Emphysema Imaging Edit

8/13/2019 Emphysema Imaging Edit

1/23


2/23

http://emedicine.medscape.com/article/355688-overview

2

significant emphysema is found on HRCT, no further workup is necessary;

specifically, lung biopsy is not needed.

Studies are under way to assess the role of computed tomography (CT) in theearly detection oflung cancer in patients with COPD and in predicting response

to lung-volumereduction surgery (LVRS).[5] Radionuclide scanning and MRI

have a potential role in patients being assessed for LVRS.

Images of emphysema are displayed below.

Chest radiograph of an emphysematous patient shows hyperinflated lungs with

reduced vascular markings. Pulmonary hila are prominent, suggesting some

degree of pulmonary hypertension (Corra da Silva, 2001).
http://emedicine.medscape.com/article/362919-overviewhttp://refimgshow%2820%29/http://refimgshow%281%29/http://refimgshow%2820%29/http://refimgshow%281%29/http://emedicine.medscape.com/article/362919-overview


3/23


3

CT densitovolumetry in a heavy smoker with emphysema revealed compromise

of about 22% of the lung parenchyma (Corra da Silva, 2001).

CT densitovolumetry in a patient with lung cancer. Three-dimensional (3D)

image shows that the cancer is in the portion of the right lung that was less

affected by emphysema in a patient with poor pulmonary function (Corra da

Silva, 2001).

Ballile and Laennec described the anatomopathology of emphysema in 1793

and in 1826, respectively. After that, Lynne Reid published one of the landmark

works in our understanding of emphysema, The Pathology of Emphysema(Reid, 1967),which provided a detailed description of the anatomy of the lung

units and of the anatomopathology and pathophysiology of emphysema,

broadening the view of this complex disease.[6, 7] Various changes have

happened since then, especially the advent of the high-resolution CT (HRCT) of

the chest.

Pulmonary emphysema is defined as the permanent enlargement of airspaces

distal to the terminal bronchioles and the destruction of the alveolar walls.

Pathology reveals a marked increase in the size of the airspaces, resulting in

labored breathing and an increased susceptibility to infection. It can be caused

by irreversible expansion of the alveoli or by the destruction of alveolar walls.

Fibrosis is not associated with this condition.
http://emedicine.medscape.com/article/301226-overviewhttp://refimgshow%2821%29/http://emedicine.medscape.com/article/301226-overview


4/23


4

Pulmonary emphysema and chronic bronchitis are important components of

chronic obstructive pulmonary disease (COPD). Emphysema often coexists

with chronic bronchitis in the COPD population, and from a clinical point of

view, they are generally considered as one entity. Although a tissue diagnosis of

emphysema is possible, in advanced cases it can usually be confidently

diagnosed on the basis of the patient's history, physical findings, pulmonary

function, and imaging results.

Limitations of techniques

Chest radiographic findings are not good indicators of the severity of disease

and do not help in identifying patients with COPD without clinically significant

emphysema. Imaging information from HRCT does not alter the management

of emphysema; therefore, HRCT has no place in the day-to-day care of patients

with COPD. In their early stages, the 3 forms of emphysema can be

distinguished morphologically by using HRCT. However, as the disease

becomes more extensive, the distinction becomes difficult or impossible, bothradiographically and pathologically.

Radiography

In moderate-to-severe emphysema, chest radiographic findings include

bilaterally hyperlucent lungs of large volume, flattened hemidiaphragms with

widened costophrenic angles, horizontal ribs, and a narrow mediastinum. Theperipheral vascular markings are attenuated, but the markings become

prominent when the patient has pulmonary hypertension and right-sided heart

failure. A lateral view shows increased retrosternal airspace and flattening of the

anterior diaphragmatic angle. In addition, bullae and an irregular distribution of

the lung vasculature may be present. When pulmonary hypertension develops,

the hilar vascular shadows become prominent, with filling of the lower
http://emedicine.medscape.com/article/297664-overviewhttp://emedicine.medscape.com/article/297664-overview


5/23


5

retrosternal airspace due to right ventricular enlargement. (See the images

below.)

Chest radiograph of an emphysematous patient shows hyperinflated lungs withreduced vascular markings. Pulmonary hila are prominent, suggesting some

degree of pulmonary hypertension (Corra da Silva, 2001).

Schematic representation of 1 criterion for defining flattening of the diaphragm

on the lateral chest radiograph: drawing a line from the posterior to anterior

costophrenic angles and measuring the distance from this line to the apex of the
http://refimgshow%282%29/http://refimgshow%281%29/http://refimgshow%282%29/http://refimgshow%281%29/


6/23


6

diaphragm. If the height is less than 1.5 cm, the criterion of flattening is fulfilled

(Corra da Silva, 2001). Schematic representation of another criterion for

defining flattening of the diaphragm on the lateral chest radiograph. When the

angle formed by the contact point between the diaphragm and the anterior

thoracic wall is more than or equal to 90, the criterion is fulfilled (Corra da

Silva, 2001).

