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Systemic air embolism is a rare but potentially life-threatening complication of computed tomography (CT)-guided lung biopsy. The largest lung biopsy audits report an incidence rate of approximately 0.061% for systemic air embolism, with a mortality rate of 0.07-0.15%. A prompt diagnosis with high index of suspicion is essential, and hyperbaric oxygen treatment (HBOT) is the definitive management. We report the case of a 44-year-old lady who developed a lateral ST elevation myocardial infarction from coronary artery air embolism following CT-guided lung biopsy for evaluation of a left lung lesion. The biopsy was performed in the right lateral decubitus position, and the patient reported chest pain after coughing during the procedure. The clinician decided to proceed, taking four biopsy samples as no pneumothorax was identified in the intraprocedural CT image. The patient was noted to have hypotension with ongoing chest pain post-procedure. Resuscitative measures were taken to stabilise her haemodynamics, and she was successfully treated with HBOT with total resolution of air embolism. She developed a left sided pneumothorax post-treatment and needed intercostal chest drain insertion. The left lung fully re-expanded, and the patient was discharged home after day two of admission., Competing Interests: The authors report no conflicts of interest in this work., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

This retrospective study analysed a series of investigations on lung function in military divers and the importance of computed tomography (CT) scans concerning fitness to dive. We examined the incidence of blebs and bullae in a population of military divers with large lungs prompted by six cases of pulmonary barotrauma. All of these divers' medicals were normal apart from having large lungs (FVC > 120% predicted). A subsequent survey of the database of all divers and submariners of the Royal Netherlands Navy (RNLN) found another 72 divers/submariners with large lungs who were then evaluated by a CT scan. This resulted in the identification of three further individuals with blebs and/or bullae, who were then declared unfit to dive. In total, the incidence of these lung abnormalities in this cohort was 11.5%. We discuss the possible consequences for fitness to dive with regard to the current literature on the subject, and also consider the most recent standards of reference values for pulmonary function indices. Based on our results and additional insights from other studies, we advise using the Global Lung Initiative reference values for pulmonary function, while performing high resolution CT scans only in divers with clinical indications., Competing Interests: The authors report no conflicts of interest in this work., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)

Competing Interests: Conflict of interest: none declared.

Children are at higher risk of atelectasis due to their anatomical and physiological particularities. Several physiotherapy techniques are used to treat atelectasis, but only four studies cite methods in pediatric patients undergoing Invasive Mechanical Ventilation (IMV). The objective of this study was to evaluate the Structured Respiratory Physiotherapy Protocol (SRPP) for airway clearance and lung reexpansion for infants on IMV with atelectasis. This is a prospective study including 30 infants (mean ± standard deviation age 8.9 ± 8.0 months; weight 7.5 ± 3.0 kg; BMI 15.8 ± 1.6 kg/cm 2 and IMV duration 7.7 ± 4.3 days). The sample was randomized into a Control Group (CG), which received routine physiotherapy, and an Intervention Group (IG), submitted to SRPP (postural drainage, mechanical thoracic vibration, manual hyperinflation, stretching of the accessory respiratory muscles, and functional positioning). Both groups were evaluated before and after physiotherapy for respiratory effort using the Wood Downes Score (WD) and pulmonary aeration using lung ultrasonography (Lung Ultrasound Score ‒ LUS). The outcome of the intervention was evaluated by the magnitude of the effect by the Hedges' g test [(small (0.2 < Hedges' g < 0.5), moderate (0.5 < Hedges' g < 0.8) and large (Hedges' g > 0.8) effects]. There were large within-group effects on the reduction of WD in the CG after intervention in both the CG (Hedges' g = -1.53) and IG (Hedges' g = -2.2). There was a moderate effect on LUS reduction in the CG (Hedges' g = -0.64) and a large effect on IG (Hedges' g = -1.88). This study has shown that the SRPP appears to be safe and may be effective in improving airway clearance and lung reexpansion in children on IMV with atelectasis., Competing Interests: Conflicts of interest The authors declare no conflicts of interest., (Copyright © 2024 HCFMUSP. Published by Elsevier España, S.L.U. All rights reserved.)

