9

High Resolution Computed Tomography and

Chronic Obstructive Pulmonary Disease
Prem Parkash Gupta
Department of Respiratory Medicine and COPD Clinic,
Postgraduate Institute of Medical Sciences,
University of Health Sciences, Rohtak,
India

1. Introduction
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable respiratory
disease with some significant extrapulmonary effects that may contribute to the severity in
individual patients. Its pulmonary components are characterized by airflow limitation that is
not fully reversible. COPD is a leading cause of morbidity and mortality worldwide. The
economic and social burdens due to it are substantial and anticipated to increase in the coming
decades due to continued exposure to COPD risk factors and the changing age profile of the
worlds population. COPD mortality trends generally track several decades behind smoking
trends. In US in 2000, more women than men died of COPD or its related complications.
COPD comprise of a heterogeneous group of disorders conventionally including
emphysema, chronic bronchitis, peripheral airways disease and pulmonary vascular
disease. It is a disease state that has seen significant changes in defining and excluding
criteria over past 50 years. Spirometry, the most frequently used tool to diagnose COPD and
to assess response to treatment in these patients, can provide only functional assessment. In
contrast to spirometry, radiological imaging allows for regional assessment of the various
compartments involved i.e. airways, parenchyma and vasculature. High-resolution
computed tomography (HRCT) is recommended for the non-invasive and sensitive
assessment of morphological changes in emphysema and has been shown to correlate well
with pathology. With the advent of new imaging techniques like multi-detector row CT
(MDCT), contrast-enhanced CT methods, spirometric controlled MDCT, use of Xenon gas to
assess regional ventilation of the lungs, magnetic resonance imaging (MRI) of the lung
developing its own arsenal like hyperpolarized He-3 MRI new avenues are being opened
up which are now increasingly supplemented with advanced and dedicated softwares.

2. Advantages of high resolution computed tomography

At present the diagnostic criteria recommended by the Global Strategy for the Diagnosis,
Management and Prevention of Chronic Obstructive Lung Disease (GOLD guidelines) do
not consider CT findings during initial diagnostic assessment (Pauwels & Buist 2001) and
principally rely on spirometry. However, enough scientific literature suggests that HRCT is
an important and indispensable tool for evaluation of COPD. Some of the uses of HRCT are
described below in next sections.

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2.1 Identifying causes of airway obstruction other than COPD

Chronic airflow obstruction may be caused by a wide variety of diseases like bronchiectasis,
upper airway lesions, bronchiolar diseases, interstitial lung diseases etc that may often
produce clinical symptoms inseparable those due to COPD. HRCT can clearly identify
different causes of airflow obstruction. Kurashima et al (2005) showed in 516 consecutive
patients whose postbronchodilator FEV1/FVC was less than 70%, HRCT was able to
identify 12.7% of patients with pulmonary diseases other than COPD including sarcoidosis,
diffuse panbronchiolitis and pneumoconiosis. The exact diagnosis of underlying pathology
leading to air flow obstruction is essential in management and to predict response to
treatment in these patients.

2.2 Identification of emphysema before appearance of clinical symptoms

HRCT can detect pulmonary emphysema even in asymptomatic smokers with normal lung
functions. Recent GOLD guidelines have abolished stage 0 that included asymptomatic
patients who were smokers and had normal lung functions; however, Sverzellati et al (2007)
observed that 13/18 subjects with stage 0 had emphysema detected over HRCT scan. It reflects
that HRCT is a sensitive tool to detect emphysema before it is manifesting clinically or with
deranged pulmonary functions. Detection of early emphysema may be of enormous value to
prevent its progression by smoking cessation and medical intervention (Morgan 1992).

2.3 Identifying and quantifying emphysema in patients with COPD

Emphysema, characterised by a parenchymal-predominant pathology in COPD and chronic
bronchitis with an airway-predominant one are distinct phenotypes and might have evolved
due to different responses to and pathogenesis related to smoking (Patel et al 2006). The
emphysematous phenotype is conventionally associated with a more severe form of disease
(Boschetto et al 2003, 2006). COPD patients with emphysema on HRCT have been observed
to have higher BODE index (body mass index, airflow obstruction, dyspnoea, exercise
performance) and a lower inspiratory capacity to total lung capacity ratio (IC/TLC) than
those without emphysema. This suggests emphysematous patients have more extensive
systemic involvements (Boschetto et al 2006). The ability to separate airway-predominant
from parenchymal-predominant pathology in COPD may prove useful in applying specific
therapies designed to prevent airway remodelling and parenchymal destruction (Grenier
2005).
HRCT often makes it possible to distinguish between different phenotypes of emphysema:
smoking related phenotype, the centriacinar emphysema; and phenotype associated with
1-antitrypsin deficiency, panacinar emphysema. Moreover, HRCT can detect the
coexistence of both panacinar and centriacinar emphysema in the same individual, as some
patients with 1-antitrypsin deficiency may also be smokers (Copley et al 2002).

