Imaging in chronic obstructive pulmonary disease

Domenico Capone*
Rafael Capone
Abdiel Rolim
Leonardo P. Bruno
Agnaldo J. Lopes

Abstract such as bronchiolectasis and the tree-in-bud

appearance, and abnormal ventilation inclu-
Chronic obstructive pulmonary disease
ding mosaic perfusion. This review will discuss
is defined by irreversible airflow obstruction
imaging of the chest in patients with pulmonary
due to emphysematous destruction of the lung
emphysema. Definitions of types of emphysema
parenchyma and small airways remodeling. It
within the framework of chronic obstructive
is a heterogeneous disease affecting the airways
pulmonary disease are given. The classic findin-
and/or the parenchyma with different severity
gs on the chest radiograph are described, and the
during the course of the disease. Obstructive
advances in sensitivity and specificity achieved
lung diseases may be associated with a variety
with computed tomography scanning are noted.
of pathologic findings, including emphysema,
large and small airways abnormalities. Com- Keywords: Pulmonary disease, chronic obs-
puted tomography has become the standard tructive; Radiography; Thoracic; Tomography;
modality to objectively visualize lung dise- Pulmonary emphysema.
ase. High resolution computed tomography
(HRCT) can reveal morphologic abnormalities Introduction
associated with obstructive lung disease with a Chronic obstructive pulmonary disease
greater accuracy than plain radiographs. HRCT (COPD) is characterized by airflow limitation.
is more sensitive than radiographs in showing From a pathogenic point of view, it is considered
emphysema, large airways abnormalities such to involve chronic inflammation, destruction of
as bronchiectasis, small airways abnormalities, the pulmonary parenchyma, and narrowing of

Corresponding address:
*

R. Bogari, 43/201
Rio de Janeiro, RJ, Brazil. Zip code: 22471-340.

50 revista.hupe.uerj.br
 Imaging in chronic obstructive pulmonary disease

the small airways. These changes occur at the the subtypes described above.
same time and the predominance of one above Scar: occurs in areas of lung scarring,
other pathological changes is determined by without preferential location. In Brazil, this type
different features of COPD. Currently, there of emphysema is often found in patients with
is a tendency to establish clinical phenotypes tuberculosis. It is typically limited in its extent
of COPD for better control and approaches and significance.
to treatment. It is possible to establish these
phenotypes on the basis of imaging results. In Correlation of clinical,
this way, a predominance of destructive paren-
chymal changes is referred to as emphysema
radiological and functional
and changes in the small airways are referred to criteria with diagnosis of
as chronic bronchitis. The diagnosis of COPD COPD
is based on clinical and radiological data, as
well as functional respiratory and pathological Multiple clinical presentations are com-
anatomical changes.1-4 patible with a diagnosis of COPD, especially if
COPD is a pathology with a cosmopolitan we take into account the variation of severity
distribution, since its main causal factor is the resulting from the duration of the illness and the
widespread habit of tobacco smoking,1 which degree of exposure to current or previous risk
is performed by most societies worldwide. The factors. Thus, it was necessary to establish at least
clinical course of COPD is variable, with the one criterion that was present in most patients
spectrum ranging from minimal impact to limi- who share a diagnosis of COPD.4 Among all the
tation of daily activities and chronic respiratory possible manifestations of COPD, the spirome-
failure requiring home oxygen therapy.5 try finding of fixed airway obstruction is usually
Currently, COPD is the fourth most com-
present independently of any other existing va-
mon cause of death in the world1 and contributes
riable. The presence of a Tiffeneau index of less
significantly to respiratory diseases, which are
than 70% predicted in any age group and both
the fourth most common cause of mortality in
sexes that is not fully reversible after bronchodi-
Brazil.3 In this review, we describe the radio-
lator inhalation in a patient exposed to any risk
logical changes related to COPD and its main
factor associated with COPD is thought to be a
complications, considering the following 4
reasonable set of criteria for confirmation of the
morphological types of emphysema.6
COPD diagnosis. Clinical criteria are important,
Centroacinar or centrolobular: invol-
but can also be non-specific, reproducible, and
ves dilation or destruction of the respiratory
subjective, with interpersonal discrepancy and
bronchioles. This type of emphysema is asso-
ciated with the habit of smoking in most cases dependence on functional and radiological
and predominates in the upper lobes. disease severity. For example, the same degree
Panacinar or panlobular: related to of airway obstruction can be related to different
1-antitrypsin deficiency, which causes dilation sensations of dyspnea.2,7
and complete destruction of the acini. This type In general, radiological findings are mani-
of emphysema predominates in the base of the festations of the natural history of COPD and are
lung. not always associated with functional changes.
Paraseptal: occurs on the periphery of Changes interpreted as devastating upon chest
the lung, in the pleura, or interlobularly. This computed tomography (CT) may be present in
type of emphysema is most commonly associa- asymptomatic patients, in the same way that
ted with spontaneous pneumothorax in young symptomatic patients do not always exhibit
people and usually occurs simultaneously with prominent radiographic changes.4

