Worsening respiratory function in mechanically ventilated intensive care patients: feasibility and value of xenon-enhanced dual energy CT

Functional imaging for assessing regional lung ventilation in preclinical and clinical research

Dynamic heterogeneity in lung ventilation is an important measure of pulmonary function and may be characteristic of early pulmonary disease. While standard indices like spirometry, body plethysmography, and blood gases have been utilized to assess lung function, they do not provide adequate information on regional ventilatory distribution nor function assessments of ventilation during the respiratory cycle. Emerging technologies such as xenon CT, volumetric CT, functional MRI and X-ray velocimetry can assess regional ventilation using non-invasive radiographic methods that may complement current methods of assessing lung function. As a supplement to current modalities of pulmonary function assessment, functional lung imaging has the potential to identify respiratory disease phenotypes with distinct natural histories. Moreover, these novel technologies may offer an optimal strategy to evaluate the effectiveness of novel therapies and therapies targeting localized small airways disease in preclinical and clinical research. In this review, we aim to discuss the features of functional lung imaging, as well as its potential application and limitations to adoption in research.

Imaging the Injured Lung: Mechanisms of Action and Clinical Use

Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.

A hybrid multibreath wash-in wash-out lung function quantification scheme in human subjects using hyperpolarized 3 He MRI for simultaneous assessment of specific ventilation, alveolar oxygen tension, oxygen uptake, and air trapping

PURPOSE

To present a method for simultaneous acquisition of alveolar oxygen tension (PA O2 ), specific ventilation (SV), and apparent diffusion coefficient (ADC) of hyperpolarized (HP) gas in the human lung, allowing reinterpretation of the PA O2 and SV maps to produce a map of oxygen uptake (R).

METHOD

An imaging scheme was designed with a series of identical normoxic HP gas wash-in breaths to measure ADC, SV, PA O2 , and R in less than 2 min. Signal dynamics were fit to an iterative recursive model that regionally solved for these parameters. This measurement was successfully performed in 12 subjects classified in three healthy, smoker, and chronic obstructive pulmonary disease (COPD) cohorts.

RESULTS

The overall whole lung ADC, SV, PA O2 , and R in healthy, smoker, and COPD subjects was 0.20 ± 0.03 cm2 /s, 0.39 ± 0.06,113 ± 2 Torr, and 1.55 ± 0.35 Torr/s, respectively, in healthy subjects; 0.21 ± 0.03 cm2 /s, 0.33 ± 0.06, 115.9 ± 4 Torr, and 0.97 ± 0.2 Torr/s, respectively, in smokers; and 0.25 ± 0.06 cm2 /s, 0.23 ± 0.08, 114.8 ± 6.0Torr, and 0.94 ± 0.12 Torr/s, respectively, in subjects with COPD. Hetrogeneity of SV, PA O2 , and R were indicators of both smoking-related changes and disease, and the severity of the disease correlated with the degree of this heterogeneity. Subjects with symptoms showed reduced oxygen uptake and specific ventilation.

CONCLUSION

High-resolution, nearly coregistered and quantitative measures of lung function and structure were obtained with less than 1 L of HP gas. This hybrid multibreath technique produced measures of lung function that revealed clear differences among the cohorts and subjects and were confirmed by correlations with global lung measurements. Magn Reson Med 78:611-624, 2017. © 2016 International Society for Magnetic Resonance in Medicine.

Dual energy CT: how well can pseudo-monochromatic imaging reduce metal artifacts?

PURPOSE

Dual Energy CT (DECT) provides so-called monoenergetic images based on a linear combination of the original polychromatic images. At certain patient-specific energy levels, corresponding to certain patient- and slice-dependent linear combination weights, e.g., E = 160 keV corresponds to α = 1.57, a significant reduction of metal artifacts may be observed. The authors aimed at analyzing the method for its artifact reduction capabilities to identify its limitations. The results are compared with raw data-based processing.

