Quantitative assessment of airway dimensions in young children with cystic fibrosis lung disease using chest computed tomography

Children with severe asthma have substantial structural airway changes on computed tomography

Background

In adults with severe asthma (SA) bronchial wall thickening, bronchiectasis and low attenuation regions (LAR) have been described on chest computed tomography (CT) scans. The extent to which these structural abnormalities are present in children with SA is largely unknown. Our aim was to study the presence and extent of airway abnormalities on chest CT of children with SA.

Methods

161 inspiratory and expiratory CT scans, either spirometer-controlled or technician-controlled, obtained in 131 children with SA (mean±SD age 11.0±3.8 years) were collected retrospectively. Inspiratory scans were analysed manually using a semi-quantitative score and automatically using LungQ (v2.1.0.1; Thirona B.V., Nijmegen, the Netherlands). LungQ segments the bronchial tree, identifies the generation for each bronchus-artery (BA) pair and measures the following BA dimensions: outer bronchial wall diameter (Bout), adjacent artery diameter (A) and bronchial wall thickness (Bwt). Bronchiectasis was defined as Bout/A ≥1.1, bronchial wall thickening as Bwt/A ≥0.14. LAR, reflecting small airways disease (SAD), was measured automatically on inspiratory and expiratory scans and manually on expiratory scans. Functional SAD was defined as FEF25-75 and/or FEF75 z-scores <-1.645. Results are shown as median and interquartile range.

Results

Bronchiectasis was present on 95.8% and bronchial wall thickening on all CTs using the automated method. Bronchiectasis was present on 28% and bronchial wall thickening on 88.8% of the CTs using the manual semi-quantitative analysis. The percentage of BA pairs defined as bronchiectasis was 24.62% (12.7-39.3%) and bronchial wall thickening was 41.7% (24.0-79.8%) per CT using the automated method. LAR was observed on all CTs using the automatic analysis and on 82.9% using the manual semi-quantitative analysis. Patients with LAR or functional SAD had more thickened bronchi than patients without.

Conclusion

Despite a large discrepancy between the automated and the manual semi-quantitative analysis, bronchiectasis and bronchial wall thickening are present on most CT scans of children with SA. SAD is related to bronchial wall thickening.

Automatic analysis of bronchus-artery dimensions to diagnose and monitor airways disease in cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) lung disease is characterised by progressive airway wall thickening and widening. We aimed to validate an artificial intelligence-based algorithm to assess dimensions of all visible bronchus-artery (BA) pairs on chest CT scans from patients with CF.

METHODS

The algorithm fully automatically segments the bronchial tree; identifies bronchial generations; matches bronchi with the adjacent arteries; measures for each BA-pair bronchial outer diameter (Bout), bronchial lumen diameter (Bin), bronchial wall thickness (Bwt) and adjacent artery diameter (A); and computes Bout/A, Bin/A and Bwt/A for each BA pair from the segmental bronchi to the last visible generation. Three datasets were used to validate the automatic BA analysis. First BA analysis was executed on 23 manually annotated CT scans (11 CF, 12 control subjects) to compare automatic with manual BA-analysis outcomes. Furthermore, the BA analysis was executed on two longitudinal datasets (Copenhagen 111 CTs, ataluren 347 CTs) to assess longitudinal BA changes and compare them with manual scoring results.

RESULTS

The automatic and manual BA analysis showed no significant differences in quantifying bronchi. For the longitudinal datasets the automatic BA analysis detected 247 and 347 BA pairs/CT in the Copenhagen and ataluren dataset, respectively. A significant increase of 0.02 of Bout/A and Bin/A was detected for Copenhagen dataset over an interval of 2 years, and 0.03 of Bout/A and 0.02 of Bin/A for ataluren dataset over an interval of 48 weeks (all p<0.001). The progression of 0.01 of Bwt/A was detected only in the ataluren dataset (p<0.001). BA-analysis outcomes showed weak to strong correlations (correlation coefficient from 0.29 to 0.84) with manual scoring results for airway disease.

CONCLUSION

The BA analysis can fully automatically analyse a large number of BA pairs on chest CTs to detect and monitor progression of bronchial wall thickening and bronchial widening in patients with CF.

Automatic bronchus and artery analysis on chest computed tomography to evaluate the effect of inhaled hypertonic saline in children aged 3-6 years with cystic fibrosis in a randomized clinical trial

BACKGROUND

SHIP-CT showed that 48-week treatment with inhaled 7% hypertonic saline (HS) reduced airway abnormalities on chest CT using the manual PRAGMA-CF method relative to isotonic saline (IS) in children aged 3-6 years with cystic fibrosis (CF). An algorithm was developed and validated to automatically measure bronchus and artery (BA) dimensions of BA-pairs on chest CT. Aim of the study was to assess the effect of HS on bronchial wall thickening and bronchial widening using the BA-analysis.

METHODS

The BA-analysis (LungQ, version 2.1.0.1, Thirona, Netherlands) automatically segments the bronchial tree and identifies the segmental bronchi (G0) and distal generations (G1-G10). Dimensions of each BA-pair are measured: diameters of bronchial outer wall (Bout), bronchial inner wall (Bin), bronchial wall thickness (Bwt), and artery (A). BA-ratios are computed: Bout/A and Bin/A to detect bronchial widening and Bwt/A and Bwa/Boa (=bronchial wall area/bronchial outer area) to detect bronchial wall thickening.

