The clinical characteristics of the bronchopulmonary system in patients with MM, without exacerbation of AML, depended on the stage of tumor progression. Patients of group I had no osteodestructive syndrome. In patients of this group who did not abuse smoking and who did not have concomitant bronchopulmonary pathology, the chest was regular in shape, painless on palpation, percutaneous over the entire lung surface was determined by a clear pulmonary sound, during auscultation listened to vesicular breathing, adverse respiratory sounds not noted.

Patients of group II are characterized by a pronounced osteodestructive syndrome, including in the bones that form the chest. In 24 patients of group II, percussion over the entire lung surface was determined clear pulmonary sound, vesicular breathing was heard, there were no side respiratory sounds. In 10 patients with a significant deformation of the chest, who were in a forced position during percussion and auscultation of the lungs, the changes were interpreted as interpreted as manifestations of circulatory failure, emphysema, and pulmonary fibrosis; lower parts of the lungs. In 8 patients, MM was complicated by myelomatous lesion of the pleura with the development of exudative pleurisy; in the affected area, weakening of breathing, dulling of the pulmonary sound, and increased voice tremor were observed.

In 17 patients with MM of group III (stage IIIB), a pronounced osteo-destructive process of the chest occurred. In 8 people (IB and stage IIB), the osteodestructive syndrome was absent. In patients with MM of group III, with the initial manifestations of renal failure, with percussion and auscultation of the lungs there were no significant violations. In the terminal stage of chronic kidney disease, all had nephrogenic pulmonary edema. Clinical manifestations of nephrogenic edema were shortness of breath, bouts of shortness of breath, or choking with increased respiration, occurring with a rapid increase in body weight. During bouts of nephrogenic edema, a boxed shade of percussion sound or shortening of sound over the lower parts of the lungs and in the interscapular region was determined. Auscultation noted weakened or hard breathing, dry scattered rales, less often moist fine wheezing, with uremic lesions of the pleura – pleural friction noise (5 patients).

All 123 patients with multiple myeloma were x-rayed. The study began with traditional radiography of the lungs in two projections or large-frame x-ray of the chest, later on, when detecting pathological changes in the lungs, ERTG and CT were performed.

In the majority of cases (72 people — 58.5%), when conducting traditional X-ray diffraction, interstitial changes were detected: increased vascular pattern, pneumosclerosis and emphysema. Radiographic signs of damage to the intestinal lung tissue were more often recorded in patients with stage III disease, especially in the presence of myeloma nephropathy and renal failure. Very rarely, interstitial changes were found in the early stages of tumor progression (IA, IIA stages according to the classification of B. Durie and S. Salmon, 1975). Gain and deformation of the pulmonary pattern in MM is explained by stagnation of blood in small vessels and the development of pneumosclerosis, since blood flow in the pulmonary capillaries is slowed down due to increased plasma viscosity. Analyzing the group of patients with MM with interstitial changes in the lungs, it was found that in most cases these were patients over the age of 50 years (52 people — 72.2% of the total number of patients with interstitial changes in the lungs), with pronounced monoclonal secretion (G or A) and high serum total protein content (45 people – 62.5%). In 25 patients with interstitial changes in the lungs, renal failure was diagnosed (34.7%).

In patients with stage III, multiple destruction of the ribs characteristic of MM, pathological ribs of the ribs occurred. In 7 patients, tumors emanating from the re- cers, compressing the corresponding zones of the lung tissue and creating the effect of a lung tumor, were noted . Subsequently, after autopsy, histological examination of tumors emanating from the ribs showed characteristic myelocytocellular growths.

The presence of inflammatory infiltrates was diagnosed in 33 patients (in 44 cases, taking into account repeated pneumonia). In most cases, pneumonia was detected in patients with MM in the later stages of tumor progression with chest deformity and renal failure.

Fluid in the pleural cavities was detected in 47 patients (38.2%). Subsequently, during the pleural puncture or at autopsy, the etiology of pleural effusion was established. In 8 cases there was a specific pleurisy, due to myeloma pleural infiltration; in 11 cases, infectious pleurisy as a complication of pneumonia; 28 people were diagnosed with transudate (pleural manifestation of renal failure).