Schematic representation of another sign of emphysema on the lateral chest

radiograph. When the retrosternal space (defined as the space between the

posterior border of the sternum and the anterior wall of the mediastinum) is

larger than 2.5 cm, it is highly suggestive of overinflated lungs. This radiograph

is from a patient with pectus carinatum, an important differential diagnosis to


7/23


7

consider when this space is measured (Corra da Silva, 2001).

Close-up image shows emphysematous bullae in the left upper lobe. Note the

subpleural, thin-walled, cystlike appearance (Corra da Silva, 2001).

A, Frontal posteroanterior (PA) chest radiograph shows no abnormality of the

pulmonary vasculature, with normal intercostal spaces and a diaphragmatic

dome between the 6th and 7th anterior ribs on both sides. B, Image in a patient

with emphysema demonstrating reduced pulmonary vasculature resulting in

hyperlucent lungs. The intercostal spaces are mildly enlarged, and the

diaphragmatic domes are straightened and below the extremity of the seventh

rib (Corra da Silva, 2001).


8/23


8

A, Lateral radiograph of the chest shows normal pulmonary vasculature, a

retrosternal space within normal limits (< 2.5 cm), and a normal angle between

the diaphragm and the anterior thoracic wall. B, Lateral view of the chest shows

increased pulmonary transparency, increased retrosternal space (>2.5 cm), and

an angle between the thoracic wall and the diaphragm >90. Straightening of the

diaphragm can be more evident in this projection than on others (Corra da

Silva, 2001).

Degree of confidence

In clinical practice, reliance is placed on the patient's history, lung function, and

abnormal chest radiographs to diagnose emphysema. Chest radiographic

findings generally cannot establish the diagnosis of mild emphysema; however,

when emphysema is fully established, classic radiographic findings are typically

observed. Findings on routine chest radiographs can suggest emphysema, but

this is not a sensitive technique for diagnosis. However, chest radiography isuseful to look for complications during acute exacerbations and to exclude other

pathologies, such as superadded infection or lung cancer.

The chest radiograph is not a good indicator of the severity of disease and does

not help in identifying patients with COPD without significant emphysema.

Thurlbeck and Simon found that only 41% of those with moderately severe
http://refimgshow%287%29/


9/23


9

emphysema and two thirds of those with severe emphysema had evidence of

disease on chest radiography.[8]

Computed Tomography

CT scanning of the chest, especially high-resolution CT (HRCT), has a much

greater sensitivity and specificity than those of plain chest radiography in

diagnosing and assessing the severity of emphysema (see the images below).

CT can depict surgically treatable areas of bullous disease that are not evident

on plain chest radiography. CT is also useful in predicting the outcome of

surgery. HRCT may be useful in diagnosing subclinical or mild emphysema,

and HRCT can be used to differentiate the pathologic types of emphysema.

However, CT scanning is not yet used to routinely evaluate patients with

COPD. Instead, it is being reserved for patients in whom the diagnosis is in

doubt, to look for coexistent pathologies, and to assess their suitability for

surgical intervention.[4, 9, 10, 11, 12, 13, 14, 15, 16]

High-resolution CT (HRCT) in a patient after viral bronchiolitis obliterans

demonstrates areas of airtrapping, which is predominant in the inferior lobes

and associated with bronchiectasis in the left lower lobe. Note that the

decreased attenuation caused by the airtrapping can simulate emphysema

(Corra da Silva, 2001).


10/23


10

Pediatric high-resolution CT (HRCT) shows a hyperinflated right lung with

large pulmonary bullae due to congenital lobar emphysema (Corra da Silva,

2001).

High-resolution CT (HRCT) demonstrates areas of centriacinar emphysema.

Note the low attenuation areas without walls due to destruction of the alveoli

septae centrally in the acini. Red element shows the size of a normal acinus

(Corra da Silva, 2001).


11/23


11

High-resolution CT (HRCT) shows large bullae in both inferior lobes due to

uniform enlargement and destruction of the alveoli walls causing distortion of

the pulmonary architecture (Corra da Silva, 2001).

Hruban et al[17] and Bergin C et al[18] have shown an excellent correlation

between HRCT and histologic findings. They used low-resolution (10 mm)

scans and were still able to show that CT findings were better predictors of

emphysema than results of pulmonary function tests.

Semiautomated assessment of emphysema by using HRCT data is possible andcan help eliminate interobserver and intraobserver variability and provide a

reproducible assessment of the percentage of lung affected. Gould et al[19]

measured the mean density in vivo of the lowest fifth percentile of the

distribution of pixels and compared it with a computed quantification of

emphysema on the subsequently excised lungs and showed a strong correlation

between lung attenuation and distal airspace size.

