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Gamma camera detection of oleic acid alveolar-capillary albumin leak
JOURNAL
OF SURGICAL
RESEARCH
29, 93-99(1980)
PRELIMINARY REPORT Gamma Camera Detection of Oleic Acid Alveolar-Capillary Albumin Leak HARVEYJ. SUGERMAN,M.D.,’ JERRYI.,,HIRSCH,PHARM.D., ALFREDM.STRASH,PH.D., PHILIP T. KAN, PH.D., ALTON R. SHARPE,JR.,M.D., JOHN STONEBURNER,B.S., ANDLAZAR J. GREENFIELD, M.D. Departments
of Surgery and Radiology,
Medical College of Virginia, Richmond, Virgina 23298
Virginia
Commonwealth
University,
Submitted for publication April 18, 1979 The computerized gamma camera was able to record and quantitate the alveolar-capillary membrane leak of radioactive technetium-99m-tagged human serum albumin in two dogs following intravenous oleic acid. In dog 1, given 0.1 ml/kg oleic acid, the increase in 1ung:heart radioactivity ratio, following oleic acid, became statistically significant within 12 (P < 0.05) and 18 min (P < 0.001); whereas, in dog 2, given 0.3 ml/kg oleic acid, the increase in 1ung:heart radioactivity ratio became statistically significant within 7 (P < 0.05) and 19 min (P < 0.001). Based on this preliminary study, the computerized gamma camera may prove to be a useful clinical tool for the study of acute respiratory distress syndrome in both patients and animals.
Acute respiratory distress syndrome (ARDS) probably arises from damage to the pulmonary alveolar-capillary membrane, with leakage of intravascular fluid and p.rotein into the interstitial space and then the alveolus. Leakage of large molecular weight substances has been documented by Robin ef al. [9] in clinical ARDS by the finding of intravenously injected low and high molecular weight dextrans in tracheal aspirates of septic patients. This has been confirmed by the demonstration of 1311-radioiodinated serum albumin (RISA) administered intravenously, in the tracheal aspirates of patients suffering from drug overdose [ 1l] and septic [l]-induced ARDS. Got-in et al. [3] noted an increase in gamma emission of 113mIn-transferrin from the chest of sheep I Address reprint requests to: Harvey J. Sugerman, M.D., P.O. Box 519. Medical College of Virginia, Richmond, Va. 23298.
following intravenous injection of Pseudobacteria using a portable scintillation detection probe. Radioactive technetium-labeled human serum albumin (99”Tc-HSA) distributes within the whole body blood pool after intravenous injection and remains essentially within the vascular compartment 151. Its distribution in the body can be imaged using the gamma scintillation camera. This study was designed to test the hypothesis that radioactive albumin would leak through the alveolar-capillary membrane of the injured lung and be detected by imaging with the gamma camera. monas aeruginosa
METHODS
AND MATERIALS
Two mongrel dogs were anesthetized with pentobarbital(30 mg/kg), ventilated via endotracheal tube with a Harvard mechanical respirator and 100% oxygen, using 93
0022-4804/80/070093-07$01.00/O Copyright 0 1980 by Academic Ress, Inc. All rights of reproduction in any form reserved.
94
JOURNAL OF SURGICAL RESEARCH: VOL. 29, NO. 1, JULY 1980
FIG. 1. Areas of interest (lungs and heart) selected in dog 1, with computerized gamma scintillation camera, 8 set after 5 mCi 99mTc-HSA.