In 52 patients with MM (42.3%), complicated by myeloma nephropathy and renal failure, nephrogenic pulmonary edema of degrees I, II and III was detected according to the classification of V.M. Perelman et al. (1964). The main diagnostic sign of nephrogenic pulmonary edema is a cloud-like darkening in the central regions on the chest radiograph in a direct projection . Its shape resembled a butterfly due to the free peripheral zone 2-4 cm wide. The darkening consisted of unsharply delineated rounded foci, the size of which depended on the number of alveoli filled with transudate. With accumulation in the interstitial spaces and pleural crevices of the edematous fluid, there were visible bands of darkening radiating away from the central part of the butterfly (26 patients — 50% of the total number of patients with nephrogenic edema). However, in 26 patients (50%), the blackout was unilateral, segmental, located mainly in the lower sections, combined with hydrothorax.

Only in one patient, radiological examination was able to detect calcification in the lungs . Calcium deposits are of very small size, and in the overwhelming majority of cases it is not possible to detect them during X-ray examination.

In two patients, a mediastinal tumor was diagnosed radiologically, which later at autopsy turned out to be an extramedullary foci of blood formation in the mediastinal tissue.

Great opportunities for the diagnosis of bronchopulmonary manifestations of multiple myeloma appear when using computed tomography (CT). CT scan of the thoracic cavity organs was performed in patients with MM in cases where traditional X-ray examination did not allow to establish an accurate diagnosis, as well as in contradictions between the clinical picture and the clinical picture. Hos major task of RT – clarify the nature and localization of the pathological process Skog, its extent and prevalence with osed- of bodies . In MM CT, considerable assistance was provided in the diagnosis of tumors emanating from the ribs that squeezed the lungs and, in traditional X-ray examinations, created the effect of a “lung tumor”. 7 such patients are registered. In a traditional X-ray examination, radiologists expressed the opinion that these patients have peripheral lung cancer. Knowing the peculiarities of the osteodestructive MM process, CT scan of the chest cavity was performed. QD has a higher resolution in contrast than conventional techniques, and makes it possible to clearly identify organic structures . During the CT in these patients were able to establish that “tumor” is destroyed tissue edges, it comes out of it and causes compression of adjacent areas and second portion of the lung tissue. Pe ripheral lung cancer was excluded.

As an example, here is a brief extract from the case history No 45019. Patient M., born 1953 It was observed in the hematology department of the Amur regional clinical hospital from 1998 to 2003. with a diagnosis of multiple myeloma, diffuse-focal form, synthesizing PIg G, stage IIIA. In 2003, the development of chronic renal failure was established. From 1998 to 2003 radiographs of the chest were determined characteristic of MM destruction of the ribs. In 2003, during a survey of the lungs on the right, in the area of ​​the 6th rib, a “formation” was detected, which was initially regarded by the radiologist as peripheral lung cancer. . When performing CT, it was found that the tumor comes from the 6th rib on the right. These data were subsequently confirmed by autopsy results. In the middle third of the 6th rib on the right, a 10 × 8 cm formation was found, which gave a shadow on the radiograph. Histological examination revealed a characteristic pattern of myeloma tumor.

CT scan has provided significant assistance in the diagnosis of pleural myelomatous lesions. According to the histological examination after autopsy, specific myeloma pleural infiltration was observed in 8 patients. In 6 of them, myelomatous lesion was suspected during CT. The pleura in these patients was thickened. In two cases revealed focal, in six cases diffuse infiltration.

As an example, here is a brief extract from the history of the disease No 392. Diagnosis Multiple myeloma, which synthesizes PiGG, was exposed in 2002. At the initial course, he received treatment according to the protocol M 2 -VBMCP, reached the plateau phase, which lasted until 2007. Supportive therapy was conducted under this protocol. In January 2007, the disease recurred: a marked pain syndrome reappeared in the chest cell and spine, multiple bone destruction on radiographs of the skull, ribs, pelvic bones, and spinal column. Treatment according to the PAD protocol. The clinical effect is not marked. Since June 2007, tumor screening of the left pleura is determined on CT scan of the chest cavity, which significantly increased in size by October 2007. During the histological study of the puncture biopsy material of the “tumor” of the pleura, plasma cells were found. Currently, the patient is undergoing radiation therapy to the area of ​​pleural lesion.