2.4 Detection of co-existing bronchiectasis

Presence of bronchiectasis in COPD patients on functional evaluation using spirometry is often
not detected; this fact become appreciable when HRCT studies are done. One study observed
that 29% of COPD patients who were having frequent exacerbations had bronchiectatic
changes detected on HRCT (OBrien et al 2000). Patel et al (2004) found that the extent of lower
lobes bronchiectasis in these patients was related to colonization by the potential pathogens,
increased inflammatory markers, and a longer time to symptom recovery after exacerbation.

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The likely pathogenesis for typical structural abnormalities seen on HRCT include damaged
muco-ciliary transport, localized or diffuse peripheral obliteration of the bronchial tree and
lung tissue scarring all these may be acting in concert in COPD.

2.5 Evaluation of large airways

Airway predominant pathology in COPD is significant and it is diagnosed conventionally
based on clinical symptomatology of chronic or recurrent excess of mucus secretion in the
bronchial tree (chronic was defined as occurring on most days of three months of a year, for
at least two successive years), in whom other causes of chronic cough have been excluded
(American thoracic society 1995). With the development of multidetector-row computed
tomography (MDCT) understanding of the larger airway diseases has been improved
dramatically. Volumetric thin-section CT scans are able to detect small pits or diverticulae
along the inner surfaces of the large bronchi (Zompatori et al 2006). These pits are supposed
to correspond to dilated bronchial gland ducts opening into the large airway lumen (Grenier
et al 2004; Zompatori et al 2006).

2.6 Assessment of regional distribution of emphysema

HRCT scan can also provide details regarding regional distribution of emphysema. The role
of distribution of emphysema on HRCT as a predictor of mortality is a hot topic. One study
reported a greater proportion of emphysema in the lower lung versus the upper lung to be
predictive of mortality; the authors speculated that lower-lobe emphysema may be either a
marker of increased disease severity or, alternatively, a phenotypic or pathobiologic variant
(Martinez et al 2006). Other studies explored the influence of the distribution pattern of
emphysema on different lung function parameters. A higher percentage of emphysema in
the core was associated with a more reduction in diffusion capacity (Aziz et al 2005). The
contribution of emphysema at core to pulmonary dysfunction (with FEV1/ FVC %) may be
larger than at periphery (Nakano et al 1999).

2.7 Essential for surgical interventions in COPD

Two surgical therapies, bullectomy and lung volume reduction surgery (LVRS), are sometimes
recommended in COPD patients. A chest radiograph may suggest the presence of bullae, but
accurate existence and extent of such lesions can only be assessed with chest CT scans
(Martinez & Chang 2005). Similarly, the presence, extent, and distribution of emphysema can
precisely be determined with a chest CT scan. The work over lung volume reduction surgery
(LVRS) suggests more benefits in patients with upper lobe emphysema (Cooper et al 1995).
A chest CT scan is an important tool to determine patients who should not undergo LVRS
(Group NETTR 2001). In NETT, LVRS was associated with a high risk of death (16% with
LVRS compared with 0% in subjects treated medically) at 30 days in two types of subjects
with emphysema: (1) those with FEV1 of less than or equal to 20% of predicted and non
upper lobepredominant disease, and (2) subjects with FEV1 of less than or equal to 20% of
predicted and a diffusing capacity less than or equal to 20% of predicted.

3. High resolution computed tomography: evolution with the time

During the last couple of decades, HRCT has been widely used to evaluate emphysematous
and chronic bronchitis components of COPD. The initial work by Edinburg group was to

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use computed tomography to diagnose emphysema in living patients (Gould et al 1988).

