COPD Flip part 1

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COPD Flip part 1

• JK Amorosa

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Emphysema

• Centriacinar (centrilobular)
• Panlobular
• Paraseptal
• Irregular

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Emphysema definitions

• Centriacinar cigarette smoking, upper lobes
• Dilitation second order respiratory
  bronchioles, respiratory bronchiolitis may be
  precursor
• Panlobular lower lobes, involves entire
  lobule, seen in senile emphysema and
  alpha-1-antiprotease deficiency
• Paraseptal involves periphery of secondary
  pulmonary lobule, assoc with scars, ptx
• Bullae Emphysema with more than 1 cm in diameter
  with wall thickness lt 1mm

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Emphysema Chest X-ray

• Hyperinflation
• Flat diaphragms
• Widened retrosternal air space
• Lung height increased
• Small narrow heart

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Emphysema lung parenchyma

• Arterial deficiency, increased branching angle of
  remaining vessels
• Increased markings / bronchial wall thickening or
  superimposed enphysematous walls

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Emphysema secondary manifestations

• PA hypertension

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HRCT

• Emphysematous holes have no walls, attenuation
  values of -950 HU or less on thin-section CT
  scans with a 10-mm interval correlate well with
  pulmonary function test results and the
  pathologic distribution of emphysema, reduced CT
  attenuation coefficients
• Bronchial wall thickening
• Hyperinflation
• Expiratory air-trapping
• Vascular pruning

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Emphysema-predominant
airway-dominant
Radiology Oct 2011
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Figure 1 Axial CT image obtained in a 66-
year-old man with COPD and severe airflow
obstruction (percentage of predicted FEV1, 40.8)
shows mild emphysema (relative low-attenuation
area with attenuation of -950 HU or lower, 5.8).
Low-attenuation areas representing emphysematous
change (holes) are indicated by
arrowheads. RadioGraphics, http//pubs.rsna.org/
doi/abs/10.1148/rg.301095110
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Figure 3b (a) Axial CT image obtained in a
72-year-old man with COPD shows multiple
low-attenuation areas of emphysema. (b) Axial CT
image obtained with data segmentation shows the
same lung field as in a. The total lung
parenchymal area (areas with attenuation of -500
to -1024 HU) is depicted in red, and vascular and
other structures are shown in gray. (c) Axial CT
image obtained with data segmentation shows the
same lung field as in a and b. Voxels with
attenuation of -950 HU or lower are depicted in
red, and those with attenuation of -500 to -949
HU are depicted in black. (Vascular and other
nonparenchymal structures are shown in gray.) To
quantify the extent of emphysema, the percentage
of the total lung area occupied by voxels with
attenuation of -950 HU or lower (ie, the relative
low-attenuation area) can be calculated from
these segmented CT image data. RadioGraphics,
http//pubs.rsna.org/doi/abs/10.1148/rg.301095110

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Figure 3c (a) Axial CT image obtained in a
72-year-old man with COPD shows multiple
low-attenuation areas of emphysema. (b) Axial CT
image obtained with data segmentation shows the
same lung field as in a. The total lung
parenchymal area (areas with attenuation of -500
to -1024 HU) is depicted in red, and vascular and
other structures are shown in gray. (c) Axial CT
image obtained with data segmentation shows the
same lung field as in a and b. Voxels with
attenuation of -950 HU or lower are depicted in
red, and those with attenuation of -500 to -949
HU are depicted in black. (Vascular and other
nonparenchymal structures are shown in gray.) To
quantify the extent of emphysema, the percentage
of the total lung area occupied by voxels with
attenuation of -950 HU or lower (ie, the relative
low-attenuation area) can be calculated from
these segmented CT image data. RadioGraphics,
http//pubs.rsna.org/doi/abs/10.1148/rg.301095110

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Emphysema Pathology

• Abnormal enlargement of airspaces distal to
  terminal bronchioles with destruction of alveolar
  walls

