Emphysema: Imaging for Endoscopic Lung Volume Reduction

Abstract

Chronic obstructive pulmonary disease (COPD) is characterized by two entities, the more airway-predominant type (“bronchitis”) on the one hand, and emphysema-predominant type on the other. Imaging via high-resolution computed tomography plays an important role in phenotyping COPD. For patients with advanced lung emphysema, new endoscopic lung volume reduction therapies (ELVR) have been developed. Proper selection of suitable patients requires thin-section reconstruction of volumetric CT image data sets also in coronal and sagittal orientation are required. In the current manuscript we will describe emphysema subtypes (centrilobular, paraseptal, panlobular), options for quantifying emphysema and this importance of regional distribution (homogeneous or heterogeneous, target area) as this is crucial for patient selection. Analysis of the interlobular fissures is obligatory despite the lack of standardization, as incomplete fissures indicate collateral ventilation (CV) via parenchymal bridges, which is an important criterion in choosing endoscopic methods of LVR. Every radiologist should be familiar with modern LVR therapies such as valves and coils, and furthermore should know what a lung doctor expects from radiologic evaluation (before and after ELVR). Finally we present a checklist as a quick reference for all steps concerning imaging for ELVR.

Key points:

• High-resolution computed tomography with 3 D reconstructions becomes increasingly important in phenotyping COPD and diagnosing emphysema.

• Patient selection is crucial for modern techniques of lung volume reduction, such as valves or coils.

• Radiology plays a key role for fissural analysis and identifying a target area.

• Success of this therapy depends on experience and multidisciplinary cooperation.

Citation Format:

• Storbeck B, Schröder TH, Oldigs M et al. Emphysema: Imaging for Endoscopic Lung Volume Reduction. Fortschr Röntgenstr 2015; 187: 543 – 554

Zusammenfassung

Die Chronisch Obstruktive Lungenerkrankung (COPD) ist eine Erkrankung mit zwei verschiedenen Ausprägungsarten, dem eher atemwegdominierten Typ („Bronchitis“) und dem emphysemdominierten Typ. Für die Phänotypisierung spielt die Bildgebung mittels hochauflösender Computertomografie eine wichtige Rolle. Im Falle eines fortgeschrittenen Emphysems bestehen neue zielgerichtete endoskopische Verfahren zur Lungenvolumenreduktion (ELVR). Zur Prüfung der Indikation ist die Erhebung von Volumendatensätzen nötig, die dünne Rekonstruktionen auch in koronarer und sagittaler Schnittführung ermöglichen. Im Folgenden werden neben der Differenzierung zwischen den verschiedenen Emphysemarten (zentrilobulär, panlobulär, paraseptal) auch die Möglichkeiten der Quantifizierung und die Bedeutung der regionalen Emphysemverteilung (homogen oder heterogen, Zielareal) für die Patientenselektion erläutert. Die Analyse der interlobären Fissuren ist trotz bislang fehlender Standardisierung obligat, da bei inkompletten Fissuren von einer Kollateralventilation (CV) über Parenchymbrücken auszugehen ist, einem wichtigen Kriterium für die Auswahl des Verfahrens. Jeder Radiologe sollte die modernen Verfahren der LVR wie Ventile oder Coils kennen und wissen, welche radiologischen Informationen der Pneumologe vor und nach der Anwendung der ELVR benötigt. Dazu wurde zusammenfassend eine Checkliste für die radiologische Emphysemdiagnostik erstellt.

Key words

emphysema - thoracic imaging - endoscopic lung volume reduction

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