Since then, HRCT has been widely established to detect and quantify COPD and its
subtypes. Several workers have studied the correlation of semi-quantitative scoring of
COPD by HRCT, pathology, clinical features and pulmonary function tests (Sanders et al
1988; Gupta et al 2008, 2009). HRCT indices of emphysema reflect lung anatomy and
represent the best way to assess emphysema severity in life (Newell et al 2004). The
introduction of multidetector-row CT (MDCT) scanners has provided powerful tools to
evaluate changes in both small and large airways. In addition, dynamic imaging via MDCT
allows the assessment of perfusion and ventilation in the lung parenchyma. Therefore, CT is
able to precisely define the pathological process by providing accurate anatomic
informations as well as functional data from the area of interest.
The parameters that have been extensively used by different workers to detect and
differentiate various diseases grouped under COPD, and to quantify these diseases are
described in following sections.

4. Measurements of lung density

The digital data provided by HRCT can be analyzed to detect the presence and severity of
emphysema by several means. The measurement of lung density for quantifying
emphysema may be done by visual estimation or automated techniques, both of which
have their proponents (Desai et al 2006). These methods demonstrated good correlation with
pathological assessment of emphysema severity (Muller et al 1988; Gevenois et al 1996). The
extent of the lung density representing the disease can be visually graded according to a
categorical scale. A potential drawback of visual estimation is inter-observer variation,
although observer disagreement in scoring the extent of emphysema has been an
insignificant factor in many of previous studies (Desai et al 2006). The potential
interobserver variation is balanced by the speed and the simplicity of the technique.
The extent of emphysema can be determined by using a threshold technique for image
segmentation. This is accompanied by setting of lower threshold for normal lung
attenuation. The total area of volume of lung is calculated first using the lower threshold
value and amount of emphysematous lung is determined by calculating the percentage of
lung that is less than threshold value (Muller et al 1988). This technique is called as
density mask method. Routinely, 910 HU is taken as threshold value. In a study,
authors compared CT lung densitometry in 20 COPD patients and in control subjects
(Lamers et at al 1994). They found that percentage of pixels with attenuation less than
910 HU correlated well with visual emphysema score. In another study, HRCT scans were
obtained with 1 cm intervals in 38 subjects (Gevenois et al 1996). The percentage areas
occupied by attenuation values inferior to thresholds ranging from 900 HU to 970 HU
were calculated. Emphysema was microscopically quantified in resected lung specimen.
The strongest correlation was found for 950 HU and pulmonary function tests also
correlated with emphysema measured by density mask method. However, other workers
tried to correlate relative areas occupied by attenuation values lower than eight
thresholds ranging from 900 to 970 HU with macroscopic emphysema and observed
that a standard can not be recommended for the measurement of emphysema. Using
precise morphometric evaluation of resected lung tissue, Bankier et al (1999) showed that
observers, regardless of their experience, tend to overestimate the extent of emphysema
on CT, whereas CT densitometry correlates better with the morphometric reference. The

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density mask has been used to identify subgroups of patients who may show benefit from
lung volume reduction surgery (Fishman et al 2003). The percentage of emphysema
quantified by density mask is also predictive of survival in 1-antitrypsininduced
emphysema (Dawkins et al 2003).
Another objective way to measure emphysema on HRCT is assessment of mean lung
density (Nowell 2002). CT density is expressed as a linear scale in HU (water = 0, air =
1000). In this range, lung density is a direct measure of physical density and is determined
by the relative mix of air, blood and interstitial fluid in tissue. Emphysema will lead to
decrease in mean lung density on CT. Several studies have assessed CT lung density in
normal subjects. However, the range of normality remains to be standardized. In a study,
authors assessed the progression of pulmonary emphysema in 23 patients by means of lung
density (Zagiers et al 1996). Patients were scanned twice with a 1 year interval. Mean lung
densities decreased within this duration and proved to be more sensitive than FEV1 and
carbon monoxide diffusion.
The image histogram curve of CT lung density values can be obtained using softwares and
measures of skewness can be looked at as another mean of detecting and assessing the
presence of emphysema. Tail of high density value is produced by large vessels and airways
and in emphysema, there is an increase in the numbers of low density pixels and the whole
curve is shifted to the left (MacNee et al 1991). In a study, three groups of individuals, 20
with emphysema, 20 with chronic bronchitis and healthy individuals underwent CT and
cut-off point in the histogram that defines the lowest 10th percentile of the histogram was
derived (Lamers et al 1994). They observed that it is possible to classify lung disease using
this parameter.
The softwares available in addtion with MDCT scanners make it possible to recognize and
quantify emphysema faster than human evaluation; and it is now possible to apply techniques
measuring lung density to volumetric data. The resolution achieved in thoracic HRCT allows
the application of high-precision 3D image analytic tools to CT data (Kuhnigk et al 2005). The
analyses allow a convenient regional assessment of CT parameters including total volume,
mean density, pixel index, and emphysema type (Kuhnigk et al 2005).
A density-masking approach alone is not sufficient to accurately distinguish between
normal and diseased lung, especially in the case of early or mixed pathologic processes
(Uppaluri et al 1997, 1999; Hoffman et al 2006). Further, CT densitometry is known to be
influenced by several factors (eg, age, weight, beam hardening from adjacent ribs etc.) and
calibration must be performed in order to obtain reliable densitometry. Neither visual nor
pure densitometric approaches to CT quantification of emphysema are, therefore, perfect.
In addition to assessment of percentage of voxels below a certain threshold, more
sophisticated analytic softwares may analyse the CT scan data, contiguous
emphysematous lesions can be clustered to obtain the volumes for small-sized, medium-
sized, and large-sized emphysematous areas (cluster distribution) (Blechschmidt et al
2001; Zaporozhan et al 2005). A serial assessment of cluster distribution is useful in
revealing the pattern of progression of emphysema. Uppaluri et al (1997, 1999) examined
multiple features of the CT images and X-ray attenuation values to describe the lung and
developed the Adaptive Multiple-Feature Method (AMFM), which can assess up to 22
independent textural features from HRCT scans to classify a tissue pattern. This is found
to be useful to distinguish smokers from non-smokers in the absence of other disease
(Hoffman et al 2006).