Background: The diagnosis of peripheral isolated nodular lesions that are suspected as pulmonary tuberculosis (PTB) is challenging, which are not easily accessible via conventional bronchoscopy. This study evaluated the combined use of Xpert MTB/RIF assay and endobronchial ultrasonography with a guide sheath (EBUS-GS) for detecting MTB infection in peripheral lung bands, for early detection of PTB., Methods: The clinical data of 232 patients with suspected peripheral nodular PTB who underwent EBUS-GS between June 2020 and October 2023 were retrospectively reviewed. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) of acid-fast bacilli smear, culture, Xpert MTB/RIF assay, and pathological examination were calculated. To assess diagnostic accuracy, the results of the four methods were directly compared with the final clinical diagnosis., Results: In total, 146 and 86 patients were clinically diagnosed with peripheral nodular PTB and non-PTB, respectively. The sensitivity, specificity, PPV, NPV, and AUC values of combined Xpert MTB/RIF assay and EBUS-GS were 47.26%, 100.0%, 100.0%, 52.76%, and 0.74; those of acid-fast bacilli smear were 8.22%, 97.67%, 85.71%, 38.53%, and 0.53; those of culture were 31.51%, 100.0%, 100.0%, 46.24%, and 0.66; and those of pathological examination were 23.97%, 97.67%, 94.59%, 43.08%, and 0.61, respectively., Conclusion: The diagnostic accuracy of the combined Xpert MTB/RIF assay and EBUS-GS was significantly better than that of other conventional tests. Hence, this novel technique can be routinely applied for diagnosing and managing peripheral nodular PTB., (© 2024. The Author(s).)

Background: CT-scan and inflammatory and coagulation biomarkers could help in prognostication of COVID-19 in patients on ICU admission., Objective: The objectives of this study were to measure the prognostic value of the extent of lung parenchymal lesions on computed tomography (CT) and of several coagulation and inflammatory biomarkers, and to explore the characteristics of the patients depending on the extent of lung parenchymal lesions., Design: Retrospective monocentric observational study achieved on a dataset collected prospectively., Setting: Medical ICU of the university hospital of Clermont-Ferrand, France., Patients: All consecutive adult patients aged ≥18 years admitted between 20 March, 2020 and 31 August, 2021 for COVID-19 pneumonia., Interventions: Characteristics at baseline and during ICU stay, and outcomes at day 60 were recorded. The extent of lung parenchyma lesions observed on the chest CT performed on admission was established by artificial intelligence software., Measurements: Several clinical characteristics and laboratory features were collected on admission including plasma interleukin-6, HLA-DR monocytic-expression rate (mHLA-DR), and the extent of lung parenchymal lesions. Factors associated with day-60 mortality were investigated by uni- and multivariate survival analyses., Results: 270 patients were included. Inflammation biomarkers including the levels of neutrophils, CRP, ferritin and Il10 were the indices the most associated with the severity of the extent of the lung lesions. Patients with more extensive lung parenchymal lesions (≥ 75%) on admission had higher CRP serum levels. The extent of lung parenchymal lesions was associated with a decrease in the PaO2/FiO2 ratio(p<0.01), fewer ventilatory-free days (p = 0.03), and a higher death rate at day 60(p = 0.01). Extent of the lesion of more than 75% was independently associated with day-60 mortality (aHR = 1.72[1.06; 2.78], p = 0.03). The prediction of death at day 60 was improved when considering simultaneously biological and radiological markers obtained on ICU admission (AUC = 0.78)., Conclusions: The extent of lung parenchyma lesions on CT was associated with inflammation, and the combination of coagulation and inflammatory biomarkers and the extent of the lesions predicted the poorest outcomes., Competing Interests: no competing of interest, (Copyright: © 2024 Krisht et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Systemic autoimmune rheumatic diseases (SARDs) related pulmonary disease is highly prevalent, with variable clinical presentation and behavior, and thus is associated with poor outcomes and negatively impacts quality of life. Chest high resolution computed tomography (HRCT) is still considered a fundamental imaging tool in the screening, diagnosis, and follow-up of pulmonary disease in patients with SARDs. However, radiation exposure, economic burden, as well as lack of point-of-care CT equipment limits its application in some clinical situation. Ultrasound has found a place in numerous aspects of the rheumatic diseases, including the vasculature, skin, muscle, joints, kidneys and in screening for malignancies. Likewise it has found increasing use in the lungs. In the past two decades, lung ultrasound has started to be used for pulmonary parenchymal diseases such as pneumonia, pulmonary edema, lung fibrosis, pneumothorax, and pleural lesions, although the lung parenchymal was once considered off-limits to ultrasound. Lung ultrasound B-lines and irregularities of the pleural line are now regarded two important sonographic artefacts related to diffuse parenchymal lung disease and they could reflect the lesion extent and severity. However, its role in the management of SARDs related pulmonary involvement has not been fully investigated. This review article will focus on the potential applications of lung ultrasound in different pulmonary scenarios related with SARDs, such as interstitial lung disease, diffuse alveolar hemorrhage, diaphragmatic involvement, and pulmonary infection, in order to explore its value in clinical daily practice., (© 2024. The Author(s).)

