Assessment of lung water distribution by nuclear magnetic resonance. A new method for quantifying and monitoring experimental lung injury

Noninvasive Imaging Methods for Quantification of Pulmonary Edema and Congestion: A Systematic Review

Quantification of pulmonary edema and congestion is important to guide diagnosis and risk stratification, and to objectively evaluate new therapies in heart failure. Herein, we review the validation, diagnostic performance, and clinical utility of noninvasive imaging modalities in this setting, including chest x-ray, lung ultrasound (LUS), computed tomography (CT), nuclear medicine imaging methods (positron emission tomography [PET], single photon emission CT), and magnetic resonance imaging (MRI). LUS is a clinically useful bedside modality, and fully quantitative methods (CT, MRI, PET) are likely to be important contributors to a more accurate and precise evaluation of new heart failure therapies and for clinical use in conjunction with cardiac imaging. There are only a limited number of studies evaluating pulmonary congestion during stress. Taken together, noninvasive imaging of pulmonary congestion provides utility for both clinical and research assessment, and continued refinement of methodologic accuracy, validation, and workflow has the potential to increase broader clinical adoption.

Monitoring of water content and water distribution in ischemic hearts

We determined water content and water distribution by fitting dielectric spectra of ischemic canine hearts between 5 MHz and 3 GHz with a newly developed model which describes heart cells and subcellular organelles as rotational ellipsoids filled with electrolyte enclosed by an isolating membrane. The fraction of dry material is modelled by spherical particles with a small dielectric permittivity. Free model parameters were water content, cell volume fraction, and the conductivity of the electrolytes. Resulting model parameters were compared to data from tissue desiccation and to conductivity changes produced by protons and lactate ions. We investigated hearts in two states: during ischemia after interruption of blood flow (pure ischemia, PI, n=5) and during ischemia after resuscitation with Tyrode's solution (IAR, n=14). The difference between water content determined by tissue desiccation and by dielectric spectroscopy was less than 0.5%. During 360 min of ischemia, water content in IAR decreased from 85+/-1.6% to 83+/-2.2% and in PI from 80+/-0.8% to 78+/-1.5%. Cellular volume fraction in IAR increased from 0.47+/-0.045 to 0.63+/-0.031 and in PI from 0.62+/-0.014 to 0.73+/-0.013, which is consistent with published morphometric data. After 180 min of ischemia, the increase of the cytosolic conductivity was 0.14+/-0.02 S/m as calculated from the dielectric spectrum and was similar to the conductivity increase which was roughly estimated on the basis of tissue lactate concentration. In conclusion, dielectric spectroscopy combined with our model analysis facilitates the monitoring of water content and distribution by means of nondestructive surface probes.

Serial changes in nasal potential difference and lung electrical impedance tomography at high altitude

Recent work suggests that treatment with inhaled beta(2)-agonists reduces the incidence of high-altitude pulmonary edema in susceptible subjects by increasing respiratory epithelial sodium transport. We estimated respiratory epithelial ion transport by transepithelial nasal potential difference (NPD) measurements in 20 normal male subjects before, during, and after a stay at 3,800 m. NPD hyperpolarized on ascent to 3,800 m (P < 0.05), but the change in potential difference with superperfusion of amiloride or isoprenaline was unaffected. Vital capacity (VC) fell on ascent to 3,800 m (P < 0.05), as did the normalized change in electrical impedance (NCI) measured over the right lung parenchyma (P < 0.05) suggestive of an increase in extravascular lung water. Echo-Doppler-estimated pulmonary artery pressure increases were insufficient to cause clinical pulmonary edema. There was a positive correlation between VC and NCI (R(2) = 0.633) and between NPD and both VC and NCI (R(2) = 0.267 and 0.418). These changes suggest that altered respiratory epithelial ion transport might play a role in the development of subclinical pulmonary edema at high altitude in normal subjects.

