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Bugenhagen SM, Grant JCE, Rosenbluth DB, Bhalla S. Update on the Role of Chest Imaging in Cystic Fibrosis. Radiographics 2024; 44:e240008. [PMID: 39172707 DOI: 10.1148/rg.240008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Cystic fibrosis is a genetic disease with multisystem involvement and associated morbidity and mortality that are most directly related to progressive lung disease. The hallmark findings of cystic fibrosis in the lungs are chronic inflammation and infection, leading to progressive loss of pulmonary function and often requiring lung transplant. Predominant lung findings include mucous plugging, bronchiectasis, and air trapping, often with associated atelectasis, consolidation, and emphysema; these findings form the basis of several clinical scoring systems that are used for imaging assessment. Recently, there have been major breakthroughs in the pharmacologic management of cystic fibrosis, including highly effective modulator therapies that directly target the underlying cystic fibrosis transmembrane conductance regulator molecular defect, often leading to remarkable improvements in lung function and quality of life with corresponding significant improvements in imaging markers. The authors review current guidelines regarding cystic fibrosis with respect to disease monitoring, identifying complications, and managing advanced lung disease. In addition, they discuss the evolving role of imaging, including current trends, emerging technologies, and proposed updates to imaging guidelines endorsed by international expert committees on cystic fibrosis, which favor increased use of cross-sectional imaging to enable earlier detection of structural changes in early disease and more sensitive detection of acute changes in advanced disease. It is important for radiologists to be familiar with these trends and updates so that they can most effectively assist clinicians in guiding the management of patients with cystic fibrosis in all stages of disease. ©RSNA, 2024.
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Affiliation(s)
- Scott M Bugenhagen
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Jacob C E Grant
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Daniel B Rosenbluth
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
| | - Sanjeev Bhalla
- From the Mallinckrodt Institute of Radiology (S.M.B, J.C.E.G, S.B.) and Department of Medicine (D.B.R.), Washington University, 660 S Euclid Ave, St. Louis, MO 63110
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2
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Gupta S, Dubey AK, Singh R, Kalra MK, Abraham A, Kumari V, Laird JR, Al-Maini M, Gupta N, Singh I, Viskovic K, Saba L, Suri JS. Four Transformer-Based Deep Learning Classifiers Embedded with an Attention U-Net-Based Lung Segmenter and Layer-Wise Relevance Propagation-Based Heatmaps for COVID-19 X-ray Scans. Diagnostics (Basel) 2024; 14:1534. [PMID: 39061671 PMCID: PMC11275579 DOI: 10.3390/diagnostics14141534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 07/10/2024] [Accepted: 07/10/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Diagnosing lung diseases accurately is crucial for proper treatment. Convolutional neural networks (CNNs) have advanced medical image processing, but challenges remain in their accurate explainability and reliability. This study combines U-Net with attention and Vision Transformers (ViTs) to enhance lung disease segmentation and classification. We hypothesize that Attention U-Net will enhance segmentation accuracy and that ViTs will improve classification performance. The explainability methodologies will shed light on model decision-making processes, aiding in clinical acceptance. Methodology: A comparative approach was used to evaluate deep learning models for segmenting and classifying lung illnesses using chest X-rays. The Attention U-Net model is used for segmentation, and architectures consisting of four CNNs and four ViTs were investigated for classification. Methods like Gradient-weighted Class Activation Mapping plus plus (Grad-CAM++) and Layer-wise Relevance Propagation (LRP) provide explainability by identifying crucial areas influencing model decisions. Results: The results support the conclusion that ViTs are outstanding in identifying lung disorders. Attention U-Net obtained a Dice Coefficient of 98.54% and a Jaccard Index of 97.12%. ViTs outperformed CNNs in classification tasks by 9.26%, reaching an accuracy of 98.52% with MobileViT. An 8.3% increase in accuracy was seen while moving from raw data classification to segmented image classification. Techniques like Grad-CAM++ and LRP provided insights into the decision-making processes of the models. Conclusions: This study highlights the benefits of integrating Attention U-Net and ViTs for analyzing lung diseases, demonstrating their importance in clinical settings. Emphasizing explainability clarifies deep learning processes, enhancing confidence in AI solutions and perhaps enhancing clinical acceptance for improved healthcare results.