Background: Hysteroscopic surgery is a safe procedure used for diagnosing and treating intrauterine lesions, with a low rate of intraoperative complications. However, it is important to be cautious as fluid overload can still occur when performing any hysteroscopic surgical technique., Case Presentation: In this case report, we present a unique instance where lung ultrasound was utilized to diagnose pulmonary edema in a patient following a hysteroscopic myomectomy procedure. The development of pulmonary edema was attributed to the excessive absorption of fluid during the surgical intervention. By employing lung ultrasound as a diagnostic tool, we were able to promptly identify and address the pulmonary edema. As a result, the patient received timely treatment with no complications. This case highlights the importance of utilizing advanced imaging techniques, such as lung ultrasound, in the perioperative management of patients undergoing hysteroscopic procedures., Conclusions: This case report underscores the significance of early detection and intervention in preventing complications associated with fluid overload during hysteroscopic myomectomy procedures., (© 2024. The Author(s).)

We would like to extend our gratitude to Dr. da Hora Passos et al. for their interest in our recently published review and meta-analysis in Critical Care. In this response, we will elaborate on the points raised by the authors. We agree with the authors that LUS, like any other diagnostic technique, is valuable and safe only when utilized by trained operators. The authors expressed uncertainty regarding the sensitivity of LUS in detecting mild ARDS or ARDS at an early stage. This variance in sensitivity is more likely due to diversity in diagnostic thresholds. We advocate for global collaboration among LUS experts to align LUS methodologies and strengthen the evidence supporting LUS in the diagnosis of ARDS and its morphological subphenotypes., (© 2024. The Author(s).)

Two cystic fibrosis (CF) rat models, one carrying the common Phe508del mutation and the other a nonsense cystic fibrosis transmembrane conductance regulator (CFTR) mutation (knockout) were previously characterised. Although relevant CFTR mRNA reductions were present in the lung, no overt CF lung disease was observed. This study used flexiVent lung mechanic assessment and regional ventilation assessment via X-ray velocimetry (XV) functional imaging to assess the lung phenotype in both models. To determine the sensitivity of XV regional ventilation imaging, the effect of a localised physical obstruction (delivery of agar beads to part of the lungs) on lung ventilation was examined. At baseline, Phe508del and knockout CF rats had a lower inspiratory capacity, total respiratory system compliance, and static compliance than wildtype rats. Following agar bead delivery all XV ventilation parameters were altered, with substantial increases in poorly ventilated regions and ventilation heterogeneity. XV ventilation maps accurately identified locations of bead-induced airflow changes. Despite unremarkable lung histopathology, this study indicated that CF rats display altered respiratory mechanics, with CF rats needing to exert additional effort to expand and deflate their lungs due to increased stiffness. This study demonstrated the utility of XV imaging providing spatial lung ventilation information., (© 2024. The Author(s).)

We herein report a rare case of hypersensitivity pneumonitis (HP) that was initially demonstrated as solitary pure ground-glass opacity (GGO) on chest computed tomography (CT). A 51-year-old woman with a history of breast cancer underwent follow-up CT, which revealed solitary pure GGO. The patient developed exertional dyspnea after two years, and CT revealed diffuse centrilobular nodules in addition to GGO, which had increased in size. An antigen avoidance test was performed to diagnose HP, leading to the resolution of CT abnormalities, including the GGO. Our findings suggested that nonfibrotic HP can present as solitary pure GGO.