When performing CT with a large degree of confidence It is intended to diagnose interstitial changes in the lungs in patients with MM: deformity of the pulmonary vascular pattern, pulmonary fibrosis, pulmonary emphysema. In patients with MM, even in the absence of a concomitant broncho-obstructive process, a large percentage of emphysematous transformed lung tissue is determined. As the tumor progresses, the percentage of emphysema increases. This was established using the method of emphysema detection when performing CT using the Hitachi W-800 computed tomography program using the Level Detect program. tomographic slice [157]. According to CT data in patients with IA and IIA disease stages (I group), the percentage of emphysematous tissue per unit. area averaged 25.14 ± 0,22; in patients with stage IIIA (group II) – 41.7 ± 0.28%; in stage IIIB of the disease (group III) – 42.21 ± 0.22%.

Computed tomography is a verification method of radiological examination of the organs of the thoracic cavity in patients with MM complicated by CRF. The sensitivity of CT in the detection of pulmonary changes in patients with chronic renal failure increases significantly. When performing CT, it is possible to diagnose not only structural, but also functional changes in the lungs in patients with MM with the presence of renal failure. Computed tomography provides significant assistance in the diagnosis of pneumonia in patients with MM, developed on the background of agranulocytosis after cytostatic treatment. Due to the deficiency of neutrophils in these patients, it is very rarely possible to identify a clear inflammatory focus in a standard X-ray study. With CT, most of these patients still managed to determine the presence of infiltration.

Myeloma, proceeding from the pleura.

Summarizing the above, we can conclude the following:

1. The main radiological manifestations of pulmonary complications of multiple myeloma are: interstitial type of changes (increased pulmonary pattern, emphysema, pneumosclerosis), presence of destruction and ribs tumors, inflammatory infiltrates, nephrogenic pulmonary edema, fluid in the pleural cavities.

2. Computed tomography is the most effective method for detecting local pathological processes in the lungs with MM. CT is the leading method of X-ray diagnostics of pneumonia adhering against the background of agranulocytosis.

3. When using the method of quantitative evaluation of radiological data at CT in patients with MM, as the tumor progression revealed an increase in the percentage of emphysematous tissue.

As MM progressed, there was a deterioration in the indices of cellular and humoral immunity .

The respiratory function was studied by spirography in 70 patients with MM without concomitant COPD. In half of the patients (35 people), no violations of VFL were detected. These are patients from group I and group II, with a disease duration of 1-2 years, in whom no changes were detected during x-ray examination of the lungs. In 35 patients, moderate violations of VFL were diagnosed: in 10 patients in restrictive mode, and in 25 in mixed types. These are patients of group II, who had a diagnosis of MM more than two years ago, and patients from group III. In all, during the X-ray examination of the lungs, changes in the interstitial type were observed (increased vascular pattern, pneumosclerosis and emphysema). According to spirography, 19 patients with myeloma G, 10 with myeloma A,1 with non-secretive myeloma and 5 people with Bens-Jones myeloma, of whom 15 patients had ESRD. Most of these patients were diagnosed with a small reduction in lung volumes. Reduction of VC was diagnosed in all 35 patients (68.4 ± 2.0% D; P <0.001). In 25 patients, a moderate decrease in FEV was observed. 1 (72.9 ± 2.1; P <0.001).