a tidal volume of 15ml/kg. After the animal’s chest was positioned anterior-posteriorly beneath the gamma camera and fitted with a low-energy parallel hole collimator, each dog was injected with 5 mCi ss”Tc-HSA (prepared from a commercial stannous kit) via an indwelling femoral venous catheter. The ss”Tc-HSA radiopharmaceutical was analyzed prior to administration by instant thin-layer chromatography according to the method of Thrall et al. [IO]. Using the computerized gamma camera, data were collected at 1-set intervals for 60 set and then at I-min intervals for 3 hr. During the initial pass of radiopharmaceutical, it was possible to define the lungs and the heart anatomically for subsequent computer analysis (Fig. 1). Oleic acid, 0.1 and 0.3 ml/kg, was given as a bolus intravenously, 30 and 150 min following the administration of ssmTc-HSA in the first and second animals, respectively. Scintillation images of the
lungs and heart were obtained, which could be color-coded by the computer to grade the intensity of radioactivity. Computergenerated curves of radioactivity per pixel per second over the lungs and the heart regions, as previously defined (Fig. l), were obtained, as well as 1ung:heat-tradioactivity ratios. The statistical confidence limits of the data were analyzed by considering the integral of the Gaussian distribution. RESULTS
Technetium-99m-tagged HSA was found to be more than 95% labeled with absence of the s5mTc-colloid. Computer generated curves of counts per pixel per second following s9”Tc-HSA administration revealed a progressive diminution of radioactivity over the heart (Fig. 2) throughout the study in each dog. The computer-generated curve or radioactivity over the lung also revealed progressive diminution of radioactivity until
SUGERMAN
0
I 00.er
ET AL.:
00’01
ALBUMIN
00’8
LEAK
00’9
-l3XId/ON033S/SlNn83
SEEN WITH
OO’ll
GAMMA
CAMERA
I 00-z
oc
95
00
0.1 6LEIC
110.00
ML/KG WID
TIME
I b3.00
LUNG
I 120.00
HERRT
(MINUTES)
-
I 160.00
RRTI6
200.00
FIG. 4. Computer-constructed lungheart ratio curve following 5 mCi 99mTc-HSAin dog 1. The increase in 1ung:heart radioactivity ratio became statistically significant, within 12 min (P < 0.05) and within 18 min (P < O.OOl),following the administration of oleic acid.
Oo’.
u,L 9-i
o
z.
LEFT
CA00
I 40.00
TIME
80.00
LUNG
120.00
0.3 OLEIC
HEaRT
RRTIB
160.00
ML/KG WID
(MINUTES)
-
I 200.00
FIG. 5. Computer-constructed lungheart ratio curve following 5 mCi 9smTc-HSA in dog 2. The increase in 1ung:heart radioactivity ratio became statistically significant, within 7 min (P < 0.05) and within 9 min (I’ < O.OOl),following the administration of oleic acid.
s d
P d
LEFT
SUGERMAN
ET AL.: ALBUMIN
LEAK
SEEN WITH GAMMA
CAMERA
97
in pulmonary edema fluid of two septicemic patients with ARDS. Katz et al. [6] found an increase in the albumin content and Wilen et al. [ 1l] found an increase in radioiodinated serum albumin (1251-RISA)in the tracheal aspirates of patients with drugoverdose pulmonary edema in contrast to cardiogenic pulmonary edema. Anderson et al. [l] were also able to document a leak of ‘“‘I-RISA in the tracheal aspirates of four septic patients. Using a portable scintillation detection probe, Gorin et al. [3] were able to document a significant increase in gamma emissions of 113mIn-transferrin from the chest of sheep following the intravenous injection of Pseudomonas aeruginosa bacteria, which correlated with the directly measured accumulation of this isotope in lung lymph. They felt that external radioflux detection appeared to be a valid measurement of transvascular protein flux in the lung. The computerized gamma scintillation camera provided a noninvasive and relatively simple method for visualizing and quantitating the pulmonary alveolar-capillary membrane leak of albumin in two dogs immediately after oleic acid administration. The computer-generated, radiointensity DISCUSSION color-coded scintiscans were even more Attempts to document and quantitate the impressive. The severity of injury was leakage of water and protein through the greater in dog 2, given the larger dose of pulmonary alveolar-capillary membrane in a oleic acid, than in dog 1 as evidenced by variety of disorders have been fraught with the more rapid and more profound fall in frustration. Previous studies have been arterial