Volume 12, issue 2, april-june/2013 51

HUPE Journal, Rio de Janeiro, 2013;12(2):50-57

Simple radiography in COPD described the measurement of lung size as a

predictor of obstructive disease found similar re-
sults with respect to certain degrees of flattening
Conventional chest radiography is usually
of the diaphragm and airflow limitation. These
one of the first examinations requested in the
changes are more specific in the diaphragmatic
evaluation of a patient with complaints and
radiographic diagnosis of COPD and also have
exposure history compatible with COPD. Ho-
prognostic value as they indicate reversal of the
wever, few morphological changes are detected main muscle of respiration. Increased antero-
in the early stages with this method.8 posterior diameter and retrosternal space are
With progression of the disease, conven- other manifestations associated with increased
tional radiography can be used to detect some pulmonary volume.9
changes with reasonable sensitivity and low Vascular changes can also be seen in pa-
specificity. The presence of overinflated lungs tients with COPD, representing radiological
constitutes one of these findings, although expression of the destruction of the alveolar sep-
this can be present in other situations (figure tum that is involved in the genesis of pulmonary
1). Previous studies have correlated objective emphysema. Identification of a deficiency in
measurement of lung size on chest radiographs blood volume (oligemia) is not a pathognomo-
with lung function, indicating good positive nic sign of illness with fixed airway obstruction,
predictive values, reproducibility, and reliabi- since it can be present in other situations such
lity. Another relatively common and similarly as pulmonary arterial hypertension and pulmo-
nonspecific finding in conventional radiography nary thromboembolism.6
is flattening and straightening of the diaphrag- Another radiological presentation substan-
matic dome. The same group that studied and tially associated with COPD is the formation of

Figure 1: PA chest radiograph showing marked signs of lung hyperinflation.

52 revista.hupe.uerj.br
 Imaging in chronic obstructive pulmonary disease

lung bullae, which are islands of nonvasculari- relevance in the context of obstructive disease,
zed tissue devoid of functioning lung parenchy- since it is a result of destructive and fibrotic lung
ma. Lung bullae are responsible for worsening processes secondary to previous damage and its
respiratory function attributed to compression functional manifestation is constraint.
of adjacent preserved tissue and can potentially The development of new techniques, in
cause pneumothorax, a prevalent complication addition to improvement of previously used
in the context of bullous disease. Despite the methods, has brought a new perspective to the
clear association between bullae formation and tomographic evaluation of emphysema. High
emphysema, other diseases may also present the resolution computed tomography (HRCT), whi-
same manifestation.10 ch allows sections of up to 1 mm, has enhanced
Radiographic changes found in chronic viewing and made accurate quantification of
bronchitis are often described as thickening of more advanced pathology possible, even with
the sheath, although it is sometimes difficult to subjective and examiner dependent evaluation.
detect bronchovascular changes.4 The diagnosis of emphysema in the incipient
phase can be enhanced by the technique of
Computed tomography in minimum-intensity projection. This technique
COPD uses software capable of identifying areas of
the lung parenchyma with low attenuation and
The application of CT techniques has re-
volutionized imaging of the thorax as a whole. simultaneously suppressing normal pulmonary
Changes only suggested by conventional radio- parenchyma and pulmonary vessels, making it
graphy are seen directly and clearly when using more sensitive for the detection of emphysema.11
CT. Emphysema is easily distinguishable from The quantitative mode of CT has improved
normal parenchyma on CT, as its attenuation the quantification of emphysematous disease.
value is low when compared to adjacent tissue. Tomographic density is based on the measu-
As mentioned earlier, there are 4 types of em- rement of Hounsfield units (HU). The quanti-
physemapanacinar, centrolobular, paraseptal, fication of lung tissue with a lower attenuation
and scareach with distinct presentations and coefficient than a particular reference value
anatomical distributions on CT images.4 considered compatible with areas of emphysema
Centrolobular emphysema is characteris- (e.g., -910 HU) can be easily established. From
tic of smokers, is normally located in the lung the acquisition of such data, a histogram of the
apices, and appears as multiple small rounded distribution of these densities can be created and
areas that are not limited by walls, unlike cysts the analysis of such a graph provides tangible in-
(figure 2). formation allowing classification of emphysema
Panacinar emphysema is normally located as mild, moderate, or severe. Another possibility
in the lower portions of the lungs and is charac- is the use of this technique for quantification of
terized by homogeneous destruction of the side air trapping, a parameter that shows greater cor-
lobes, generating images with low attenuation relation with clinical deterioration and severity
continuously distributed by parenchyma bands. of disease than the amount of emphysema itself.
It is typical of patients with 1-antitrypsin defi- Some previous studies were able to confirm a
ciency (figure 3). significant correlation between the information
Paraseptal emphysema occupies more obtained by tomographic density and patholo-
peripheral areas of the lung parenchyma, pre- gical findings. This interesting discovery has led
senting as bullous formations near the pleura or experts to continue looking for simple methods
interlobularly. It is usually associated with other of quantification that are potentially applicable
types of emphysema (figure 4). to everyday clinical practice.8,10-12
The scar emphysema subtype has little The recent development of spiral CT

