Measurement of three-dimensional lung tree structures by using computed tomography

Airway Wall Thickness in Cigarette Smokers: Quantitative Thin-Section CT Assessment

PURPOSE

To design and validate a dedicated software tool to measure airway dimensions on thin-section computed tomographic (CT) images and to use the tool to prospectively compare airway wall thickness in nonsmokers with normal lung function with that in smokers with and without chronic obstructive pulmonary disease (COPD).

MATERIALS AND METHODS

All subjects gave written informed consent. The study was approved by local ethics committee. With Laplacian of Gaussian algorithm, software was tested in phantom and excised sheep lung fixed in inflation and validated with Bland-Altman analysis. Study prospectively included nine nonsmokers (six women, three men; mean age, 53 years +/- 5.6 [standard error of the mean]) with normal lung function (group 1), seven smokers (three women, four men; mean age, 56 years +/- 5.6) with normal lung function (group 2), and eight smokers (zero women, eight men; mean age, 65 years +/- 4.0) with COPD. Calculations were determined with spirometrically gated CT: For each selected bronchus, the wall area (WA), internal area (IA), airway caliber (sum of IA and WA), and WA/IA ratio were calculated. For each patient, summation of WA to summation of IA (SigmaWA/SigmaIA) ratio, which reflected normalized airway wall thickness, was calculated. Groups were compared by using analysis of variance with generalized linear model and unpaired t test. Pearson correlation coefficient was used to assess correlation between software measurements and pulmonary function test results.

RESULTS

Comparison of measurements in phantom and excised sheep lung with algorithm measurements revealed that the latter were reliable and repeatable. In clinical study, SigmaWA/SigmaIA ratio was significantly different among three groups (P < .001). Normalized airway wall thickness and IA were significantly related to lung function test data, including forced expiratory volume in 1 second (r = -0.54, P = .006), specific airway conductance (r = -0.45, P = .03), and forced expiratory flow between 25% and 75% of vital capacity (r = -0.65, P < .001).

CONCLUSION

This software provides accurate and reproducible measurements of IA and WA of bronchi on thin-section CT images and demonstrates that in vivo normalized airway wall thickness was larger in smokers with COPD than it was in smokers or nonsmokers without COPD.

Anatomically based finite element models of the human pulmonary arterial and venous trees including supernumerary vessels

Studies of the origin of pulmonary blood flow heterogeneity have highlighted the significant role of vessel branching structure on flow distribution. To enable more detailed investigation of structure-function relationships in the pulmonary circulation, an anatomically based finite element model of the arterial and venous networks has been developed to more accurately reflect the geometry found in vivo. Geometric models of the arterial and venous tree structures are created using a combination of multidetector row X-ray computed tomography imaging to define around 2,500 vessels from each tree, a volume-filling branching algorithm to generate the remaining accompanying conducting vessels, and an empirically based algorithm to generate the supernumerary vessel geometry. The explicit generation of supernumerary vessels is a unique feature of the computational model. Analysis of branching properties and geometric parameters demonstrates close correlation between the model geometry and anatomical measures of human pulmonary blood vessels. A total of 12 Strahler orders for the arterial system and 10 Strahler orders for the venous system are generated, down to the equivalent level of the terminal bronchioles in the bronchial tree. A simple Poiseuille flow solution, assuming rigid vessels, is obtained within the arterial geometry of the left lung, demonstrating a large amount of heterogeneity in the flow distribution, especially with inclusion of supernumerary vessels. This model has been constructed to accurately represent available morphometric data derived from the complex asymmetric branching structure of the human pulmonary vasculature in a form that will be suitable for application in functional simulations.

Three-dimensional segmentation and skeletonization to build an airway tree data structure for small animals

Quantitative analysis of intrathoracic airway tree geometry is important for objective evaluation of bronchial tree structure and function. Currently, there is more human data than small animal data on airway morphometry. In this study, we implemented a semi-automatic approach to quantitatively describe airway tree geometry by using high-resolution computed tomography (CT) images to build a tree data structure for small animals such as rats and mice. Silicon lung casts of the excised lungs from a canine and a mouse were used for micro-CT imaging of the airway trees. The programming language IDL was used to implement a 3D region-growing threshold algorithm for segmenting out the airway lung volume from the CT data. Subsequently, a fully-parallel 3D thinning algorithm was implemented in order to complete the skeletonization of the segmented airways. A tree data structure was then created and saved by parsing through the skeletonized volume using the Python programming language. Pertinent information such as the length of all airway segments was stored in the data structure. This approach was shown to be accurate and efficient for up to six generations for the canine lung cast and ten generations for the mouse lung cast.

In vivo evaluation of the effectiveness of bronchial thermoplasty with computed tomography

A recent study has reported that the application of thermal energy delivered through a bronchoscope (bronchial thermoplasty) impairs the ability of airway smooth muscle to shorten in response to methacholine (MCh)(Danek CJ, Lombard CM, Dungworth DL, Cox PG, Miller JD, Biggs MJ, Keast TM, Loomas BE, Wizeman WJ, Hogg JC, and Leff AR. J Appl Physiol 97: 1946-1953, 2004). If such a technique is successful, it has the potential to serve as a therapy to attenuate airway narrowing in asthmatic subjects regardless of the initiating cause that stimulates the smooth muscle. In the present study, we have applied high-resolution computed tomography to accurately quantify the changes in airway area before and after a standard MCh aerosol challenge in airways treated with bronchial thermoplasty. We studied a total of 193 airways ranging from 2 to 15 mm in six dogs. These were divided into treated and control populations. The MCh dose-response curves in untreated airways and soon-to-be-treated airways were superimposable. In contrast, the dose-response curves in treated airways were shifted upward at all points, showing a significantly decreased sensitivity to MCh at both 2 and 4 wk posttreatment. These results thus show that treated airways have significantly increased luminal area at any dose of inhaled MCh compared with untreated airways. The work in this study thus supports the underlying concept that impairing the smooth muscle may be an effective treatment for asthma.

