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Year : 2015 | Volume : 3 | Issue : 2 | Page : 116 - 120  


Original Articles
A study of Pulmonary Function Tests in type II Diabetes Mellitus

1Vinayak Shegokar, 2Shalini P Agrawal, 3Prashant R Kokiwar

1Professor & HOD of Medicine, C.M. Medical College, Kachandur, Durg (Chattishgarh State)

2 Physician, Siddhivinayak Eye & Health Clinic, Gorakhpur, (UP)

3Professor & HOD of Community Medicine, Malla Reddy Institute of Medical Sciences, Hyderabad (Telangana)

Corresponding Author:

Dr. Vinayak Shegokar

Email: drvshegokar@rediffmail.com

Abstract:

Background: The fact that DM affects the microcirculation was recognized over a century ago but the concept that there might be a specific angiopathy underlying many of the late complications of diabetes was not known till the survey of Lundback.

Objectives: This study was undertaken to find out the effects of type II DM on pulmonary functions and whether these effects have a correlation with the diabetic status of the patients as well as the presence of other microvascular complications.

Methods: The present study was cross sectional, observation study. 70 patients were screened as per the protocol of the study. The obtained data was analyzed by chi square test and one way Analysis of variance (ANOVA) test and independent sample t-test. For all statistical comparisions, P value < 0.05 was considered statistically significant.

Results: The mean age of the study population was 55.39+11.39 years. 40% were found to have more than one microvascular complications. Retinal complication was the most common (18.57%) neural was found in 8.57% and renal was the least common (7.14%) . 51.4% had a normal PFT pattern. Of those having an abnormal PFT most (21.4%) were found to have a restrictive pattern. Out of the 36 patients who had normal PFT, 15 (41.67%) had no associated microvascular complication. there is significant association between the duration of diabetes and decline in pulmonary function parameters (p value=0.0299).

Conclusion: Patients of Type II diabetes were prone to decline in lung function and restrictive pulmonary pattern. Decline in pulmonary function is more in the presence of other microvascular complications.

Key words: Pulmonary Funciton Test, Diabetes, Microvascular Complicaitons

INTRODUCTION:

Diabetes mellitus refers to a group of common metabolic disorders that share the phenotype of hyperglycemia. It is a heterogeneous disorder caused by complex interaction of genetics, environmental factors and lifestyle choices. 1 The term diabetes mellitus, literally meaning, ‘a flow of sweetness’ was coined to indicate the presence of sugar in urine. 2

The fact that DM affects the microcirculation was recognized over a century ago 3 but the concept that there might be a specific angiopathy underlying many of the late complications of diabetes was not known till the survey of Lundback. 4

A ‘Triopathy’ of retinal damage, renal disease and neuropathy was recognized which has subsequently been broadened to the generic term microangiopathy with the observation that numerous microvascular beds are influenced by the diabetic process including those of the heart, 5 skin, 6 subcutaneous fat, 7 muscle, 8 lungs and nerve. 9

Several groups have expounded a haemodynamic hypothesis of diabetic microangipathy. 10 – 12 According to the hypotheis early in the disease process increased microvascular flow and pressure occurs which leads to microvascular sclerosis with ultimate limitation of perfusion and loss of autoregulation.

This study was undertaken to find out the effects of type II DM on pulmonary functions and whether these effects have a correlation with the diabetic status of the patients as well as the presence of other microvascular complications.

MATERIAL AND METHODS

The present study “A study of pulmonary” Function Tests in Type II Diabetes Mellitus” was conducted from 1st February 2007 to 30th Nov. 2008.

The study was approved by the Institutional Ethics committee of the Institution.

Type of study: Cross-Sectional, observation study.

Study group: 70 patients of type II DM on regular treatment for diabetes.

Methodology

250 patients of diabetes mellitus, on oral hypoglycemic agents, who were not on insulin therapy, registered in diabetes OPD and on regular follow up were examined. Out of these, 70 were found to meet the inclusion criteria and enrolled. Written, informed and witnessed consent was taken from the enrolled participants for their willingness to participate in the study.

