2.emphysema Imaging - Overview, Radiography, Computed Tomography

8/7/2017 Emphysema Imaging: Overview, Radiography, Computed Tomography
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Emphysema Imaging
Updated: Mar 08, 2016
Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Eugene C Lin, MD more...
OVERVIEW
Overview
Conventional chest radiography is generally the first imaging procedure performed in patients with
respiratory symptoms, and frontal and lateral chest radiographs may reveal changes of emphysema.
A chest radiograph is universally available, noninvasive, and inexpensive, and it poses an acceptable
radiation exposure. [1, 2, 3]
For further information, see the Medscape Reference topics Imaging in Congenital Lobar
Emphysema, Imaging in Emphysematous Pyelonephritis, and Imaging in Pulmonary Interstitial
Emphysema.
High-resolution computed tomography (HRCT) scanning is more sensitive than chest radiography in
diagnosing emphysema and in determining its type and extent of disease. [4] HRCT also has a high
specificity for diagnosing emphysema with virtually no false-positive diagnoses. However, in clinical
practice, more reliance is placed on patient history, lung function tests, and abnormal chest
radiographs to diagnose emphysema. However, some patients with early emphysema, particularly
those with early disease, may present with atypical symptoms, and it is in these patients that an
HRCT is most rewarding. If significant emphysema is found on HRCT, no further workup is necessary;
specifically, lung biopsy is not needed.
A number of studes have assessed the role of computed tomography (CT) in the early detection of
lung 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.
CT characterization of heterogeneous parenchymal abnormalities can provide criteria for selection of
the preferable treatment in each patient and improve the outcome of LVR. In particular, emphysema
distribution pattern and fissures integrity can be evaluated to tailor the choice of the most appropriate
LVR technique. [6]
Images of emphysema are displayed below.
http://emedicine.medscape.com/article/355688-overview 1/20
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).
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CT densitovolumetry in a heavy smoker with emphysema revealed compromise of about 22% of the lung
parenchyma (Corra da Silva, 2001).
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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).
View Media Gallery
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. [7, 8] 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.
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, both radiographically 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. The peripheral 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
retrosternal airspace due to right ventricular enlargement. (See the images 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).
View Media Gallery
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 diaphragm. If the height is less than 1.5 cm, the criterion of flattening is fulfilled (Corra da Silva,
2001).
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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).
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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 consider when this space is measured (Corra da
Silva, 2001).
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Close-up image shows emphysematous bullae in the left upper lobe. Note the subpleural, thin-walled, cystlike
appearance (Corra da Silva, 2001).
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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).
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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).
View Media Gallery
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 is useful 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 emphysema and two thirds of those with severe emphysema had
evidence of disease on chest radiography. [9]
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, 10,
11, 12, 13, 14, 15, 16, 17, 18]
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).
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Pediatric high-resolution CT (HRCT) shows a hyperinflated right lung with large pulmonary bullae due to
congenital lobar emphysema (Corra da Silva, 2001).
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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).
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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).
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Hruban et al [19] and Bergin C et al [20] 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 and can help eliminate
interobserver and intraobserver variability and provide a reproducible assessment of the percentage
of lung affected. Gould et al [21] 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 [22] and Kinsella et al [23] 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 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. [24]
Kuwano et al [25] 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 [26] found that CT can cause underestimation of the extent of emphysema when lesions are
less than 0.5 cm. However, in their study, the inflation 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. [27]
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.
[28]
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. [29]
Paraseptal emphysema usually involves the distal part of the secondary lobule and 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.
High-resolution CT (HRCT) shows subpleural bullae consistent with paraseptal emphysema. Red mark shows the
size of a normal acinus (Corra da Silva, 2001).
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Bullous emphysema is generally seen in association with centriacinar emphysema and paraseptal
emphysema. [30] 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.
Yahaba et al performed a study on 91 patients who underwent inspiratory and expiratory multidetector
CT (MDCT) to determine whether emphysematous changes alter the relationships between airflow
limitation and airway dimensions. Images were evaluated for mean airway luminal area (Ai); wall area
percentage (WA%) from the third to the fifth generation of 3 bronchi (B1, B5, B8) in the right lung; and
low attenuation volume percent (LAV%). In patients without emphysema, Ai and WA% from both the
inspiratory and expiratory scans were significantly correlated with FEV1, but no correlation was found
in patients with emphysema. Also, emphysematous COPD patients with GOLD (Global Initiative for
Chronic Obstructive Lung Disease) stage 1 or 2 disease had significantly lower changes in B8 Ai than
nonemphysematous patients. [31]
In a retrospective cohort study by Kurashima et al, the presence of CT-diagnosed emphysema