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5. Mosaic attenuation pattern and air trapping

Abnormalities on HRCT that reflect small airways disease can be broadly categorized into
indirect and direct signs: widespread scarring and obliteration of the bronchioles results in
the indirect sign of patchy density differences of the lung parenchyma, representing areas of
under-ventilated and under-perfused lung (mosaic attenuation pattern). The considerable
thickening of the small airways walls by inflammatory infiltrate and/or luminal and
surrounding exudate render the affected small airways directly visible (Hansell 2001). Air
trapping or hyperinflation is a common manifestation of COPD (Stern & Frank 1994).
Persistent aeration caused by collateral pathways, or hyperaeration from trapped air,
produces the mosaic attenuation pattern which is characterized by nonhomogenous lung
density, i.e. areas that remain relatively lucent interspersed with areas of normal higher lung
density. The air trapping and mosaic attenuation pattern is more pronounced, on scans
obtained at end-exhalation instead of the more conventional end-inspiration technique
(Arakawa & Webb 1998). In a recent study, it was found that mosaic attenuation pattern in
addition to other HRCT features is helpful in distinguishing different entities grouped
under COPD (Copley et al 2002).

Fig. 1. HRCT scans showing non-homogenous lung density a cardinal feature of mosaic
attenuation pattern (A-F) observed on HRCT scan obtained from different COPD patients.

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High Resolution Computed Tomography and Chronic Obstructive Pulmonary Disease 155

In our studies (Gupta et al 2008, 2009) including 40 COPD patients who were diagnosed
based on GOLD criteria and who were evaluted for HRCT characteristics, 16/40 patients
had classic mosaic attenuation pattern; the HRCT scans were undertaken during full
inspiration. Some of these are shown in figure 1 (A to F).

6. Directly visible small airways

Several pathological studies have shown that the major site of airway obstruction in COPD
is in airways with internal diameter lesser than 2 mm. The 2 mm airways are located
between the fourth and the 14th generation of the tracheobronchial tree. These airways are
not visible on HRCT scan in normal subjects. However, considerable thickening of the
bronchiolar walls by inflammatory infiltrate and/or luminal and surrounding exudates
render them directly visible (Hansell 2001). These diseased airways are visible on HRCT as
dilated, air-filled, branching, tubular or ring-like structures in the lung periphery by wall
thickening and dilation. When the airways are obliterated by submucosal or peribronchial
fibrosis, nodular, linear, or branching peripheral opacities may be seen (Teel et al 1996). In
our study, 36 out of 40 COPD patients showed directly visible small airways (figure 2).

Fig. 2. HRCT axial scans showing directly visible small airways as (A-C) air filled ring like
structures and (D) air filled branching tubular structures.