Inclusion and exclusion criteria:

Inclusion criteria:

Patients of type II DM not on regular insulin therapy

Type II DM as defined by the American Diabetic Association (ADA) criteria for diagnosis of DM 2004 –

  • Symptoms of DM plus random blood glucose concentration

≥1.1 mmol/L (200 mg/dl) or

  • Fasting plasma glucose ≥7.0 mmol/L (126 mg/dl) or
  • Two hour plasma glucose ≥11.1 mmol/L (200 mg/dl) during an oral glucose tolerance test.

Exclusion criteria:

  1. Smoking, consumption of alcohol/drugs acting on CNS
  2. Suffering from COPD, asthma or cardiovascular diseases
  3. Past history of significant respiratory illnesses e.g. Pulmonary tuberculosis (PTB), cystic fibrosis, necrotizing pneumonia
  4. Evidence of pleural or parenchymal lung disease on clinical examination or chest roentgenogram
  5. Ascitis
  6. Gestational diabetes, pregnant and lactating women
  7. Evidence of ischaemic heart disease and cerebrovascular illness
  8. Recent acute illness requiring treatment for more than five days on outpatient basis, hospitalization in past six months
  9. Occupation with known respiratory hazards
  10. known allergies
  11. Chest wall or neuro-muscular abnormalities
  12. Claustrophobia
  13. Severe anemia

Procedure:

  1. To screen for the above criteria, the following method was adopted.
  2. History of respiratory illness or recent illness
  3. Clinical examinations for chest wall or bony cage abnormalities, anemia, cardiac failure, respiratory infection, cardiovascular events.
  4. Baseline electrocardiography to rule out cardiac illness.
  5. Chest roentgenography to rule out any major pleural or parenchymal lung pathologies.
  6. These patients then underwent retinal examination by an ophthalmologist, renal function test (blood urea nitrogen and serum creatinine) in the institution’s Biochemistry laboratory and urine albumin testing by dipstick method. Patients were enquired for the symptomatology and clinically examined for peripheral neuropathy. Their HbA1c level was measured from a standard laboratory by high performance liquid chromatography (HPLC) method.
  7. Patients were then subjected to pulmonary function testing in the institution’s department of chest and Tuberculosis (TB), in the OPD. Pulmonary function testing was done in standing position, at room temperature and at the same altitude for all patients. The test was done using a SPIROLAB II portable spirometer. FEV1 FVC and their ratio as well as forced expiratory flow rates at 25%, 50% and 75% of expiration were measured. The test was repeated thrice to ensure reproducibility and repeatability and patients were encouraged to use maximal force.
  8. Their pulmonary function parameters were then observed for the type of pattern using the guidelines of American Thoracic Society- European Respiratory society (ATS-ERS) 1986 for assigning the type of pattern to each patient.
  9. Correlation was drawn with regards to their diabetes status, duration of DM and existence of other known microvascular complications of DM in the patients.

The obtained data was analyzed by chi square test and one way Analysis of variance (ANOVA) test and independent sample t-test. For all statistical comparisions, P value < 0.05 was considered statistically significant.

RESULTS:

70 patients were studied of which of 40 were women (57.14%) Most of these patients (64.29%) belonged to the age group of 40-60 years. 8.51% of the patients were <40 Years and 27.14% were >60Years old.

The mean age of the study population was 55.39� 11.39 Years with a minimum age of 35 Years and maximum 82Years.

Table 1: distribution of microvascular complications, duration and status of DM in them:

Complication

No. of cases

Avg. Duration

of DM

HbA1c%

Retinal

13

7.27 Yrs

9.56

Renal

5

7.6 Yrs

10.16

Neural

6

13.4 Yrs

8.43

>1

28

10.75 Yrs

9.7

Nil

18

6.15 Yrs

9.2

P value=0.3461

70 patients were studied of which 28 (40%) were found to have more than one microvascular complications. Amongst isolated complications, retinal was the most common (18.57%) neural was found in 8.57% and renal was the least common (7.14%) . No microvascular complication was found in the remaining 25.71% patients.

The average duration of diabetes was found to be 9.339+5.756 Years with minimum duration of 1 year and maximum duration of 22 Years.

The average duration of diabetes was maximum in patients with isolated neural complication (13.4 Years) followed by those having more than one complication (10.75 Years). The duration was least in patients having no microvascular complication (6.15 Years).

Isolated renal microvascular complication was associated with poor control of diabetes while all the other categories showed a moderate control of diabetes.