Mller et al[20] and Kinsella et al[21] used a CT attenuation mask to highlight

voxels in a given attenuation range to quantitate emphysema and define areas of

abnormally low attenuation. They compared different masks, mean lung

attenuations, and visual appearances and pathologic grades of emphysema in 28

patients undergoing lung resection for tumor. In each patient, a single

representative CT image was compared with corresponding pathologic


12/23


12

specimens. They found good correlation between the extent of emphysema as

assessed by using the attenuation mask and the pathologic grade. Such methods

not only eliminate interobserver and intraobserver variability but also enable

reproducible assessment of the percentage of lung that is affected. Although

quantitative CT measurements have problems, these methods hold real promise

for improving our understanding of lung function.[22]

Kuwano et al[23] visually quantified emphysema on 1- and 5-mm HRCT scans

by using resected specimens. They found an excellent correlation; however, as

expected, the 5-mm sections tended to cause underestimation of the degree of

emphysema. They concluded that HRCT scans could depict mild emphysema in

patients without clinical evidence of airflow limitation and that they could be

used to exclude emphysema in patients with moderate or severe airflow

limitation.

Miller et al[24] found that CT can cause underestimation of the extent of

emphysema when lesions are less than 0.5 cm. However, in their study, theinflation pressures of the fixed lung specimens were not controlled, and a

number of their patients had only thick-section (10 mm) studies.

Increased airway wall thickness and lung parenchymal destruction contribute to

airflow imitation in emphysema. Recent advances in CT postprocessing

imaging can quantify this feature. Dijkstra et al in a population survey studied

the relationship of increased airway thickening, lung function, emphysema, and

respiratory symptoms. The authors conclude that postprocessing standardization

of airway wall measurements provides a reliable and useful method to assess

airway wall thickness. The authors also suggested that increased airway wall

thickness contributed more to airflow limitation than emphysema in a smoking

male population, even after adjustment for smoking behavior.[25]


13/23


13

Mild-to-moderate degrees of centrilobular emphysema are depicted on HRCT

as small, round areas of low attenuation, several millimeters in diameter,

grouped near the center of secondary pulmonary lobules, with no discernible

walls in many cases. Although the centrilobular location of these lucencies

cannot always be appreciated on HRCT, lung parenchymal changes are

diagnostic of emphysema.[26]

Alpha 1-PI deficiency is classically associated with panlobular emphysema,

though panlobular emphysema may also be seen in smokers without alpha 1-PI

deficiency, in the elderly, and in people with distal bronchial and bronchiolar

obliteration. It is almost always most severe in the lower lobes. In severe

panlobular emphysema, the characteristic HRCT appearance is that of decreased

lung attenuation, with few visible pulmonary vessels in the abnormal regions;

bullae or cysts are characteristically absent. Mild and even moderately severe

panlobular emphysema can be subtle and difficult to detect.[27]

Paraseptal emphysema usually involves the distal part of the secondary lobuleand is therefore most obvious in subpleural regions. Paraseptal emphysema may

be seen in isolation or in combination with centrilobular emphysema. It is often

asymptomatic, but it can be associated with spontaneous pneumothorax in

young adults. As demonstrated in the image below, HRCT shows the bullae or

air cysts associated with paraseptal emphysema well despite their thin walls.
http://emedicine.medscape.com/article/360796-overviewhttp://refimgshow%2816%29/http://emedicine.medscape.com/article/360796-overview


14/23


14

High-resolution CT (HRCT) shows subpleural bullae consistent with paraseptal

emphysema. Red mark shows the size of a normal acinus (Corra da Silva,

2001).

Bullous emphysema is generally seen in association with centriacinar

emphysema and paraseptal emphysema.[28] Although a bullous emphysema is

not a specific pathologic entity, a syndrome of giant bullous emphysema or

vanishing lung syndrome has been described on the basis of clinical and

radiologic features. Giant bullous emphysema is often seen in young men in

association with large, progressive upper-lobe bullae that occupy a considerable

volume of a hemithorax. Most patients with giant bullous emphysema smoke

cigarettes, but this entity may also occur in nonsmokers.

Helical CT

Because of the great variability of the machines, with single helical scanners

and several models of multisection CT scanners, no technique has been

standardized, and the detection rate of emphysema varies with the technique.

Even with thick sections, the detection and quantification of emphysema is

better than it is with conventional radiography and pulmonary function tests.

The great advantage of helical CT is that the whole chest can be scanned in a

single acquisition of less than 20 seconds.

For the visual detection of emphysema, use of a high-definition algorithm (boneor lung settings) is helpful. However, for the automatic detection of emphysema

by computer, the standard algorithm is probably best. High-definition filters

affect the attenuation measured by the computer, deviating from the values from

the real Hounsfield scale and generally increasing the attenuation to variable

degrees depending on the air-lung-tissue proportion. This effect is even more


15/23


15

important when the attenuation of the lungs is compared for high-definition

processing with scanners from different suppliers.