Serial Change in Airway Lumen and Wall Thickness at Thin-Section CT in Asymptomatic Subjects

PURPOSE

To retrospectively analyze serial changes in airway lumen and wall thickness (WT) at multi-detector row computed tomography (CT) in asymptomatic subjects.

MATERIALS AND METHODS

Institutional review board did not require its approval or informed patient consent. Airway dimensions were analyzed in 52 patients (30 men and 22 women) without known cardiopulmonary disease. Contiguous 2-mm CT sections were obtained after reconstruction, extending from origin of right posterior basal segmental bronchi to posterior subsegmental bronchi. Following parameters were determined with semiautomatic image-processing program: luminal area (LA), total airway area (TA), short axis of lumen (LSD), and short axis of total airway (TSD). In airways in which adjacent vessel or branching of small bronchus abutted boundary of airway, extrapolated line was traced by one radiologist. Airway wall area (WA) was calculated as TA - LA, and WT was calculated as (TSD - LSD)/2. Relative WA (WA% = [WA/TA] . 100) and ratio of airway WT to total diameter (D) (WT/D = WT/TSD) were calculated. Linear regression analysis and Spearman rank correlation were used to evaluate relationship between airway parameters (LA, WA%, and WT/D ratio) and distance from origin of segmental bronchi.

RESULTS

LA decreased as CT proceeded from hilum to periphery (r = -0.765, P < .001). In 308 (32.7%) of 943 bronchi, however, LA increased as CT proceeded from hilum to periphery. LA increased by 10% or more in 101 (10.7%) of 943 bronchi. Mean changes in WA% and WT/D ratio between two contiguous sections were 0.66 +/- 5.05 (standard deviation) and 0.003 +/- 0.024, respectively. WA% changed by more than 5% between two contiguous sections in 274 (29.0%) of 943 bronchi. WT/D ratio changed by more than 0.02 between two contiguous sections in 338 (35.8%) of 943 bronchi.

CONCLUSION

Variation of airway lumen and WT is found in asymptomatic subjects without known cardiopulmonary disease.

Structural airway abnormalities in infants and young children with cystic fibrosis

OBJECTIVES

To determine whether the airway structure of infants and young children with cystic fibrosis (CF) differs from that of normal children by using high-resolution computed tomography (HRCT) imaging. Study design Full-inflation, controlled ventilation HRCT images of the lungs were obtained at four anatomic levels in 34 infants with CF (age, 2.4+/-1.4 years) and 20 control infants (age, 1.8+/-1.4 years). Short axis diameters of all clearly identifiable, round airway/vessel pairs were measured to obtain airway wall thickness (AWT), airway lumen diameter (ALD), and vessel diameter (VD).

RESULTS

In infants with CF, mean AWT (+/-SD) was 0.58+/-0.13 mm, ALD was 1.31+/-0.56 mm, and VD was 1.62+/-0.58 mm. In control infants, mean AWT was 0.49+/-0.13 mm, ALD was 1.07+/-0.42 mm, and VD was 1.86+/-0.64 mm. Mean AWT and ALD were greater in children with CF than in normal subjects (P<.001). ALD:VD ratios increased with age in patients with CF compared with control subjects (P=.026).

CONCLUSIONS

The airways of infants and young children with CF have thicker walls and are more dilated than those of normal infants.

Future generation CT imaging

X-ray CT technology has been available for more than 30 years, yet continued technological advances have kept CT imaging at the forefront of medical imaging innovation. Consequently, the number of clinical CT applications has increased steadily. Other imaging modalities might be superior to CT imaging for some specific applications, but no other single modality is more often used in chest imaging today. Future technological developments in the area of high-resolution detectors, high-capacity x-ray tubes, advanced reconstruction algorithms, and improved visualization techniques will continue to expand the imaging capability. Future CT imaging technology will combine improved imaging capability with advanced and specific computer-assisted tools, which will expand the usefulness of CT imaging in many areas.

Maximizing quantitative accuracy of lung airway lumen and wall measures obtained from X-ray CT imaging

To objectively quantify airway geometry from three-dimensional computed tomographic (CT) images, an idealized (circular cross section) airway model is parameterized by airway luminal caliber, wall thickness, and tilt angle. Using a two-dimensional CT slice, an initial guess for the airway center, and the full-width-half-maximum principle, we form an estimate of inner and outer airway wall locations. We then fit ellipses to the inner and outer airway walls via a direct least squares fit and use the major and minor axes of the ellipses to estimate the tilt and in-plane rotation angles. Convolving the airway model, initialized with these estimates, with the three-dimensional scanner point-spread function forms the predicted image. The difference between predicted and actual images is minimized by refining the model parameter estimates via a multidimensional, unconstrained, nonlinear minimization routine. When optimization converges, airway model parameters estimate the airway inner and outer radii and tilt angle. Results using a Plexiglas phantom show that tilt angle is estimated to within +/-4 degrees and both inner and outer radii to within one-half pixel when a "standard" CT reconstruction kernel is used. By opening up the ability to measure airways that are not oriented perpendicular to the scanning plane, this method allows evaluation of a greater sampling of airways in a two-dimensional CT slice than previously possible. In addition, by combining the tilt-angle compensation with the deconvolution method, we provide significant improvement over the previous full-width-half-maximum method for assessing location of the luminal edge but not the outer edge of the airway wall.