Serial changes in spirometry during an ascent to 5,300 m in the Nepalese Himalayas

The aims of the present study were to determine the changes in forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1) and peak expiratory flow (PEF), during an ascent to 5,300 m in the Nepalese Himalayas, and to correlate the changes with arterial oxygen saturation measured by pulse oximetry (SpO2) and symptoms of acute mountain sickness (AMS). Forty-six subjects were studied twice daily during an ascent from 2,800 m (mean barometric pressure 550.6 mmHg) to 5,300 m (mean barometric pressure 404.3 mmHg) during a period of between 10 and 16 days. Measurements of FVC, FEV1, PEF, SpO2, and AMS were recorded. AMS was assessed using a standardized scoring system. FVC fell with altitude, by a mean of 4% from sea level values [95% confidence intervals (CI) 0.9% to 7.4%] at 2,800 m, and 8.6% (95% CI 5.8 to 11.4%) at 5,300 m. FEV1 did not change with increasing altitude. PEF increased with altitude by a mean of 8.9% (95% CI 2.7 to 15.1%) at 2,800 m, and 16% (95% CI 9 to 23%) at 5,300 m. These changes were not significantly related to SpO2 or AMS scores. These results confirm a progressive fall in FVC and increase in PEF with increasing hypobaric hypoxia while FEV1 remains unchanged. The increase in PEF is less than would be predicted from the change in gas density. The fall in FVC may be due to reduced inspiratory force producing a reduction in total lung capacity; subclinical pulmonary edema; an increase in pulmonary blood volume, or changes in airway closure. The absence of a correlation between the spirometric changes and SpO2 or AMS may simply reflect that these measurements of pulmonary function are not sufficiently sensitive indicators of altitude-related disease. Further studies are required to clarify the effects of hypobaric hypoxia on lung volumes and flows in an attempt to obtain a unifying explanation for these changes.

Magnetic resonance behavior of normal and diseased lungs: spherical shell model simulations

The alveolar air-tissue interface affects the lung NMR signal, because it results in a susceptibility-induced magnetic field inhomogeneity. The air-tissue interface effect can be detected and quantified by measuring the difference signal (Delta) from a pair of NMR images obtained using temporally symmetric and asymmetric spin-echo sequences. The present study describes a multicompartment alveolar model (consisting of a collection of noninteracting spherical water shells) that simulates the behavior of Delta as a function of the level of lung inflation and can be used to predict the NMR response to various types of lung injury. The model was used to predict Delta as a function of the inflation level (with the assumption of sequential alveolar recruitment, partly parallel to distension) and to simulate pulmonary edema by deriving equations that describe Delta for a collection of spherical shells representing combinations of collapsed, flooded, and inflated alveoli. Our theoretical data were compared with those provided by other models and with experimental data obtained from the literature. Our results suggest that NMR Delta measurements can be used to study the mechanisms underlying the lung pressure-volume behavior, to characterize lung injury, and to assess the contributions of alveolar recruitment and distension to the lung volume changes in response to the application of positive airway pressure (e.g., positive end-expiratory pressure).

In vivo Hahn spin-echo decay (Hahn-T2) observation of regional changes in the time course of oleic acid lung injury

We studied the time course of changes in the Hahn spin-echo decay (Hahn-T2) in lungs of spontaneously breathing living rats at 1 hour, 3 hours, and 7 days following oleic acid injection. Motion artifacts were minimized by using the motion-insensitive interleaved rapid line scan (ILS) imaging technique. Prior to injury, the lungs exhibited two resolvable exponential Hahn-T2 components. One and 3 hours after injury the decay showed a regionally nonuniform behavior, which was fit with one, two, or three exponential components. The short and medium components increased at 1 and 3 hours after injection. The third, much longer, component is probably due to intraalveolar pulmonary edema. After 7 days the Hahn decay was similar to that observed before injury, probably reflecting resolution of the edema. Our data suggest that Hahn-T2 measurements can be used to characterize the time course and regional distribution of lung injury in living animals.