However no significant correlation was noted between these parameters. P value (0.3461) was calculated using one way ANOVA test.

Table 2: Observed pulmonary function tests patterns:

Pulmonary Function Test Pattern

No. of cases

Normal

36.(51.4%)

Restrictive (R)

15(21.4%)

Obstructive (O)

8(11.4%)

R + O

11(15.7%)

Total

70(100%)

70 patients were studied of which most (51.4%) had a normal PFT pattern. Of those having an abnormal PFT most (21.4%) were found to have a restrictive pattern. 11.4% had an obstructive pattern and the remaining 15.7% had a mixed restrictive and obstructive pattern.

Table 3: Correlation of pulmonary function tests with duration of DM:

Pulmonary Function Test Pattern

Avg. duration of DM

Standard Deviation

Normal

9.42 Yrs

4.18

Restrictive (R)

8.33 Yrs

5.87

Obstructive (O)

10.21 Yrs

8.48

R + O

9.81 Yrs

8.13

P=0.87, F=0.23

This table shows that the association between duration of diabetes and observed PFT patterns was not significant (P value 0.87).

Table 4: Correlation of pulmonary function tests with microvascular complications of diabetes:

PFT

Retinal

Renal

Neural

>1

Nil

N

Normal

6

2

5

8

15

36

Restrictive (R

4

1

0

10

0

15

Obstructive (O)

0

0

1

5

2

8

R + O

3

2

0

4

1

11

N

13

5

6

28

14

70

P value=0.0108

Out of the 36 patients who had normal PFT, 15 (41.67%) had no associated microvascular complication.

Among the 15 patients who had a restructive PFT pattern, 66.67% had more than one associated microvascular complication. Retinal complication was the commonest among isolated complications.

8 patients showed an obstructive pattern and 62.5% of these were found to have more than one associated microvascular complication.

11 patients had a mixed restrictive and obstructive PFT and this group showed an even distribution of associated and no associated microvascular complications.

Using chi square test, significant correlation was found between the presence of microvascular complications and abnormal PFT (p value=0.0108).

Table 5: Correlation of duration of diabetes with FEV, FVC AND FEF 50%

Duration

Observations

FEV1 (in %)

FVC (in%)

FEF 50%

< 5 Years

16

75.88

71.94

66.81

5-10 Years

28

90.75

89.18

67.00

>10 Years

26

85.38

82.54

60.42

P value=0.0299, F=6.664

This table shows that there is significant association between the duration of diabetes and decline in pulmonary function parameters (p value=0.0299). However this association was less significant as compared with diabetic control and presence of microvascular complications. Moreover as seen in table no. the association is not strong enough to cause a specific pattern of abnormal lung function despite of a decline in individual pulmonary function parameters.

DISCUSSION:

40% of the study population was found to have more than one coexisting microangiopathies.

Among isolated complications, retinal angiopathy was most common and renal the least. The study done by pinar Celik et al 13 had 46.7% of the study population affected by microvascular complication of which retinal was the most common. Sinha et al 14 reported an incidence of microvascular complications in 40% of the study group. Patients found to have no microvascular complications at the time of study showed a significantly shorter duration of diabetes and a better control of diabetic status in them. Similar findings were reported by sinha et al 14 and pinar celik et al. 13 Patients with more than one or isolated neural complications had a significantly longer duration of diabetes. A poorer diabetic control was associated with renal, retinal or more than one microvascular complications.

70 patients of type II DM participated in the study . Approximately half the patients (51.4%) had normal pulmonary function tests but half of these asymptomatic patients had evidence of deranged pulmonary function tests – the most common type of deranged pattern was restrictive (21.4%) while 15.7% had a mixed pattern. This finding was also reported by the Framantle diabetes study15 which had evidence that reduced lung volumes and airflow limitation complicate diabetes. However the aforementioned study was a prospective one and these findings applied to all the diabetic patients studied over a period of 7 Years. It compared the finding with patient’s baseline pulmonary function test while the present study is cross sectional and compares the measurements by the ATS-ERS guidelines of 1986. P. Lange et al 16 also reported a significant association between reduction in lung function and raised plasma glucose concentration. Tricia M. Mckeever et al 17 suggested that impaired glucose auto regulation is associated with impaired lung function.