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Affiliation(s)
- Siddharth Gupta
- Department of Computer Science and Engineering, Bharati Vidyapeeth’s College of Engineering, New Delhi 110063, India;
| | - Arun K. Dubey
- Department of Information Technology, Bharati Vidyapeeth’s College of Engineering, New Delhi 110063, India; (A.K.D.); (N.G.)
| | - Rajesh Singh
- Department of Research and Innovation, Uttaranchal Institute of Technology, Uttaranchal University, Dehradun 248007, India;
| | - Mannudeep K. Kalra
- Department of Radiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA;
| | - Ajith Abraham
- Department of Computer Science, Bennett University, Greater Noida 201310, India;
| | - Vandana Kumari
- School of Computer Science and Engineering, Galgotias University, Greater Noida 201310, India;
| | - John R. Laird
- Heart and Vascular Institute, Adventist Health St. Helena, St. Helena, CA 94574, USA;
| | - Mustafa Al-Maini
- Allergy, Clinical Immunology and Rheumatology Institute, Toronto, ON M5G 1N8, Canada;
| | - Neha Gupta
- Department of Information Technology, Bharati Vidyapeeth’s College of Engineering, New Delhi 110063, India; (A.K.D.); (N.G.)
| | - Inder Singh
- Department of Radiology and Ultrasound, University Hospital for Infectious Diseases, 10000 Zagreb, Croatia;
| | - Klaudija Viskovic
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), 09100 Cagliari, Italy;
| | - Luca Saba
- Department of ECE, Idaho State University, Pocatello, ID 83209, USA;
| | - Jasjit S. Suri
- Department of ECE, Idaho State University, Pocatello, ID 83209, USA;
- Stroke Diagnostics and Monitoring Division, AtheroPoint™, Roseville, CA 95661, USA
- Department of Computer Engineering, Graphic Era (Deemed to be University), Dehradun 248002, India
- Department of Computer Science & Engineering, Symbiosis Institute of Technology, Nagpur Campus 440008, Symbiosis International (Deemed University), Pune 412115, India
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3
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Wang S, Ren J, Guo X. A high-accuracy lightweight network model for X-ray image diagnosis: A case study of COVID detection. PLoS One 2024; 19:e0303049. [PMID: 38889106 PMCID: PMC11185471 DOI: 10.1371/journal.pone.0303049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/15/2024] [Indexed: 06/20/2024] Open
Abstract
The Coronavirus Disease 2019(COVID-19) has caused widespread and significant harm globally. In order to address the urgent demand for a rapid and reliable diagnostic approach to mitigate transmission, the application of deep learning stands as a viable solution. The impracticality of many existing models is attributed to excessively large parameters, significantly limiting their utility. Additionally, the classification accuracy of the model with few parameters falls short of desirable levels. Motivated by this observation, the present study employs the lightweight network MobileNetV3 as the underlying architecture. This paper incorporates the dense block to capture intricate spatial information in images, as well as the transition layer designed to reduce the size and channel number of the feature map. Furthermore, this paper employs label smoothing loss to address the inter-class similarity effects and uses class weighting to tackle the problem of data imbalance. Additionally, this study applies the pruning technique to eliminate unnecessary structures and further reduce the number of parameters. As a result, this improved model achieves an impressive 98.71% accuracy on an openly accessible database, while utilizing only 5.94 million parameters. Compared to the previous method, this maximum improvement reaches 5.41%. Moreover, this research successfully reduces the parameter count by up to 24 times, showcasing the efficacy of our approach. This demonstrates the significant benefits in regions with limited availability of medical resources.