Reduction of VC indicates a loss of elasticity in the lungs and the development of a restrictive respiratory failure (DN). Increased plasma viscosity, the presence of intravascular protein stasis, and increased protein infiltration into the alveoli lead to the lysis of the elastic framework of the lungs. Dystrophy of the elastic framework and the development of emphysema contributes to impaired blood circulation in the lungs in these patients. The filling of part of the alveoli with paraprotein with MM leads to the shutdown of these alveoli from ventilation and the development of emphysema, which in this case is also of compensatory nature. [57]. This reasoning is also supported by a large number of patients with myeloma A, who have impaired VFL, as myeloma A has a more pronounced hyperviscose syndrome . Specific lymphoid and plasma cell lung infiltration may contribute to the development of restrictive type DN. In chronic kidney disease, an important reason for the development of a restrictive type of DN is the presence of uremic changes in the lungs – uremic pulmonary edema, uremic pneumonitis and calcification. A decrease in the FEV 1 value combined with a decrease in the VC indicates the development of a mixed type of DN. When conducting radiological (including ERTG and CT) and bronchoscopic examinations, no patient had an intrabronchial myeloma growth. Therefore, the decrease in FEV 1 can be attributed to edema, specific lymphoid and plasma cell infiltration, sclerotic changes of the bronchial mucosa, with the addition of CRF to uremic lesions, nephrogenic edema and uremic bronchitis. The above changes are more pronounced in the later stages of MM tumor progression. Therefore, it was not revealed in patients with IA, IIA, or the IIA stage of myeloma with a short tumor duration of any violations of VFL recorded by the method of spirography.

The parameters of peak flow measurements of patients with normal spirogram indices did not differ from those in the control group and were within 95% of the proper values ​​in the morning and 100% in the evening, the daily fluctuations averaged up to 5% of the initial value. The PSV data of patients who had a moderate decrease in FEV 1 during spirography were lower than in the control group, averaging 65% D in the morning and 75% D in the evening. Daily changes in HRP throughout the study did not change and were within 10%.

In group I patients, the value of bronchial resistance (R aw ) on inspiration (2.78 ± 0.1 cm water / l / s) and on expiration (3.06 ± 0.08 cm water / l / s) did not significantly differ from similar indicators in the control group (2.8 ± 0.1 and 3.0 ± 0.06 cm. / l / s, respectively; P> 0.05). In group II, the value of bronchial inspiratory resistance (3.1 ± 0.2 cm. Water / l / s) did not change (P> 0.05), R aw during exhalation was increased (3.9 ± 0.2 see / l / s; P <0.001). In patients with group III, a significant increase in bronchial resistance was noted: R aw on inspiration – 4.2 ± 0.15 cm water / l / s and R aw on expiration – 4.5 ± 0.26 cm. water / l / s (P <0.001). In patients of group II, plasma-cell and lymphoid infiltration of the bronchi, edema and sclerosis of the bronchial mucosa are already taking place. The leading cause of a pronounced increase in bronchial resistance in patients with group III is nephro genic edema of the lungs and bronchial mucosa, as a manifestation of renal failure.

Diagnostic fibrobronchoscopy was performed on 60 patients with MM who did not abuse smoking and did not have concomitant COPD (20 patients of group I, 20 patients of group II, and 20 patients of group III). All patients of group I had a bronchoscopic picture of a normal tracheobronchial tree. No hypersensitivity of the bronchi was observed.

In 10 patients of group II, bilateral diffuse atrophic endobronchitis was diagnosed. The bronchial mucosa in these patients was atrophied, pale, thinned. In the lumen of the bronchi mucous secret was absent or was very scarce. A bronchoscopic picture of a normal tracheobronchial tree was diagnosed in 10 patients. In all patients, contact bleeding of the bronchial mucosa was noted.

Bilateral diffuse atrophic endobronchitis was diagnosed in 12 patients of group III. The bronchial mucosa was atrophied, pale, thinned. In 8 patients of this group, there was a picture of a normal tracheobronchial tree. As in patients of group II, in all patients of group III, contact bleeding of the bronchial mucosa was observed, due to impaired hemostasis in the later stages of tumor progression in patients with MM . Thus, when conducting fibrobronchoscopy in 50% of patients with MM IIIA and in 60% of patients with renal insufficiency, bilateral diffuse atrophic endobronchitis occurs (40% of the total number of patients with MM).