RESULTS

113 baseline and 102 48-week scans of 115 SHIP-CT participants were analysed. LungQ measured at baseline and 48-weeks respectively 6,073 and 7,407 BA-pairs in the IS-group and 6,363 and 6,840 BA-pairs in the HS-group. At 48 weeks, Bwt/A (mean difference 0.011; 95%CI, 0.0017 to 0.020) and Bwa/Boa (mean difference 0.030; 95% 0.009 to 0.052) was significantly higher (worse) in the IS-group compared to the HS-group representing more severe bronchial wall thickening in the IS-group (p=0.025 and p=0.019 respectively). Bwt/A and Bwa/Boa decreased and Bin/A remained stable from baseline to 48 weeks in the HS while it declined in the IS-group (all p<0.001). There was no difference in progression of Bout/A between two treatment groups.

CONCLUSION

The automatic BA-analysis showed a positive impact of inhaled HS on bronchial lumen and wall thickness, but no treatment effect on progression of bronchial widening over 48 weeks.

The clinical impact of Lumacaftor-Ivacaftor on structural lung disease and lung function in children aged 6-11 with cystic fibrosis in a real-world setting

BACKGROUND

Data from clinical trials of lumacaftor-ivacaftor (LUM-IVA) demonstrate improvements in lung clearance index (LCI) but not in FEV1 in children with Cystic Fibrosis (CF) aged 6-11 years and homozygous for the Phe508del mutation. It is not known whether LUM/IVA use in children can impact the progression of structural lung disease. We sought to determine the real-world impact of LUM/IVA on lung structure and function in children aged 6-11 years.

METHODS

This real-world observational cohort study was conducted across four paediatric sites in Ireland over 24-months using spirometry-controlled CT scores and LCI as primary outcome measures. Children commencing LUM-/IVA as part of routine care were included. CT scans were manually scored with the PRAGMA CF scoring system and analysed using the automated bronchus-artery (BA) method. Secondary outcome measures included rate of change of ppFEV1, nutritional indices and exacerbations requiring hospitalisation.

RESULTS

Seventy-one participants were recruited to the study, 31 of whom had spirometry-controlled CT performed at baseline, and after one year and two years of LUM/IVA treatment. At two years there was a reduction from baseline in trapped air scores (0.13 to 0.07, p = 0.016), but an increase from baseline in the % bronchiectasis score (0.84 to 1.23, p = 0.007). There was no change in overall % disease score (2.78 to 2.25, p = 0.138). Airway lumen to pulmonary artery ratios (AlumenA ratio) were abnormal at baseline and worsened over the course of the study. In 28 participants, the mean annual change from baseline LCI2.5 (-0.055 (-0.61 to 0.50), p = 0.85) measurements over two years were not significant. Improvements from baseline in weight (0.10 (0.06 to 0.15, p < 0.0001), height (0.05 (0.02 to 0.09), p = 0.002) and BMI (0.09 (0.03 to 0.15) p = 0.005) z-scores were seen with LUM/IVA treatment. The mean annual change from baseline ppFEV1 (-2.45 (-4.44 to 2.54), p = 0.66) measurements over two years were not significant.

CONCLUSION

In a real-world setting, the use of LUM/IVA over two years in children with CF aged 6-11 resulted in improvements in air trapping on CT but worsening in bronchiectasis scores. Our results suggest that LUM/IVA use in this age group improves air trapping but does not prevent progression of bronchiectasis over two years of treatment.

The effect of CFTR modulators on structural lung disease in cystic fibrosis

Background: Newly developed quantitative chest computed tomography (CT) outcomes designed specifically to assess structural abnormalities related to cystic fibrosis (CF) lung disease are now available. CFTR modulators potentially can reduce some structural lung abnormalities. We aimed to investigate the effect of CFTR modulators on structural lung disease progression using different quantitative CT analysis methods specific for people with CF (PwCF). Methods: PwCF with a gating mutation (Ivacaftor) or two Phe508del alleles (lumacaftor-ivacaftor) provided clinical data and underwent chest CT scans. Chest CTs were performed before and after initiation of CFTR modulator treatment. Structural lung abnormalities on CT were assessed using the Perth Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF), airway-artery dimensions (AA), and CF-CT methods. Lung disease progression (0-3 years) in exposed and matched unexposed subjects was compared using analysis of covariance. To investigate the effect of treatment in early lung disease, subgroup analyses were performed on data of children and adolescents aged <18 years. Results: We included 16 modulator exposed PwCF and 25 unexposed PwCF. Median (range) age at the baseline visit was 12.55 (4.25-36.49) years and 8.34 (3.47-38.29) years, respectively. The change in PRAGMA-CF %Airway disease (-2.88 (-4.46, -1.30), p = 0.001) and %Bronchiectasis extent (-2.07 (-3.13, -1.02), p < 0.001) improved in exposed PwCF compared to unexposed. Subgroup analysis of paediatric data showed that only PRAGMA-CF %Bronchiectasis (-0.88 (-1.70, -0.07), p = 0.035) improved in exposed PwCF compared to unexposed. Conclusion: In this preliminary real-life retrospective study CFTR modulators improve several quantitative CT outcomes. A follow-up study with a large cohort and standardization of CT scanning is needed to confirm our findings.

MDCT-based longitudinal automated airway and air trapping analysis in school-age children with mild cystic fibrosis lung disease

OBJECTIVES

Quantitative computed tomography (QCT) offers some promising markers to quantify cystic fibrosis (CF)-lung disease. Air trapping may precede irreversible bronchiectasis; therefore, the temporal interdependencies of functional and structural lung disease need to be further investigated. We aim to quantify airway dimensions and air trapping on chest CT of school-age children with mild CF-lung disease over two years.