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Affiliation(s)
- Shujuan Wang
- College of Mathematics and Information Science, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Jialin Ren
- College of Mathematics and Information Science, Zhengzhou University of Light Industry, Zhengzhou, China
| | - Xiaoli Guo
- College of Mathematics and Information Science, Zhengzhou University of Light Industry, Zhengzhou, China
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4
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Terlizzi V, Farrell PM. Update on advances in cystic fibrosis towards a cure and implications for primary care clinicians. Curr Probl Pediatr Adolesc Health Care 2024; 54:101637. [PMID: 38811287 DOI: 10.1016/j.cppeds.2024.101637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
During the past quarter century, the diagnosis and treatment of cystic fibrosis (CF) have been transformed by molecular sciences that initiated a new era with discovery of the cystic fibrosis transmembrane conductance regulator (CFTR) gene. The knowledge gained from that breakthrough has had dramatic clinical impact. Although once a diagnostic dilemma with long delays, preventable deaths, and irreversible pathology, CF can now be routinely diagnosed shortly after birth through newborn screening programs. This strategy of pre-symptomatic identification has eliminated the common diagnostic "odyssey" that was a failure of the healthcare delivery system causing psychologically traumatic experiences for parents. Therapeutic advances of many kinds have culminated in CFTR modulator treatment that can reduce the effects of or even correct the molecular defect in the chloride channel -the basic cause of CF. This astonishing advance has transformed CF care as described fully herein. Despite this impressive progress, there are challenges and controversies in the delivery of care. Issues include how best to achieve high sensitivity newborn screening with acceptable specificity; what course of action is appropriate for children who are identified through the unavoidable incidental findings of screening tests (CFSPID/CRMS cases and heterozygote carriers); how best to ensure genetic counseling; when to initiate the very expensive but life-saving CFTR modulator drugs; how to identify new CFTR modulator drugs for patients with non-responsive CFTR variants; how to adjust other therapeutic modalities; and how to best partner with primary care clinicians. Progress always brings new challenges, and this has been evident worldwide for CF. Consequently, this article summarizes the major advances of recent years along with controversies and describes their implications with an international perspective.
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Affiliation(s)
- Vito Terlizzi
- Department of Pediatric Medicine, Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Center, Viale Gaetano Pieraccini 24, Florence, Italy
| | - Philip M Farrell
- Departments of Pediatrics and Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Clinical Sciences Center (K4/948), 600 Highland Avenue, Madison, WI 53792, USA.
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5
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Burgel PR, Southern KW, Addy C, Battezzati A, Berry C, Bouchara JP, Brokaar E, Brown W, Azevedo P, Durieu I, Ekkelenkamp M, Finlayson F, Forton J, Gardecki J, Hodkova P, Hong G, Lowdon J, Madge S, Martin C, McKone E, Munck A, Ooi CY, Perrem L, Piper A, Prayle A, Ratjen F, Rosenfeld M, Sanders DB, Schwarz C, Taccetti G, Wainwright C, West NE, Wilschanski M, Bevan A, Castellani C, Drevinek P, Gartner S, Gramegna A, Lammertyn E, Landau EEC, Plant BJ, Smyth AR, van Koningsbruggen-Rietschel S, Middleton PG. Standards for the care of people with cystic fibrosis (CF); recognising and addressing CF health issues. J Cyst Fibros 2024; 23:187-202. [PMID: 38233247 DOI: 10.1016/j.jcf.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/19/2024]
Abstract
This is the third in a series of four papers updating the European Cystic Fibrosis Society (ECFS) standards for the care of people with CF. This paper focuses on recognising and addressing CF health issues. The guidance was produced with wide stakeholder engagement, including people from the CF community, using an evidence-based framework. Authors contributed sections, and summary statements which were reviewed by a Delphi consultation. Monitoring and treating airway infection, inflammation and pulmonary exacerbations remains important, despite the widespread availability of CFTR modulators and their accompanying health improvements. Extrapulmonary CF-specific health issues persist, such as diabetes, liver disease, bone disease, stones and other renal issues, and intestinal obstruction. These health issues require multidisciplinary care with input from the relevant specialists. Cancer is more common in people with CF compared to the general population, and requires regular screening. The CF life journey requires mental and emotional adaptation to psychosocial and physical challenges, with support from the CF team and the CF psychologist. This is particularly important when life gets challenging, with disease progression requiring increased treatments, breathing support and potentially transplantation. Planning for end of life remains a necessary aspect of care and should be discussed openly, honestly, with sensitivity and compassion for the person with CF and their family. CF teams should proactively recognise and address CF-specific health issues, and support mental and emotional wellbeing while accompanying people with CF and their families on their life journey.