A method for the reconstruction of four-dimensional synchronized CT scans acquired during free breathing

Breathing motion is a significant source of error in radiotherapy treatment planning for the thorax and upper abdomen. Accounting for breathing motion has a profound effect on the size of conformal radiation portals employed in these sites. Breathing motion also causes artifacts and distortions in treatment planning computed tomography (CT) scans acquired during free breathing and also causes a breakdown of the assumption of the superposition of radiation portals in intensity-modulated radiation therapy, possibly leading to significant dose delivery errors. Proposed voluntary and involuntary breath-hold techniques have the potential for reducing or eliminating the effects of breathing motion, however, they are limited in practice, by the fact that many lung cancer patients cannot tolerate holding their breath. We present an alternative solution to accounting for breathing motion in radiotherapy treatment planning, where multislice CT scans are collected simultaneously with digital spirometry over many free breathing cycles to create a four-dimensional (4-D) image set, where tidal lung volume is the additional dimension. An analysis of this 4-D data leads to methods for digital-spirometry, based elimination or accounting of breathing motion artifacts in radiotherapy treatment planning for free breathing patients. The 4-D image set is generated by sorting free-breathing multislice CT scans according to user-defined tidal-volume bins. A multislice CT scanner is operated in the ciné mode, acquiring 15 scans per couch position, while the patient undergoes simultaneous digital-spirometry measurements. The spirometry is used to retrospectively sort the CT scans by their correlated tidal lung volume within the patient's normal breathing cycle. This method has been prototyped using data from three lung cancer patients. The actual tidal lung volumes agreed with the specified bin volumes within standard deviations ranging between 22 and 33 cm3. An analysis of sagittal and coronal images demonstrated relatively small (<1 cm) motion artifacts along the diaphragm, even for tidal volumes where the rate of breathing motion is greatest. While still under development, this technology has the potential for revolutionizing the radiotherapy treatment planning for the thorax and upper abdomen.

Duration of deep inspiration and subsequent airway constriction in vivo

The effects of a deep inspiration (DI) in asthmatics differ from those observed in healthy subjects. When considering the effects of a DI, an implicit assumption is that all the airways are distending at the same rate as the lung parenchyma. However, with such rapid lung inflation, the ability of contracted airways to dynamically follow the lung parenchyma was recently shown to significantly lag the lung inflation. Another potentially important variable in the response of the individual airways to a DI that has not been well studied is the duration of the DI maneuver. The current study examines the effects of increasing duration at TLC during a DI on subsequent airway caliber. In five anesthetized and ventilated mongrel dogs, after DIs of increasing duration, changes in airway size were measured over the subsequent 5-minute period using high-resolution computed tomography. Results show that the duration of the maneuver is extremely important, leading to a qualitative change in the airway response. A long DI (> or = 30 seconds) caused subsequent airway dilation, while a shorter DI (< 30 seconds) caused bronchoconstriction. The precise mechanism underlying these observations is uncertain but seems to be related to intrinsic properties within the contracted airway smooth muscle.

Non-invasive imaging of regional lung function using x-ray computed tomography

The use of imaging technologies has progressed beyond the depiction of anatomic abnormalities to providing non-invasive regional structure and functional information in intact subjects. These data are particularly valuable in studies of the lung, since lung disease is heterogeneous and significant loss of function may occur before it is detectable by traditional whole lung measurements such as oxygenation, compliance, or spirometry. While many imaging modalities are available, X-ray computed tomography (CT) is emerging as the preferred method for imaging the lung because of its widespread availability, resolution, high signal/noise ratio for lung tissue, and speed. Utilizing the quantitative density and dimensional information available from conventional CT images, it is possible to measure whole and regional lung volumes, distribution of lung aeration and recruitment behavior under various clinical conditions and interventions, and important regional mechanical properties. In addition, using the radiodense gas xenon (Xe) as a contrast agent, regional ventilation or gas transport may also be obtained. This communication will review recent advances in CT based techniques for the measurement of regional lung function.

HRCT imaging of airway responsiveness: effects of anesthetics

The noninvasive imaging method, high resolution computed tomography (HRCT), has been developed in animal models and applied to humans with obstructive lung disease for assessing regional and individual airway responsiveness. The ability to directly view airway responses during provocations such as tracheal intubation in an asthmatic could greatly enhance our understanding and treatment of airway hyperresponsiveness. HRCT uses increased kilovoltage peak (kVp) and milliamperage (mAs) settings, thin slices, high spacial frequency reconstruction algorithms, and small fields of view to resolve structures as small as 200 microm. Therefore, airways as small as 1-2 mm in diameter can be viewed and measured. HRCT is a more sensitive technique for resolving airway caliber changes than clinical or research methods of pulmonary function tests. HRCT allows direct in vivo measurement of airway responsiveness to pharmacological and physiological stress that induces bronchoconstriction or bronchodilation. Using HRCT, we are able to measure airway dilation at baseline airway tone with inhalation anesthetics, differentiate the bronchodilating properties of inhalational agents in airways with tone, assess bronchodilating agents commonly used as premedications prior to anesthesia, and measure airway heterogeneity at baseline tone and their response to a variety of stimuli. This ability of HRCT to measure airway caliber and response heterogeneity in vivo noninvasively will dramatically improve our understanding of pulmonary physiology in general and the effects of anesthetics on the airways specifically.