Endobronchial biopsy was performed on 10 patients of group I, 10 patients of group II and 5 patients of group III. The biopsy specimen was the same as in patients with CLL. Patients of group I were diagnosed with moderate proliferation or dystrophy of the bronchial epithelium. In patients with groups II and III, histological examination of biopsy specimens determined edema, atrophy of the bronchial mucosa, and in some cases focal squamous metaplasia of the epithelium was observed. In some patients of groups II and III, lymphocytic and plasma cell infiltration of varying severity was detected under the basement membrane. In patients of group I, there was a slight dilatation of capillaries, plethora of arterioles, capillaries and venules. Protein stasis in the vessels of the microcirculatory bed of the bronchi in patients with MM in stages IA and IIA would not be detected lo In patients with group II, dilatation and plethora of arterioles, capillaries, and venules were observed with varying degrees of severity. The number of arterio-venous anastomoses was increased. In some vessels of the microvasculature, accumulation of protein masses was noted. In patients with group III, dilatation of arterioles, capillaries, and venules was also diagnosed with varying degrees of severity. In patients with MM, complicated by CRF, in the vessels of the microvasculature, the accumulation of protein masses was more pronounced than in patients of group II. This can be explained by increased lung function in conditions of azotemic uremia .

In order to study microhemocirculation in the proximal parts of the bronchial tree, 30 patients with MM underwent endobronchal LDF (10 patients from group I, 10 from II and 10 from group III). The results were compared with the data of 20 people from the control group, who were conducted PBS and LDF. In patients with MM in the course of tumor progression, disturbances of microcirculatory blood circulation in the bronchial mucosa were recorded in terms of the nature and severity of the microcirculatory circulation.

The indicator of the microcirculation parameter (PM), which characterizes the state of tissue perfusion, was significantly reduced as MM progressed. In multiple myeloma, impaired microhemocirculation in the lungs and bronchi is primarily due to the syndrome of increased blood viscosity and anemia. In order to minimize the effect of anemia on the PM indicators, in patients with MM groups II and III, the anemic syndrome was stopped before the study. The hemoglobin level during LDF was not lower than 100 g / l, the content of erythrocytes was not lower than 3 × 10 9 / l. Thus, they tried to establish a decrease in the speed of red blood cells in the microvessels, which, in MM, is primarily due to the syndrome of increased blood viscosity. A significant inverse correlation was established between an increase in the serum paraprotein level and a decrease in PM (r = –0.8, P <0.01), between the duration of the disease MM and a decrease in PM (r = –0.64, P <0.05). ), between an increase in the level of creatinine in the blood and a decrease in the PM (r = –0.5, P <0.05).

The values ​​of the mean square deviation of PM (σ), reflecting the preservation of the mechanisms of blood flow regulation in the microcirculatory bed, in patients of groups I and II did not have significant differences compared with the control (P> 0.05), and decreased in group III ( P <0.001) . The coefficient of variation (Kv), which characterizes the dependence of tissue perfusion on blood flow modulation, increased during tumor progression and in all groups significantly exceeded control (P <0.001) .

When analyzing the rhythmic components of blood flow oscillations, a decrease in e-range fluctuations was observed in patients of groups II and III. In group I patients, the amplitude of oscillations in the E-band did not differ from the control indices (Table 30). A decrease in the amplitude of oscillations in the E-band indicates endothelial dysfunction and a decrease in the production of nitric oxide in MM patients in the later stages of the tumor progression. The decrease in endothelial oscillations correlated with the stage of the disease (r = –0.72, P <0.01), the level of paraprotein (r = –0.56, P <0.05) and blood creatinine (r = –0.56 P <0.05). Since in patients with another lymphoproliferative disease – CLL, there are no changes in endothelial oscillations, it can be assumed that, in MM, important factors for the development of endothelial dysfunction are paraproteinmia,dysproteinemia and uremic intoxication. Endothelial dysfunction of the microvasculature vessels contributes to a severe and prolonged course of inflammatory processes of the bronchopulmonary system in patients with MM and an increase in pressure in the pulmonary artery system.