The effect of gravity on the lungs has been evaluated using computed tomography (CT) in the supine and prone positions but not the standing position. However, as humans spend most of the daytime in the standing position, we aimed to compare lung attenuation gradients between the supine and standing positions, and to assess the correlations between the lung attenuation gradients and participant characteristics, including pulmonary function test results. Overall, 100 healthy participants underwent conventional/supine and upright CT, and lung attenuation gradients were measured. Lung attenuation gradients in anteroposterior direction were greater in the supine position than in standing position (all p values < 0.0001) in both upper lobes at the level of the aortic arch (right: standing/supine, -0.02 ± 0.19/0.53 ± 0.21; left: standing/supine, -0.06 ± 0.20/0.51 ± 0.21); in the right middle (standing/supine, -0.26 ± 0.41/0.53 ± 0.39), left upper (standing/supine, -0.35 ± 0.50/0.66 ± 0.54), and lower lobes at the level of the inferior pulmonary vein (right: standing/supine, -0.22 ± 0.30/0.65 ± 0.41; left: standing/supine, -0.16 ± 0.25/0.73 ± 0.54); and in both lower lobes just above the diaphragm (right: standing/supine, -0.13 ± 0.22/0.52 ± 0.32; left: standing/supine, -0.30 ± 0.57/0.55 ± 0.37). Craniocaudal gradients were greater in the standing position (right: standing/supine, 0.41 ± 0.30/0.00 ± 0.16; left: standing/supine, 0.35 ± 0.30/-0.02 ± 0.16, all p values < 0.0001). No moderate to very high correlations were observed between age, sex, height, weight, body index mass, or pulmonary function test results and each lung attenuation gradient. Lung attenuation gradients in anteroposterior direction, which was observed in the supine position, disappeared in the standing position. However, the craniocaudal lung attenuation gradient, which was not present in the supine position, appeared in the standing position., (© 2024. The Author(s).)

Background: The diagnostic yield of peripheral pulmonary lesions (PPLs) through endobronchial ultrasonography with a guide sheath transbronchial biopsy (EBUS-GS TBB) under virtual bronchoscopic navigation is unsatisfactory because radial EBUS probe is not always located within the lesion. Transbronchial needle aspiration with a guide sheath (GS-TBNA) has the potential to overcome the lower diagnostic yield by improving the relationship between the probe and the lesion and enabling repeated sampling while maintaining the location of a GS near the lesion. However, there are few data regarding the diagnostic yield and safety for diagnosing PPLs in this procedure., Methods: We retrospectively analyzed consecutive 363 lesions (83 lesions underwent GS-TBNA/EBUS-GS TBB and 280 lesions underwent EBUS-GS TBB) at our institution between April 1, 2019 and March 31, 2022. We investigated the diagnostic efficacy and complications of GS-TBNA/EBUS-GS TBB and compared them with those of EBUS-GS TBB., Results: The lesion size, distance from the hilum, presence of bronchus leading to the lesion, and EBUS images during the examination differed significantly between the two procedures. Logistic regression analysis adjusted for these 4 covariates revealed that GS-TBNA/EBUS-GS TBB was a significant factor affecting the diagnostic success of PPLs compared with EBUS-GS TBB (odds ratio=2.43, 95% CI=1.16-5.07, P=0.018). Neither procedure differed significantly in terms of complications (6.0% vs. 5.7%, P>0.999)., Conclusion: GS-TBNA performed in addition to EBUS-GS TBB might be a promising sampling method for improving the diagnostic yield for PPLs without increasing the incidence of complications., Competing Interests: Disclosure: There is no conflict of interest or other disclosures., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Frequent chest CTs within a short period during follow-up of long COVID patients may increase the risk of radiation-related health effects in the exposed individuals. We aimed to assess the image quality and diagnostic accuracy of ultra-low-dose CT (ULDCT) chest compared to standard-dose CT (SDCT) in detecting lung abnormalities associated with long COVID., Methods: In this prospective study, 100 long COVID patients with respiratory dysfunction underwent SDCT and ULDCT chest that were compared in terms of objective (signal-to-noise ratio, SNR) and subjective image quality (image graininess, sharpness, artifacts, and diagnostic accuracy along with the European guidelines on image quality criteria for CT chest), detection of imaging patterns of long COVID, CT severity score, and effective radiation dose. Additionally, the diagnostic performance of ULDCT was compared among obese (BMI≥30 kg/m 2 ) and non-obese (BMI<30 kg/m 2 ) subjects., Results: The mean age of study participants was 53 ± 12.9 years, and 68% were male. The mean SNR was 31.4 ± 5.5 and 11.3 ± 4.6 for SDCT and ULDCT respectively (p< 0.0001). Common findings seen on SDCT included ground-glass opacities (GGOs, 77%), septal thickening/reticulations (67%), atelectatic/parenchymal bands (63%) and nodules (26%). ULDCT provided sharp images, with no/minimal graininess, and high diagnostic confidence in 81%, 82% and 80% of the cases respectively. The sensitivity of ULDCT for various patterns of long COVID was 72.7% (GGOs), 71.6% (interlobular septal thickening/reticulations), 100% (consolidation), 81% (atelectatic/parenchymal bands) and 76.9% (nodules). ULDCT scans in non-obese subjects exhibited a significantly higher sensitivity (88% vs. 60.3%, p < 0.0001) and diagnostic accuracy (97.7% vs. 84.9%, p < 0.0001) compared to obese subjects. ULDCT showed very strong correlation with SDCT in terms of CT severity score (r = 0.996, p < 0.0001). The mean effective radiation dose with ULDCT was 0.25 ± 0.02 mSv with net radiation dose reduction of 94.8% ± 1.7% (p < 0.0001) when compared to SDCT (5.5 ± 1.96 mSv)., Conclusion: ULDCT scans achieved comparable diagnostic accuracy to SDCT for detecting long COVID lung abnormalities in non-obese patients, while significantly reducing radiation exposure., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Devkota, Garg, Debi, Dhooria, Dua, Prabhakar, Soni, Maralakunte, Gulati, Singh and Sandhu.)