METHODS

Fully-automatic software analyzed 144 serial spirometer-controlled chest CT scans of 36 children (median 12.1 (10.2-13.8) years) with mild CF-lung disease (median ppFEV1 98.5 (90.8-103.3) %) at baseline, 3, 12 and 24 months. The airway wall percentage (WP_5-10), bronchiectasis index (BEI), as well as severe air trapping (A3) were calculated for the total lung and separately for all lobes. Mixed linear models were calculated, considering the lobar distribution of WP_5-10, BEI and A3 cross-sectionally and longitudinally.

RESULTS

WP_5-10 remained stable (P = 0.248), and BEI changed from 0.41 (0.28-0.7) to 0.54 (0.36-0.88) (P = 0.156) and A3 from 2.26% to 4.35% (P = 0.086) showing variability over two years. ppFEV1 was also stable (P = 0.276). A robust mixed linear model showed a cross-sectional, regional association between WP_5-10 and A3 at each timepoint (P < 0.001). Further, BEI showed no cross-sectional, but another mixed model showed short-term longitudinal interdependencies with air trapping (P = 0.003).

CONCLUSIONS

Robust linear/beta mixed models can still reveal interdependencies in medical data with high variability that remain hidden with simpler statistical methods. We could demonstrate cross-sectional, regional interdependencies between wall thickening and air trapping. Further, we show short-term regional interdependencies between air trapping and an increase in bronchiectasis. The data indicate that regional air trapping may precede the development of bronchiectasis. Quantitative CT may capture subtle disease progression and identify regional and temporal interdependencies of distinct manifestations of CF-lung disease.

Quantitative Airway Assessment of Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) on CT as a Novel Biomarker

Objectives: Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) occurs due to abnormal proliferation of pulmonary neuroendocrine cells. We hypothesized that performing a quantitative analysis of airway features on chest CT may reveal differences to matched controls, which could ultimately help provide an imaging biomarker. Methods: A retrospective quantitative analysis of chest CTs in patients with DIPNECH and age matched controls was carried out using semi-automated post-processing software. Paired segmental airway and artery diameters were measured for each bronchopulmonary segment, and the airway:artery (AA) ratio, airway wall thickness:artery ratio (AWTA ratio) and wall area percentage (WAP) calculated. Nodule number, size, shape and location was recorded. Correlation between CT measurements and pulmonary function testing was performed. Results: 16 DIPNECH and 16 control subjects were analysed (all female, mean age 61.7 +/− 11.8 years), a combined total of 425 bronchopulmonary segments. The mean AwtA ratio, AA ratio and WAP for the DIPNECH group was 0.57, 1.18 and 68.8%, respectively, compared with 0.38, 1.03 and 58.3% in controls (p < 0.001, <0.001, 0.03, respectively). DIPNECH patients had more nodules than controls (22.4 +/− 32.6 vs. 3.6 +/− 3.6, p = 0.03). AA ratio correlated with FVC (R2 = 0.47, p = 0.02). A multivariable model incorporating nodule number, AA ratio and AWTA-ratio demonstrated good performance for discriminating DIPNECH and controls (AUC 0.971; 95% CI: 0.925−1.0). Conclusions: Quantitative CT airway analysis in patients with DIPNECH demonstrates increased airway wall thickness and airway:artery ratio compared to controls. Advances in knowledge: Quantitative CT measurement of airway wall thickening offers a potential imaging biomarker for treatment response.

Association between early respiratory viral infections and structural lung disease in infants with cystic fibrosis

BACKGROUND

Infants with cystic fibrosis (CF) develop structural lung disease early in life, and viral infections are associated with progressive lung disease. We hypothesized that the presence of respiratory viruses would be associated with structural lung disease on computed tomography (CT) of the chest in infants with CF.

METHODS

Infants with CF were enrolled before 4 months of age. Multiplex PCR assays were performed on nasal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent CT imaging at approximately 12 months of age. Associations between Perth-Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) CT scores and respiratory viruses and symptoms were assessed with Spearman correlation coefficients.

RESULTS

Sixty infants were included for analysis. Human rhinovirus was the most common virus detected, on 28% of tested nasal swabs and in 85% of participants. The median (IQR) extent of lung fields that was healthy based on PRAGMA-CF was 98.7 (0.8)%. There were no associations between PRAGMA-CF and age at first virus, or detection of any virus, including rhinovirus, respiratory syncytial virus, or parainfluenza. The extent of airway wall thickening was associated with ever having wheezed (ρ = 0.31, p = 0.02) and number of encounters with cough (ρ = 0.25, p = 0.0495).

CONCLUSIONS

Infants with CF had minimal structural lung disease. We did not find an association between respiratory viruses and CT abnormalities. Wheezing and frequency of cough were associated with early structural changes.

Detection and Classification of Bronchiectasis Through Convolutional Neural Networks

PURPOSE

Bronchiectasis is a chronic disease characterized by an irreversible dilatation of bronchi leading to chronic infection, airway inflammation, and progressive lung damage. Three specific patterns of bronchiectasis are distinguished in clinical practice: cylindrical, varicose, and cystic. The predominance and the extension of the type of bronchiectasis provide important clinical information. However, characterization is often challenging and is subject to high interobserver variability. The aim of this study is to provide an automatic tool for the detection and classification of bronchiectasis through convolutional neural networks.