In patients with MM, no significant changes in the oscillations in the H-, M-, D- bands were detected. The amplitudes of oscillations in the C-band in patients with MM decreased in the course of tumor progression; in group I, they did not have significant differences compared to control; in groups II and III, the indices of cardiac waves decreased significantly (P <0.05 and P <0.001, respectively). A decrease in cardiac wave values ​​indicates a decrease in arterial blood flow into the microvasculature due to the development of a syndrome of increased blood viscosity. According to the data of endobronchial biopsy, in patients of the third group, protein stasis is more pronounced than in patients of the second group; therefore, in the presence of renal insufficiency, the smallest indicators of vibration amplitudes in the C-band were recorded.Significant inverse correlations were found between the level of serum paraprotein of the blood and a decrease in fluctuations in the C-range (r = –0.7, P <0.01), between the duration of MM disease and a decrease in the fluctuations in the C-range r = – 0.58, P <0.05), between the level of blood creatinine and the decrease in fluctuations in the C-band (r = –0.5, P <0.05).

It is obvious that similar violations of microhemocirculation occur in the lungs. Thus, in a significant number of patients with MM II and III groups, during radiological methods of examination, there is an increase and deformation of the pulmonary pattern, which is caused by stagnation of blood in small vessels with the development of pneumosclerosis, since due to the increased viscosity of the plasma, blood flow slows down pulmonary capillary system.

Disruption of microhemocirculation contributes to the violation of tissue trophism, the development of tissue hypoxia, metabolic disorders in the cells of the bronchial mucosa. The consequence of this are atrophic changes in the bronchial mucosa. In 40% of MM patients, bilateral diffuse atrophic endoscopy develops. At the same time, in patients with MM, in contrast to patients with CLL, outside the attachment of AML, in no case was a latent inflammatory process occurring in the bronchial mucosa, despite the fact that CLL also shows markedly abnormal microhemomas in the process of tumor progression. – circulation. This can be explained by a more pronounced decrease in cellular and humoral immunity in patients with CLL compared with patients with MM . In patients with CLL, due to the deep mismatch of all parts of the cellular and humoral immunity, against the background of a violation of the trophism of the bronchial tissues, the inflammatory process quickly develops and then acquires a chronic course.

Disruption of microhemocirculation in the vessels of the lungs and bronchi, along with pronounced secondary immunodeficiency, lymphoid and plasma cell infiltration of the lung tissue, paraproteoinosis of the lungs, contribute to the occurrence of severe and prolonged pneumonia in patients with MM. So in patients with MM I group, where no microcirculation disorders were detected, pneumonia was not registered. In group II, pneumonia was diagnosed in 10 patients (18% of the total number of patients in this group), in group III in 23 patients (42%).

The effect of cytostatic therapy on microhemocirculation indices in patients with MM was studied. In cases where, after carrying out cytostatic treatment, it was possible to reach the phase of a stable “plateau”, a decrease in blood paraprotein was noted, endobronchial LDF was repeated for MM patients. In all, an increase in the PM indices was noted, but in no case did the PM indices completely normalize. An improvement in the amplitudes of oscillations in the endothelial and cardiac ranges was noted. (Table 31).

The persistence of endobronchial microhemocirculation disorders in patients with MM, after reaching the “stable plateau” phase, is explained by the multifactorial nature of the microcirculatory disorders. In addition to the syndrome of increased blood viscosity and anemia, impaired platelet and plasma hemostasis, vascular endothelium, regulation of tissue vascular tone, pH and pO 2 , hormonal background and many other factors affect the microcirculation . In the majority of patients with MM, the plateau phase maintains a minimum PIg production.

As in CLL patients with MM, a high degree of effectiveness of the endobronchial LDF method was noted for identifying vascular and intravascular disorders of the microvasculature of the mucous bronchi in the early stages of the pathological process. The role of LDF in the diagnosis of endothelial dysfunction of microvasculature vessels is very important . The use of this method allows to assess the dynamics of microcirculatory disorders in the mucous membrane of the proximal bronchi during the treatment of myeloma.

According to the data of zonal rheography of the lung in patients of the I group, there were no violations of the general and regional ventilation of the lungs, the vertical gradient of ventilation characteristic of healthy people remained unchanged . The ratio of MOVR of the upper zones / MOVR of the lower zones did not have significant differences compared with the control . No significant impairment of the pulsatory blood flow in this group was also detected. The regional VPO indicators and the total VPO indicator of both lungs did not differ from the control indicators.