Novel assessment of acute lung injury by in vivo near-infrared spectroscopy

We investigated the feasibility and validity of near-infrared (NIR) spectroscopy for evaluation of acute lung injury (ALI). In an in vitro model simulating the spectrophotometric characteristics of the lung, NIR spectroscopy could precisely detect changes in water volume, suggesting its ability to assess the extent of pulmonary edema caused by ALI. The different grades of ALI were induced in rats by administering oleic acid and varying the pulmonary ventilation conditions, and NIR spectroscopy was employed to determine lung water content and hemoglobin (Hb) oxygenation of the lungs. NIR spectroscopy detected increased water content even in histologically mild ALI. The changes in lung water content measured by NIR spectroscopy were significantly correlated with gravimetric lung water content (r = 0.877, p < 0.0001). Deoxy-Hb measured by NIR spectroscopy consistently reflected the histological changes in the lungs, and the deoxy-Hb levels correlated with changes in SaO2 (r = -0.798, p < 0.0001). These findings demonstrate that NIR spectroscopy can evaluate lung water content and Hb oxygenation quantitatively, and may be a useful tool for assessing pathological status in ALI.

The measurement of lung water

INTRODUCTION: In this review, we compare the spectrum of currently available methods for quantifying pulmonary edema in patients. REVIEW: Imaging and indicator dilution techniques comprise the most common strategies for measuring lung water at the bedside. The most accurate (within 10% of the gravimetric gold standard) and most reproducible (< 5% between-test variation) are also, unfortunately, the most expensive and most difficult to implement for purposes of large-scale clinical trials or for routine clinical practice. CONCLUSION: The standard chest radiograph remains the best screening test for the detection of pulmonary edema. Indicator-dilution techniques are probably the best available method at present for quantitation in patient groups.

Regional measurements of pulmonary edema by using magnetic resonance imaging

A three-dimensional magnetic resonance imaging (MRI) method to measure pulmonary edema and lung microvascular barrier permeability was developed and compared with conventional methods in nine mongrel dogs. MRIs were obtained covering the entire lungs. Injury was induced by injection of oleic acid (0.021-0.048 ml/kg) into a jugular catheter. Imaging followed for 0.75-2 h. Extravascular lung water and permeability-related parameters were measured from multiple-indicator dilution curves. Edema was measured as magnetic resonance signal-to-noise ratio (SNR). Postinjury wet-to-dry lung weight ratio was 5.30 +/- 0.38 (n = 9). Extravascular lung water increased from 2.03 +/- 1.11 to 3.00 +/- 1.45 ml/g (n = 9, P < 0.01). Indicator dilution studies yielded parameters characterizing capillary exchange of urea and butanediol: the product of the square root of equivalent diffusivity of escape from the capillary and capillary surface area (D1/2S) and the capillary permeability-surface area product (PS). The ratio of D1/2S for urea to D1/2S for butanediol increased from 0.583 +/- 0.027 to 0.852 +/- 0.154 (n = 9, P < 0.05). Whole lung SNR at baseline, before injury, correlated with D1/2S and PS ratios (both P < 0.02). By using rate of SNR change, the mismatch of transcapillary filtration flow and lymph clearance was estimated to be 0.2-1.8 ml/min. The filtration coefficient was estimated from these values. Results indicate that pulmonary edema formation during oleic acid injury can be imaged regionally and quantified globally, and the results suggest possible regional quantification by using three-dimensional MRI.

Nuclear magnetic resonance Hahn spin-echo decay (T2) in live rats with endotoxin lung injury

To determine the possibility of using nuclear magnetic resonance imaging to study experimentally induced lung injury, we measured in the lungs of spontaneously breathing living rats the time course of both the Hahn spin-echo decay (T2) and the proton density after endotoxin injury. In order to minimize artifacts arising from motions of the nearby chest wall and heart, we used a motion-insensitive technique (the interleaved line scan). A typical Hahn T2 measurement was obtained over a region of interest from a series of images each with a different echo time, which ranged from 16 to 110 ms. Lung water content was determined by integrating the proton density over the region of interest. The Hahn T2 and proton density were measured before and at 1, 3, 6, and 9 h after intravenous injection of endotoxin. The effects of the treatment administered before and after endotoxin injection were also evaluated. Endotoxin treatment caused lengthening of both fast (T2f) and slow (T2s) Hahn T2 components but had no significant effect on the proton density, consistent with the notion that endotoxin causes lung injury without significant lung water accumulation in rats. However, the methylprednisolone treatment prevented the lengthening of T2s but did not seem to have a significant effect on T2f. Our results suggest that NMR imaging can be used to detect and monitor experimental lung injury in intact living animals, even in the absence of variations of lung water content.

