health and medicine

1. Radiological imaging of chronic obstructive pulmonary disease.
Dr/ ABD ALLAH NAZEER. MD.

2. Chronic obstructive pulmonary disease is defined as a
preventable and treatable disease state characterized by
airflow limitation that is not fully reversible. The airflow
limitation is usually progressive and is associated with an
abnormal inflammatory response of the lungs to noxious
particles or gases, primarily caused by cigarette smoking.
Emphysema is one of its components, along with asthma
and chronic bronchitis.
Emphysema is defined pathologically as permanent
enlargement of the airspaces distal to the terminal
bronchioles, accompanied by destruction of their walls
and without obvious fibrosis.
Chronic bronchitis is defined as chronic productive cough
for 3 months in each of 2 successive years in a patient in
whom other causes of chronic cough have been excluded.

4. Clinical presentation
The clinical features of emphysema should be distinguished from the
signs and symptoms of chronic bronchitis. Patients with emphysema
are hypocapnoeic and are often referred to as "pink puffers". This
compares with the hypercapnoea and cyanosis of chronic bronchitis
with patients referred to as "blue bloaters". In practice, features of
these two syndromes coexist as chronic obstructive pulmonary disease.
Patients typically report dyspnea without significant sputum
production.
Signs of emphysema include:
tachypnoea
absence of cyanosis
pursed-lip breathing
chest hyperinflation
reduced breath sounds
hyper-resonant to percussion
Cor pulmonale (late)

6. Radiographic features
Plain film
Except in the case of very advanced disease with bulla formation, chest radiography does
not image emphysema directly, but rather infers the diagnosis due to associated features:
hyperinflation:
flattened hemidiaphragm(s): most reliable sign
increased and usually irregular radiolucency of the lungs
increased retrosternal airspace
increased antero-posterior diameter of chest
widely spaced ribs
sternal bowing
tenting of the diaphragm
saber-sheath trachea
vascular changes:
paucity of blood vessels, often distorted
pulmonary arterial hypertension
pruning of peripheral vessels
increased caliber of central arteries
right ventricular enlargement
It should be remembered, however, that the most common plain film appearance of COPD
is "normal" and the role of chest radiography is to eliminate other causes of lung
symptoms such as infection, bronchiectasis or cancer .

7. CT is currently the modality of choice for detecting emphysema; HRCT is
particularly effective. It should be noted, however, that there is relatively poor
correlation between autopsy-proven emphysema, pulmonary function test
abnormalities and CT with 20% of pathology-proven cases not being evident
on CT and 40% of patients with abnormal CT having normal pulmonary function
tests. CT is able to discriminate between centrilobular, panlobular, and
paraseptal emphysema.
Centrilobular emphysema
Centrilobular is by far the most common type encountered, and is a common
finding in asymptomatic elderly patients. It is predominantly located in the upper
zones of each lobe (i.e. apical and posterior segments of the upper lobes, and
superior segment of the lower lobes) and has a patchy distribution. It appears as
focal lucencies (emphysematous spaces) which measure up to 1 cm in diameter,
located centrally within the secondary pulmonary lobule, often with a central or
peripheral dot representing the central brochovascular bundle
Panlobular emphysema
Panlobular emphysema is predominantly located in the lower lobes, has a
uniform distribution across parts of the secondary pulmonary lobule, which
are homogeneously reduced in attenuation.

8. Paraseptal emphysema
Paraseptal emphysema is located adjacent to the pleura and
septal lines with a peripheral distribution within the secondary
pulmonary lobule. The affected lobules are almost always
subpleural, and demonstrate small focal lucencies up to 10 mm
in size.
Any lucency larger than 10 mm should be referred to as
subpleural blebs or subpleural bullae (synonymous).
In all three subtypes, the emphysematous spaces are not
bounded by any visible wall.
MRI
MRI is in the research phases for evaluation of lung parenchymal
abnormalities like emphysema. Dynamic breathing MRI may
have a future role in assessing pulmonary emphysema

9. Emphysema
Emphysema typically presents as areas of low attenuation without visible walls as
a result of parenchymal destruction.
Centrilobular emphysema
Most common type
Irreversible destruction of alveolar walls in the centrilobular portion of the
lobule
Upper lobe predominance and uneven distribution
Strongly associated with smoking.
Panlobular emphysema
Affects the whole secondary lobule
Lower lobe predominance
In alpha-1-antitrypsin deficiency, but also seen in smokers with advanced
emphysema
Paraseptal emphysema
Adjacent to the pleura and interlobar fissures
Can be isolated phenomenon in young adults, or in older patients with
centrilobular emphysema
In young adults often associated with spontaneous pneumothorax