Quantitative assessment of airway remodeling using high-resolution CT

Asthma and COPD are the most prevalent of lung diseases and contribute an enormous burden of morbidity in North America and globally. In both conditions, inflammation leads to airway remodeling, which contributes to airway narrowing. To date, airway remodeling has only been assessed using histological examination of airways. However, it may now be possible to assess and quantify the extent of airway remodeling in vivo using high-resolution CT (HRCT). The aim of this article is to review the use of HRCT in the investigation of airway remodeling. A number of investigators have reported techniques to make measurements of airway dimensions using CT and an increasing number of quantitative methods are being developed. Using these techniques, airway dimensions have been examined in patients with asthma and COPD. In patients with asthma, the airway wall area was increased without a decrease in luminal area, whereas in patients with COPD, the airway luminal area was decreased and airway wall area was increased. The different pattern of remodeling may reflect fundamental differences in the inflammatory processes in asthma and COPD and could influence the reversibility of the narrowing. It has also been shown that, by quantifying both the extent of emphysema and of airway remodeling, CT is useful in differentiating COPD patients who have primarily parenchymal disease from those who have primarily airway pathology. With additional advances in technology, it is likely that quantitative assessment of airway wall dimensions will ultimately provide a valuable tool for the study of airway disease.

System for upper airway segmentation and measurement with MR imaging and fuzzy connectedness

RATIONALE AND OBJECTIVES

The purpose of this study was to evaluate whether a computerized system developed to help delineate the upper airway and surrounding structures with magnetic resonance (MR) imaging was effective for aiding in the diagnosis of upper airway disorders in children.

MATERIALS AND METHODS

The authors performed axial T2-weighted MR imaging to gather information about different aspects of the airway and its surrounding soft-tissue structures, including the adenoid and palatine tonsils, tongue, and soft palate. Images were processed and segmented to compute the architectural parameters of the airway (eg, surface description, volume, central [medial] line, and cross-sectional areas at planes perpendicular to the central line). The authors built a software package for the visualization, segmentation, registration, prefiltering, interpolation, standardization, and quantitative analysis of the airway and tonsils.

RESULTS

The system was tested with 40 patient studies. For every study, the system segmented and displayed a smooth three-dimensional rendition of the airway and its central line and a plot of the cross-sectional area of the airway orthogonal to the central line as a function of the distance from one end of the central line. The precision and accuracy for segmentation was 97%. The mean time taken per study was about 4 minutes and included the operator interaction time and processing time.

CONCLUSION

This method provides a robust and fast means of assessing the airway size, shape, and level of restriction, as well as a structural data set suitable for use in modeling studies of airflow and mechanics.

Three-dimensional human airway segmentation methods for clinical virtual bronchoscopy

RATIONALE AND OBJECTIVES

The segmentation of airways from CT images is a critical first step for numerous virtual bronchoscopic (VB) applications. Automatic or semiautomatic methods are necessary, since manual segmentation is prohibitively time consuming. The methods must be robust and operate within a reasonable time frame to be useful for clinical VB use. The authors developed an integrated airway segmentation system and demonstrated its effectiveness on a series of human images.

MATERIALS AND METHODS

The authors' airway segmentation system draws on two segmentation algorithms: (a) an adaptive region-growing algorithm and (b) a new hybrid algorithm that uses both region growing and mathematical morphology. Images from an ongoing VB study were segmented by means of both the adaptive region-growing and the new hybrid methods. The segmentation volume, branch number estimate, and segmentation quality were determined for each case.

RESULTS

The results demonstrate the need for an integrated segmentation system, since no single method is superior for all clinically relevant cases. The region-growing algorithm is the fastest and provides acceptable segmentations for most VB applications, but the hybrid method provides superior airway edge localization, making it better suited for quantitative applications. In addition, the authors show that prefiltering the image data before airway segmentation increases the robustness of both region-growing and hybrid methods.

CONCLUSION

The combination of these two algorithms with the prefiltering options allowed the successful segmentation of all test images. The times required for all segmentations were acceptable, and the results were suitable for the authors' VB application needs.

Automatic axis generation for virtual bronchoscopic assessment of major airway obstructions

Virtual bronchoscopy (VB) has emerged as a paradigm for more effective 3D CT image evaluation. Systematic evaluation of a 3D CT chest image using VB techniques, however, requires precomputed guidance data. This guidance data takes the form of central axes, or centerlines, through the major airways. We propose an axes-generation algorithm for VB assessment of 3D CT chest images. For a typical high-resolution 3D CT chest image, the algorithm produces a series of airway-tree axes, corresponding airway cross-sectional area measurements, and a segmented airway tree in a few minutes on a standard PC. Results for phantom and human airway-obstruction cases demonstrate the efficacy of the algorithm. Also, the algorithm is demonstrated in the context of VB-based 3D CT assessment.

Decreased pulmonary vascular permeability in aquaporin-1-null humans

The molecular determinants of water permeability in the human lung are incompletely defined. Aquaporins (AQP) are water-specific membrane channel proteins. AQP1 is present in endothelial cells in the lung, including those in the vascular plexus around the airways. Rare individuals have been identified who are deficient in AQP1. High-resolution computed tomography scans of the lung were used to evaluate the response to i.v. fluid challenge in two unrelated AQP1-null individuals and five normal controls. The airways and pulmonary vessels were measured at baseline and after i.v. administration of 3 liters of saline. Increases in airway wall thickness after fluid administration reflect peribronchiolar edema formation. Both control and AQP1 null subjects had approximately a 20% increase in pulmonary vessel area in response to saline infusion, suggesting similar degrees of volume loading. Control subjects had a 44% increase in the thickness of the airway wall, consistent with peribronchiolar edema formation. In marked contrast, airway wall thickness did not change in AQP1-null subjects in response to saline infusion. These studies indicate that AQP1 is a determinant of vascular permeability in the lung, and demonstrate a role for aquaporins in human pulmonary physiology.