To enhance the margins of adjacent structures with different attenuations,processing artificially changes the original attenuation of the interface planes

between the adjacent high- and low-attenuating structures, as in the case of the

lung parenchyma and the air content of the lungs. This phenomenon is more

obvious in the lung and skin than in solid viscera. This is probably why

thresholds for discriminating emphysema differ in the current literature. The

authors' personal experience suggests that the threshold -950 HU, as Gevenois

suggested, with the standard algorithm without edge enhancement is the most

appropriate method. This method may be most consistent and reliable for

measuring the lung attenuation by using different machines.

Various authors have been investigating volumetric quantification of

emphysema based on the Hounsfield scale by using CT pulmonary

densitovolumetry (shown in the images below). Some have suggested thatprecocious detection with quantification and 3-dimensional (3D) demonstration

of the extension and distribution of emphysema could be helpful in smoking

cessation programs or in risk assessments for occupational exposures.


16/23


16

CT densitovolumetry of a nonsmoker, healthy young patient shows normal

lungs. Less than 0.35% of lungs have attenuations below -950 HU (Corra da

Silva, 2001).

CT densitovolumetry in a patient with lung cancer. Three-dimensional (3D)image shows that the cancer is in the portion of the right lung that was less

affected by emphysema in a patient with poor pulmonary function (Corra da

Silva, 2001).

CT densitovolumetry shows the attenuation mask. Green areas are those with

attenuation below the selected threshold (here, -950 HU to evaluate

emphysema), and pink areas are those with attenuations above the threshold.

Area outside the patient is highlighted in green because of air (Corra da Silva,

2001).

Degree of confidence

HRCT is more sensitive than standard chest radiography.[29] HRCT is useful in

the workup of smokers with new-onset or progressive dyspnea. The severity of

emphysematous change may be underestimated on conventional radiography,

whereas HRCT depicts combined fibrosis and emphysema. Patients with these


17/23


17

conditions may have relatively normal lung volumes and spirometric results, but

they may have severe dyspnea and a reduced diffusing capacity.

In healthy nonsmokers aged 19-40 years, a maximum of 0.35% of the area ofemphysema can be detected by means of CT quantification.[30]

Using 1.5- and 10-mm collimation scans, Miller et al[24] showed that the extent

of centriacinar and panacinar emphysema was consistently underestimated with

CT, because it missed most lesions less than 0.5 cm in diameter. They

concluded that CT is insensitive in detecting the earliest lesions of emphysema.

However, the inflation pressures of the fixed lung specimens were not

controlled, and a number of their patients had only thick-section (10 mm)

studies.

Magnetic Resonance Imaging

Hyperpolarized gases are contrast agents that, when inhaled, provide images of

the lung airspaces with high temporal and spatial resolution. The availability of

these gases has great potential in the study of diffuse lung disease, particularly

emphysema.[31]

Ley et al assessed emphysematous enlargement of distal airspaces and

concomitant large- and small-airway disease by using diffusion-weighted

helium MRI, high-resolution CT (HRCT), and lung function tests. Helium MRI

and HRCT scanning results agreed better than did HRCT scanning results and

functional characterizations of emphysema in terms of hyperinflation and large-

and small-airway disease, as assessed on lung function tests.[32]

Sergiacomi et al[33] used lung-perfusion 2-dimensional (2D) dynamic breath-

hold technique in patients with severe emphysema and found a high sensitivity

(86.7%) and good specificity (80.0%) in detecting perfusion defects. They


18/23


18

observed low peak signal intensities in emphysematous regions and concluded

that lung perfusion MRI is a potential alternative to nuclear medicine study in

the evaluation of severe pulmonary emphysema.

Nuclear Imaging

Functional evaluation of the lungs can be carried out by using xenon-133 (133

Xe) lung ventilation scintigraphy before and after lung-volumereduction

surgery (LVRS) in patients with pulmonary emphysema.

Xenon-133 washout curves during lung scintigraphy exhibit a biphasic pattern:(1) the first component of the washout curve, m(r), corresponds to an initial

rapid phase in washout that reflects emptying of the large airways, and (2) the

second component, m(s),reflects a slower phase of washout that is attributed to

gas elimination in the small airways.[34, 35]

Radionuclide ventilation scans enable a useful assessment of lung function

before and after LVRS. Travaline et al[36] demonstrated that small-airway

ventilation in lung regions that were surgically treated and also in those areas

that were not surgically treated in the same patient were associated with

increased improvement in lung function after LVRS.


19/23


19

Contributor Information and DisclosuresAuthor

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and

Honorary Professor, North Manchester General Hospital Pennine Acute NHSTrust, UK

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the followingmedical societies:American Association for the Advancement of Science,American Institute of Ultrasound in Medicine,British Medical Association,British Society of Interventional Radiology,Royal College of Physicians,RoyalCollege of Physicians and Surgeons of the United States,Royal College ofRadiologists,andRoyal College of Surgeons of England

Disclosure: Nothing to disclose.

