Advance Imaging in

Lung Emphysema
Yopi Simargi

Pertemuan Ilmiah Tahunan

Perhimpunan Dokter Spesialis Radiologi Klinis Indonesia
27 April 2024
EPIDEMIOLOGY OF COPD

Global of Disease Study (2016) : 251 mi

Death : 3.17 mi (90% developing country)
Rank : 4th cause of death → 3rd (2020)

Prevalence 2060 : 5.4 mi death/year

Rank 6th cause disability

RISKESDAS (2013) : 3.7% (>= 30 year)

 TOP 10 DALY’S LOSS in INDONESIA

Siswanto, Kepala Badan Penelitian dan Pengembangan Kemenkes RI

Credit: Sintak Gunawan
 PATHOGENESIS

Spurzem JR, et al.Semin Respir Crit Care Med. 2005.

 Chronic Obstructive Pulmonary Disease
Diagnosed using spirometry (FEV1/FVC <70%) with GOLD system to stratify severity.
Same GOLD stages may have 2 different morphologic appearance

Lynch DA, et al. CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A Statement of the Fleischner Society. Radiology. 2015.
Barnes PJ, et al. Chronic obstructive pulmonary disease. Nat Rev Dis Primers. 2015 Dec 3;1:15076. doi: 10.1038/nrdp.2015.76. PMID: 27189863.
01
01 GET TO KNOW EMPHYSEMA
Irreversible destruction of alveolar walls → enlargement of distal
airspaces
● 2.0 million adults (1.6%) of those ages 18 or older, had
emphysema.
● Rates were greater among:
○ Non-Hispanic white individuals compared to other
CDC (2018)
racial and ethnic groups
○ Men compared to women
○ Those ages 65 and older compared to younger age
group.

Research studies
Simargi Y, et al. ● Occurence of Emphysema : 46.88% (n=15)
(2021) ○ Mild Emphysema : 86.7% (n = 13)
○ Severe Emphysema : 13.3% (n = 2)
Simargi Y, Seprianto J, Santi BT. The Correlation Between Air Pollution Exposure Duration and Occurence of Emphysema Based on Chest CT Scan in Public Transportation Drivers.
Jurnal Respirologi Indonesia. 2021 Apr 30;41(2):129–33.
Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey, 1999-2018. Analysis by the American Lung Assocation Research
and Program Services Division using SPSS software.
Why is it important to identify emphysema?
Correlated with lung cancer
● Correlated: Bae KS, et al. Medicine2016; Gonzales J. Plos One. 2019;
● %LAA not correlated: Kishi K, et al. ERJ 2002; Maldonado, et al. Chest 2010

Correlated with mortality

● Ash SY, et al. Radiology 2021 → 1g/L/year faster rate
decline of Perc15, increase respiratory mortality by
22% (HR, 1.22; 95% CI: 1.13, 1.31; P <.001).
● Johannessen A, et al. AJRCCM 2013 → %LAA as a
strong independent mortality predictor
● Oelsner EC, et al. Thorax 2016 → %LAA-950 strongly
associated with increased mortality due to respiratory
diseases (adjusted HR 2.94, 95%CI 1.68 to 5.15)
● Humphries SM, et al. Radiology 2020 → Greater
mortality rate in any emphysema pattern

Lynch DA, et al. CT-based Visual Classification of Emphysema: Association with Mortality in the COPDGene Study. Radiology 2018
02 Traditional Imaging of Emphysema
Modality Chest X-ray CT Scan Scintigraphy

Advantages ➔ Wide availability ➔ High spatial resolution ➔ Detection of

➔ Low cost ➔ 3D reformation severly
➔ Fast implementation ➔ Quantification emphysema
affected areas
➔ High agreement
of lung perfusion

Disadvantages ➔ Sensitivity 40% ➔ Higher radiation dose ➔ Lack of

➔ Little specificity additional
➔ High interobserver information
disagreement
➔ Impossible to distinguish
equal density structures

Indication Investigate concomitant finding IMAGING OF CHOICE Evaluation of severe

Follow up imaging Heterogeneity and distribution of emphysema
Post interventional evaluation emphysema
Identify concomitant conditions Visualization V/Q
Selection for LVR/endobronchial valve
replacement
Martini K, et al. Advances in imaging for lung emphysema. Ann Transl Med. 2020.
 Traditional Imaging of Emphysema
Chest X-ray

Barrel
Chest

Martini K, et al. Advances in imaging for lung emphysema. Ann Transl Med. 2020.
 CT-Scan
● Viewed at window level settings suitable for lung evaluation
○ Window level of -700 HU and window width of 1500 HU
○ Narrower window width (750–1000 HU) may be useful for detecting or
excluding early emphysema
● Minimum intensity projection (Min IP)
○ Highlight areas with reduced CT attenuation such as emphysema
○ Subtracting the normal lung and pulmonary vasculature
○ (Not widely used)