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Affiliation(s)
- Pierre-Régis Burgel
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris (AP-HP), Institut Cochin, Inserm U1016, Université Paris-Cité, Paris, France
| | - Kevin W Southern
- Department of Women's and Children's Health, Institute in the Park, Alder Hey Children's Hospital, University of Liverpool, Eaton Road, Liverpool L12 2AP, UK.
| | - Charlotte Addy
- All Wales Adult Cystic Fibrosis Centre, University Hospital Llandough, Cardiff and Vale University Health Board, Cardiff, UK
| | - Alberto Battezzati
- Clinical Nutrition Unit, Department of Endocrine and Metabolic Medicine, IRCCS Istituto Auxologico Italiano, and ICANS-DIS, Department of Food Environmental and Nutritional Sciences, University of Milan, Milan, Italy
| | - Claire Berry
- Department of Nutrition and Dietetics, Alder Hey Children's NHS Trust, Liverpool, UK
| | - Jean-Philippe Bouchara
- University of Brest, Fungal Respiratory Infections Research Unit, SFR ICAT, University of Angers, Angers, France
| | - Edwin Brokaar
- Department of Pharmacy, Haga Teaching Hospital, The Hague, the Netherlands
| | - Whitney Brown
- Cystic Fibrosis Foundation, Inova Fairfax Hospital, Bethesda, Maryland, USA, Falls Church, VA, USA
| | - Pilar Azevedo
- Cystic Fibrosis Reference Centre-Centro, Hospitalar Universitário Lisboa Norte, Portugal
| | - Isabelle Durieu
- Cystic Fibrosis Reference Center (Constitutif), Service de médecine interne et de pathologie vasculaire, Hospices Civils de Lyon, Hôpital Lyon Sud, RESearch on HealthcAre PErformance (RESHAPE), INSERM U1290, Université Claude Bernard Lyon 1, 8 avenue Rockefeller, 69373 Lyon Cedex 08, France; ERN-Lung Cystic Fibrosis Network, Frankfurt, Germany
| | - Miquel Ekkelenkamp
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Felicity Finlayson
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | | | - Johanna Gardecki
- CF Centre at Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Pavla Hodkova
- CF Center at University Hospital Motol, Prague, Czech Republic
| | - Gina Hong
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Jacqueline Lowdon
- Clinical Specialist Paediatric Cystic Fibrosis Dietitian, Leeds Children's Hospital, UK
| | - Su Madge
- Royal Brompton Hospital, Part of Guys and StThomas's Hospital, London, UK
| | - Clémence Martin
- Institut Cochin, Inserm U1016, Université Paris-Cité and National Reference Center for Cystic Fibrosis, Hôpital Cochin AP-HP, ERN-Lung CF Network, Paris 75014, France
| | - Edward McKone
- St.Vincent's University Hospital and University College Dublin School of Medicine, Dublin, Ireland
| | - Anne Munck
- Hospital Necker Enfants-Malades, AP-HP, CF Centre, Université Paris Descartes, Paris, France
| | - Chee Y Ooi
- School of Clinical Medicine, Discipline of Paediatrics and Child Health, Faculty of Medicine & Health, Department of Gastroenterology, Sydney Children's Hospital, University of New South Wales, Sydney, NSW, Australia
| | - Lucy Perrem
- Department of Respiratory Medicine, Children's Health Ireland, Dublin, Ireland
| | - Amanda Piper
- Central Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Andrew Prayle
- Child Health, Lifespan and Population Health & Nottingham Biomedical Research Centre, School of Medicine, University of Nottingham, Nottingham, UK
| | - Felix Ratjen
- Division of Respiratory Medicine, Department of Pediatrics and Translational Medicine, Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA, USA