10. Types of emphysema: line diagram shows the parts of secondary pulmonary lobule that are
affected in different types of emphysema. Respiratory bronchioles are primarily affected by
centrilobular emphysema; peripheral alveolar ducts, sacs, and alveoli in paraseptal
emphysema (PLE); all the components (i.e., respiratory bronchioles, alveolar ducts, alveolar
sacs, and alveoli) in panlobular emphysema (PLE), and any part in irregular or
paracicatricial emphysema.

13. Centrilobular emphysema (CLE) and edema: A, Chest radiographs, postero-
anterior and lateral views, show hyperinflation of the lungs (flattened
diaphragm), increased translucency in the upper lungs with vascular attenuation
and loss of arborization. B, Emphysematous spaces outlined by edema fluid filling
the surrounding airspaces give an appearance of reticulation in this patient with
lung edema superimposed on confluent, upper-lung predominant CLE.

14. Centrilobular Emphysema in a Cigarette Smoker. Axial CT image through the upper lungs
shows numerous well-defined lucencies, many of which are traversed by a central vessel.

15. Centrilobular emphysema due to smoking. The periphery of the lung is spared (blue
arrows). Centrilobular artery (yellow arrows) is seen in the center of the hypodense area.

16. Centrilobular pulmonary emphysema

17. Centrilobular emphysema:
A, Transverse computed
tomography images shows
centrilobular
hypoattenuation with upper
lung predominance. Note
the resemblance of the
macroscopic pathologic
image in Figure 4A. B,
Coronal minimum intensity
projection image brings out
the distribution and extent
of emphysema.

18. Centrilobular emphysema: Transverse computed tomography images in the first
row and minimum intensity projection images in the second row show confluent
centrilobular hypoattenuation with posterior lung predominance (arrows), Also
note para-septal emphysema in the left upper lobe (arrow heads).

20. Panlobular emphysema (PLE) from a-1–antitrypsin deficiency: chest radiographs
in postero-anterior and lateral projections show hyperinflation and increased
translucency in the lower lungs with vascular attenuation, indicating PLE.

21. Panlobular emphysema (PLE) from a-1–antitrypsin deficiency: computed tomography
images (first row) show confluent lower-lung predominant panlobular
hypoattenuation, indicating PLE. The confluence, panlobular distribution, lower-lung
predominance, and vascular attenuation are better shown by the coronal minimum
intensity projection and maximum intensity projection images (second row).

22. A- Chest tomography in axial cut showing areas of panlobular emphysema in predominately
lower lobes. Note cylindroids bronchiectasis and thickening of bronchial walls, most evidence
in right. B- coronal reformatted showing hyper-inflation areas in lower lobes.

23. Ritalin lung with panlobular emphysema: chest radiographs, postero-anterior projection,
and computed tomography (coronal reformatted image) show basal-predominant
panlobular hypoattenuation similar to that found in a-1–antitrypsin deficiency.

24. Panlobular Emphysema in a Patient with Alpha-1 Antitrypsin Deficiency. Axial image through
the lower lungs shows homogenous decrease in lung attenuation in both lower
lobes. Some of the interlobular septa in the right lower lobe are accentuated by the emphysema.

25. Panlobular emphysema

27. Paraseptal emphysema: computed tomography shows rectangular cysts sharing
walls in subpleural upper lobes and the superior segment of the left lower lobe.
Centrilobular emphysema is also evident in the upper lobes (arrows).

28. Paraseptal Emphysema in a Cigarette Smoker. Axial image through the upper
lungs shows multiple well-demarcated subpleural air-containing spaces.

29. Paraseptal emphysema with small bullae.

31. Paracicatricial emphysema (PCE) from progressive massive fibrosis caused by silicosis:
computed tomography images in lung window show conglomerate masses in the
posterior upper lobes with surrounding low attenuation (arrows) indicating PCE.
Hyperinflation of the anterior upper lungs is from traction by the conglomerate masses.