oxygen tension. This difference was directed at attempts to measure pulmonary also reflected in the 1ung:heart radioactivity extravascular lung water using isotopic ratios, since the slope of the curve was indicator dilution techniques. This method- 0.0022 and 0.0133 mm-’ in dogs 1 and 2, ology, based on studies by Chinard and respectively (Figs. 4 and 5). Enns [2] has been shown by Korsgren et ~2. Using 1ung:heat-t ratios should alleviate [7] and Marshall et al. [8] to be inaccurate, the necessity for quantitative accuracy in since it is flow dependent. The triple isotope ggmTc-HSA administration and simplify the dilution technique of Gump et al. [4] is also collection of normal, control data. We are based on an erroneous assumption that proceeding with the collection of data in radioactive serum albumin will not leak patients to determine whether this techout of the intravascular space in ARDS. nique can detect an albumin leak in ARDS Robin ef al. [9] were able to detect a leak and if it can be quantitated. If these goals of both low molecular weight (70,000) and are feasible, then the computerized gamma high molecular weight (500,000) dextrans camera may prove to be a very useful
the administration of oleic acid, when there was a prompt and progressive rise (Fig. 3). The computer-constructed 1ung:heart ratio curves remained constant in both lungs in both animals until the administration of oleic acid, when a rapid increase in the ratio occurred (Figs. 4, 5). The increase in lung: heart radioactivity ratio following oleic acid became statistically significant at the P < 0.05 level within 12 min in dog 1 and 7 min in dog 2 and P < 0.001 within 18 and 9 min in dogs 1 and 2, respectively. Black and white scintiphotos provided obvious visual demonstration of radioalbumin leakage upon comparison of pre- (Fig. 6) and post- (Fig. 7) oleic acid administration. This was even more dramatic when the computerized color-coded analysis of the intensity of radioactivity was seen. In the first animal, given 0.1 ml/kg oleic acid, the arterial oxygen tension decreased minimally from 546 to 470 mm Hg 2 hr after the administration of oleic acid. In the second animal, given 0.3 ml/kg oleic acid, the arterial oxygen tension fell from 535 to 365 mm Hg at 30 min and to 76 mm Hg at 45 min following oleic acid injection.
98
JOURNAL
OF SURGICAL
RESEARCH:
VOL. 29, NO. 1, JULY
1980
SUGERMAN ET AL.: ALBUMIN
LEAK SEEN WITH GAMMA CAMERA
clinical tool for the study of ARDS in both patients and animals. REFERENCES 1. Anderson, R., Sibblad, W. J., Holliday, R. et al. Increased pulmonary capillary permeability in human sepsis. Int. Care Med. 3: 110, 1977. 2. Chinard, F. P., and Enns, T. Transcapillary pulmonary exchange of water in the dog. Amer. J. Physiol.
178: 197, 1954.
3. Gorin, A. B., Weidner, W. J., Demling, R. H. et nl. Noninvasive measurement of pulmonary transvascular protein flux in sheep. J. Appl. Physiol. 45: 225, 1978. 4. Gump, F. E., Mashima, Y., Jorgensen, S. et a/. Simultaneous use of three indicators to evaluate pulmonary capillary damage to man. Surgery 70: 262, 1971. 5. Heindel, N. D. Principles of target tissue localization of radiopharmaceuticals. In N. D. Heindel, H. D. Burns, T. Honda, and L. W. Brady, (Eds.),
The Chemistry of Radiopharmaceuticals. York: Masson, 1978. P. 11.
99 New
6. Katz, S., Aberman, A., Frand, U. I. et al. Heroin pulmonary edema. Evidence for increased pulmonary capillary permeability. Amer. Rev. Resp. Dis. 106: 472, 1972. 7. Korsgren, M., Luepker, R., Liander, B. et al. Pulmonary intra and extravascular fluid volume changes withexercise. Cardiovnsc. Res. 3: 1,1969. 8. Marshall, B. E., Teichner, R. L., Kallos, T. et al. Effects of posture and exercise on the pulmonary extravascular water volume in man. J. Appl. Physiol. 31: 375, 1971. 9. Robin, E. D., Carey, L. C., Grenyik, A. et al. Capillary leak syndrome with pulmonary edema. Arch. Intern. Med. 130: 66, 1972. 10. Thrall, J. H., Freitas, J. E., Swanson, D. et al. Clinical comparison of cardiac blood pool visualization with Technetium-99m red blood cells labeled in vivo and with Technetium-99m human serum albumin. J. Nucl. Med. 19: 796, 1978. 11. Wilen, S., Rubin, J., and Lyons, H. Vascular leakage of protein in non-cardiac and cardiac pulmonary edema. Circulation 52 (2): 130, 1975.