CT virtual bronchoscopy of the central airways in patients with Wegener's granulomatosis

OBJECTIVES

To compare CT virtual bronchoscopy (VB) to CT alone and to conventional bronchoscopy for evaluation of central airway stenoses in patients with Wegener's granulomatosis.

DESIGN

Prospective observer study, in which 18 thin-section helical CT scans of the trachea and bronchi of 11 patients with Wegener's granulomatosis were obtained. VB was performed using surface rendering and was evaluated by one bronchoscopist and one radiologist in a blinded fashion. Bronchoscopic correlation within an average of 1.8 days of CT was available.

MEASUREMENTS AND RESULTS

VB displayed 188 of 198 bronchi (95%). Thirty-two of 40 stenoses (80%) were detected by VB by at least one of two physicians (double reading), and 22 of 40 stenoses (55%) were detected by a third physician reading only the CT.

CONCLUSIONS

VB depicts bronchi to the segmental level and detects the majority of central airway stenoses in patients with Wegener's granulomatosis. A team approach is useful to attain optimal clinical benefit from VB for these patients.

Airway response to deep inspiration: role of inflation pressure

Deep inspirations (DIs) have been shown to have both bronchoprotective and bronchodilator effects in healthy subjects; however, the bronchodilator effects of a DI appear to be impaired in asthmatic compared with healthy subjects. Because the ability to generate high transpulmonary pressures at total lung capacity depends on both the lung properties and voluntary effort, we wondered how the response of airways to DI might be altered if the maneuver were done with less than maximal inflation. The present work was undertaken to examine the effects of varying the magnitude of lung inflation during the DI maneuver on subsequent airway caliber. In five anesthetized and ventilated dogs during methacholine infusion, changes in airway size after DIs of increasing magnitude were measured over the subsequent 5-min period using high-resolution computed tomography. Results show that the magnitude of lung inflation is extremely important, leading to a qualitative change in the airway response. A large DI (45 cmH(2)O airway pressure) caused subsequent airway dilation, whereas smaller DIs (< or =35 cmH(2)O) caused bronchoconstriction. The precise mechanism underlying these observations is uncertain, but it seems to be related to an interaction between intrinsic properties of the contracted airway smooth muscle and the response to mild stretch.

Pulmonary arterial morphometry from microfocal X-ray computed tomography

The objective of this study was to develop an X-ray computed tomographic method for pulmonary arterial morphometry. The lungs were removed from a rat, and the pulmonary arterial tree was filled with perfluorooctyl bromide to enhance X-ray absorbance. At each of four pulmonary arterial pressures (30, 21, 12, and 5.4 mmHg), the lungs were rotated within the cone of the X-ray beam that was projected from a microfocal X-ray source onto an image intensifier, and 360 images were obtained at 1 degrees increments. The three-dimensional image volumes were reconstructed with isotropic resolution with the use of a cone beam reconstruction algorithm. The luminal diameter and distance from the inlet artery were measured for the main trunk, its immediate branches, and several minor trunks. These data revealed a self-consistent tree structure wherein the portion of the tree downstream from any vessel of a given diameter has a similar structure. Self-consistency allows the entire tree structure to be characterized by measuring the dimensions of only the vessels comprising the main trunk of the tree and its immediate branches. An approach for taking advantage of this property to parameterize the morphometry and distensibility of the pulmonary arterial tree is developed.

Effects of tidal volume stretch on airway constriction in vivo

Tidal stresses are thought to be involved in maintaining airway patency in vivo. The present study examined the effects of normal stresses exerted by the lung parenchyma during tidal ventilation on recovery from agonist-induced airway constriction. In seven anesthetized dogs, one lung was selectively ventilated with a Univent endotracheal tube (Vitaid, Lewiston, NY). Airway tone was increased either transiently (intravenous bolus) or continuously (intravenous infusion) with methacholine (MCh). During one-lung ventilation, changes in the airway size of both lungs were measured for up to 40 min during recovery from constriction by using high-resolution computed tomography. After recovery to baseline, the alternate lung was ventilated, and the protocol was repeated. The absence of tidal stresses led to an attenuated recovery from either transient or steady-state airway constriction. The effectiveness or lack thereof of normal tidal stress in stabilizing airway size may be one factor that contributes to the lack of reversal with tidal breathing and deep inspiration seen in asthmatic subjects.

Microfocal X-ray CT imaging and pulmonary arterial distensibility in excised rat lungs

The objective of this study was to develop an X-ray computed tomographic method for measuring pulmonary arterial dimensions and locations within the intact rat lung. Lungs were removed from rats and their pulmonary arterial trees were filled with perfluorooctyl bromide to enhance X-ray absorbance. The lungs were rotated within the cone of the X-ray beam projected from a microfocal X-ray source onto an image intensifier, and 360 images were obtained at 1 degrees increments. The three-dimensional image volumes were reconstructed with isotropic resolution using a cone beam reconstruction algorithm. The vessel diameters were obtained by fitting a functional form to the image of the vessel circular cross section. The functional form was chosen to take into account the point spread function of the image acquisition and reconstruction system. The diameter measurements obtained over a range of vascular pressures were used to characterize the distensibility of the rat pulmonary arteries. The distensibility coefficient alpha [defined by D(P) = D(0)(1 + alphaP), where D(P) is the diameter at intravascular pressure (P)] was approximately 2.8% mmHg and independent of vessel diameter in the diameter range (about 100 to 2,000 mm) studied.