32. Coronal reformat demonstrating heterogeneous opacity in the right upper lobe
and areas of centrilobular emphysema and para-septal. Tuberculosis in COPD.

33. Bullous emphysema: postero-anterior radiograph and coronal computed tomography
multiplanar reformation and maximum intensity projection images show a large bulla
in the right upper lobe with atelectasis of the adjacent lung (arrows).

34. Apical bleb: computed tomography through the lung apex and multiplanar
reformation show a left apical bleb floating in small pneumothorax
(arrows). Also note unruptured blebs in the right lung apex.

39. Quantification of Emphysema and Air Trapping in 66 year old Individual with GOLD Stage 3 COPD (FEV1 43% predicted)
(a) Inspiratory CT: coronal image depicts voxels with CT attenuation less than -950HU indicating emphysema (14% in
this case). Color coding: Indicates lobes. (b) Inspiratory CT: coronal image depicts distribution of sizes of
emphysematous clusters, with color coding depending on cluster size. (c) Expiratory CT: coronal image depicts voxels
with CT attenuation less than -856HU indicating air trapping (38% in this case). (d) Image map derived from co-
registered inspiratory and expiratory images depicts change in voxel attenuation from inspiration to expiration.
Color coding: Red indicates voxels that were less than -950 HU on inspiration and less than -856 HU on expiration
(emphysema). Yellow indicates voxels that were greater than -950 HU on inspiration, but less than -856 HU on expiration
(air trapping). Green indicates voxels that were less than -950 HU on inspiration and less than -856 on expiration
(normal). White indicates voxels that were greater than -950 HU on inspiration but less than -856 on expiration.
Progress in Imaging COPD, 2004-2014

40. Follow up CT Analysis in Same Subject as Shown in Figure 6. Color coding: Same as in Figure 6. (a) %
LAA-950 has increased from 14% to 23%. (b) Cluster sizes have also increased. (c)Air trapping appears
to have increased from 38% to 45%. (d) Inspiratory-expiratory registration shows that only the amount
of emphysema increased, while the amount of gas trapping remained constant. (e) Longitudinal
registration of baseline and follow up inspiratory scans with micro mapping shows areas of stable
emphysema in red, new areas of emphysema in yellow, and stable normal lung in green.

41. Images in representative
patients with mild-to-
moderate or severe
chronic obstructive
pulmonary disease
(COPD).

42. Chronic bronchitis (CB) is often defined as the presence of
productive cough for 3 months in two successive years in a
patient in whom other causes of chronic cough, such as
tuberculosis, lung cancer and heart failure, have been
excluded. It can be an important pathological component
of chronic obstructive pulmonary disease. (often
considered as a distinct phenotype of COPD)
Pathology
Chronic bronchitis most often results from overproduction
and hypersecretion of mucus by goblet cells. This can in
turn lead to worsening airflow obstruction by luminal
obstruction of small airways, epithelial remodeling, and
alteration of airway surface tension predisposing to
collapse.

43. Diagnosis:
A physical examination will often reveal decreased intensity of
breath sounds, wheezing, rhonchi, and prolonged expiration. Most
physicians rely on the presence of a persistent dry or wet cough as
evidence of bronchitis.
A variety of tests may be performed in patients presenting with
cough and shortness of breath:
A chest X-ray is useful to exclude pneumonia which is more common
in those with a fever, fast heart rate, fast respiratory rate, or who
are old.
A sputum sample showing neutrophil granulocytes (inflammatory
white blood cells) and culture showing that has pathogenic
microorganisms such as Streptococcus species.
A blood test would indicate inflammation (as indicated by a raised
white blood cell count and elevated C-reactive protein).

44. Chronic bronchitis with bronchial wall thickening with increased brochovascular
markings, enlarged vessels and cardiomeagly (abnormal enlargement of the heart).

45. Chronic bronchitis: postero-anterior radiograph (A) and computed tomography
(B) show bilateral bronchial wall thickening, the so-called, ‘‘dirty lung.’’

46. Computed tomography (CT) scan in an elderly patient with known chronic
bronchitis. The scans demonstrate thickening of the bronchial walls (purple
arrows) and bronchi filled with mucus or phlegm (blue arrows).

47. Computed tomography (CT) scan in patient with chronic bronchitis showing thickening
of the bronchial walls (red arrows) and mucous within the bronchi (yellow arrows).

50. Thank You.