Lynch DA, et al. CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A Statement of the Fleischner Society. Radiology. 2015.
Smith BM, et al. Pulmonary emphysema subtypes on computed tomography: the MESA COPD study. Am J Med. 2014.
Types of Emphysema
Centrilobular emphysema

● Focal region of hypoattenuation,

surrounded by normal lung
attenuation

● Central portion of secondary

pulmonary lobules

Smith BM, et al. Pulmonary emphysema subtypes on computed tomography: the MESA COPD study. Am J Med. 2014.
Takahashi M, et al. Imaging of pulmonary emphysema: a pictorial review. Int J Chron Obstruct Pulmon Dis. 2008.
 Types of Emphysema
Centrilobular emphysema

● Classification:
○ Trace: Minimal centrilobular lucencies, <0.5% of any lung zone
○ Mild: Scattered centrilobular lucencies, 0.5 - 5% of any lung zone
○ Moderate: Many well-defined centrilobular lucencies, >5% of any lung zones
○ Confluent: Coalescent centrilobular / lobular lucencies, including multiple regions of lucencies that
span several secondary pulmonary lobule, but no hyperexpansion or architectural distortion
○ Advanced destructive: Panlobular hyperlucencies with hyperexpansion of secondary pulmonary
lobules and distortion of pulmonary architecture
Lynch DA, et al. CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A Statement of the Fleischner Society. Radiology. 2015.
El Kaddouri B, et al. Fleischner Society Visual Emphysema CT Patterns Help Predict Progression of Emphysema in Current and Former Smokers: Results from the COPDGene Study.
Radiology. 2021
 Trace Centrilobular Confluent
Centrilobular

Moderate Centrilobular Advanced

Destructive
 Early Stage of Centriacinar Emphysema Moderately
Progressed
Centriacinar
Emphysema

Advanced Centriacinar
Emphysema

Takahashi M, et al. Imaging of pulmonary emphysema: a pictorial review. Int J Chron Obstruct Pulmon Dis. 2008.
Types of Emphysema
Panlobular emphysema

● Diffuse region of hypoattenuation

→ destruction of all acini more or
less equally
● Associated with α1-antitrypsin
deficiency

Lynch, DA et al. CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A Statement of the Fleischner Society. Radiology. 2015
Types of Emphysema
Paraseptal emphysema

● Region of hypoattenuation adjacent to visceral

pleura
● Classification:
○ Mild : Small (≤ 1 cm), well-demarcated
juxtapleural lucencies, along pleural
margin/interlobar fissure
○ Substantial: Mainly large (> 1 cm)
juxtapleural cyst-like lucencies or bullae.

Lynch DA, et al. CT-Definable Subtypes of Chronic Obstructive Pulmonary Disease: A

Statement of the Fleischner Society. Radiology. 2015.
Takahashi M, et al. Imaging of pulmonary emphysema: a pictorial review. Int J Chron
Obstruct Pulmon Dis. 2008.
 Emphysema Quantification

Percentage of LAA Score Grading

0-5 0 Normal = 0

5 - 25 1 Mild = 1 -7
VISUAL
SCORING 25 - 50 2 Moderate = 8 - 15

50 - 75 3 Severe = 16 - 24

75 - 100 4

Percentage of low attenuation area in the upper, middle, and lower zones of right
and left lungs are calculated
Martini K, et al. Advances in imaging for lung emphysema. Ann Transl Med. 2020.
Mohammed YM et al. Updates in computed tomography assessment of emphysema using computed tomography lung analysis.Egypt J Bronchol. 2017
 Emphysema Quantification
Color coding CT densitometry → density mask with threshold -950 to -1024 HU

SEMI
QUANTITATIVE

GODDARD SCORE = 0
2 GODDARD
GODDARDSCORE
SCORE==0.5
1

Martini K, et al. Advances in imaging for lung emphysema. Ann Transl Med. 2020.
Mohsen LA. et al. CT quantification of emphysema: Is semi-quantitative scoring a reliable enough method?
 Emphysema Quantification Threshold
Technique
● %Low attenuation area (%LAA)
● Mean lung density (MLD)
● Percentile index (Emphysema Index/EI)
Histogram
Technique

QUANTITATIVE

Sayegh K, et al. Imaging of Emphysema: A Comprehensive Review. IntechOpen. 2023.

Contoh pasien
Tn. D, 64 y.o
FEV1/FVC = 66%, FEV1pp = 89 (GOLD I), PPOK Grup C
Tn. E, 63 y.o
FEV1/FVC = 42%, FEV1pp = 30.57 (GOLD III), PPOK Grup D
Thank you!
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