Distribution of pulmonary ventilation using Xe-enhanced computed tomography in prone and supine dogs

Xe-enhanced computed tomography (CT; Xe-CT) is a method for the noninvasive measurement of regional pulmonary ventilation in intact subjects, determined from the washin and washout rates of the radiodense, nonradioactive gas Xe, as measured in serial CT scans. We used the Xe-CT ventilation method, along with other quantitative CT measurements, to investigate the distribution of regional lung ventilation and air content in healthy, anesthetized, mechanically ventilated dogs in the prone and supine postures. Vertical gradients in regional ventilation and air content were measured in five mongrel dogs in both prone and supine postures at four axial lung locations. In the supine position, ventilation increased with dependent location, with a mean slope of 7.3%/cm lung height, whereas no ventilation gradients were found at any location in the prone position. These results agree quantitatively with other published studies. In addition, six different animals were studied (3 supine, 3 prone) to examine the longitudinal distribution of ventilation and air content. The prone lungs were more uniformly inflated compared with the supine, which were less well expanded at the base than apex. Ventilation index, a measure of regional ventilation relative to whole lung ventilation, increased steeply from apex to base in the supine animals, whereas it was again more uniform in the prone condition. We conclude that the Xe-CT method provides a reasonable, quantitative measurement of regional ventilation and promises to be a valuable tool for the noninvasive determination of regional lung function.

In vivo measurement of lung volumes in mice

We describe longitudinal measurements of functional residual capacity (FRC) in breathing mice using a clinical computed tomography (CT) scanner. Lungs of anesthetized mice from the A/J and C3H/HeJ strains were scanned over a 10-s period. Using a fixed threshold for CT density, we could accurately and reproducibly obtain the amount of air in the lungs at FRC, with a 10% coefficient of variation. Total lung volume, and the fractions in left and right lungs, were measured in the two strains from 4 to 12 wk of age. Results show that in both strains the FRC increases only up to 6 wk of age and then remains stable despite a steady increase in body weight. Over this time period, FRC was consistently about 50% greater in the C3H/HeJ strain compared with the A/J strain. The C3H/HeJ strain also has a significantly smaller fraction of the total lung volume in the left lung. We conclude that accurate measurements of FRC in breathing mice can be made using a standard clinical CT scanner. This method may be useful for repeated noninvasive assessment of both structural and functional changes in the lungs of experimental and genetically manipulated mice.

Delayed distension of contracted airways with lung inflation in vivo

A deep inspiratory sigh is one of the most severe dynamic stresses that lungs normally experience. It typically is a very transient phenomenon, normally lasting only about 2 to 3 s. The airway response to a deep inspiration has been shown to be different in asthmatic and normal individuals. When airway smooth muscle (ASM) is contracted in normal subjects, a deep inspiration results in a subsequent dilation of the airways. However, in asthmatic subjects, a deep inspiration often results in little change in airway function, and sometimes results in an even further contraction of ASM. The mechanism underlying this difference depends on the dynamic behavior of both ASM and the lung parenchyma. If the contracted muscle had slower dynamic responses than the lung parenchyma, the timing of the deep inspiratory maneuver could affect the airway response. In the present study, we designed an experiment to determine how well matched the dynamic response is of airways to that of the lung parenchyma. The results clearly demonstrate that airways contracted with methacholine dilate at about a rate four times slower than that of the lung parenchyma during rapid lung inflation and deflation. This effect may play a role in the unique response of asthmatic subjects to deep inspiration. The mechanism of this dynamic slowness of contracted airways probably involves intrinsic properties of the smooth-muscle contractile processes.

Airway closure with high PEEP in vivo

When airway smooth muscle is contracted in vitro, the airway lumen continues to narrow with increasing concentrations of agonist until complete airway closure occurs. Although there remains some controversy regarding whether airways can close in vivo, recent work has clearly demonstrated that, if the airway is sufficiently stimulated with contractile agonists, complete closure of even large cartilaginous conducting airways can readily occur with the lung at functional residual capacity (Brown RH and Mitzner W. J Appl Physiol 85: 2012-2017, 1998). This result suggests that the tethering of airways in situ by parenchymal attachments is small at functional residual capacity. However, at lung volumes above functional residual capacity, the outward tethering of airways should increase, because both the parenchymal shear modulus and tethering forces increase in proportion to the transpulmonary pressure. In the present study, we tested whether we could prevent airway closure in vivo by increasing lung volume with positive end-expiratory pressure (PEEP). Airway smooth muscle was stimulated with increasing methacholine doses delivered directly to airway smooth muscle at three levels of PEEP (0, 6, and 10 cmH(2)O). Our results show that increased lung volume shifted the airway methacholine dose-response curve to the right, but, in many airways in most animals, airway closure still occurred even at the highest levels of PEEP.

Potential mechanism of hyperresponsive airways

It has been known for many years that the response of asthmatic subjects to a deep inspiration differs from that observed in normal healthy subjects. A deep inspiration causes a decrease in airway resistance in normal subjects, whereas asthmatics demonstrate either no change or a slight increase in airway resistance. It has been suggested by several investigators that the inability to dilate airways during lung inflation may be a primary defect in asthma. One study (Skloot and colleagues, J. Clin. Invest. 1995;96:2393- 2403) showed that in the absence of a deep inspiration during methacholine (MCh) challenge, normal subjects had a greatly exaggerated and sustained response to this agonist. It was suggested that asthmatic airways could be modeled by this condition in normal, subjects. Other investigators, however, suggest that there are more intrinsic differences between the responses to lung inflation in airways from asthmatic and normal subjects (Brusasco and colleagues, J. Appl. Physiol. 1999;87:567-573). Resolution of this controversy requires the ability to assess the responses of airways directly, but unfortunately conventional pulmonary function tests in human subjects are not specific enough to allow this evaluation. In the present study, we have performed experiments using a direct imaging approach that allows us to obtain measurements of airway and parenchymal dimensions that can be used to test the responses of individual airways to deep inspiration in vivo. Our results show that the presence of normal tidal stresses allows airway smooth muscle to respond normally to deep inspirations. Removing tidal stresses at FRC after MCh challenge is sufficient to change the normal dilatory response to deep inspiration into an abnormal one of contraction. Altered sensitivity of airway smooth muscle to normal tidal stresses thus may be operative in the development of the asthmatic pathology.