Background: Point-of-care ultrasound is rapidly gaining traction in clinical practice, including primary care. Yet, logistical challenges and geographical isolation hinder skill acquisition. Concurrently, an evidentiary gap exists concerning such guidance's effectiveness and optimal implementation in these settings., Methods: We developed a lung point-of-care ultrasound (POCUS) curriculum for primary care physicians in a rural, medically underserved region of the south of Israel. The course included recorded lectures, pre-course assessments, hands-on training, post-workshop lectures, and individual practice. To evaluate our course, we measured learning outcomes and physicians' proficiency in different lung POCUS domains using hands-on technique assessment and gathered feedback on the course with a multi-modal perception approach: an original written pre- and post-perception and usage questionnaire., Results: Fifty primary care physicians (PCPs) showed significant improvement in hands-on skills, increasing from 6 to 76% proficiency (p < 0.001), and in identifying normal versus abnormal views, improving from 54 to 74% accuracy (p < 0.001). Ten weeks after training, primary care physicians reported greater comfort using lung ultrasound, rising from 10 to 54% (p < 0.001), and improved grasp of its potential and limits, increasing from 27.5% to 84% (p < 0.001). Weekly usage increased from none to 50%, and the number of primary care physicians not using at all decreased from 72 to 26% (p < 0.001)., Conclusions: A two-day focused in-person and remote self-learning lung-POCUS training significantly improved primary care physicians' lung ultrasound skills, comfort, and implementation., (© 2024. The Author(s).)

Left atrial (LA) physiology and hemodynamics are intimately connected to cardiac and lung function in health and disease. This study examined the relationship between MRI-based left atrial (LA) size and function with MRI-based lung volume and pulmonary function testing (PFT) parameters in the population-based KORA study cohort of 400 participants without overt cardiovascular disease. MRI quantification assessed LA size/function in sequences with and without ECG synchronization, alongside lung volume. Regression analysis explored the relationship of LA with MRI lung volume and PFT parameters. Among 378 participants (average age 56.3 ± 9.2 years; 42.3% women), non-gated LA size averaged 16.8 cm 2 , while maximal and minimal LA size from gated measurements were 19.6 cm 2 and 11.9 cm 2 respectively. The average MRI-derived lung volume was 4.0 L, with PFT showing a total lung capacity of 6.2 L, residual lung volume of 2.1 L, and forced vital capacity of 4.1 L. Multivariate regression analysis, adjusted for age, gender, and cardiovascular risk factors, revealed an inverse association between maximum LA size, non-gated LA, and LA area fraction with lung volume (ß = - 0.03, p = 0.006; ß = - 0.03, p = 0.021; ß = - 0.01, p = 0.012), with no significant association with PFT parameters. This suggests that MRI-based assessment may offer greater sensitivity in detecting subclinical LA impairment than PFT., (© 2024. The Author(s).)