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7. Measurements of airway wall thickness

It has been observed that the size of the large and intermediate airways reflect airway
dimensions in the smaller airways (Nakano et al 2005). Due to the interobserver
disagreement in the visual interpretation of bronchial wall thickness on CT scans (Muller
and Coxson 2002), there has been considerable interest in the development of objective
measurements of airway wall dimensions. The most frequently reported method for
measuring the airway lumen and wall areas relies on the full-width-at-half-maximum (or
half-max) technique, in which the inner and outer airway wall boundaries are defined as
the point corresponding to the half maximal intensity of the airway wall voxels (Nakano et
al 2000; de Jong et al 2005). Using the half-max method, Nakano et al (2000) showed that an
increased thickness of the apical right upper lobe bronchus over HRCT correlated with the
severity of airflow obstruction in COPD patients. However, the measurements of airway
lumen and wall area depends on the lung volume and angle between the airway central axis
and the plane of section (Grenier et al 2004).
In 42 COPD patients, bronchi with external diameter of greater than 2 mm and maximum to
minimum diameter ratio less than 1.5 were selected (Orlandi et al 2005). Thickness to
diameter ratio (TDR) and the percentage wall area (PWA) of these bronchi were computed.
For each patient, mean TDR and mean PWA were calculated. The combination of PWA,
TDR and PWA normalized to body weight correlated significantly (P < 0.05) with
FEV1/SVC ratio and DLco in patients with chronic bronchitis but not in patients without
chronic bronchitis.
In another study, thickness to diameter ratio (TDR), and percentage of wall area (WA%)
were calculated on HRCT in 4 groups of patients : group O - healthy non smokers, group I -
healthy current smokers, group II - patients with moderate COPD and group III - those with
severe COPD as per GOLD classification (Deveci et al 2004). Both groups II and III had
higher T/D ratio and WA% than group I and group I had higher values than group O.
Airway wall thickening was found to be inversely correlated with FEV1 and positively
related to the quantum of smoking.

8. Low attenuation areas of emphysema

HRCT is a reliable tool for demonstrating even subtle changes in secondary pulmonary
lobules. Low attenuation areas of emphysema are distinctly visible on HRCT scan. These
focal areas of decreased attenuation present differently in different types of emphysema
(Nowell 2002).
Centriacinar emphysema is the commonest type of pulmonary emphysema and is
characterized by an enlargement of the centriacinar airspace, with the effect mainly
occurring in proximal respiratory bronchioles, leaving normal distal alveolar ducts and sacs.
In centriacinar emphysema, focal areas of decreased attenuation have no discernable wall
and usually have a focal arteriole at or near the centre of lesion (Figure 3 A-F). Centriacinar
abnormalities always have a distance of about 2.5 mm from the perilobular structure,
including interlobular septum, pleura and large pulmonary vessels. Cigarette smoking and
dust inhalation are the most important risk factors for the development of centriacinar
emphysema. The disease is usually distributed to the upper lobe or the superior segment of
the lower lobe. The inner zone is more severely affected than the outer zone, probably due

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High Resolution Computed Tomography and Chronic Obstructive Pulmonary Disease 157

Fig. 3. HRCT scans in patients with centriacinar emphysema showing multiple, round lucent
regions of various sizes surrounded by normal parenchyma (A-F).
to zonal differences in respiratory kinetics and lymph flow. HRCT in early centriacinar
emphysema shows evenly distributed centrilobular tiny areas of low attenuation with ill-
defined borders; with enlargement of the dilated airspace, the surrounding lung
parenchyma is compressed and a clear border may be observed between the
emphysematous area and normal lung.

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Panacinar emphysema is characterized by a uniform dilatation of the air space from the
respiratory bronchioles to the alveoli, leading to evenly distributed emphysematous changes
within secondary lobules. Panacinar emphysema is characterized by large areas of
decreased lung density or decreased attenuation on CT with poorly defined margins; the
caliber of the vessels in the involved area is decreased due to overinflation of the air space
[Figure 4 (A-D)]. Alpha 1-antitrypsin deficiency is thought to be a major cause of panacinar
emphysema. Other rare etiologies, including Swyer-James syndrome and ritalin abuse, have
been reported. The characteristics that distinguish panacinar emphysema from centriacinar
emphysema are as follows: the disease is dominant in the lower lung field, the degree of
lung inflation is greater than that in centriacinar emphysema; there is a tendency for the
airway to be narrowed; and bullous formation is less frequently observed compared to
centriacinar emphysema.