MATERIALS AND METHODS

Two distinct approaches were adopted: (i) direct network performing a multilabel classification of 32×32 regions of interest (ROIs) into 4 classes: healthy, cylindrical, cystic, and varicose and (ii) a 2-network serial approach, where the first network performed a binary classification between normal tissue and bronchiectasis and the second one classified the ROIs containing abnormal bronchi into one of the 3 bronchiectasis typologies. Performances of the networks were compared with other architectures presented in the literature.

RESULTS

Computed tomography from healthy individuals (n=9, age=47±6, FEV1%pred=109±17, FVC%pred=116±17) and bronchiectasis patients (n=21, age=59±15, FEV1%pred=74±25, FVC%pred=91±22) were collected. A total of 19,059 manually selected ROIs were used for training and testing. The serial approach provided the best results with an accuracy and F1 score average of 0.84, respectively. Slightly lower performances were observed for the direct network (accuracy=0.81 and F1 score average=0.82). On the test set, cylindrical bronchiectasis was the subtype classified with highest accuracy, while most of the misclassifications were related to the varicose pattern, mainly to the cylindrical class.

CONCLUSION

The developed networks accurately detect and classify bronchiectasis disease, allowing to collect quantitative information regarding the radiologic severity and the topographical distribution of bronchiectasis subtype.

Radiology of Bronchiectasis

Bronchiectasis is a radiological diagnosis made using computed tomographic (CT) imaging. Although visual CT assessment is necessary for the diagnosis of bronchiectasis, visual assessment of disease severity and progression is challenging. Computer tools offer the potential to improve the characterization of lung damage in patients with bronchiectasis. Newer imaging techniques such as MRI with hyperpolarized gas inhalation have the potential to identify early forms of disease and are without the constraints of requiring ionizing radiation exposure.

Management of respiratory tract exacerbations in people with cystic fibrosis: Focus on imaging

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.

Structural lung disease in preschool children with cystic fibrosis: An 18 month natural history study

BACKGROUND

This study was performed to describe the natural history of CF lung disease in young children over an 18 month period to assess the use of CT scanning as an outcome measure for intervention trials.

METHODS

Chest CT scans were obtained at baseline and after 18 months in 42 two- to six-year-old children with CF. CT scans were scored by 2 experienced radiologists for the presence and severity of bronchiectasis, mucous plugging, and air trapping.

RESULTS

Mean age at baseline 3.5 (1.3) (mean, sd) years. One or more findings of CF lung disease was seen on the first CT in 27 (64%) and at 18 months in 30 (75%). From baseline to 18 months bronchiectasis, mucous plugging, and air trapping increased from 50% to 53%, 14% to 28%, and 48% to 58% respectively. There was marked variability in the rate of progression, with subjects commonly showing improvement in lung disease. Bronchiectasis worsened in 14 (33%) and improved in 13 (31%). Single subjects with F508del/class III and F508del/class V demonstrated greater worsening and improvement respectively than F508del homozygous and class I genotypes.

CONCLUSIONS

The natural history of CF lung disease over 18 months varies widely between subjects. Factors including genotype may affect natural history as well as the effectiveness of mediators and could be an important confounder if not recognized. These findings suggest that the use of CT scanning as an outcome surrogate for CF lung disease in young children may be more challenging than has been previously recognized.

Lung inflammation and simulated airway resistance in infants with cystic fibrosis

Cystic fibrosis (CF) is characterized by small airway disease; but central airways may also be affected. We hypothesized that airway resistance estimated from computational fluid dynamic (CFD) methodology in infants with CF was higher than controls and that early airway inflammation in infants with CF is associated with airway resistance. Central airway models with a median of 51 bronchial outlets per model (interquartile range 46,56) were created from chest computed tomography scans of 18 infants with CF and 7 controls. Steady state airflow into the trachea was simulated to estimate central airway resistance in each model. Airway resistance was increased in the full airway models of infants with CF versus controls and in models trimmed to 33 bronchi. Airway resistance was associated with markers of inflammation in bronchoalveolar lavage fluid obtained approximately 8 months earlier but not with markers obtained at the same time. In conclusion, airway resistance estimated by CFD modeling is increased in infants with CF compared to controls and may be related to early airway inflammation.

Functional respiratory imaging in relation to classical outcome measures in cystic fibrosis: a cross-sectional study

Background

Functional Respiratory Imaging (FRI) combines HRCT scans with computational fluid dynamics to provide objective and quantitative information about lung structure and function. FRI has proven its value in pulmonary diseases such as COPD and asthma, but limited studies have focused on cystic fibrosis (CF). This study aims to investigate the relation of multiple FRI parameters to validated imaging parameters and classical respiratory outcomes in a CF population.

Methods

CF patients aged > 5 years scheduled for a chest CT were recruited in a cross-sectional study. FRI outcomes included regional airway volume, airway wall volume, airway resistance, lobar volume, air trapping and pulmonary blood distribution. Besides FRI, CT scans were independently evaluated by 2 readers using the CF-CT score. Spirometry and the 6-Minute Walk Test (6MWT) were also performed. Statistical tests included linear mixed-effects models, repeated measures correlations, Pearson and Spearman correlations.