predicted poor prognosis in patients who had COPD and asthma with chronic airflow obstruction
(CAO). Patients with asthma without emphysema had the best prognosis, followed by those with
asthma with emphysema, COPD without emphysema, and COPD with emphysema. [32]
Using low-dose CT scans of 62,124 current, former, and never smokers, emphysema was identified in
28.5% (6,684) of current smokers, 20.6% (5,422) of former smokers, and 1.6% (194) of never
smokers. The prevalence of lung cancer in current smokers was 1.1% for those without emphysema
and 2.3% for those with emphysema; in former smokers, 0.9% for those without emphysema and
1.8% for those with emphysema; and in never smokers, 0.4% for those without emphysema and 2.6%
for those with emphysema. [33]
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 (bone or 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 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 that precocious 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.
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).
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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).
View Media Gallery
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).
View Media Gallery
Degree of confidence
HRCT is more sensitive than standard chest radiography. [34] 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 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 of emphysema can be
detected by means of CT quantification. [35]
Using 1.5- and 10-mm collimation scans, Miller et al [26] 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. [36]
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. [37]
Sergiacomi et al [38] 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 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. [39, 40]
Radionuclide ventilation scans enable a useful assessment of lung function before and after LVRS.
Travaline et al [41] 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.
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Media Gallery
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).
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 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 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).
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).
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).
Pediatric high-resolution CT (HRCT) shows a hyperinflated right lung with large pulmonary
bullae due to congenital lobar emphysema (Corra da Silva, 2001).
Algorithmic representation of emphysema that Reid proposed in 1956.
Pulmonary acinus measures 6-10 mm (red or blue). When normal, the distal terminal bronchiole
used to define the acinus cannot be resolved on high-resolution CT (HRCT). Image represents
the proportion of acini in relation to the lung image. One lobule, as Reid defined it, can have 3-5
acini (red groups). A secondary pulmonary lobule described by the interstitial septa can have as
many as 100 acini (blue groups, the biggest one showing a pulmonary lobule containing about
35 acini) (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).
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).
Panacinar emphysema of the left lung in a patient with a right lung transplant. Note the red
element showing the size of a normal acinus and its discrepancy with the destroyed and
enlarged airspaces of the left lower lobe (Corra da Silva, 2001).
High-resolution CT (HRCT) shows bullae distributed in the subpleural spaces including the
fissures; this is characteristic of paraseptal emphysema (Corra da Silva, 2001).
High-resolution CT (HRCT) shows subpleural bullae consistent with paraseptal emphysema.
Red mark shows the size of a normal acinus (Corra da Silva, 2001).
High-resolution CT (HRCT) shows enlarged air-spaces or bullae adjoining pulmonary scars,
consistent with paracicatricial emphysema. Red mark shows the size of a normal acinus (Corra
da Silva, 2001).
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).
Expiratory CT densitovolumetry shows no areas of airtrapping (Corra da Silva, 2001).
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).
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).
CT densitovolumetry demonstrates irregular distribution of the emphysema, with substantial
predominance in the left lung (Corra da Silva, 2001).
of 23
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Contributor Information and Disclosures
Author
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR Consultant Radiologist and Honorary Professor, North
Manchester General Hospital Pennine Acute NHS Trust, UK
Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR is a member of the following medical societies:
American Association for the Advancement of Science, American Institute of Ultrasound in Medicine,
British Medical Association, Royal College of Physicians and Surgeons of the United States, British
Society of Interventional Radiology, Royal College of Physicians, Royal College of Radiologists, Royal
College of Surgeons of England
Disclosure: Nothing to disclose.
Coauthor(s)
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 medical societies: Royal College of
Physicians
Klaus L Irion, MD, PhD Consulting Staff, The Cardiothoracic Centre Liverpool NHS Trust, The Royal
Liverpool University Hospital, UK
Klaus L Irion, MD, PhD is a member of the following medical societies: American Roentgen Ray
Society, Radiological Society of North America
Pablo Rydz Pinheiro Santana, MD Radiology Consultant, Department of Cardiothoracic Radiology,

Medimagem - H. Beneficncia Portuguesa, So Paulo, Brazil
Sarah Al Ghanem, MBBS Consulting Staff, Department of Medical Imaging, King Fahad National
Guard Hospital, Saudi Arabia
Specialty Editor Board
Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation
Services, Hutt Valley District Health Board, New Zealand
Chief Editor
Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology
Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology,
University of Washington School of Medicine
Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear
Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear
Medicine and Molecular Imaging
Additional Contributors
Judith K Amorosa, MD, FACR Clinical Professor of Radiology and Vice Chair for Faculty
Development and Medical Education, Rutgers Robert Wood Johnson Medical School
Judith K Amorosa, MD, FACR is a member of the following medical societies: American College of
Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological
Society of North America, Society of Thoracic Radiology

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Images of emphysema are displayed below.

In a retrospective cohort study by Kurashima et al, the presence of CT-diagnosed emphysema

Magnetic Resonance Imaging

Sergiacomi et al [38] used lung-perfusion 2-dimensional (2D) dynamic breath-hold technique in

3. Sharma V, Shaaban AM, Berges G, Gosselin M. The radiological spectrum of small-airway

4. Takahashi M, Fukuoka J, Nitta N, Takazakura R, Nagatani Y, Murakami Y, et al. Imaging of

6. Milanese G, Silva M, Sverzellati N. Lung volume reduction of pulmonary emphysema: the

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

9. Thurlbeck WM, Simon G. Radiographic appearance of the chest in emphysema. AJR Am J

11. Matsuoka S, Kurihara Y, Yagihashi K, Hoshino M, Watanabe N, Nakajima Y. Quantitative

16. Jgi J, Ekberg M, Jonson B, Bozovic G, Bajc M. Ventilation/perfusion SPECT in chronic

32. Kurashima K, Fukuda C, Nakamoto K, Takaku Y, Hijikata N, Hoshi T, et al. CT-diagnosed

Chest radiograph of an emphysematous patient shows hyperinflated lungs with reduced

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

Contributor Information and Disclosures

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

Pablo Rydz Pinheiro Santana, MD Radiology Consultant, Department of Cardiothoracic Radiology,

Disclosure: Nothing to disclose.

Disclosure: Nothing to disclose.

Specialty Editor Board

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Disclosure: Nothing to disclose.

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