Fig. 4. (A-B): Panacinar emphysema: HRCT scans showing diffuse low attenuation lung
parenchyma typical of panacinar emphysema
Distal acinar emphysema is characterized by focal areas of subpleural emphysema. Distal
acinar or paraseptal emphysema is characterized by an enlarged airspace at the periphery of
acini. The lesion is usually limited in extent, occurs most commonly along the dorsal surface
of the upper lung. The patients are usually asymptomatic, but distal acinar emphysema is
considered to be a cause of pneumothorax in young adults.
The subtypes of emphysema can usually be determined in mild or moderate cases, but
classification into anatomic subtypes becomes more difficult by HRCT and pathological
examinations as emphysema becomes more severe, with even highly trained and
experienced pathologists sometimes disagreeing on the classification. Centriacinar and
panacinar emphysema may coexist in the same patient; for example, with centriacinar
emphysema in the upper lobe and panacinar emphysema in the lower lobe.

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High Resolution Computed Tomography and Chronic Obstructive Pulmonary Disease 159

Fig. 4. (C-D): Some more HRCT scans showing panacinar emphysema

Fig. 5. (A-D): HRCT scans showing small subpleural areas of hyperlucency characteristic
of paraseptal emphysema.
Studies have been done to assess the accuracy of CT in diagnosis of emphysema by visual
scoring of low attenuation areas. In a study, CT thorax was performed on 32 patients
scheduled for elective thoracotomies for suspected lung tumours (Bergin et al 1986). Each
slice was assessed and graded depending upon the percentage area showing
emphysematous areas. Similarly, emphysema was graded on the resected lung specimens. It
was found that compared to pulmonary function tests, CT was a better predictor of
assessing the presence and severity of emphysema.

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A retrospective study used HRCT scans for scoring the severity of emphysema (Klein et al
1992). Each of the six lung sections was evaluated and extent of emphysema multiplied by
the severity was summed for the six sections. Concomitant chest radiographs and
pulmonary function tests were reviewed. The severity of emphysema on HRCT correlated
inversely with single breath carbon monoxide diffusion capacity. HRCT allowed detection
of emphysema in symptomatic patients when chest radiographs and pulmonary function
tests were non-diagnostic.

Fig. 6. (A-D) : HRCT scans of different COPD patients showing vascular attenuation
characterized by thinning of pulmonary vessels at the peripheral lung field along with
reduction in their number.

9. Vascular attenuation and vascular distortion

On HRCT of emphysema patients, low attenuation areas are frequently accompanied with
vascular attenuation and distortion (Norwell 2002). Vascular attenuation is defined as
thinning of pulmonary vessels and reduction in their number [figure 6 (A-D)]. Vascular
distortion is increased branching angles, excessive straightening or bowing of vessels.
[figure 7 (A-D)].

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Fig. 7. (A-D): HRCT axial scans from COPD patients showing vascular distortion characterized
by increased branching angles and excessive straightening of pulmonary vessels.
In a study, two radiologists and one chest physician assessed for destructive changes of
emphysema manifested by low attenuation areas and disruption of vascular pattern (Kuwano
et al 1990). Each slice was individually assessed using a modification of the picture-grading
system of Thurlback (1994). CT scores correlated significantly with the pathological scores and
it was concluded that HRCT can help to identify the presence and grading of mild
emphysema. Other studies have found that vascular disruption in addition to areas of low
attenuation is helpful in assessing and grading emphysema (Bergin et al 1986).

10. Saber-sheath trachea and tracheal index

In cross-section, the resting trachea is roughly horse-shoe shaped, with the open end of the
cartilage rings closed by a compliant posterior sheath. In COPD patients, the coronal
diameter is reduced and the saggital diameter correspondingly increased, a condition called
saber-sheath trachea [Figure 8 (A-D)] . Tracheal index is a ratio of the coronal to the saggital
length, measured 1 cm above the aortic arch.

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In a study, it was found that patients with COPD had a reduced tracheal index. Saber-sheath
trachea (tracheal index < 2/3) was observed to be a specific radiographic diagnostic
parameter for the diagnosis of COPD (specificity, 92.9%), although sensitivity (39.1%) was
low (Tsao et al 1994).

Fig. 8. (A-D): Saber sheath trachea over CT scans in COPD patients

In another study (Trigaux et al 1994), 20 patients with saber-sheath trachea were compared
with 20 controls without saber-sheath trachea by measuring standard HRCT indices of
COPD and functional tests including FEV1, DLco and FRC. Tracheal index was significantly
correlated with the FRC values and it was concluded that saber-sheath trachea is basically a
sign of hyperinflation in COPD pateints. Similarly, in a different study (Arakawa 1998),
reduced tracheal index and other signs of hyperinflation of thoracic cage on CT were found
to correlate significantly with pulmonary functions of chronic airway obstruction.