Volume 12, issue 2, april-june/2013 53

HUPE Journal, Rio de Janeiro, 2013;12(2):50-57

A B
Figure 2: A- Chest tomography in axial cut showing areas of panlobular emphysema in predominately lower
lobes. Note cilindrics bronchiectasias and thickening of bronchical walls, most evidence in right. B- coronal
reformatated showing hyperinsuflation areas in lower lobes.

Figure 3: CT slice at the level of the upper lobes Figure 4: CT slice at the level of the upper lobes sho-
demonstrating numerous areas of centrilobular wing peripheral areas of emphysema paraseptal.
emphysema.

scanners with multiple detectors allows the has excellent correlation with functional tests.
acquisition of a full chest image in just 1 Studies have compared lung volume measure-
deep inspiration. This technology enables the ment by CT and plethysmography, observing
threedimensional reconstruction of lung significant correlation between the 2 techniques,
images, lung volume measurements, as well as but with an underestimated total lung capacity
assessment of parenchymal changes and their measured by tomography. This was probably due
rate of progression. Measurement of the volume to the patient being placed in a supine position
of emphysema can be established through use in the CT scanner compared to the sitting po-
of equation dividing the lung volume by the sition used for plethysmography. Although few
normal density. This allows establishment of the studies have been conducted in this area, it is
rate of emphysema development. Some authors possible to predict that in the near future lung
point out that CT is a safe method for assessing volume measurement by CT will be embedded
the rate of progression of emphysema, given in clinical practice, becoming even more use-
that it is relevant during clinical follow-up and ful for the diagnosis, severity assessment, and

54 revista.hupe.uerj.br
 Imaging in chronic obstructive pulmonary disease

Figure 5: CT section at the level of the carina Figure 6: Coronal reformat demonstrating hete-
showing opacity looking speckled due to the rogeneous opacity in the right upper lobe and
substrate emphysema. areas of centrilobular emphysema and paraseptal.
Tuberculosis in COPD.
follow-up of patients with COPD.4,12 lihood of reinfection/reactivation of this disease.
The radiographic findings of tuberculosis are
Major complications of COPD nonspecific and often present as heterogeneous
Radiological assessment is particularly consolidations, pleural effusion, and areas of
useful for the possible complications of COPD.13 excavation with no nodular lipid infiltrate.
In relation to infectious processes potentially Location in the apical and posterior segments
linked to COPD, we must remember that of the upper lobes and the superior segment of
community-acquired pneumonia is often the the lower lobes is most common. CT changes
cause of differences in basic pathology, which described as having a budding tree appearance
is a common occurrence in this population. In are not always present, while this anatomical
general, evaluation by simple thoracic radio- change is often associated with COPD (figure
graph is sufficient, and should be used when 6).12 Histoplasmosis, a fungal disease, is also
diagnostic tomography is in doubt or for better relevant in patients with emphysema. In this
defining the extent of the illness. Consolidation context, we should remember the chronic infec-
can have a multifocal or lobar distribution. The tious conditions in presentation, it wont affect
radiographic pattern in patients with COPD this group of patients so preferred. The main
is not always similar to the parenchymal des- radiological finding is the presence of opacities
truction observed in basic disease, with some with digging areas and this allows the differential
modification of the classic picture expected, e.g., diagnosis of pulmonary tuberculosis.4
fog aspect opacities on an irregular pathological Pneumothorax is a mechanical complica-
substrate (figure 5). Viral infections may lead tion of COPD. It occurs mainly in patients with
to a form of presentation or reticular aspect advanced disease, as well as in patients with
characterized as bronchovascular network pulmonary and paraseptal emphysema. It can
enhancement, especially in bronchitic patients.4 be identified using conventional radiography
Tuberculosis must also be considered as a as a thin pleural line limited to parenchymal
differential diagnosis in this population, espe- structures with hyperlucent areas in contact with
cially since the misuse of systemic corticoste- the chest wall. CT can be used in ambiguous
roids is creating potentially immunosuppressed cases for better assessment of the size of the
patients and consequently increasing the like- pneumothorax and satisfactory placement of