Computer-aided diagnosis for lung cancer

CAD methods may provide radiologists with tools to obtain more accurate diagnoses for lung cancer. Considerable effort has been devoted to developing CAD tools for CXR; however, these are limited by the fundamental constraints of the projective CXR modality. CT provides far more detailed information that can be exploited better by CAD systems. There has been very little work done in this area to date, although the basic technology has already been developed through the more extensive research in the computer vision areas supported by industry and the military. Initial prototype CT CAD systems have been described that are highly effective in detecting small pulmonary nodules and in predicting malignancy of nodules. CT is now achieving momentum in the study of lung cancer. It has taken time for this modality to gain acceptance because of several factors: higher radiation dose, higher cost, and the novelty of use in this application. It is important to note that the technology for CT scanners is still rapidly evolving. As the speed, resolution, and cost of CT scanners continue to improve, computer techniques for the measurement and analysis of nodules will also achieve corresponding improvements in accuracy and diagnostic utility. Future knowledge-based CT CAD systems will provide detailed analysis of the related conditions of the lungs, such as emphysema, and diagnostic analysis of nodules. The issue is not whether CAD will improve the performance and capabilities of the radiologist, but at what rate their development and the corresponding improvement will occur. Current prototype CAD systems may be considered as tools. As such they will improve the performance of the user/radiologist if they are well engineered and if the user understands their capabilities and limitations. These systems need to be improved by knowledge-based engineering, which is notoriously difficult to implement robustly and requires model refinement and optimization based on a large database of cases. Research should be directed at developing these methods rather than comparing prototype systems with current practices. Future performance should be expected to exceed that of today's grand masters.

Computer-aided diagnosis of small pulmonary nodules

Computer-aided methods are now being developed for the detection and characterization of pulmonary nodules found in CT images, based on techniques from computer vision, image processing, and pattern classification. With the increasing resolution of modern CT scanners, computer methods provide continually improving accuracy, reproducibility, and utility in analyzing the larger numbers of images acquired in a lung screening exam or diagnostic study. This article describes the fundamental tools and issues involved in computer-aided nodule detection and characterization, as we move from two-dimensional toward three-dimensional automated methods. In particular, we focus on the new domain of "small" pulmonary nodules.

An analysis algorithm for measuring airway lumen and wall areas from high-resolution computed tomographic data

High-resolution computed tomography (HRCT) has been used to examine airway narrowing. We developed an automated computed tomographic image analysis algorithm (computed tomographic airway morphometry; CTAM) to measure airway lumen area (Ai ), airway wall area (Awa), and airway angle of orientation. Tubes of varying size were embedded in Styrofoam and then scanned at angles between 0 degrees and 50 degrees to assess the accuracy of measurements made with CTAM. Two excised pig lungs were fixed in inflation, sectioned, and scanned. Ai and Awa were measured planimetrically from the cut surfaces to optimize CTAM measurement parameters. In CTAM, Ai was defined according to an airway-size-dependent threshold value, and total Awa was determined through a score-guided erosion method. Results were compared with measurements made through a previously validated method (manual method). CTAM provided accurate measurements of the tubes' Ai values at all angles; Awa was overestimated in direct relation to airway size. The manual method underestimated Ai and overestimated Awa in a manner directly related to airway size as well as to airway angle of orientation. In the excised lung, the mean errors of Ai and Awa measurements made with CTAM were 0.52 +/- 0.24 mm(2) and 0.17 +/- 0.32 mm(2) (mean +/- SEM), respectively. Ai errors with the manual method were similar, but Awa was overestimated to a greater degree (6.3 +/- 0.38 mm(2); p < 0.01) and the error was proportional to Awa (r = 0.64; p < 0.01). CTAM allows accurate measurements of airway dimensions and angle of orientation.

Airway reactivity to bronchoconstrictor and bronchodilator: assessment using thin-section and volumetric three-dimensional CT

OBJECTIVE

To determine the extent to which thin-section and volumetric threedimensional CT can depict airway reactivity to bronchostimulator, and to assess the effect of different airway sizes on the degree of reactivity.

MATERIALS AND METHODS

In eight dogs, thin-section CT scans were obtained before and after the administration of methacholine and ventolin. Cross-sectional areas of bronchi at multiple levels, as shown by axial CT, proximal airway volume as revealed by three-dimensional imaging, and peak airway pressure were measured. The significance of airway change induced by methacholine and ventolin, expressed by percentage changes in cross-sectional area, proximal airway volume, and peak airway pressure was statistically evaluated, as was correlation between the degree of airway reactivity and the area of airways.

RESULTS

Cross-sectional areas of the bronchi decreased significantly after the administration of methacholine, and scans obtained after a delay of 5 minutes showed that normalization was insufficient. Ventolin induced a significant increase in cross-sectional areas and an increase in proximal airway volume, while the effect of methacholine on the latter was the opposite. Peak airway pressure increased after the administration of methacholine, and after a 5-minute delay its level was near that of the control state. Ventolin, however, induced no significant decrease. The degree of airway reactivity did not correlate with airway size.

CONCLUSION

Thin-section and volumetric spiral CT with three-dimensional reconstruction can demonstrate airway reactivity to bronchostimulator. The degree of reactivity did not correlate with airway size.