Results

39 CT scans of 24 (17M/7F) subjects were analyzed. Patients were 24 ± 9 years old and had a ppFEV₁ of 71 ± 25% at the time of the first CT. All FRI parameters showed significant low-to-moderate correlations with the total CF-CT score, except for lobar volume. When considering the relation between FRI parameters and similar CF-CT subscores, significant correlations were found between parameters related to airway volume, air trapping and airway wall thickening. Air trapping, lobar volume after normal expiration and pulmonary blood distribution showed significant associations with all spirometric parameters and oxygen saturation at the end of 6MWT. In addition, air trapping was the only parameter related to the distance covered during 6MWT. A subgroup analysis showed considerably higher correlations in patients with mild lung disease (ppFEV₁ ≥ 70%) compared to patients with moderate to severe lung disease (ppFEV₁ < 70%) when comparing FRI to CF-CT scores.

Conclusions

Multiple structural characteristics determined by FRI were associated with abnormalities determined by CF-CT score. Air trapping and pulmonary blood distribution appeared to be the most clinically relevant FRI parameters for CF patients due to their associations with classical outcome measures. The FRI methodology could particularly be of interest for patients with mild lung disease, although this should be confirmed in future research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01622-3.

Artificial intelligence in CT for quantifying lung changes in the era of CFTR modulators

RATIONALE

Chest computed tomography (CT) remains the imaging standard for demonstrating cystic fibrosis airway structural disease in vivo. However, visual scorings as an outcome measure are time-consuming, require training, and lack high reproducibility.

OBJECTIVE

To validate a fully automated artificial intelligence-driven scoring of cystic fibrosis lung disease severity.

METHODS

Data were retrospectively collected in three cystic fibrosis reference centers, between 2008 and 2020, in 184 patients 4 to 54-years-old. An algorithm using three two-dimensional convolutional neural networks was trained with 78 patients' CTs (23 530 CT slices) for the semantic labeling of bronchiectasis, peribronchial thickening, bronchial mucus, bronchiolar mucus, and collapse/consolidation. 36 patients' CTs (11 435 CT slices) were used for testing versus ground-truth labels. The method's clinical validity was assessed in an independent group of 70 patients with or without lumacaftor/ivacaftor treatment (n=10 and 60, respectively) with repeat examinations. Similarity and reproducibility were assessed using Dice coefficient, correlations using Spearman test, and paired comparisons using Wilcoxon rank test.

MEASUREMENT AND MAIN RESULTS

The overall pixelwise similarity of artificial intelligence-driven versus ground-truth labels was good (Dice coefficient=0.71). All artificial intelligence-driven volumetric quantifications had moderate to very good correlations to a visual imaging scoring (p<0.001) and fair to good correlations to FEV1% at pulmonary function test (p<0.001). Significant decreases in peribronchial thickening (p=0.005), bronchial mucus (p=0.005), bronchiolar mucus (p=0.007) volumes were measured in patients with lumacaftor/ivacaftor. Conversely, bronchiectasis (p=0.002) and peribronchial thickening (p=0.008) volumes increased in patients without lumacaftor/ivacaftor. The reproducibility was almost perfect (Dice>0.99).

CONCLUSION

Artificial intelligence allows a fully automated volumetric quantification of cystic fibrosis-related modifications over an entire lung. The novel scoring system could provide a robust disease outcome in the era of effective CFTR modulator therapy.

Novel imaging techniques for cystic fibrosis lung disease

With an increasing number of patients with cystic fibrosis (CF) receiving highly effective CFTR (cystic fibrosis transmembrane regulator protein) modulator therapy, particularly at a young age, there is an increasing need to identify imaging tools that can detect and regionally visualize mild CF lung disease and subtle changes in disease state. In this review, we discuss the latest developments in imaging modalities for both structural and functional imaging of the lung available to CF clinicians and researchers, from the widely available, clinically utilized imaging methods for assessing CF lung disease-chest radiography and computed tomography-to newer techniques poised to become the next phase of clinical tools-structural/functional proton and hyperpolarized gas magnetic resonance imaging (MRI). Finally, we provide a brief discussion of several newer lung imaging techniques that are currently available only in selected research settings, including chest tomosynthesis, and fluorinated gas MRI. We provide an update on the clinical and/or research status of each technique, with a focus on sensitivity, early disease detection, and possibilities for monitoring treatment efficacy.

The Clinical Use of Lung MRI in Cystic Fibrosis: What, Now, How?

To assess airway and lung parenchymal damage noninvasively in cystic fibrosis (CF), chest MRI has been historically out of the scope of routine clinical imaging because of technical difficulties such as low proton density and respiratory and cardiac motion. However, technological breakthroughs have emerged that dramatically improve lung MRI quality (including signal-to-noise ratio, resolution, speed, and contrast). At the same time, novel treatments have changed the landscape of CF clinical care. In this contemporary context, there is now consensus that lung MRI can be used clinically to assess CF in a radiation-free manner and to enable quantification of lung disease severity. MRI can now achieve three-dimensional, high-resolution morphologic imaging, and beyond this morphologic information, MRI may offer the ability to sensitively differentiate active inflammation vs scarring tissue. MRI could also characterize various forms of inflammation for early guidance of treatment. Moreover, functional information from MRI can be used to assess regional, small-airway disease with sensitivity to detect small changes even in patients with mild CF. Finally, automated quantification methods have emerged to support conventional visual analyses for more objective and reproducible assessment of disease severity. This article aims to review the most recent developments of lung MRI, with a focus on practical application and clinical value in CF, and the perspectives on how these modern techniques may converge and impact patient care soon.