Coauthor(s)

Sarah Al Ghanem, MBBS Consulting Staff, Department of Medical Imaging,King Fahad National Guard Hospital, Saudi Arabia


Klaus L Irion, MD, PhD Consulting Staff, The Cardiothoracic CentreLiverpool NHS Trust, The Royal Liverpool University Hospital, UK

Klaus L Irion, MD, PhD is a member of the following medical societies:American Roentgen Ray SocietyandRadiological Society of North America


Chitra P Nagarajaiah, MBBS, MRCP Acute Medicine Specialist Registrar,City Hospital of Birmingham, UK

Chitra P Nagarajaiah, MBBS, MRCP is a member of the following medicalsocieties:Royal College of Physicians of the United Kingdom


Pablo Rydz Pinheiro Santana, MD Radiology Consultant, Department ofCardiothoracic Radiology, Medimagem - H. Beneficncia Portuguesa, SoPaulo, Brazil

http://www.aaas.org/http://www.aaas.org/http://www.aaas.org/http://www.aium.org/http://www.aium.org/http://www.bma.org.uk/ap.nsf/content/splashpagehttp://www.bma.org.uk/ap.nsf/content/splashpagehttp://www.bma.org.uk/ap.nsf/content/splashpagehttp://www.rcplondon.ac.uk/http://www.rcplondon.ac.uk/http://www.rcplondon.ac.uk/http://www.rcpsus.com/http://www.rcpsus.com/http://www.rcpsus.com/http://www.rcpsus.com/http://www.rcr.ac.uk/http://www.rcr.ac.uk/http://www.rcr.ac.uk/http://www.rcr.ac.uk/http://www.rcseng.ac.uk/http://www.rcseng.ac.uk/http://www.rcseng.ac.uk/http://www.arrs.org/http://www.arrs.org/http://www.rsna.org/http://www.rsna.org/http://www.rsna.org/http://www.mrcpuk.org/Pages/Home.aspxhttp://www.mrcpuk.org/Pages/Home.aspxhttp://www.mrcpuk.org/Pages/Home.aspxhttp://www.mrcpuk.org/Pages/Home.aspxhttp://www.rsna.org/http://www.arrs.org/http://www.rcseng.ac.uk/http://www.rcr.ac.uk/http://www.rcr.ac.uk/http://www.rcpsus.com/http://www.rcpsus.com/http://www.rcplondon.ac.uk/http://www.bma.org.uk/ap.nsf/content/splashpagehttp://www.aium.org/http://www.aaas.org/


20/23


20

Specialty Editor Board

Judith K Amorosa, MD, FACR Clinical Professor and Vice-Chair forAcademic Affairs and Faculty Development, Department of Radiology,

University of Medicine and Dentistry of New Jersey, Robert Wood JohnsonMedical School; Consulting Staff, Department of Radiology, Robert WoodJohnson University Hospital

Judith K Amorosa, MD, FACR is a member of the following medical societies:American College of Radiology,American Roentgen Ray Society,Associationof University Radiologists,Radiological Society of North America,andSocietyof Thoracic Radiology


Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department ofSpecialist Rehabilitation Services, Hutt Valley District Health Board, NewZealand


Robert M Krasny, MD Resolution Imaging Medical Corporation

Robert M Krasny, MD is a member of the following medical societies:American Roentgen Ray SocietyandRadiological Society of North America


Chief Editor

Kavita Garg, MD Professor, Department of Radiology, University ofColorado School of Medicine

Kavita Garg, MD is a member of the following medical societies:AmericanCollege of Radiology,American Roentgen Ray Society,Radiological Society of

North America,andSociety of Thoracic Radiology

http://www.acr.org/http://www.acr.org/http://www.arrs.org/http://www.arrs.org/http://www.arrs.org/http://www.aur.org/http://www.aur.org/http://www.aur.org/http://www.aur.org/http://www.rsna.org/http://www.rsna.org/http://www.rsna.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.arrs.org/http://www.arrs.org/http://www.rsna.org/http://www.rsna.org/http://www.rsna.org/http://www.acr.org/http://www.acr.org/http://www.acr.org/http://www.acr.org/http://www.arrs.org/http://www.arrs.org/http://www.arrs.org/http://www.rsna.org/http://www.rsna.org/http://www.rsna.org/http://www.rsna.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.rsna.org/http://www.rsna.org/http://www.arrs.org/http://www.acr.org/http://www.acr.org/http://www.rsna.org/http://www.arrs.org/http://www.thoracicrad.org/http://www.thoracicrad.org/http://www.rsna.org/http://www.aur.org/http://www.aur.org/http://www.arrs.org/http://www.acr.org/


21/23


21

References

1. Cleverley JR, Muller NL. Advances in radiologic assessment of chronicobstructive pulmonary disease. Clin Chest Med. Dec 2000;21(4):653-63.