11. Sterno-aortic distance and mediastinal anterior junctional line

In retrosternal region, right and left lung with their corresponding pleural layers
approach each other so closely that the area of contrast form a linear density. When
present, the line is 1 to 2 mm wide and formed by two pleural layers on each side of a
narrow zone of mediastinal connective tissue. This line is called anterior junctional line
(AJL) [figure 9 (A-D)].

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Fig. 9. (A-D): HRCT scans from COPD showing increased sterno-aortic distance and the
anterior junctional line.
In a study, AJL and sterno-aortic distance (distance between sternum and ascending aorta)
were measured in CT sections at carinal level in 22 patients with emphysema and 22 control
subjects (Hagen & Kolebenstvedt 1993). The AJL could be measured in all emphysema
patients. In the control group the line was non-existent in 11 of the 22 patients. The AJL was 3
cm or more in 10 of the emphysema patients, but in none of the controls. The sterno-aortic
distance was 4 cm or more in 16 of the emphysema patients, but in none among control group.
In another study, significant correlation was found between FEV1 / FVC and sterno-aortic
distance (measured at tracheal carina on CT) in 74 patients who underwent thoracic surgery
for lung cancer (Arakawa et al 1998).

12. Thoracic cage ratio and barrel chest

Arakawa et al (1998) measured thoracic cage ratios (anteroposterior/ transverse diameters)
at carina and 5 cm below carina on CT in 74 patients. Other measurements of hyperinflation
were also calculated and it was found that increased thoracic cage ratio correlated most
significantly with a pulmonary functions of chronic airway obstruction.
In another study, normal thoracic cage ratio was 0.70 to 0.75 in adults. The thoracic cage
ratio was found high in COPD patients and may reach upto > 0.9 which was called as barrel
chest (Pierce et al 1958). Figure 10 (A-B) shows HRCT scans with barrel chest feature found
in our studies (Gupta et al 2008, 2009).

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Fig. 10. (A-B): A marked increase in thoracic cage ratio above 0.9 described as barrel
chest

13. Thoracic cross-sectional area (TCSA) index

The assessment of thoracic cross-sectional area (TCSA) is an important measure of
thoracic cage hyperinflation commonly seen in advance COPD with air trapping and
increased total lung capacity. TCSA is the area surrounded by the rib cage measured on
CT scan made 1 cm below the top of the aortic arch. In a study (Kasai et al 2003) TCSA
and pulmonary functions and dyspnea grade were measured in 24 COPD patients. In the
group with grade IV dyspnea, the TCSA/ht2 ratios were significantly greater than those in
the groups with grade II and III dyspnea, combined. Analysis of data showed a good
correlation between TCSA and total lung capacity, as well as functional residual capacity
and residual volume.

14. HRCT characteristics observed in our studies

Our studies included 40 male patients with COPD. Their mean age was 58.55 years
(range: 50-69 years). Total duration of illness due to COPD was in range from 2 to 25 years
with a mean of 12.63 years. All subjects were significant smoker with mean smoking
history of 33.25 pack years (range 20-74 pack years). They were evaluated for HRCT
features including vascular attenuation and distortion, mosaic attenuation pattern,
directly visible small airways, low attenuation areas of emphysema and measures of
hyperinflation of lungs: tracheal index, sterno-aortic distance, thoracic cage ratio and
thoracic cross-sectional area. Individual COPD patients having characteristics HRCT
findings were as shown in table-1.
In our studies, tracheal index was observed to have significant inverse correlations with
duration of illness, smoking pack years, and dyspnea scale; and had direct correlations with
FEV1, PEFR, FEV1/FVC ratio, and FEV1/SVC ratio. Thoracic cage ratio at carina as well as
thoracic cage ratio at 5 cm below carina had direct correlations with duration of illness,
smoking pack years and dyspnea scale; and had inverse correlations with FEV1, FEV1/FVC
ratio and FEV1/SVC ratio. Sterno-aortic distance and thoracic cross sectional area had
correlations with duration of illness, smoking pack years and dyspnea scale; and they had
inverse correlations with FEV1, FEV1/FVC ratio, and FEV1/SVC ratio.

