PMC5125985_01
Chest HRCT and Chartis reading of the patient.. Notes: (A) HRCT of the chest upon admission in the horizontal section. (B) HRCT of the chest upon admission. Heterogeneous emphysema was present in both upper lobes and the middle lobe. The right diaphragm was lower than the left diaphragm, indicating significant hyperinflation. The long vertical line indicates the distance from the apex of the right lung to the highest point of the right diaphragm (267 mm). The short vertical line indicates the distance from the apex of the right lung to the oblique fissure (161 mm). (C) A minor leak in the horizontal fissure seen in a coronary view (red arrow). The minimal integrity of the horizontal fissure in a coronary view was 91.6%. (D) A minor peripheral leak in the horizontal fissure in the sagittal view (red arrow). The minimal integrity of the horizontal fissure was 91%. The lesions in the RUL had obvious calcification and no evidence of malignancy. (E) A Chartis reading for the RUL showing sudden stops in expiratory flow during the three breathing maneuvers that were accompanied by a sharp increase in the airway resistance index. The total expiratory volume was only 17.33 mL, confirming the low-flow phenotype that resulted from distal airway collapse. (F) A Chartis reading for the RML revealed a flow signal with a gradual downward trend that resulted in no flow until 4 min after the activation of the valve. This effect might have been related to the absence of CV or a CV-positive status with on and offs during deeper and lower breathing maneuvers related to mini-collaterals. (G) A Chartis reading for the RLL showing a good signal with a gradual downward trend that was indicative of CV-negative status. (H) HRCT of the chest 1 month after EBV insertion into the right upper bronchus. No obvious changes relative to the CT scan taken on admission were observed, and no evidence of RUL collapse was present. (I) Comparison of HRCT images of the chest taken at baseline to those acquired 2 weeks after EBV insertion into the middle bronchus. The mediastinum shifted to the right side, and the volume of the RML was decreased. (J) HRCT of the chest 2 weeks after EBV insertion into the middle bronchus. The RUL and RML had begun to shrink, and the RLL re-expanded. The right diaphragm appeared to be higher than before. The long vertical line indicates the distance from the apex of the right lung to the highest point of the right diaphragm (255 mm). The short line next to the long line indicates the distance from the apex of the right lung to the oblique fissure (139.5 mm). Both lines were obviously shortened compared with the baseline results.. Abbreviations: CT, computed tomography; CV, collateral ventilation; EBV, endobronchial valve; HRCT, high-resolution chest CT; RLL, right lower lobe; min, minutes; RML, right middle lobe; RUL, right upper lobe.
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High-resolution chest CT (HRCT) indicated heterogeneous emphysema with a marked predominance in the bilateral upper lobes and middle lobe (Figure 1A and B). The right oblique fissure was complete, and a peripheral minor defect was found on the horizontal fissure in the coronary and sagittal views; however, we calculated the integrity of horizontal fissure to be 91.6% and 91%, respectively (Figure 1C and D). This assessment revealed sudden stops in expiratory flow during the three breathing maneuvers that were accompanied by sharp increases in resistance, which is a common characteristic of the low-flow phenotype (Figure 1E). Assessment of the middle lobe revealed that CV was negative or CV was positive with on/offs in expiratory flow that occurred during deeper and lower breathing maneuvers, which were signs of mini-collaterals that were open only during deeper inspirations (Figure 1F). Assessment of the right lower lobe (RLL) revealed a good signal with a gradual downward trend without CV (Figure 1G). One month later, the patient exhibited limited improvements in lung function, 6MWD, and volume reduction of the RUL on HRCT (Figure 1H). Two weeks later, quantitative analysis of the HRCT images (Lung CAD1.2; Neusoft, Shenyang, People's Republic of China) revealed that the volume of the right lung had decreased from 3,838 to 2,935 mL, the RUL and RML had begun to shrink, the right diaphragm had become elevated, and the mediastinum had shifted to the right side (Figure 1I and J).