[Medline].2. Raoof S, Raoof S, Naidich DP. Imaging of unusual diffuse lung diseases.Curr Opin Pulm Med. Sep 2004;10(5):383-9.

3. Sharma V, Shaaban AM, Berges G, Gosselin M. The radiologicalspectrum of small-airway diseases. Semin Ultrasound CT MR. Aug2002;23(4):339-51.[Medline].

4. Takahashi M, Fukuoka J, Nitta N, Takazakura R, Nagatani Y, MurakamiY, et al. Imaging of pulmonary emphysema: a pictorial review.Int JChron Obstruct Pulmon Dis. 2008;3(2):193-204.[Medline].[Full Text].

5. Gierada DS. Radiologic assessment of emphysema for lung volumereduction surgery. Semin Thorac Cardiovasc Surg. Oct 2002;14(4):381-90.[Medline].

6. Reid L. The Pathology of Emphysema (Review: J Clin Pathol. 1967November; 20(6): 923.). PubMed Central. Available athttp://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1.Accessed February 13, 2009.

7. Reid L. The Pathology of Emphysema. London: Lloyd-Luke; 1967:xi,372.

8. Thurlbeck WM, Simon G. Radiographic appearance of the chest inemphysema.AJR Am J Roentgenol. Mar 1978;130(3):429-40.[Medline].

9. Lynch DA. Imaging of small airways disease and chronic obstructivepulmonary disease. Clin Chest Med. Mar 2008;29(1):165-79.[Medline].

10.Matsuoka S, Kurihara Y, Yagihashi K, Hoshino M, Watanabe N,Nakajima Y. Quantitative assessment of air trapping in chronicobstructive pulmonary disease using inspiratory and expiratoryvolumetric MDCT.AJR Am J Roentgenol. Mar 2008;190(3):762-9.[Medline].

11.Nakano Y, Muller NL, King GG, et al. Quantitative assessment of airwayremodeling using high-resolution CT. Chest. Dec 2002;122(6Suppl):271S-275S.[Medline].

12.Webb WR. High-resolution computed tomography of obstructive lungdisease.Radiol Clin North Am. Jul 1994;32(4):745-57.[Medline].

13.Webb WR, Stein MG, Finkbeiner WE, et al. Normal and diseasedisolated lungs: high-resolution CT.Radiology. Jan 1988;166(1 Pt 1):81-7.[Medline].

14.Webb WR, Stern EJ, Kanth N, Gamsu G. Dynamic pulmonary CT:findings in healthy adult men.Radiology. Jan 1993;186(1):117-24.

[Medline].
http://reference.medscape.com/medline/abstract/11194777http://reference.medscape.com/medline/abstract/11194777http://reference.medscape.com/medline/abstract/12465689http://reference.medscape.com/medline/abstract/12465689http://reference.medscape.com/medline/abstract/12465689http://reference.medscape.com/medline/abstract/18686729http://reference.medscape.com/medline/abstract/18686729http://reference.medscape.com/medline/abstract/18686729http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629965/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629965/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629965/http://reference.medscape.com/medline/abstract/12652443http://reference.medscape.com/medline/abstract/12652443http://reference.medscape.com/medline/abstract/12652443http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1http://reference.medscape.com/medline/abstract/415543http://reference.medscape.com/medline/abstract/415543http://reference.medscape.com/medline/abstract/415543http://reference.medscape.com/medline/abstract/18267190http://reference.medscape.com/medline/abstract/18267190http://reference.medscape.com/medline/abstract/18267190http://reference.medscape.com/medline/abstract/18287450http://reference.medscape.com/medline/abstract/18287450http://reference.medscape.com/medline/abstract/12475796http://reference.medscape.com/medline/abstract/12475796http://reference.medscape.com/medline/abstract/12475796http://reference.medscape.com/medline/abstract/8022978http://reference.medscape.com/medline/abstract/8022978http://reference.medscape.com/medline/abstract/8022978http://reference.medscape.com/medline/abstract/3336706http://reference.medscape.com/medline/abstract/3336706http://reference.medscape.com/medline/abstract/8416550http://reference.medscape.com/medline/abstract/8416550http://reference.medscape.com/medline/abstract/8416550http://reference.medscape.com/medline/abstract/3336706http://reference.medscape.com/medline/abstract/8022978http://reference.medscape.com/medline/abstract/12475796http://reference.medscape.com/medline/abstract/18287450http://reference.medscape.com/medline/abstract/18267190http://reference.medscape.com/medline/abstract/415543http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1http://www.pubmedcentral.nih.gov/pagerender.fcgi?artid=473643&pageindex=1http://reference.medscape.com/medline/abstract/12652443http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629965/http://reference.medscape.com/medline/abstract/18686729http://reference.medscape.com/medline/abstract/12465689http://reference.medscape.com/medline/abstract/11194777


22/23


22

15.Jgi J, Ekberg M, Jonson B, Bozovic G, Bajc M. Ventilation/perfusionSPECT in chronic obstructive pulmonary disease: an evaluation byreference to symptoms, spirometric lung function and emphysema, asassessed with HRCT.Eur J Nucl Med Mol Imaging. Jul 2011;38(7):1344-

52.[Medline].16.Haruna A, Muro S, Nakano Y, Ohara T, Hoshino Y, Ogawa E, et al. CTscan findings of emphysema predict mortality in COPD. Chest. Sep2010;138(3):635-40.[Medline].