Semi-automated tabulation of the 3D topology and morphology of branching networks using CT: application to the airway tree

Detailed information on biological branching networks (optical nerves, airways or blood vessels) is often required to improve the analysis of 3D medical imaging data. A semi-automated algorithm has been developed to obtain the full 3D topology and dimensions (direction cosine, length, diameter, branching and gravity angles) of branching networks using their CT images. It has been tested using CT images of a simple Perspex branching network and applied to the CT images of a human cast of the airway tree. The morphology and topology of the computer derived network were compared with the manually measured dimensions. Good agreement was found. The airways dimensions also compared well with previous values quoted in literature. This algorithm can provide complete data set analysis much more quickly than manual measurements. Its use is limited by the CT resolution which means that very small branches are not visible. New data are presented on the branching angles of the airway tree.

The myth of maximal airway responsiveness in vivo

A sine qua non of hyperresponsive airway disease in asthmatic subjects is the lack of a maximal response with increasing doses of aerosol agonist challenge. Normal subjects, however, often appear to exhibit an airway response plateau effect even when challenged with high concentrations of agonist. To investigate this question of maximal narrowing in individual airways in vivo, we used high-resolution computed tomography to visualize canine airways narrowed by two routes of agonist challenge. We compared airway narrowing induced by methacholine (MCh) via the conventional aerosol route to that caused by local atomization of MCh directly to individual airways. Our results showed that, with aerosol challenge, airway responses never reached a truly flat plateau even at the highest possible nebulizer concentrations. Airway closure was never observed. However, when MCh was delivered directly to the airway luminal surface, airways could be easily narrowed to complete closure at modest (10 mg/ml) agonist concentrations. Thus neither the elastic recoil of the lung nor limitations of smooth muscle shortening can be responsible for the apparent plateauing of dose-response curves. We suggest that the plateau results from limitations associated with the delivery of high concentration of agonists via the aerosol route.

Segmentation of intrathoracic airway trees: a fuzzy logic approach

Three-dimensional (3-D) analysis of airway trees extracted from computed tomography (CT) image data can provide objective information about lung structure and function. However, manual analysis of 3-D lung CT images is tedious, time consuming and, thus, impractical for routine clinical care. We have previously reported an automated rule-based method for extraction of airway trees from 3-D CT images using a priori knowledge about airway-tree anatomy. Although the method's sensitivity was quite good, its specificity suffered from a large number of falsely detected airways. We present a new approach to airway-tree detection based on fuzzy logic that increases the method's specificity without compromising its sensitivity. The method was validated in 32 CT image slices randomly selected from five volumetric canine electron-beam CT data sets. The fuzzy-logic method significantly outperformed the previously reported rule-based method (p < 0.002).

Individual canine airways responsiveness to aerosol histamine and methacholine in vivo

Inhalational challenges to histamine and methacholine (Mch) are commonly used to measure airway reactivity. In this study, we investigated the serial distribution of individual airway responsiveness in vivo following stimulation with histamine or methacholine by directly measuring airway area with high resolution computed tomography (HRCT). Anesthetized dogs were challenged on separate days to increasing aerosol concentrations of histamine or Mch. Airway areas of 13 or 14 individual airways in each dog ranging in size from 1.1 to 16.9 mm in diameter at baseline were measured. Dose response curves for each agonist showed a similar responsiveness to each agonist over all airway sizes measured. There was a slightly greater individual airway responsiveness to Mch throughout the airway tree, and this greater responsiveness was also present in those airways that are responsible for the decreased Cdyn observed with Mch challenge. We conclude that in vivo aerosol challenges with histamine or methacholine do not lead to preferential construction of large or small airways.

New techniques and developments in physiologic imaging of airways

Recently, noninvasive imaging methods for assessing regional and individual airway responsiveness have been developed in animal models and applied to humans with obstructive lung disease. This article examines the technique of high-resolution CT scan and MR imaging and their applications to the imaging of airways.

Accurate measurement of intrathoracic airways

Airway geometry measurements can provide information regarding pulmonary physiology and pathophysiology. There has been considerable interest in measuring intrathoracic airways in two-dimensional (2-D) slices from volumetric X-ray computed tomography (CT). Such measurements can be used to evaluate and track the progression of diseases affecting the airways. A popular airway measurement method uses the "half-max" criteria, in which the gray level at the airway wall is estimated to be halfway between the minimum and maximum gray levels along a ray crossing the edge. However, because the scanning process introduces blurring, the half-max approach may not be applicable across all airway sizes. We propose a new measurement method based on a model of the scanning process. In our approach, we examine the gray-level profile of a ray crossing the airway wall and use a maximum-likelihood method to estimate the airway inner and outer radius. Using CT scans of a physical phantom, we present results showing that the new approach is more accurate than the half-max method at estimating wall location for thin-walled airways.

Nonlinear filtering approach to 3-D gray-scale image interpolation

Three-dimensional (3-D) images are now common in radiology. A 3-D image is formed by stacking a contiguous sequence of two-dimensional cross-sectional images, or slices. Typically, the spacing between known slices is greater than the spacing between known points on a slice. Many visualization and image-analysis tasks, however, require the 3-D image to have equal sample spacing in all directions. To meet this requirement, one applies an interpolation technique to the known 3-D image to generate a new uniformly sampled 3-D image. The authors propose a nonlinear-filter-based approach to gray-scale interpolation of 3-D images. The method, referred to as column-fitting interpolation, is reminiscent of the maximum-homogeneity filter used for image enhancement. The authors also draw upon the paradigm of relaxation labeling to devise an improved column-fitting interpolator. Both methods are typically more effective than traditional gray-scale interpolation techniques.