OF SURGICAL
RESEARCH
29, 93-99(1980)
PRELIMINARY REPORT Gamma Camera Detection of Oleic Acid Alveolar-Capillary Albumin Leak HARVEYJ. SUGERMAN,M.D.,’ JERRYI.,,HIRSCH,PHARM.D., ALFREDM.STRASH,PH.D., PHILIP T. KAN, PH.D., ALTON R. SHARPE,JR.,M.D., JOHN STONEBURNER,B.S., ANDLAZAR J. GREENFIELD, M.D. Departments
of Surgery and Radiology,
Medical College of Virginia, Richmond, Virgina 23298
Virginia
Commonwealth
University,
Submitted for publication April 18, 1979 The computerized gamma camera was able to record and quantitate the alveolar-capillary membrane leak of radioactive technetium-99m-tagged human serum albumin in two dogs following intravenous oleic acid. In dog 1, given 0.1 ml/kg oleic acid, the increase in 1ung:heart radioactivity ratio, following oleic acid, became statistically significant within 12 (P < 0.05) and 18 min (P < 0.001); whereas, in dog 2, given 0.3 ml/kg oleic acid, the increase in 1ung:heart radioactivity ratio became statistically significant within 7 (P < 0.05) and 19 min (P < 0.001). Based on this preliminary study, the computerized gamma camera may prove to be a useful clinical tool for the study of acute respiratory distress syndrome in both patients and animals.
Acute respiratory distress syndrome (ARDS) probably arises from damage to the pulmonary alveolar-capillary membrane, with leakage of intravascular fluid and p.rotein into the interstitial space and then the alveolus. Leakage of large molecular weight substances has been documented by Robin ef al. [9] in clinical ARDS by the finding of intravenously injected low and high molecular weight dextrans in tracheal aspirates of septic patients. This has been confirmed by the demonstration of 1311-radioiodinated serum albumin (RISA) administered intravenously, in the tracheal aspirates of patients suffering from drug overdose [ 1l] and septic [l]-induced ARDS. Got-in et al. [3] noted an increase in gamma emission of 113mIn-transferrin from the chest of sheep I Address reprint requests to: Harvey J. Sugerman, M.D., P.O. Box 519. Medical College of Virginia, Richmond, Va. 23298.
following intravenous injection of Pseudobacteria using a portable scintillation detection probe. Radioactive technetium-labeled human serum albumin (99”Tc-HSA) distributes within the whole body blood pool after intravenous injection and remains essentially within the vascular compartment 151. Its distribution in the body can be imaged using the gamma scintillation camera. This study was designed to test the hypothesis that radioactive albumin would leak through the alveolar-capillary membrane of the injured lung and be detected by imaging with the gamma camera. monas aeruginosa
METHODS
AND MATERIALS
Two mongrel dogs were anesthetized with pentobarbital(30 mg/kg), ventilated via endotracheal tube with a Harvard mechanical respirator and 100% oxygen, using 93
0022-4804/80/070093-07$01.00/O Copyright 0 1980 by Academic Ress, Inc. All rights of reproduction in any form reserved.
94
JOURNAL OF SURGICAL RESEARCH: VOL. 29, NO. 1, JULY 1980
FIG. 1. Areas of interest (lungs and heart) selected in dog 1, with computerized gamma scintillation camera, 8 set after 5 mCi 99mTc-HSA.