17.Hruban RH, Meziane MA, Zerhouni EA, et al. High resolution computedtomography of inflation-fixed lungs. Pathologic-radiologic correlation ofcentrilobular emphysema.Am Rev Respir Dis. Oct 1987;136(4):935-40.[Medline].

18.Bergin C, Muller N, Nichols DM, et al. The diagnosis of emphysema. Acomputed tomographic-pathologic correlation.Am Rev Respir Dis. Apr1986;133(4):541-6.[Medline].

19.Gould GA, Redpath AT, Ryan M, et al. Lung CT density correlates withmeasurements of airflow limitation and the diffusing capacity.Eur Respir

J. Feb 1991;4(2):141-6.[Medline].20.Muller NL, Staples CA, Miller RR, Abboud RT. "Density mask". An

objective method to quantitate emphysema using computed tomography.Chest. Oct 1988;94(4):782-7.[Medline].

21.Kinsella M, Muller NL, Staples C, et al. Hyperinflation in asthma andemphysema. Assessment by pulmonary function testing and computed

tomography. Chest. Aug 1988;94(2):286-9.[Medline].22.Goldin JG. Quantitative CT of the lung.Radiol Clin North Am. Jan

2002;40(1):145-62.[Medline].23.Kuwano K, Matsuba K, Ikeda T, et al. The diagnosis of mild emphysema.

Correlation of computed tomography and pathology scores.Am RevRespir Dis. Jan 1990;141(1):169-78.[Medline].

24.Miller RR, Mller NL, Vedal S, et al. Limitations of computedtomography in the assessment of emphysema.Am Rev Respir Dis. Apr1989;139(4):980-3.[Medline].

25.Dijkstra AE, Postma DS, ten Hacken N, Vonk JM, Oudkerk M, vanOoijen PM, et al. Low-dose CT measurements of airway dimensions andemphysema associated with airflow limitation in heavy smokers: a crosssectional study.Respir Res. Jan 28 2013;14:11.[Medline].[Full Text].

26.Murata K, Khan A, Herman PG. Pulmonary parenchymal disease:evaluation with high-resolution CT.Radiology. Mar 1989;170(3 Pt1):629-35.[Medline].

27.Parr DG, Sevenoaks M, Deng C, Stoel BC, Stockley RA. Detection ofemphysema progression in alpha 1-antitrypsin deficiency using CT

densitometry; methodological advances.Respir Res. Feb 13 2008;9(1):21.[Medline].
http://reference.medscape.com/medline/abstract/21365251http://reference.medscape.com/medline/abstract/21365251http://reference.medscape.com/medline/abstract/21365251http://reference.medscape.com/medline/abstract/20382712http://reference.medscape.com/medline/abstract/20382712http://reference.medscape.com/medline/abstract/20382712http://reference.medscape.com/medline/abstract/3310774http://reference.medscape.com/medline/abstract/3310774http://reference.medscape.com/medline/abstract/3963623http://reference.medscape.com/medline/abstract/3963623http://reference.medscape.com/medline/abstract/3963623http://reference.medscape.com/medline/abstract/2044729http://reference.medscape.com/medline/abstract/2044729http://reference.medscape.com/medline/abstract/2044729http://reference.medscape.com/medline/abstract/3168574http://reference.medscape.com/medline/abstract/3168574http://reference.medscape.com/medline/abstract/3168574http://reference.medscape.com/medline/abstract/3396405http://reference.medscape.com/medline/abstract/3396405http://reference.medscape.com/medline/abstract/3396405http://reference.medscape.com/medline/abstract/11813816http://reference.medscape.com/medline/abstract/11813816http://reference.medscape.com/medline/abstract/11813816http://reference.medscape.com/medline/abstract/2297175http://reference.medscape.com/medline/abstract/2297175http://reference.medscape.com/medline/abstract/2297175http://reference.medscape.com/medline/abstract/2930075http://reference.medscape.com/medline/abstract/2930075http://reference.medscape.com/medline/abstract/2930075http://reference.medscape.com/medline/abstract/23356533http://reference.medscape.com/medline/abstract/23356533http://reference.medscape.com/medline/abstract/23356533http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570364/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570364/http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570364/http://reference.medscape.com/medline/abstract/2916013http://reference.medscape.com/medline/abstract/2916013http://reference.medscape.com/medline/abstract/2916013http://reference.medscape.com/medline/abstract/18271964http://reference.medscape.com/medline/abstract/18271964http://reference.medscape.com/medline/abstract/18271964http://reference.medscape.com/medline/abstract/2916013http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3570364/http://reference.medscape.com/medline/abstract/23356533http://reference.medscape.com/medline/abstract/2930075http://reference.medscape.com/medline/abstract/2297175http://reference.medscape.com/medline/abstract/11813816http://reference.medscape.com/medline/abstract/3396405http://reference.medscape.com/medline/abstract/3168574http://reference.medscape.com/medline/abstract/2044729http://reference.medscape.com/medline/abstract/3963623http://reference.medscape.com/medline/abstract/3310774http://reference.medscape.com/medline/abstract/20382712http://reference.medscape.com/medline/abstract/21365251