Chest computed tomography outcomes in a randomized clinical trial in cystic fibrosis: Lessons learned from the first ataluren phase 3 study

A phase 3 randomized double blind controlled, trial in 238 people with cystic fibrosis (CF) and at least one nonsense mutation (nmCF) investigated the effect of ataluren on FEV1. The study was of 48 weeks duration and failed to meet its primary endpoint. Unexpectedly, while FEV1 declined, chest computed tomography (CT) scores using the Brody-II score as secondary outcome measures did not show progression in the placebo group. Based on this observation it was concluded that the role of CT scans in CF randomized clinical trials was limited. However, more sensitive scoring systems were developed over the last decade warranting a reanalysis of this unique dataset. The aim of our study was to reanalyse all chest CT scans, obtained in the ataluren phase 3 study, using 2 independent scoring systems to characterize structural lung disease in this cohort and to compare progression of structural lung disease over the 48 weeks between treatment arms. 391 study CT scans from 210 patients were reanalysed in random order by 2 independent observers using the CF-CT and Perth-Rotterdam Annotated Grid Morphometric Analysis for CF (PRAGMA-CF) scoring systems. CF-CT and PRAGMA-CF subscores were expressed as %maximal score and %total lung volume, respectively. PRAGMA-CF subscores %Disease (p = 0.008) and %Mucus Plugging (p = 0.029) progressed over 48 weeks. CF-CT subscores did not show progression. There was no difference in progression of structural lung disease between treatment arm and placebo independent of tobramycin use. PRAGMA-CF Chest CT scores can be used as an outcome measure to study the effect of potential disease modifying drugs in CF on lung structure.

Airway-artery quantitative assessment on chest computed tomography in paediatric primary ciliary dyskinesia

Chest computed tomography (CT) is the gold standard for detecting structural abnormalities in patients with primary ciliary dyskinesia (PCD) such as bronchiectasis, bronchial wall thickening and mucus plugging. There are no studies on quantitative assessment of airway and artery abnormalities in children with PCD. The objectives of the present study were to quantify airway and artery dimensions on chest CT in a cohort of children with PCD and compare these with control children to analyse the influence of covariates on airway and artery dimensions.

Chest CTs of 13 children with PCD (14 CT scans) and 12 control children were collected retrospectively. The bronchial tree was segmented semi-automatically and reconstructed in a three-dimensional view. All visible airway–artery (AA) pairs were measured perpendicular to the airway centre line, annotating per branch inner and outer airway and adjacent artery diameter and computing inner airway diameter/artery ratio (AinA ratio), outer airway diameter/artery ratio (AoutA ratio), wall thickness (WT), WT/outer airway diameter ratio (Awt ratio) and WT/artery ratio.

In the children with PCD (38.5% male, mean age 13.5 years, range 9.8–15.3) 1526 AA pairs were measured versus 1516 in controls (58.3% male, mean age 13.5 years, range 8–14.8). AinA ratio and AoutA ratio were significantly higher in children with PCD than in control children (both p<0.001). Awt ratio was significantly higher in control children than in children with PCD (p<0.001).

Our study showed that in children with PCD airways are more dilated than in controls and do not show airway wall thickening.

Chest CT is the gold standard for detecting structural abnormalities in patients with PCD, and this study is the first on quantitative assessment of airway and artery abnormalities in children with PCDhttps://bit.ly/2XZYWjU

The radiological diagnosis of bronchiectasis: what's in a name?

Diagnosis of bronchiectasis is usually made using chest computed tomography (CT) scan, the current gold standard method. A bronchiectatic airway can show abnormal widening and thickening of its airway wall. In addition, it can show an irregular wall and lack of tapering, and/or can be visible in the periphery of the lung. Its diagnosis is still largely expert based. More recently, it has become clear that airway dimensions on CT and therefore the diagnosis of bronchiectasis are highly dependent on lung volume. Hence, control of lung volume is required during CT acquisition to standardise the evaluation of airways. Automated image analysis systems are in development for the objective analysis of airway dimensions and for the diagnosis of bronchiectasis. To use these systems, clear and objective definitions for the diagnosis of bronchiectasis are needed. Furthermore, the use of these systems requires standardisation of CT protocols and of lung volume during chest CT acquisition. In addition, sex- and age-specific reference values are needed for image analysis outcome parameters. This review focusses on today's issues relating to the radiological diagnosis of bronchiectasis using state-of-the-art CT imaging techniques.

Bronchiectasis diagnosis is expert based. Clear definitions, standardisation of lung volume and CT protocols, and reference values are needed to allow automated image analysis for its diagnosis and to be used for clinical management and clinical studies.http://bit.ly/35vASqz

Assessment of early lung disease in young children with CF: A comparison between pressure-controlled and free-breathing chest computed tomography

BACKGROUND

Chest computed tomography (CT) in children with cystic fibrosis (CF) is sensitive in detecting early airways disease. The pressure-controlled CT-protocol combines a total lung capacity scan (TLC PC-CT) with a near functional residual capacity scan (FRC PC-CT) under general anesthesia, while another CT-protocol is acquired during free breathing (FB-CT) near functional residual capacity. The aim of this study was to evaluate the sensitivity in detecting airways disease of both protocols in two cohorts.

METHODS

Routine PC-CTs (Princess Margaret Children's Hospital) and FB-CTs (Erasmus MC-Sophia Children's Hospital) were retrospectively collected from CF children aged 2 to 6 years. Total airways disease (%disease), bronchiectasis (%Bx), and low attenuation regions (%LAR) were scored on CTs using the Perth-Rotterdam annotated grid morphometric analysis-CF method. The Wilcoxon signed-rank test was used for differences between TLC and FRC PC-CTs and the Wilcoxon rank-sum test for differences between FRC PC-CTs and FB-CTs.

