 25 per min. Heart sounds are muffled, rhythmic heart rate - 98 beats. min, BP 150/90 mm Hg The abdomen is soft, painless. No swelling.

OAK, OAM without features.

General sputum analysis - white blood cells 25-60 in the s / s; on a chest x-ray without focal and infiltrative changes. Microbiological analysis of sputum revealed 2 cultures of microorganisms: M. catharralis 3 × 10 ² CFU / ml, N. influenzae 2 × 10 ⁶ CFU / ml.

ECG: EOS deviation to the left, sinus tachycardia 96 beats. in min, focal blockade of PNPG, violation of the processes of myocardial repolarization. In the study of FVD: VC - 55.2%, FVC - 77.3%, FEV1 - 37.6% of the due.

Based on the data of the HPF, in order to assess the prognosis of COPD progression, the immune status was assessed. For this, the content of soluble molecules of the membrane antigen CD8 ^{+ was} determined using the proposed formula sCD8 ⁺ = 231.94 + 2.0012 × 37.6%, CD8 ⁺ = 306.54, which is lower than 351, which indicated the depletion of the pool of cytotoxic cells, the progressing adverse course of COPD, the need for immunomodulating therapy.

Against the background of the treatment, positive dynamics were noted, shortness of breath, cough, the amount of sputum being separated decreased, the temperature returned to normal. Objectively: in the lungs, dry scattered rales on all pulmonary fields of BH 20 per min. Heart rate - 90 beats. in minutes, blood pressure - 140/90 mm RT. During the control study, FEV1 increased to 48%, and an increase in sCD8 ⁺ = 327 was also observed.

At discharge, the patient, along with standard bronchodilator and anti-inflammatory therapy, is recommended to take immunomodulating drugs.

Clinical example 2: Patient S., 72, was sent to the pulmonology department of hospital No. 10. Diagnosis at admission: Chronic obstructive pulmonary disease of the II degree, moderate course, in the acute phase, NAM II Art. IHD: stable angina pectoris II KFK, NK I. On admission: complaints of increased cough with sputum, shortness of breath during physical exertion. From the anamnesis it is known that he suffers from chronic bronchitis for about 20 years. The smoking index is 20 packs / year. Exacerbations not more than 1 time per year, the last exacerbation - 2 years ago (treated stationary).

Ambulatory episodically takes fluimucil (with increased cough), with difficulty breathing - "Berodual" - up to 2-3 inhalations per day. Deterioration of about 1 month; due to the inefficiency of outpatient treatment sent to the hospital. Objectively: the patient’s state of moderate severity, proper physique, moderate nutrition, percussion sound above the lungs is boxed, in the lungs there is a moderate amount of dry dispersed rales, RR 21 per min. Heart sounds are muffled, rhythmic heart rate - 72 beats. in min, single extrasystoles HELL 130/90 mm Hg The abdomen is soft, painless. No swelling.

OAK, OAM without features

General sputum analysis - white blood cells 20-30 in the s / s; on a chest x-ray without focal and infiltrative changes. Microbiological analysis of sputum revealed 1 culture of microorganisms: M. catharralis 5 × 10 ² CFU.

ECG: EOS is normal, sinus rhythm is 96 beats. in minutes

FVD: ZHEL-70%, FEV1 - 65.3% of the due.

Based on the HPF data, the content of soluble molecules of the membrane antigen sCD8 ⁺ - sCD8 ⁺ = 231.94 + 2.0012 × 65.3%, sCD8 ⁺ = 362.6 was determined, which indicated a relatively favorable course of COPD.

Against the background of the treatment, positive dynamics were noted, shortness of breath, cough decreased. During the control study, FEV 1 increased to 69.2%, an increase in sCD8 ⁺ = 370.4 was also observed.

At discharge, the patient, along with standard bronchodilator and anti-inflammatory therapy, is recommended to take immunomodulating drugs.

Claims (1)

A method for predicting the progression of chronic obstructive pulmonary disease (COPD), including measuring the volume of forced expiration for 1 s (FEV1,%), characterized in that the content of soluble molecules of the membrane antigen CD8 ^{+ is} determined by the formula:
soluble molecules of the membrane antigen CD8 ⁺ = a + b * FEV1,
where a is a constant equal to 231.94;
b - non-standardized coefficient equal to 2,0012,
and when the content of soluble molecules of the membrane antigen CD8 ^{+ is} less than 351, an unfavorable progressive course of chronic obstructive pulmonary disease is determined.

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