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Figure 4 Coronal CT image obtained in a
62-year-old man with COPD shows
upper-lungpredominant emphysema. The relative
low-attenuation area with attenuation of -950 HU
or lower (red) is 46.8, and the percentage of
predicted FEV1 is 56.8. RadioGraphics,
http//pubs.rsna.org/doi/abs/10.1148/rg.301095110

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Figure 5 Coronal CT image obtained in a
72-year-old man shows lower-lungpredominant
emphysema. The relative low-attenuation area with
attenuation of -950 HU or lower (red) is 45.8,
and the percentage of predicted FEV1 is 45.6.
The extent of lower-lungpredominant emphysema is
more closely correlated with the result of
pulmonary function testing than the extent of
upper-lungpredominant emphysema. (In both
figures, black indicates areas with attenuation
of -500 to -949 HU and gray indicates vascular
and other nonparenchymal structures.) RadioGraphi
cs, http//pubs.rsna.org/doi/abs/10.1148/rg.30109
5110
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Figure 8a Volumetric CT-based measurement of
airway dimensions. (a) Schema obtained with the
region-growing method shows airway segmentation
and selection of a bronchial pathway (black line)
for measurement. A curved multiplanar reformatted
image is reconstructed along the selected
pathway, and a short-axis image is reconstructed
in a plane exactly perpendicular to the long axis
of the airway. The red dot indicates the location
of the short-axis image in b. (b) Short-axis
image with overlaid diagram shows the radii (red
and green lines) used to delimit the inner lumen
and calculate its area. From the point of their
intersection, the centroid point, rays (blue
lines) are drawn over a 360 radius through the
airway wall to allow calculation of the airway
wall thickness by using the full width at half
maximum principle. RadioGraphics,
http//pubs.rsna.org/doi/abs/10.1148/rg.301095110

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Figure 8b Volumetric CT-based measurement of
airway dimensions. (a) Schema obtained with the
region-growing method shows airway segmentation
and selection of a bronchial pathway (black line)
for measurement. A curved multiplanar reformatted
image is reconstructed along the selected
pathway, and a short-axis image is reconstructed
in a plane exactly perpendicular to the long axis
of the airway. The red dot indicates the location
of the short-axis image in b. (b) Short-axis
image with overlaid diagram shows the radii (red
and green lines) used to delimit the inner lumen
and calculate its area. From the point of their
intersection, the centroid point, rays (blue
lines) are drawn over a 360 radius through the
airway wall to allow calculation of the airway
wall thickness by using the full width at half
maximum principle. RadioGraphics,
http//pubs.rsna.org/doi/abs/10.1148/rg.301095110

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• Airway-predominant
• Rx medical
• Small airway disease cannot be visualized
  directly with current radiographic techniques,
  calculate the expiratory-inspiratory attenuation
  ratio see volumetric CT based measurement

• Emphysema-predominant
• Rx Sx

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• 30 of lung has to be destroyed to alter
  pulmonary function

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Pulmonary functions

• Increased total and residual volumes
• RV(residual volume) gt120 predicted
• Decreased flow volumes
• FEV Forced Expiratory Volume) lt80 predicted
• Decreased diffusion capacity lt80 predicted

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Alpha 1-Antiprotease deficiency, normally enzyme
blocks proteolytic enzymes

• Panlobular emphysema
• Lower lobes
• Common Pi ZZ phenotype 1 in 200, gene 14
• Normal phenotype Pi MM Pi MZ 60 normal
• Liver disease in infancy
• Premature development of emphysema, worse with
  smoking

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References

• Regan EA, Hokanson JE, Murphy JR, et al.. Genetic
  epidemiology of COPD (COPDGene) study design.
  COPD 20107(1)3243. CrossRef Medline
• SS Kim D Lynch Chronic Obstructive Pulmonary
  Disease Lobe-based Visual Assessment of
  Volumetric CT by Using Standard ImagesComparison
  with Quantitative CT and Pulmonary Function Test
  in the COPDGene Study Radiology, 2013, Vol.266
  626-635, 10.1148/radiol.12120385
• S Matsuoka Quantitative CT Assessment of COPD