a tidal volume of 15ml/kg. After the animal’s chest was positioned anterior-posteriorly beneath the gamma camera and fitted with a low-energy parallel hole collimator, each dog was injected with 5 mCi ss”Tc-HSA (prepared from a commercial stannous kit) via an indwelling femoral venous catheter. The ss”Tc-HSA radiopharmaceutical was analyzed prior to administration by instant thin-layer chromatography according to the method of Thrall et al. [IO]. Using the computerized gamma camera, data were collected at 1-set intervals for 60 set and then at I-min intervals for 3 hr. During the initial pass of radiopharmaceutical, it was possible to define the lungs and the heart anatomically for subsequent computer analysis (Fig. 1). Oleic acid, 0.1 and 0.3 ml/kg, was given as a bolus intravenously, 30 and 150 min following the administration of ssmTc-HSA in the first and second animals, respectively. Scintillation images of the
lungs and heart were obtained, which could be color-coded by the computer to grade the intensity of radioactivity. Computergenerated curves of radioactivity per pixel per second over the lungs and the heart regions, as previously defined (Fig. l), were obtained, as well as 1ung:heat-tradioactivity ratios. The statistical confidence limits of the data were analyzed by considering the integral of the Gaussian distribution. RESULTS
Technetium-99m-tagged HSA was found to be more than 95% labeled with absence of the s5mTc-colloid. Computer generated curves of counts per pixel per second following s9”Tc-HSA administration revealed a progressive diminution of radioactivity over the heart (Fig. 2) throughout the study in each dog. The computer-generated curve or radioactivity over the lung also revealed progressive diminution of radioactivity until
SUGERMAN
0
I 00.er
ET AL.:
00’01
ALBUMIN
00’8
LEAK
00’9
-l3XId/ON033S/SlNn83
SEEN WITH
OO’ll
GAMMA
CAMERA
I 00-z
oc
95
00
0.1 6LEIC
110.00
ML/KG WID
TIME
I b3.00
LUNG
I 120.00
HERRT
(MINUTES)
-
I 160.00
RRTI6
200.00
FIG. 4. Computer-constructed lungheart ratio curve following 5 mCi 99mTc-HSAin dog 1. The increase in 1ung:heart radioactivity ratio became statistically significant, within 12 min (P < 0.05) and within 18 min (P < O.OOl),following the administration of oleic acid.
Oo’.
u,L 9-i
o
z.
LEFT
CA00
I 40.00
TIME
80.00
LUNG
120.00
0.3 OLEIC
HEaRT
RRTIB
160.00
ML/KG WID
(MINUTES)
-
I 200.00
FIG. 5. Computer-constructed lungheart ratio curve following 5 mCi 9smTc-HSA in dog 2. The increase in 1ung:heart radioactivity ratio became statistically significant, within 7 min (P < 0.05) and within 9 min (I’ < O.OOl),following the administration of oleic acid.
s d
P d
LEFT
SUGERMAN
ET AL.: ALBUMIN
LEAK
SEEN WITH GAMMA
CAMERA
97
in pulmonary edema fluid of two septicemic patients with ARDS. Katz et al. [6] found an increase in the albumin content and Wilen et al. [ 1l] found an increase in radioiodinated serum albumin (1251-RISA)in the tracheal aspirates of patients with drugoverdose pulmonary edema in contrast to cardiogenic pulmonary edema. Anderson et al. [l] were also able to document a leak of ‘“‘I-RISA in the tracheal aspirates of four septic patients. Using a portable scintillation detection probe, Gorin et al. [3] were able to document a significant increase in gamma emissions of 113mIn-transferrin from the chest of sheep following the intravenous injection of Pseudomonas aeruginosa bacteria, which correlated with the directly measured accumulation of this isotope in lung lymph. They felt that external radioflux detection appeared to be a valid measurement of transvascular protein flux in the lung. The computerized gamma scintillation camera provided a noninvasive and relatively simple method for visualizing and quantitating the pulmonary alveolar-capillary membrane leak of albumin in two dogs immediately after oleic acid administration. The computer-generated, radiointensity DISCUSSION color-coded scintiscans were even more Attempts to document and quantitate the impressive. The severity of injury was leakage of water and protein through the greater in dog 2, given the larger dose of pulmonary alveolar-capillary membrane in a oleic acid, than in dog 1 as evidenced by variety of disorders have been fraught with the more rapid and more profound fall in frustration. Previous studies have been arterial