Note: P 1 – the significance of differences compared with the control; P 2 – the significance of the difference between the indices of LDF, before and after achieving remission.

In patients with MM of group II, during reopulmonography, there is a decrease in general and regional ventilation of the lungs . A significant decrease in ventilation in the middle and lower zones of both lungs, a decrease in the total MOBP from all zones of the lungs by 29.4% (P <0.05) and redistribution of ventilation from the lower and middle to the upper zones of both lungs were diagnosed . A decrease in the rheographic index of systolic blood filling (SCR) and the index of minute pulsatory blood flow (MPCr) in the right lung was diagnosed. The mccr of the right lung is reduced, compared with the control, with a reliability of <0.05. In the left lung, a significant decrease in blood flow occurred only in the middle zone. The cumulative index of MCR had no significant difference with the control (P> 0.05) . A significant increase in vascular resistance was noted in the lower and middle (to a lesser extent) zones of both lungs, which can be judged by the decrease in HSC and in the length of the Q-interval . But there was no significant redistribution of pulmonary blood flow in patients of group II. Estimating the state of the venous outflow in the small circle of blood circulation due to DSC change, an increase in this index was found in the middle and lower zones, with the greatest values ​​of the coefficient in the basal regions of the lungs. Significantly reduced VPO upper and lower zones and the left lung as a whole (P <0.001). Despite the fact that in the right lung the integral indicator of HPE did not have significant differences with the control, the total index of HPE of both lungs was reduced .

In patients with MM of group III, pr and carrying out zonal lung reography , there is a decrease in general and regional ventilation of the lungs. A significant decrease in ventilation in all zones of both lungs and a decrease in the total MOBP from all zones of the lungs by 48.8% (P <0.001) were diagnosed. There is a redistribution of ventilation from the lower and middle to the upper zones of both lungs . A decrease in the pulsatory blood flow in both lungs was diagnosed. The cumulative MPCr index is reduced compared with the control by 46.5% (P <0.001) . In group III, due to uremic damage of the heart and blood vessels, the precapillary vascular resistance reaches maximum values. In patients with renal failure, a significant increase was diagnosed. DSC in the middle and lower zones of both lungs. In group III, the VPO in the right lung had no significant differences compared with the control (p> 0.05). On the left, the overall indicator of HPE was reduced (p <0.05), due to a decrease in the VPO of the lower zone (p <0.001). The HPE of both lungs in group III patients did not have significant differences with the control group (1.1 ± 0.053; p> 0.05).

In patients of group I, the pO2 indicator did not significantly differ from that in the control group. The decrease in pO2 in patients of groups II and III is explained by the progression of regional ventilation disorders as the tumor process develops in patients with MM. The leading role in the disturbance of blood gas composition in MM is associated with a decrease in ventilation and lung perfusion, but the progression of the anemic syndrome as the tumor process develops also plays an important role .

In group I, the SrDLA index (14.67 ± 0.5 mm Hg) did not have significant differences compared with the control group (14.99 ± 0.61 mm Hg; P> 0.05). Patients II (18.7 ± 1.0 mm Hg; P <0.05) and III (22.8 ± 0.5 mm Hg; P <0.001) of the groups showed a significant increase in SrDLA compared to control.

Echocardiography and ICGD were performed on 50 patients with MM aged 33 to 70 years without concomitant COPD (12 patients from I, 27 of II, and 11 of Group III). Patients with diseases accompanied by a primary lesion of the left heart were excluded from the study. Pulmonary hypertension was diagnosed in 26 patients (52%). The SrDLA index in these patients was within 21–39 mm Hg, and averaged 23 ± 0.9 mm Hg. All patients with PH belonged to groups II and III (17 and 9 people, respectively). In patients with renal insufficiency, the highest rates of SrDLA were noted. In 24 patients (48%), the average SrDLA in rest did not exceed 20 mm. Hg Art. Of these, in 17 people it was within 9–16 mm. Hg Art. and in 7 – 17 – 20 mm. Hg Art.