23/23


23

28.Morgan MD, Denison DM, Strickland B. Value of computed tomographyfor selecting patients with bullous lung disease for surgery. Thorax. Nov1986;41(11):855-62.[Medline].

29.Klein JS, Gamsu G, Webb WR, et al. High-resolution CT diagnosis ofemphysema in symptomatic patients with normal chest radiographs andisolated low diffusing capacity.Radiology. Mar 1992;182(3):817-21.[Medline].

30.Irion KL, Hochhegger B, Marchiori E, Porto Nda S, Baldisserotto Sde V,Santana PR. [Chest X-ray and computed tomography in the evaluation of

pulmonary emphysema].J Bras Pneumol. Dec 2007;33(6):720-32.[Medline].

31.Altes TA, Salerno M. Hyperpolarized gas MR imaging of the lung.JThorac Imaging. Oct 2004;19(4):250-8.

32.Ley S, Zaporozhan J, Morbach A, Eberle B, Gast KK, Heussel CP.Functional evaluation of emphysema using diffusion-weighted 3Helium-magnetic resonance imaging, high-resolution computed tomography, andlung function tests.Invest Radiol. Jul 2004;39(7):427-34.[Medline].

33.Sergiacomi G, Sodani G, Fabiano S, et al. MRI lung perfusion 2Ddynamic breath-hold technique in patients with severe emphysema.InVivo. Jul-Aug 2003;17(4):319-24.[Medline].

34.Kurose T, Okumura Y, Sato S, et al. Functional evaluation of lung by Xe-133 lung ventilation scintigraphy before and after lung volume reductionsurgery (LVRS) in patients with pulmonary emphysema.Acta MedOkayama. Feb 2004;58(1):7-15.[Medline].

35.Suga K, Tsukuda T, Awaya H, et al. Interactions of regional respiratorymechanics and pulmonary ventilatory impairment in pulmonaryemphysema: assessment with dynamic MRI and xenon-133 single-photonemission CT. Chest. Jun 2000;117(6):1646-55.[Medline].

36.Travaline JM, Maurer AH, Charkes ND, et al. Quantitation of regionalventilation during the washout phase of lung scintigraphy: measurementin patients with severe COPD before and after bilateral lung volumereduction surgery. Chest. Sep 2000;118(3):721-7.[Medline].
http://reference.medscape.com/medline/abstract/3824272http://reference.medscape.com/medline/abstract/3824272http://reference.medscape.com/medline/abstract/3824272http://reference.medscape.com/medline/abstract/1535900http://reference.medscape.com/medline/abstract/1535900http://reference.medscape.com/medline/abstract/18200374http://reference.medscape.com/medline/abstract/18200374http://reference.medscape.com/medline/abstract/15194914http://reference.medscape.com/medline/abstract/15194914http://reference.medscape.com/medline/abstract/15194914http://reference.medscape.com/medline/abstract/12929586http://reference.medscape.com/medline/abstract/12929586http://reference.medscape.com/medline/abstract/12929586http://reference.medscape.com/medline/abstract/15157006http://reference.medscape.com/medline/abstract/15157006http://reference.medscape.com/medline/abstract/15157006http://reference.medscape.com/medline/abstract/10858397http://reference.medscape.com/medline/abstract/10858397http://reference.medscape.com/medline/abstract/10858397http://reference.medscape.com/medline/abstract/10988194http://reference.medscape.com/medline/abstract/10988194http://reference.medscape.com/medline/abstract/10988194http://reference.medscape.com/medline/abstract/10988194http://reference.medscape.com/medline/abstract/10858397http://reference.medscape.com/medline/abstract/15157006http://reference.medscape.com/medline/abstract/12929586http://reference.medscape.com/medline/abstract/15194914http://reference.medscape.com/medline/abstract/18200374http://reference.medscape.com/medline/abstract/1535900http://reference.medscape.com/medline/abstract/3824272

Documents

Emphysema Imaging Edit