Background: To explore the associations of computed tomography (CT) image features with the serum cryptococcal antigen (CrAg) titers measured by the lateral flow assay (LFA) in localized pulmonary cryptococcosis patients., Methods: A retrospective analysis of patients with pathologically confirmed pulmonary cryptococcosis admitted to the First Affiliated Hospital of Xiamen University from January 2016 to December 2022 was performed. Clinical data, CT results, serum CrAg-LFA test results, and follow-up data were collected and analyzed., Results: A total of 107 patients with localized pulmonary cryptococcosis were included, of which 31 had a single lesion in chest CT and the other 76 had multiple lesions. The positivity rate was (94.74% vs 64.52%) and titers of serum CrAg-LFA (1.77 ± 0.87 vs 0.91 ± 0.98) in the multiple lesion group were higher than those in the single lesion group, respectively. Multivariate linear regression analysis showed that the serum CrAg titers were positively associated with the number of lesions (β, 0.08; 95% CI, 0.05 to 0.12) and the lesion size (β, 0.40; 95% CI, 0.31 to 0.50) after adjusting other covariates. The serum CrAg-LFA titers of 60 pulmonary cryptococcosis patients showed a decreasing trend with the reduction in pulmonary lesion size after effective therapy., Conclusion: In pulmonary cryptococcosis patients, the number and size of lung lesions are positively correlated with the titers of the serum CrAg-LFA test. The CrAg-LFA test could be a useful tool for the diagnosis, severity assessment, and therapeutic monitoring of localized pulmonary cryptococcosis patients., (© 2024. The Author(s).)

BACKGROUND The incidence of lung diseases in premature newborns is significantly higher than in full-term newborns due to their underdeveloped lungs. Ultrasound and X-ray are commonly-used bedside examinations in neonatology. This study primarily compares the efficacy of chest X-ray (CXR) and lung ultrasound (LUS) images in evaluating lung consolidation and edema in premature newborns at Neonatal Intensive Care Units (NICU). MATERIAL AND METHODS A retrospective analysis was conducted on LUS and CXR examination results, along with clinical records of premature newborns admitted to our hospital's NICU from November 1, 2019, to December 31, 2021. CXR and LUS scans were performed on the same newborn within a day. We evaluated the consolidations and edema by interpreting the CXR and LUS images, then compared the findings. RESULTS Out of 75 cases, 34 showed lung consolidations on LUS (45%), while only 14 exhibited consolidations on CXR (19%). The detection rate of consolidations by LUS was significantly higher compared to CXR (34/75 vs 14/75, P<0.001). Differences were observed between the 2 bedside examinations in identifying consolidations, with some cases seen only on LUS. CXR struggled to accurately assess the severity of lung edema visible on LUS, showing significant disparity in detecting interstitial edema (53/75 vs 21/75, P<0.001). CONCLUSIONS LUS outperforms chest CXR for bedside assessment of lung consolidation and edema in premature newborns.

Electrical Impedance Tomography (EIT) is a groundbreaking, non-invasive, and radiation-free imaging technique for continuous, real-time ventilation monitoring. It also has an application in pulmonary perfusion monitoring. EIT quantifies ventilation and perfusion patterns across the lung from the measurement and processing of impedance changes in the thorax. It is a powerful tool for clinicians to visualize breath-by-breath changes in pulmonary function. An innovative application of EIT is its ability to assess pulmonary perfusion using the kinetic analysis of a hypertonic solution injection during a breath-hold. The solution generates an impedance change in the thorax as it circulates through the pulmonary vasculature. This indirect method allows for the estimation of perfusion patterns, contributing significantly to our understanding of pulmonary blood flow dynamics at the bedside. EIT is not just a tool for monitoring but also can be critical for the diagnosis of respiratory pathologies such as pneumothorax and bronchial intubation. It can help identify the etiology of ventilation/perfusion (V/Q) mismatch in patients receiving invasive mechanical ventilation, which is not possible with other diagnostic tools. Moreover, EIT can assist in the individual optimization of ventilator settings, such as Positive End-Expiratory Pressure (PEEP) titration and tidal volume improving oxygenation and lung health in critical care. In summary, EIT represents a paradigm shift in bedside pulmonary monitoring and diagnostics. Its non-invasive nature and immediacy of data make EIT an indispensable tool in modern respiratory medicine. With its growing applications, EIT will be pivotal in advancing our understanding of and approach to respiratory care, particularly in intensive care settings.