The average duration of diabetes in all the patients in the study was 9.20 Years which is similar to the study done by Mori H et al 18 where the duration of diabetes was 10.8 Years. The duration of diabetes in the study done by Sinha et al 14 was 10.2 Years. In the study done by Maurizio Marvisi et al 19 the average duration of diabetes was 11.27 Years.

There was no significant association of duration of diabetes with the pulmonary pattern (p value=0.87). This finding correlates with the observations made by Pinar Celik et al 13 who found no significant correlation of duration of diabetes with pulmonary function abnormality and also the Fremantle diabetes study 15 where it was found that the duration of DM was not consistently associated with changes in lung function.

Among the patients with normal pulmonary pattern, most had no associated microvascular complications. In these patients the most common complications found was neural (peripherehal neuropathy) or more than one complications. Patients showing a restrictive pattern mostly (66.67%) had more than, one microvascular complication. Among the isolated complication, retinal was the most common (26.67%), while none of the patients with a restrictive pattern were without other microvascular complications. This finding was consistent with the study done by Davis TM et al 20 who found an independent and inverse association of retinopathy with FVC, FEV1 and VC. Maurizio Marvisi et al 19 also reported a significant correlation between pulmonary function abnormalities and signs of diabetic microangiopathy. Ljubic S. et al 21 suggested a relationship between diabetic complications, particularly microangiopathy with collagen and elastin changes in lings.

Among the patients showing purely obstructive pulmonary patterns, most had more than one associated microvascular complications (62.5%). 25% of the patients had no other microvascular complications while one patient (12.5%) had peripheral neuropathy. Among the patients showing a mixed obstructive and restrictive pattern 36.36% had more than one associated microvascular complication, 27.27% had retinal, 18.18% had renal while 9% had no associated microvascular complication.

The patients in the study group were divided into those with a known diabetes duration of <5 years, 5-10 years and >10 years since microvascular complications are known to being after 5 years and are usually detectable after 10 years. This concept however has its fallacies due to individual variation, a long period for which type II DM goes unnoticed as well as the effect of coexisting other morbidities e.g. systemic hypertension.

The various pulmonary parameters FEV1, FVC and FEF50% showed significant correlation with duration of diabetes (p value=0.0299). However no significant correlation was reported by Sinha et al 91 and Pinar Celik et al. 13 This finding is also echoed in The Fremantle Diabetes Study 16 where no consistent relation was between FEV1, FVC and FEF50% and duration.

CONCLUSION:

  1. Patients of Type II diabetes are prone to decline in lung function and restrictive pulmonary pattern is the most commonly observed abnormality.
  2. Decline in pulmonary function has no correlation with duration of diabetes.
  3. Glycaemic control is inversely related to decline in pulmonary function.
  4. Decline in pulmonary function is more in the presence of other microvascular complications.

REFERENCES:

  1. Powers Alvin C: Diabetes mellitus; Harrison’s principle of internal medicine. 17th Vol. II, 2008:2275-2305.
  2. Dodson, Guy. Mill Hill essays 1998: Insulin and Diabetes; National Institute for Medical Research.
  3. Nettleship E. diabetic retinitis. Trans opthalmol Soc UK 1986;6:331-334.
  4. Lundback K. Long term diabetes: The clinical picture in diabetes mellitus of 15-25 Years duration with a follow-up of a regional series of cases. Copenhagen Muvksgaard, 1953.
  5. Ledet T, Neubauer B, Christensen NJ, Lundback K. Diabetic Cardiopathy Diabetologia 1979; 16:207-209.
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  7. Sueki H. Diabetic microangiopathy in subcutaneous fatty tissue. J cutan pathol 1987; 217-22.
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  9. Powell HC, Rosoff J, Myers RR. Microangiopathy in human diabetic neuropathy. Acta Neuropath 1985; 68:295-305.
  10. Parving HH, Viberti GC, Keen H, Christiansen JS, Lassen NA. Hemodyanamic factors in the genesis of diabetic microangiopathy. Metabolism 1983;32:943-9.
  11. Tooke JE. Microvascular hemodyanamics in diabetes mellitus. Clin Sci 1986;70:119-25.
  12. Zatz R, Brenner BM. Pathogenesis of diabetic microangiopathy: The hemodyanamic view. Am j Med 1986;80:443-53.
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