RESULTS

Fifty patients with PC-CTs (21 male, aged 2.5-5.5 years) and 42 patients with FB-CTs (26 male, aged 2.3-6.8 years) were included. %Disease was higher on TLC PC-CTs compared with FRC PC-CTs (median 4.51 vs 2.49; P < .001). %Disease and %Bx were not significantly different between TLC PC-CTs and FB-CTs (median 4.51% vs 3.75%; P = .143 and 0.52% vs 0.57%; P = .849). %Disease, %Bx, and %LAR were not significantly different between FRC PC-CTs and FB-CTs (median 2.49% vs 3.75%; P = .055, 0.54% vs 0.57%; P = .797, and 2.49% vs 1.53%; P = .448).

CONCLUSIONS

Our data suggest that FRC PC-CTs are less sensitive than TLC PC-CTs and that FB-CTs have similar sensitivity to PC-CTs in detecting lung disease. FB-CTs seem to be a viable alternative for PC-CTs to track CF lung disease in young patients with CF.

Diagnosis and quantification of bronchiectasis using computed tomography or magnetic resonance imaging: A systematic review

BACKGROUND

Bronchiectasis is an irreversible dilatation of the airways caused by inflammation and infection. To diagnose bronchiectasis in clinical care and to use bronchiectasis as outcome parameter in clinical trials, a radiological definition with exact cut-off values along with image analysis methods to assess its severity are needed. The aim of this study was to review diagnostic criteria and quantification methods for bronchiectasis.

METHODS

A systematic literature search was performed using Embase, Medline Ovid, Web of Science, Cochrane and Google Scholar. English written, clinical studies that included bronchiectasis as outcome measure and used image quantification methods were selected. Criteria for bronchiectasis, quantification methods, patient demographics, and data on image acquisition were extracted.

RESULTS

We screened 4182 abstracts, selected 972 full texts, and included 122 studies. The most often used criterion for bronchiectasis was an inner airway-artery ratio ≥1.0 (42%), however no validation studies for this cut-off value were found. Importantly, studies showed that airway-artery ratios are influenced by age. To quantify bronchiectasis, 42 different scoring methods were described.

CONCLUSION

Different diagnostic criteria for bronchiectasis are being used, but no validation studies were found to support these criteria. To use bronchiectasis as outcome in future studies, validated and age-specific cut-off values are needed.

Chest CT scoring for evaluation of lung sequelae in congenital diaphragmatic hernia survivors

OBJECTIVES

Data on long-term structural lung abnormalities in survivors of congenital diaphragmatic hernia (CDH) is scarce. The purpose of this study was to develop a chest computed tomography (CT) score to assess the structural lung sequelae in CDH survivors and to study the correlation between the CT scoring and clinical parameters in the neonatal period and at 1 year of follow-up.

METHODS

A prospective, clinical follow-up program is organised for CDH survivors at the University Hospital of Leuven including a chest CT at the age of 1 year. The CT scoring used and evaluated, named CDH-CT score, was adapted from the revised Aukland score for chronic lung disease of prematurity.

RESULTS

Thirty-five patients were included. All CT scans showed some pulmonary abnormalities, ranging from very mild to severe. The mean total CT score was 16 (IQR: 9-23), with the greatest contribution from the subscores for decreased attenuation (5; IQR: 2-8), subpleural linear and triangular opacities (4; IQR: 3-5), and atelectasis/consolidation (2; IQR: 1-3). Interobserver and intraobserver agreement was very good for the total score (ICC coefficient > 0.9). Total CT score correlated with number of neonatal days ventilated/on oxygen as well as with respiratory symptoms and feeding problems at 1 year of age.

CONCLUSION

The CDH-CT scoring tool has a good intraobserver and interobserver repeatability and correlates with relevant clinical parameters. This holds promise for its use in clinical follow-up and as outcome parameter in clinical interventional studies.

Airway tapering: an objective image biomarker for bronchiectasis

Purpose

To estimate airway tapering in control subjects and to assess the usability of tapering as a bronchiectasis biomarker in paediatric populations.

Methods

Airway tapering values were semi-automatically quantified in 156 children with control CTs collected in the Normal Chest CT Study Group. Airway tapering as a biomarker for bronchiectasis was assessed on spirometer-guided inspiratory CTs from 12 patients with bronchiectasis and 12 age- and sex-matched controls. Semi-automatic image analysis software was used to quantify intra-branch tapering (reduction in airway diameter along the branch), inter-branch tapering (reduction in airway diameter before and after bifurcation) and airway-artery ratios on chest CTs. Biomarkers were further stratified in small, medium and large airways based on three equal groups of the accompanying vessel size.

Results

Control subjects showed intra-branch tapering of 1% and inter-branch tapering of 24–39%. Subjects with bronchiectasis showed significantly reduced intra-branch of 0.8% and inter-branch tapering of 19–32% and increased airway–artery ratios compared with controls (p < 0.01). Tapering measurements were significantly different between diseased and controls across all airway sizes. Difference in airway–artery ratio was only significant in small airways.