High quality MRI of the lungs is challenged by low tissue density, fast MRI signal relaxation, and respiratory and cardiac motion. For these reasons, structural imaging of the lungs is performed almost exclusively using Computed Tomography (CT). However, CT imaging delivers ionizing radiation, and thus is less well suited for certain vulnerable populations (e.g., pediatrics) or for research applications. As an alternative, MRI using ultra-short echo times (UTE) is attracting interest. This technique can be performed during free-breathing over the course of a ~5-10 min scan. Respiratory motion information is encoded alongside images; this information can be used to "self-gate" images. Self-gating thus removes the requirement of advanced MRI pulse sequence programming or the use of respiratory bellows, which simplifies image acquisition. In this protocol, simple, robust, and computationally efficient acquisition and reconstruction methods for acquiring high quality UTE MRI of the lungs are presented. This protocol was developed for use on a 3T MRI scanner, but the same principles can be implemented at lower magnetic field strength. The protocol includes recommended parameter settings for 3D radial UTE image acquisition as well as directions for self-gated image reconstruction to generate images at distinct respiratory phases. Through the implementation of this protocol, users can generate high-resolution UTE images of the lungs with minimal to minimal-to-no motion artifacts. These images can be used to evaluate pulmonary structure, which can be implemented for research use in a variety of pulmonary conditions.

Background: Idiopathic Pulmonary Fibrosis (IPF) is a progressive fibrotic lung disease. However, the field of quantitative CT scan analysis in conjunction with pulmonary function test for IPF patients remains relatively understudied. In this study, we evaluated the diagnostic value of features derived high-resolution computed tomography (HRCT) for patients with IPF and correlated them with pulmonary function tests., Methods: We retrospectively analyzed the chest HRCT images and pulmonary function test results of 52 patients with IPF during the same period (1 week) and selected 52 healthy individuals, matched for sex, age, and body mass index (BMI) and with normal chest HRCT as controls. HRCT scans were performed using a Philips 256-row Brilliance iCT scanner with standardized parameters. Lung function tests were performed using a Jaeger volumetric tracer for forced vital capacity (FVC), total lung capacity (TLC), forced expiratory volume in first second (FEV1), FEV1/FVC, carbon monoxide diffusing capacity (DLCO), and maximum ventilation volume (MVV) metrics. CT quantitative analysis, including tissue segmentation and threshold-based quantification of lung abnormalities, was performed using 3D-Slicer software to calculate the percentage of normal lung areas (NL%), percentage of ground-glass opacity areas (GGO%), percentage of fibrotic area (F%) and abnormal lesion area percentage (AA%). Semi-quantitative analyses were performed by two experienced radiologists to assess disease progression. The aortic-to-sternal distance (ASD) was measured on axial images as a standardized parameter. Spearman or Pearson correlation analysis and multivariate stepwise linear regression were used to analyze the relationship between the data in each group, and the ROC curve was used to determine the optimal quantitative CT metrics for identifying IPF and controls., Results: ROC curve analysis showed that F% distinguished the IPF patient group from the control group with the largest area under the curve (AUC) of 0.962 (95% confidence interval: 0.85-0.96). Additionally, with F% = 4.05% as the threshold, the Youden's J statistic was 0.827, with a sensitivity of 92.3% and a specificity of 90.4%. The ASD was significantly lower in the late stage of progression than in the early stage (t = 5.691, P < 0.001), with a mean reduction of 2.45% per month. Quantitative CT indices correlated with all pulmonary function parameters except FEV1/FVC, with the highest correlation coefficients observed for F% and TLC%, FEV1%, FVC%, MVV% (r = - 0.571, - 0.520, - 0.521, - 0.555, respectively, all P-values < 0.001), and GGO% was significantly correlated with DLCO% (r = - 0.600, P < 0.001). Multiple stepwise linear regression analysis showed that F% was the best predictor of TLC%, FEV1%, FVC%, and MVV% (R 2  = 0.301, 0.301, 0.300, and 0.302, respectively, all P-values < 0.001), and GGO% was the best predictor of DLCO% (R 2  = 0.360, P < 0.001)., Conclusions: Quantitative CT analysis can be used to diagnose IPF and assess lung function impairment. A decrease in the ASD may indicate disease progression., (© 2024. The Author(s).)

