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Emphysema Imaging
Author: Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR; Chief Editor: Kavita Garg, MD more...

Updated: May 22, 2014

Overview
Conventional chest radiography is generally the first imaging procedure performed in patients with
respiratory symptoms, and frontal and lateral chest radiographs may reveal changes of emphysema. A
chest radiograph is universally available, noninvasive, and inexpensive, and it poses an acceptable
radiation exposure.
[1, 2, 3]

For further information, see the Medscape Reference topics Imaging in Congenital Lobar
Emphysema, Imaging in Emphysematous Pyelonephritis, and Imaging in Pulmonary Interstitial
Emphysema.
High-resolution computed tomography (HRCT) scanning is more sensitive than chest radiography in
diagnosing emphysema and in determining its type and extent of disease.
[4]
HRCT also has a high
specificity for diagnosing emphysema with virtually no false-positive diagnoses. However, in clinical
practice, more reliance is placed on patient history, lung function tests, and abnormal chest radiographs
to diagnose emphysema. However, some patients with early emphysema, particularly those with early
disease, may present with atypical symptoms, and it is in these patients that an HRCT is most rewarding.
If significant emphysema is found on HRCT, no further workup is necessary; specifically, lung biopsy is
not needed.
A number of studes have assessed the role of computed tomography (CT) in the early detection of lung
cancer in patients with COPD and in predicting response to lung-volumereduction surgery
(LVRS).
[5]
Radionuclide scanning and MRI have a potential role in patients being assessed for LVRS.
Images of emphysema are displayed below.

Chest radiograph of an emphysematous patient shows hyperinflated lungs with reduced vascular markings.
Pulmonary hila are prominent, suggesting some degree of pulmonary hypertension (Corra da Silva, 2001)

.
CT densitovolumetry in a heavy smoker with emphysema revealed compromise of about 22% of the lung
parenchyma (Corra da Silva, 2001).


CT densitovolumetry in a patient with lung cancer. Three-dimensional (3D) image shows that the cancer is in the
portion of the right lung that was less affected by emphysema in a patient with poor pulmonary function (Corra
da Silva, 2001).

Ballile and Laennec described the anatomopathology of emphysema in 1793 and in 1826, respectively.
After that, Lynne Reid published one of the landmark works in our understanding of emphysema, The
Pathology of Emphysema (Reid, 1967) ,which provided a detailed description of the anatomy of the lung
units and of the anatomopathology and pathophysiology of emphysema, broadening the view of this
complex disease.
[6, 7]
Various changes have happened since then, especially the advent of the high-
resolution CT (HRCT) of the chest.
Pulmonary emphysema is defined as the permanent enlargement of airspaces distal to the terminal
bronchioles and the destruction of the alveolar walls. Pathology reveals a marked increase in the size of
the airspaces, resulting in labored breathing and an increased susceptibility to infection. It can be caused
by irreversible expansion of the alveoli or by the destruction of alveolar walls. Fibrosisis not associated
with this condition.
Pulmonary emphysema and chronic bronchitis are important components ofchronic obstructive
pulmonary disease (COPD). Emphysema often coexists with chronic bronchitis in the COPD population,
and from a clinical point of view, they are generally considered as one entity. Although a tissue diagnosis
of emphysema is possible, in advanced cases it can usually be confidently diagnosed on the basis of the
patient's history, physical findings, pulmonary function, and imaging results.
Limitations of techniques
Chest radiographic findings are not good indicators of the severity of disease and do not help in
identifying patients with COPD without clinically significant emphysema. Imaging information from HRCT
does not alter the management of emphysema; therefore, HRCT has no place in the day-to-day care of
patients with COPD. In their early stages, the 3 forms of emphysema can be distinguished
morphologically by using HRCT. However, as the disease becomes more extensive, the distinction
becomes difficult or impossible, both radiographically and pathologically.
Radiography
In moderate-to-severe emphysema, chest radiographic findings include bilaterally hyperlucent lungs of
large volume, flattened hemidiaphragms with widened costophrenic angles, horizontal ribs, and a
narrow mediastinum. The peripheral vascular markings are attenuated, but the markings become
prominent when the patient has pulmonary hypertension and right-sided heart failure. A lateral view
shows increased retrosternal airspace and flattening of the anterior diaphragmatic angle. In addition,
bullae and an irregular distribution of the lung vasculature may be present. When pulmonary
hypertension develops, the hilar vascular shadows become prominent, with filling of the lower
retrosternal airspace due to right ventricular enlargement. (See the images below.)


Chest radiograph of an emphysematous patient shows hyperinflated lungs with reduced vascular markings.
Pulmonary hila are prominent, suggesting some degree of pulmonary hypertension (Corra da Silva, 2001)
.
Schematic representation of 1 criterion for defining flattening of the diaphragm on the lateral chest radiograph: drawing a line from the
posterior to anterior costophrenic angles and measuring the distance from this line to the apex of the diaphragm. If the height is less
than 1.5 cm, the criterion of flattening is fulfilled (Corra da Silva, 2001).


Schematic representation of another criterion for defining flattening of the diaphragm on the lateral chest radiograph. When the angle
formed by the contact point between the diaphragm and the anterior thoracic wall is more than or equal to 90, the criterion is fulfilled
(Corra da Silva, 2001).


Schematic representation of another sign of emphysema on the lateral chest radiograph. When the retrosternal space (defined as the
space between the posterior border of the sternum and the anterior wall of the mediastinum) is larger than 2.5 cm, it is highly
suggestive of overinflated lungs. This radiograph is from a patient with pectus carinatum, an important differential diagnosis to
consider when this space is measured (Corra da Silva, 2001)
.
close-up image shows emphysematous bullae in the left upper lobe. Note the subpleural, thin-walled, cystlike appearance (Corra da
Silva, 2001)

.
A, Frontal posteroanterior (PA) chest radiograph shows no abnormality of the pulmonary vasculature, with normal intercostal spaces
and a diaphragmatic dome between the 6th and 7th anterior ribs on both sides. B, Image in a patient with emphysema demonstrating
reduced pulmonary vasculature resulting in hyperlucent lungs. The intercostal spaces are mildly enlarged, and the diaphragmatic
domes are straightened and below the extremity of the seventh rib (Corra da Silva, 2001).


A, Lateral radiograph of the chest shows normal pulmonary vasculature, a retrosternal space within normal limits (< 2.5 cm), and a
normal angle between the diaphragm and the anterior thoracic wall. B, Lateral view of the chest shows increased pulmonary
transparency, increased retrosternal space (>2.5 cm), and an angle between the thoracic wall and the diaphragm >90. Straightening of
the diaphragm can be more evident in this projection than on others (Corra da Silva, 2001).
Degree of confidence
In clinical practice, reliance is placed on the patient's history, lung function, and abnormal chest
radiographs to diagnose emphysema. Chest radiographic findings generally cannot establish the
diagnosis of mild emphysema; however, when emphysema is fully established, classic radiographic
findings are typically observed. Findings on routine chest radiographs can suggest emphysema, but this
is not a sensitive technique for diagnosis. However, chest radiography is useful to look for complications
during acute exacerbations and to exclude other pathologies, such as superadded infection or lung
cancer.
The chest radiograph is not a good indicator of the severity of disease and does not help in identifying
patients with COPD without significant emphysema. Thurlbeck and Simon found that only 41% of those
with moderately severe emphysema and two thirds of those with severe emphysema had evidence of
disease on chest radiography.
[8]