| | - Don B Sanders
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Carsten Schwarz
- Division Cystic Fibrosis, CF Center, Clinic Westbrandenburg, HMU-Health and Medical University, Potsdam, Germany
| | - Giovanni Taccetti
- Meyer Children's Hospital IRCCS, Cystic Fibrosis Regional Reference Centre, Italy
| | | | - Natalie E West
- Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Wilschanski
- Pediatric Gastroenterology Unit, CF Center, Hadassah Medical Center, Jerusalem, Israel
| | - Amanda Bevan
- University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Carlo Castellani
- IRCCS Istituto Giannina Gaslini, Via Gerolamo Gaslini 5, Genova 16147, Italy
| | - Pavel Drevinek
- Department of Medical Microbiology, Second Faculty of Medicine, Motol University Hospital, Charles University, Prague, Czech Republic
| | - Silvia Gartner
- Cystic Fibrosis Unit and Pediatric Pulmonology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Respiratory Unit and Adult Cystic Fibrosis Center, Università degli Studi di Milano, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Elise Lammertyn
- Cystic Fibrosis Europe, Brussels, Belgium and the Belgian CF Association, Brussels, Belgium
| | - Eddie Edwina C Landau
- The Graub CF Center, Pulmonary Institute, Schneider Children's Medical Center, Petah Tikva, Israel
| | - Barry J Plant
- Cork Centre for Cystic Fibrosis (3CF), Cork University Hospital, University College Cork, Ireland
| | - Alan R Smyth
- School of Medicine, Dentistry and Biomedical Sciences, Belfast and NIHR Nottingham Biomedical Research Centre, Queens University Belfast, Nottingham, UK
| | | | - Peter G Middleton
- Westmead Clinical School, Department Respiratory & Sleep Medicine, Westmead Hospital, University of Sydney and CITRICA, Westmead, Australia
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Hisert KB, Birket SE, Clancy JP, Downey DG, Engelhardt JF, Fajac I, Gray RD, Lachowicz-Scroggins ME, Mayer-Hamblett N, Thibodeau P, Tuggle KL, Wainwright CE, De Boeck K. Understanding and addressing the needs of people with cystic fibrosis in the era of CFTR modulator therapy. THE LANCET. RESPIRATORY MEDICINE 2023; 11:916-931. [PMID: 37699420 DOI: 10.1016/s2213-2600(23)00324-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 08/07/2023] [Accepted: 08/20/2023] [Indexed: 09/14/2023]
Abstract
Cystic fibrosis is a multiorgan disease caused by impaired function of the cystic fibrosis transmembrane conductance regulator (CFTR). Since the introduction of the CFTR modulator combination elexacaftor-tezacaftor-ivacaftor (ETI), which acts directly on mutant CFTR to enhance its activity, most people with cystic fibrosis (pwCF) have seen pronounced reductions in symptoms, and studies project marked increases in life expectancy for pwCF who are eligible for ETI. However, modulator therapy has not cured cystic fibrosis and the success of CFTR modulators has resulted in immediate questions about the new state of cystic fibrosis disease and clinical challenges in the care of pwCF. In this Series paper, we summarise key questions about cystic fibrosis disease in the era of modulator therapy, highlighting state-of-the-art research and clinical practices, knowledge gaps, new challenges faced by pwCF and the potential for future health-care challenges, and the pressing need for additional therapies to treat the underlying genetic or molecular causes of cystic fibrosis.