Volume 12, issue 2, april-june/2013 55

HUPE Journal, Rio de Janeiro, 2013;12(2):50-57

area. Pulmonary arterial hypertension is also

suspected with the finding of accentuation of
the arc of the pulmonary artery and peripheral
vascular marks mitigation.4

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56 revista.hupe.uerj.br
 Authors

Abdiel Rolim Elizabeth J. C. Bessa

Medical Residency Program and Graduate Studies Pulmonology and Tisiology Discipline. Faculty of
in Radiology. Pedro Ernesto University Hospital. Medical Science. Rio de Janeiro State University.
Rio de Janeiro State University. Rio de Janeiro, RJ, Rio de Janeiro, RJ, Brazil.
Brazil.
Gabriela A. C. Dias
Adalgisa I. M. Bromerschenckel
Immunology Service. Department of Internal
Medical Sciences Postgraduate Program. Faculty Medicine. Pedro Ernesto University Hospital. Rio
of Medical Science. Rio de Janeiro State University. de Janeiro State University. Rio de Janeiro, RJ,
Rio de Janeiro, RJ, Brazil. Brazil.

Agnaldo Jos Lopes Jorge Eduardo Pio

Pulmonology and Tisiology Discipline. Faculty of
Pulmonology and Tisiology Discipline.
Medical Science. Rio de Janeiro State University.
Department of Medical Specialties. Faculty of
Rio de Janeiro, RJ, Brazil.
Medical Science. Rio de Janeiro State University.
Rio de Janeiro, RJ, Brazil. Knia M. da Silva

Ana Paula V. Soares Medical Sciences Postgraduate Program. Faculty

of Medical Science. Rio de Janeiro State University.
Pulmonology and Tisiology Service. Piquet Rio de Janeiro, RJ, Brazil.
Carneiro Polyclinic. Rio de Janeiro State University.
Rio de Janeiro, RJ, Brazil. Leonardo P. Bruno

Anamelia C. Faria Pulmonology and Tisiology Service. Pedro Ernesto

University Hospital. Rio de Janeiro State University.
Pulmonology and Tisiology Service. Pedro Ernesto Rio de Janeiro, RJ, Brazil.
University Hospital. Rio de Janeiro State University.
Lvia I. de O. Souza
Rio de Janeiro, RJ, Brazil.
Faculty of Medical Science. Rio de Janeiro State
Domenico Capone
University. Rio de Janeiro, RJ, Brazil.
Pulmonology and Tisiology Discipline.
Mateus Bettencourt
Department of Medical Specialties. Faculty of
Medical Science. Rio de Janeiro State University. Medical Sciences Postgraduate Program. Faculty
Rio de Janeiro, RJ, Brazil. of Medical Science. Rio de Janeiro State University.
Rio de Janeiro, RJ, Brazil.
Eduardo Costa F. Silva
Paulo Roberto Chauvet
Immunology Service. Department of Internal
Medicine. Pedro Ernesto University Hospital. Rio Pulmonology and Tisiology Discipline. Faculty of
de Janeiro State University. Rio de Janeiro, RJ, Medical Science. Rio de Janeiro State University.
Brazil. Rio de Janeiro, RJ, Brazil.

Volume 12, issue 2, april-june/2013 11

Rafael Capone Srgio da Cunha
Medical Residency Program and Graduate Studies Discipline of Intensive Care. Department of
in Radiology. Pedro Ernesto University Hospital. Clinical Medicine. Faculty of Medical Science.
Rio de Janeiro State University. Rio de Janeiro, RJ, Rio de Janeiro State University. Rio de Janeiro, RJ,
Brazil. Brazil.
Renato Azambuja Thiago P. Brtholo
Pulmonology and Tisiology Service. Pedro Ernesto Pulmonology and Tisiology Service. Pedro Ernesto
University Hospital. Rio de Janeiro State University. University Hospital. Rio de Janeiro State University.
Rio de Janeiro, RJ, Brazil. Rio de Janeiro, RJ, Brazil.
Rogrio M. Brtholo Vernica S. Cmara
Medical Sciences Postgraduate Program. Faculty Pulmonology and Tisiology Service. Piquet
of Medical Science. Rio de Janeiro State University. Carneiro Polyclinic. Rio de Janeiro State University.
Rio de Janeiro, RJ, Brazil. Rio de Janeiro, RJ, Brazil.

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