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High Resolution Computed Tomography and Chronic Obstructive Pulmonary Disease 165

Number of patients Percentage of study

HRCT features
out of 40 subjects
Saber sheath trachea with tracheal index
14 35
less than 0.67
Thoracic cage ratio over 0.75 at the level of
5 12.5
carina
Thoracic cage ratio over 0.75 at the level
11 27.5
5 cm below carina
Sterno-aortic distance more than 4 cm 5 12.5
Thoracic cross-sectional area/ht2 more than
28 70
80.00 cm2/m2
Vascular attenuation 25 62.5
Vascular distortion 8 20
Mosaic attenuation pattern 16 40
Directly visible small airways 36 90
Centriacinar emphysema 16 40
Panacinar emphysema 11 27.5
Paraseptal emphysema 13 32.5
Any type of emphysema 25 62.5
Table 1. HRCT features noted in individual COPD patients
Vascular attenuation had significant correlations with duration of illness, dyspnoea scale,
smoking pack years, FEV1, FEV1/FVC ratio, and FEV1/SVC ratio. Vascular distortion had no
significant correlation with any of the observed parameter. The mosaic attenuation pattern
correlated significantly with duration of illness, dyspnea scale, smoking pack years, FEV1,
FEV1/FVC ratio, and FEV1/SVC ratio. Correlation of presence of directly visible small
airways was significant only with dyspnea scale. Centriacinar emphysema had significant
correlations with PEFR, FEV1, FVC, FEV1/FVC ratio and FEV1/SVC ratio. Correlations of
presence of any type of emphysema with age, duration, dyspnea scale, pack-years, PEFR,
FEV1, FVC, FEV1/FVC ratio and FEV1/SVC ratio were statistically significant.

15. Recent advances

COPD is a heterogeneous group of disorders and needs to be evaluated by a combination of
morphological and functional assessment. Recently, newer HRCT techniques as well as MRI
have provided new insights to characterisation of various pulmonary components of COPD in
term of morphology as well as functionality. Three-dimensional HRCT has been described as
the technique of choice for morphological imaging. Inspiratory and expiratory 3D-HRCT with
volumetric and texture analysis allows for deeper insights to regional hyperinflation and
expiratory obstruction. Three-dimensional HRCT has also been described as the gold
standard for non-invasive quantitative evaluation of airway dimensions. Newer generations
of MRI allow for better visual assessment of the lung morphology as well as comprehensive
functional imaging. The major advantage of MRI is the assessment of regional lung function
including perfusion, respiratory dynamics and ventilation. The comprehensive diagnostic
possibilities of CT complemented by MRI will allow for a more sensitive detection,
phenotype-driven characterization and dedicated therapy monitoring of COPD.

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166 Bronchitis

16. Conclusion
While all this description appears voluminous, many things have not been discussed in
detail due to want of space. The imaging techniques we are applying in day to day practice
at present have opened new avenues for morphological and functional characterisation of
various diseases incorporated under the heterogeneous group of COPD and helped in
phenotyping as well as assessment of the progression of COPD. And, this is just beginning!
In future we are definitely going to get more powerful equipments, supplemented with
dedicated and advanced softwares that will provide deeper insight into the various diseases
grouped under the umbrella of COPD.

17. Acknowledgments
The author wish to express his profound gratitude to Prof. Rohtas Yadav, Senior Professor,
Radiodiagnosis; Dr Manish Verma, Ex-Resident, Respiratory Medicine; Prof. K B Gupta,
Senior Professor, Respiratory Medicine; Dr Dipti Agarwal, Assistant Professor, Physiology;
and Dr Manoj Kumar, Expert, Biostatistics all from Postgraduate Institute of Medical
Sciences, University of Health Sciences, Rohtak, India for their kind help, necessary inputs
and critical review of the literature.

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 Bronchitis
Edited by Dr. Ignacio Martn-Loeches

ISBN 978-953-307-889-2
Hard cover, 190 pages
Publisher InTech
Published online 23, August, 2011
Published in print edition August, 2011

Lung parenchyma has been extensively investigated. Nevertheless, the study of bronchial small airways is
much less common. In addition, bronchitis represents, in some occasions, an intermediate process that easily
explains the damage in the lung parenchyma. The main target of this book is to provide a bronchial small
airways original research from different experts in the field.

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Disease, Bronchitis, Dr. Ignacio Martn-Loeches (Ed.), ISBN: 978-953-307-889-2, InTech, Available from:
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pulmonary-disease

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