oxygen tension. This difference was directed at attempts to measure pulmonary also reflected in the 1ung:heart radioactivity extravascular lung water using isotopic ratios, since the slope of the curve was indicator dilution techniques. This method- 0.0022 and 0.0133 mm-’ in dogs 1 and 2, ology, based on studies by Chinard and respectively (Figs. 4 and 5). Enns [2] has been shown by Korsgren et ~2. Using 1ung:heat-t ratios should alleviate [7] and Marshall et al. [8] to be inaccurate, the necessity for quantitative accuracy in since it is flow dependent. The triple isotope ggmTc-HSA administration and simplify the dilution technique of Gump et al. [4] is also collection of normal, control data. We are based on an erroneous assumption that proceeding with the collection of data in radioactive serum albumin will not leak patients to determine whether this techout of the intravascular space in ARDS. nique can detect an albumin leak in ARDS Robin ef al. [9] were able to detect a leak and if it can be quantitated. If these goals of both low molecular weight (70,000) and are feasible, then the computerized gamma high molecular weight (500,000) dextrans camera may prove to be a very useful
the administration of oleic acid, when there was a prompt and progressive rise (Fig. 3). The computer-constructed 1ung:heart ratio curves remained constant in both lungs in both animals until the administration of oleic acid, when a rapid increase in the ratio occurred (Figs. 4, 5). The increase in lung: heart radioactivity ratio following oleic acid became statistically significant at the P < 0.05 level within 12 min in dog 1 and 7 min in dog 2 and P < 0.001 within 18 and 9 min in dogs 1 and 2, respectively. Black and white scintiphotos provided obvious visual demonstration of radioalbumin leakage upon comparison of pre- (Fig. 6) and post- (Fig. 7) oleic acid administration. This was even more dramatic when the computerized color-coded analysis of the intensity of radioactivity was seen. In the first animal, given 0.1 ml/kg oleic acid, the arterial oxygen tension decreased minimally from 546 to 470 mm Hg 2 hr after the administration of oleic acid. In the second animal, given 0.3 ml/kg oleic acid, the arterial oxygen tension fell from 535 to 365 mm Hg at 30 min and to 76 mm Hg at 45 min following oleic acid injection.
98
JOURNAL
OF SURGICAL
RESEARCH:
VOL. 29, NO. 1, JULY
1980
SUGERMAN ET AL.: ALBUMIN
LEAK SEEN WITH GAMMA CAMERA
clinical tool for the study of ARDS in both patients and animals. REFERENCES 1. Anderson, R., Sibblad, W. J., Holliday, R. et al. Increased pulmonary capillary permeability in human sepsis. Int. Care Med. 3: 110, 1977. 2. Chinard, F. P., and Enns, T. Transcapillary pulmonary exchange of water in the dog. Amer. J. Physiol.
178: 197, 1954.
3. Gorin, A. B., Weidner, W. J., Demling, R. H. et nl. Noninvasive measurement of pulmonary transvascular protein flux in sheep. J. Appl. Physiol. 45: 225, 1978. 4. Gump, F. E., Mashima, Y., Jorgensen, S. et a/. Simultaneous use of three indicators to evaluate pulmonary capillary damage to man. Surgery 70: 262, 1971. 5. Heindel, N. D. Principles of target tissue localization of radiopharmaceuticals. In N. D. Heindel, H. D. Burns, T. Honda, and L. W. Brady, (Eds.),
The Chemistry of Radiopharmaceuticals. York: Masson, 1978. P. 11.
99 New
6. Katz, S., Aberman, A., Frand, U. I. et al. Heroin pulmonary edema. Evidence for increased pulmonary capillary permeability. Amer. Rev. Resp. Dis. 106: 472, 1972. 7. Korsgren, M., Luepker, R., Liander, B. et al. Pulmonary intra and extravascular fluid volume changes withexercise. Cardiovnsc. Res. 3: 1,1969. 8. Marshall, B. E., Teichner, R. L., Kallos, T. et al. Effects of posture and exercise on the pulmonary extravascular water volume in man. J. Appl. Physiol. 31: 375, 1971. 9. Robin, E. D., Carey, L. C., Grenyik, A. et al. Capillary leak syndrome with pulmonary edema. Arch. Intern. Med. 130: 66, 1972. 10. Thrall, J. H., Freitas, J. E., Swanson, D. et al. Clinical comparison of cardiac blood pool visualization with Technetium-99m red blood cells labeled in vivo and with Technetium-99m human serum albumin. J. Nucl. Med. 19: 796, 1978. 11. Wilen, S., Rubin, J., and Lyons, H. Vascular leakage of protein in non-cardiac and cardiac pulmonary edema. Circulation 52 (2): 130, 1975.