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Affiliation(s)
| | - Susan E Birket
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Damian G Downey
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, Northern Ireland
| | - John F Engelhardt
- Department of Anatomy and Cell Biology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Isabelle Fajac
- Assistance Publique-Hôpitaux de Paris, Université Paris Cité, Paris, France
| | - Robert D Gray
- Institution of Regeneration and Repair, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, UK
| | | | - Nicole Mayer-Hamblett
- Department of Pediatrics, Department of Biostatistics, Seattle Children's Research Institute, University of Washington, Seattle, WA, USA
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7
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Landini N, Ciet P, Janssens HM, Bertolo S, Ros M, Mattone M, Catalano C, Majo F, Costa S, Gramegna A, Lucca F, Parisi GF, Saba L, Tiddens HAWM, Morana G. Management of respiratory tract exacerbations in people with cystic fibrosis: Focus on imaging. Front Pediatr 2022; 10:1084313. [PMID: 36814432 PMCID: PMC9940849 DOI: 10.3389/fped.2022.1084313] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 12/28/2022] [Indexed: 02/09/2023] Open
Abstract
Respiratory tract exacerbations play a crucial role in progressive lung damage of people with cystic fibrosis, representing a major determinant in the loss of functional lung tissue, quality of life and patient survival. Detection and monitoring of respiratory tract exacerbations are challenging for clinicians, since under- and over-treatment convey several risks for the patient. Although various diagnostic and monitoring tools are available, their implementation is hampered by the current definition of respiratory tract exacerbation, which lacks objective "cut-offs" for clinical and lung function parameters. In particular, the latter shows a large variability, making the current 10% change in spirometry outcomes an unreliable threshold to detect exacerbation. Moreover, spirometry cannot be reliably performed in preschool children and new emerging tools, such as the forced oscillation technique, are still complementary and need more validation. Therefore, lung imaging is a key in providing respiratory tract exacerbation-related structural and functional information. However, imaging encompasses several diagnostic options, each with different advantages and limitations; for instance, conventional chest radiography, the most used radiological technique, may lack sensitivity and specificity in respiratory tract exacerbations diagnosis. Other methods, including computed tomography, positron emission tomography and magnetic resonance imaging, are limited by either radiation safety issues or the need for anesthesia in uncooperative patients. Finally, lung ultrasound has been proposed as a safe bedside option but it is highly operator-dependent and there is no strong evidence of its possible use during respiratory tract exacerbation. This review summarizes the clinical challenges of respiratory tract exacerbations in patients with cystic fibrosis with a special focus on imaging. Firstly, the definition of respiratory tract exacerbation is examined, while diagnostic and monitoring tools are briefly described to set the scene. This is followed by advantages and disadvantages of each imaging technique, concluding with a diagnostic imaging algorithm for disease monitoring during respiratory tract exacerbation in the cystic fibrosis patient.
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Affiliation(s)
- Nicholas Landini
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Pierluigi Ciet
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Radiology, University Cagliari, Cagliari, Italy.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Hettie M Janssens
- Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Silvia Bertolo
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
| | - Mirco Ros
- Department of Pediatrics, Ca'Foncello S. Maria Hospital, Treviso, Italy
| | - Monica Mattone
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Pathological Sciences, Policlinico Umberto I Hospital, "Sapienza" Rome University, Rome, Italy
| | - Fabio Majo
- Pediatric Pulmonology & Cystic Fibrosis Unit Bambino Gesú Children's Hospital, IRCCS Rome, Rome, Italy
| | - Stefano Costa
- Department of Pediatrics, Gaetano Martino Hospital, Messina, Italy
| | - Andrea Gramegna
- Department of Pathophisiology and Transplantation, University of Milan, Milan, Italy.,Respiratory Disease and Adult Cystic Fibrosis Centre, Internal Medicine Department, IRCCS Ca' Granda, Milan, Italy
| | - Francesca Lucca
- Regional Reference Cystic Fibrosis Center, University Hospital of Verona, Verona, Italy
| | - Giuseppe Fabio Parisi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Luca Saba
- Department of Radiology, University Cagliari, Cagliari, Italy
| | - Harm A W M Tiddens
- Department of Radiology and Nuclear Medicine, Erasmus MC - Sophia, Rotterdam, Netherlands.,Department of Pediatrics, division of Respiratory Medicine and Allergology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Giovanni Morana
- Department of Radiology, S. Maria Ca'Foncello Regional Hospital, Treviso, Italy
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