METHODS

Clinical DECT uses a simplified version of monochromatic imaging by linearly combining the low and the high kV images and by assigning an energy to that linear combination. Those pseudo-monochromatic images can be used by radiologists to obtain images with reduced metal artifacts. The authors analyzed the underlying physics and carried out a series expansion of the polychromatic attenuation equations. The resulting nonlinear terms are responsible for the artifacts, but they are not linearly related between the low and the high kV scan: A linear combination of both images cannot eliminate the nonlinearities, it can only reduce their impact. Scattered radiation yields additional noncanceling nonlinearities. This method is compared to raw data-based artifact correction methods. To quantify the artifact reduction potential of pseudo-monochromatic images, they simulated the FORBILD abdomen phantom with metal implants, and they assessed patient data sets of a clinical dual source CT system (100, 140 kV Sn) containing artifacts induced by a highly concentrated contrast agent bolus and by metal. In each case, they manually selected an optimal α and compared it to a raw data-based material decomposition in case of simulation, to raw data-based material decomposition of inconsistent rays in case of the patient data set containing contrast agent, and to the frequency split normalized metal artifact reduction in case of the metal implant. For each case, the contrast-to-noise ratio (CNR) was assessed.

RESULTS

In the simulation, the pseudo-monochromatic images yielded acceptable artifact reduction results. However, the CNR in the artifact-reduced images was more than 60% lower than in the original polychromatic images. In contrast, the raw data-based material decomposition did not significantly reduce the CNR in the virtual monochromatic images. Regarding the patient data with beam hardening artifacts and with metal artifacts from small implants the pseudo-monochromatic method was able to reduce the artifacts, again with the downside of a significant CNR reduction. More intense metal artifacts, e.g., as those caused by an artificial hip joint, could not be suppressed.

CONCLUSIONS

Pseudo-monochromatic imaging is able to reduce beam hardening, scatter, and metal artifacts in some cases but it cannot remove them. In all cases, the CNR is significantly reduced, thereby rendering the method questionable, unless special post processing algorithms are implemented to restore the high CNR from the original images (e.g., by using a frequency split technique). Raw data-based dual energy decomposition methods should be preferred, in particular, because the CNR penalty is almost negligible.

Hyperpolarized gas diffusion MRI for the study of atelectasis and acute respiratory distress syndrome

Considerable uncertainty remains about the best ventilator strategies for the mitigation of atelectasis and associated airspace stretch in patients with acute respiratory distress syndrome (ARDS). In addition to several immediate physiological effects, atelectasis increases the risk of ventilator-associated lung injury, which has been shown to significantly worsen ARDS outcomes. A number of lung imaging techniques have made substantial headway in clarifying the mechanisms of atelectasis. This paper reviews the contributions of computed tomography, positron emission tomography, and conventional MRI to understanding this phenomenon. In doing so, it also reveals several important shortcomings inherent to each of these approaches. Once these shortcomings have been made apparent, we describe how hyperpolarized (HP) gas MRI--a technique that is uniquely able to assess responses to mechanical ventilation and lung injury in peripheral airspaces--is poised to fill several of these knowledge gaps. The HP-MRI-derived apparent diffusion coefficient (ADC) quantifies the restriction of (3) He diffusion by peripheral airspaces, thereby obtaining pulmonary structural information at an extremely small scale. Lastly, this paper reports the results of a series of experiments that measured ADC in mechanically ventilated rats in order to investigate (i) the effect of atelectasis on ventilated airspaces, (ii) the relationship between positive end-expiratory pressure (PEEP), hysteresis, and the dimensions of peripheral airspaces, and (iii) the ability of PEEP and surfactant to reduce airspace dimensions after lung injury. An increase in ADC was found to be a marker of atelectasis-induced overdistension. With recruitment, higher airway pressures were shown to reduce stretch rather than worsen it. Moving forward, HP MRI has significant potential to shed further light on the atelectatic processes that occur during mechanical ventilation.

Imaging techniques for tumour delineation and heterogeneity quantification of lung cancer: overview of current possibilities

Imaging techniques for the characterization and delineation of primary lung tumours and lymph nodes are a prerequisite for adequate radiotherapy. Numerous imaging modalities have been proposed for this purpose, but only computed tomography (CT) and FDG-PET have been implemented in clinical routine. Hypoxia PET, dynamic contrast-enhanced CT (DCE-CT), dual energy CT (DECT) and (functional) magnetic resonance imaging (MRI) hold promise for the future. Besides information on the primary tumour, these techniques can be used for quantification of tissue heterogeneity and response. In the future, treatment strategies may be designed which are based on imaging techniques to optimize individual treatment.