Platelet activating factor antagonist enhances lung preservation

Platelet activating factor (PAF) is a potent phospholipid mediator of the immune and inflammatory responses, which causes physiologic effects similar to post-transplant pulmonary dysfunction. This study investigates the hypothesis that the use of a specific PAF antagonist (PAFA), BN 52021, in canine lung transplantation improves lung preservation. Twelve pairs of canines underwent left lung allotransplantation after pulmonary artery flushing with modified Euro-Collins (EC) solution (40 ml/kg). The experimental group (N = 6) received EC with BN 52021 (10 mg/kg). BN 52021 was administered to donors prior to harvest and to recipients prior to reperfusion. The preservation interval was 20 hr and the study period was 12 hr post-transplant. Differential pulmonary function and hemodynamics were monitored, comparing the transplanted left lung and the native right lung. Recipients were ventilated on 100% O2. Administration of the platelet activating factor antagonist, BN 52021, was associated with improvement in transplant lung oxygenation, pulmonary vascular resistance, and compliance. At 12 hr, transplant lung pulmonary venous oxygen tension in the treatment group (EC + BN 52021) was 154 +/- 21 mm Hg versus 87 +/- 10 mm Hg in the control group (EC) (P less than 0.05). Pulmonary vascular resistance of the transplant lung at 12 hr was 146 +/- 24 Dynes.sec.cm-5 in the EC + BN 52021 group as compared to 320 +/- 51 Dynes.sec.cm-5 in the EC group (P less than 0.05). Dynamic pulmonary compliance of the transplant lung at 12 hr was 32 +/- 2.9 ml/cm H2O in the EC + BN 52021 group versus 13 +/- 2.0 ml/cm H2O in the EC group (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Thoracic magnetic resonance imaging in the evaluation of HIV-1/AIDS pneumonitis

Magnetic resonance imaging of the thorax was performed on ten occasions in eight HIV-positive patients with a clinical picture suggestive of Pneumocystis carinii pneumonia. The diagnosis of PCP was subsequently confirmed on six occasions. Patients without PCP had low MRI profusion scores, while four of six patients with PCP had MRI profusion scores greater than 6/21. Neither the chest roentgenogram appearance nor computer-generated T1 and T2 relaxation times could reliably distinguish between these two groups. Magnetic resonance imaging may be useful in the early and noninvasive diagnosis of PCP in HIV-positive patients.

In vivo quantitation of water content in muscle tissues by NMR imaging

The water contents of phantoms and muscle tissues were determined directly from NMR imaging experiments. The method involves the calculation of corrected proton densities using relaxation time determinations and suitable calibration phantoms. Comparison with the values obtained from the oven-dry method yields good agreement in normal rat skeletal tissue and in rats injected with red blood cells from sickle cell patients.

Regional effects of repetition time on NMR quantitation of water in normal and edematous lungs

It is well known that pulmonary edema is, in general, spatially nonuniform. Since the NMR spin-lattice relaxation time (T1) is increased by lung edema, the spatial distribution of T1 will be nonuniform. When the repetition time (TR) is short relative to the T1 of edematous lung, lung water content will be underestimated and this underestimation will be spatially nonuniform as well. Therefore, technical artifacts which are a complex function of lung edema and its spatial distribution are expected. We compared overall and regional (topographic) lung water density measurements obtained from living rats (with normal or edematous lungs) using repetition times of 2.0 and 6.2 s (at a magnetic field of 1 T), to quantify this uneven T1 effect for normal and edematous lungs. NMR measurements at TR = 2.0 s underestimated whole lung water density (-rho H2O) TR = 6.2 s) by an average of 7.2% in normal rats and 22.5% in rats with pulmonary edema. Regional -rho H2O underestimation (%delta-rho H2O) varied from 2.2 to 8.8% (groups means) in normal lungs and from 7.3 to 30.8% in edematous lungs. As a result, the interquartile range (of the voxel distribution as a function of rho H2O) underestimated the spatial nonuniformity of lung water density by 28.0% in edematous lungs, likely because of greater loss of NMR signal from high-water-density, long-T1 lung regions. Both %delta-rho H2O and T1 were significantly correlated with -rho H2O at TR = 6.2 s.(ABSTRACT TRUNCATED AT 250 WORDS)