Conclusion

Paediatric normal values for airway tapering were established in control subjects. Tapering showed to be a promising biomarker for bronchiectasis as subjects with bronchiectasis show significantly less airway tapering across all airway sizes compared with controls. Detecting less tapering in larger airways could potentially lead to earlier diagnosis of bronchiectasis. Additionally, compared with the conventional airway–artery ratio, this novel biomarker has the advantage that it does not require pairing with pulmonary arteries.

Key Points

• Tapering is a promising objective image biomarker for bronchiectasis that can be extracted semi-automatically and has good correlation with validated visual scoring methods.

• Less airway tapering was observed in patients with bronchiectasis and can be observed sensitively throughout the bronchial tree, even in the more central airways.

• Tapering values seemed to be less influenced by variety in scanning protocols and lung volume making it a more robust biomarker for bronchiectasis detection.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06606-w) contains supplementary material, which is available to authorized users.

Early markers of cystic fibrosis structural lung disease: follow-up of the ACFBAL cohort

Little is known about early predictors of later cystic fibrosis (CF) structural lung disease. This study examined early predictors of progressive structural lung abnormalities in children who completed the Australasian CF Bronchoalveolar Lavage (ACFBAL) clinical trial at age 5-years and participated in an observational follow-up study (CF-FAB).

Eight Australian and New Zealand CF centres participated in CF-FAB and provided follow-up chest computed-tomography (CT) scans for children who had completed the ACFBAL study with baseline scans at age 5-years. CT scans were annotated using PRAGMA-CF scoring. Ordinal regression analysis and linear regression were used to investigate associations between PRAGMA-CF (Perth–Rotterdam Annotated Grid Morphometric Analysis for CF) outcomes at follow-up and variables measured during the ACFBAL study.

99 out of 157 ACFBAL children (mean±sd age 13±1.5 years) participated in the CF-FAB study. The probability of bronchiectasis at follow-up increased with airway disease severity on the baseline CT scan. In multiple regression (retaining factors at p<0.05) the extent of bronchiectasis at follow-up was associated with baseline atelectasis (OR 7.2, 95% CI 2.4–22; p≤ 0.001), bronchoalveolar lavage (BAL) log2 interleukin (IL)-8 (OR 1.2, 95% CI 1.05–1.5; p=0.010) and body mass index z-score (OR 0.49, 95% CI 0.24–1.00; p=0.05) at age 5 years. Percentage trapped air at follow-up was associated with BAL log2 IL-8 (coefficient 1.3, 95% CI 0.57–2.1; p<0.001) at age 5 years.

The extent of airway disease, atelectasis, airway inflammation and poor nutritional status in early childhood are risk factors for progressive structural lung disease in adolescence.

Airway disease on chest computed tomography of preschool children with cystic fibrosis is associated with school-age bronchiectasis

Airway wall thickening and mucus plugging are important characteristics of cystic fibrosis (CF) lung disease in the first 5 years of life.The aim of this study is to investigate the association of lung disease in preschool children (age, 2-6) with bronchiectasis and other clinical outcome measures in the school age (age >7). Deidentified computed tomography-scans were annotated using Perth-Rotterdam annotated grid morphometric analysis for CF. Preschool %disease (a composite score of %airway wall thickening, %mucus plugging, and %bronchiectasis) and %MUPAT (a composite score of %airway wall thickening and %mucus plugging) were used as predictors for %bronchiectasis and several other school-age clinical outcomes. For statistical analysis, we used regression analysis, linear mixed-effects models and two-way mixed models. Sixty-one patients were included. %Disease increased significantly with age (P  <  .01). Preschool %disease and %MUPAT were significantly associated with school-age %bronchiectasis (P  <  .01 and P  <  .01, respectively). No significant association was found between preschool %disease and %MUPAT and school-age forced expiratory volume 1 (FEV1%) predicted and quality of life (P  >  .05). Cross-sectional, %disease in school-age was associated with a low FEV1% predicted and low quality of life (P  =  .01 and P  =  .007, respectively). %Disease can be considered an early marker of diffuse airways disease and is a risk factor for school-age bronchiectasis.

Pediatric Pulmonology Year in Review 2018: Rare lung disease, neuromuscular disease, and diagnostic testing

Pediatric Pulmonology publishes original research, case reports, and review articles on topics related to a wide range of children's respiratory disorders. In this article, we highlight the past year's publications in the topic areas of rare lung diseases, respiratory complications of neuromuscular disorders, and diagnostic testing, as well as selected literature in these areas from other journals.

Cystic fibrosis year in review 2017

In this article, we highlight cystic fibrosis (CF) reports published in Pediatric Pulmonology during 2017. We also include articles from a variety of journals that are related or are of special interest to clinicians.

Paediatric lung imaging: the times they are a-changin'

Until recently, functional tests were the most important tools for the diagnosis and monitoring of lung diseases in the paediatric population. Chest imaging has gained considerable importance for paediatric pulmonology as a diagnostic and monitoring tool to evaluate lung structure over the past decade. Since January 2016, a large number of papers have been published on innovations in chest computed tomography (CT) and/or magnetic resonance imaging (MRI) technology, acquisition techniques, image analysis strategies and their application in different disease areas. Together, these papers underline the importance and potential of chest imaging and image analysis for today's paediatric pulmonology practice. The focus of this review is chest CT and MRI, as these are, and will be, the modalities that will be increasingly used by most practices. Special attention is given to standardisation of image acquisition, image analysis and novel applications in chest MRI. The publications discussed underline the need for the paediatric pulmonology community to implement and integrate state-of-the-art imaging and image analysis modalities into their structure-function laboratory for the benefit of their patients.