We present a rare finding on lung ventilation-perfusion (V/Q) scintigraphy for a woman with longstanding dyspnea. CT of the chest showed volume loss on the right side, which raised concern about possible bronchiolitis obliterans or Swyer-James-MacLeod syndrome; however, the right pulmonary artery could not be visualized. A subsequent V/Q scan showed absence of perfusion and decreased ventilation to the entire right lung, consistent with agenesis of the right pulmonary artery. The patient's clinical course and imaging features mimicked Swyer-James-MacLeod syndrome, which usually presents with a matched perfusion defect in a single lung or lobe on V/Q scanning. This case highlights the importance of a multimodality imaging approach to achieve a diagnosis., (© 2024 by the Society of Nuclear Medicine and Molecular Imaging.)

Background: A 3.0-mm ultrathin bronchoscope (UTB) with a 1.7-mm working channel provides better accessibility to peripheral bronchi. A 4.0-mm thin bronchoscope with a larger 2.0-mm working channel facilitates the use of a guide sheath (GS), ensuring repeated sampling from the same location. The 1.1-mm ultrathin cryoprobe has a smaller diameter, overcoming the limitation of the size of biopsy instruments used with UTB. In this study, we compared the endobronchial ultrasound localization rate and diagnostic yield of peripheral lung lesions by cryobiopsy using UTB and thin bronchoscopy combined with GS., Methods: We retrospectively evaluated 133 patients with peripheral pulmonary lesions with a diameter less than 30 mm who underwent bronchoscopy with either thin bronchoscope or UTB from May 2019 to May 2023. A 3.0-mm UTB combined with rEBUS was used in the UTB group, whereas a 4.0-mm thin bronchoscope combined with rEBUS and GS was used for the thin bronchoscope group. A 1.1-mm ultrathin cryoprobe was used for cryobiopsy in the two groups., Results: Among the 133 patients, peripheral pulmonary nodules in 85 subjects were visualized using r-EBUS. The ultrasound localization rate was significantly higher in the UTB group than in the thin bronchoscope group (96.0% vs. 44.6%, respectively; P < 0.001). The diagnostic yield of cryobiopsy specimens from the UTB group was significantly higher compared to the thin bronchoscope group (54.0% vs. 30.1%, respectively; p = 0.006). Univariate analysis demonstrated that the cryobiopsy diagnostic yields of the UTB group were significantly higher for lesions ≤ 20 mm, benign lesions, upper lobe lesions, lesions located lateral one-third from the hilum, and lesions without bronchus sign., Conclusions: Ultrathin bronchoscopy combined with cryobiopsy has a superior ultrasound localization rate and diagnostic yield compared to a combination of cryobiopsy and thin bronchoscopy., (© 2024. The Author(s).)

Background: We recently demonstrated that elexacaftor/tezacaftor/ivacaftor (ETI) improves the lung clearance index (LCI) and abnormalities in lung morphology detected by magnetic resonance imaging (MRI) in adolescent and adult patients with cystic fibrosis (CF). However, real-world data on the effect of ETI on these sensitive outcomes of lung structure and function in school-age children with CF have not been reported. The aim of this study was therefore to examine the effect of ETI on the LCI and the lung MRI score in children aged 6-11 years with CF and one or two F508del alleles., Methods: This prospective, observational, multicentre, post-approval study assessed the longitudinal LCI up to 12 months and the lung MRI score before and 3 months after initiation of ETI., Results: A total of 107 children with CF including 40 heterozygous for F508del and a minimal function mutation (F/MF) and 67 homozygous for F508del (F/F) were enrolled in this study. Treatment with ETI improved the median (interquartile range (IQR)) LCI in F/MF (-1.0 (-2.0- -0.1); p<0.01) and F/F children (-0.8 (-1.9- -0.2); p<0.001) from 3 months onwards. Further, ETI improved the median (IQR) MRI global score in F/MF (-4.0 (-9.0-0.0); p<0.01) and F/F children (-3.5 (-7.3- -0.8); p<0.001)., Conclusions: ETI improves early abnormalities in lung ventilation and morphology in school-age children with CF and at least one F508del allele in a real-world setting. Our results support early initiation of ETI to reduce or even prevent lung disease progression in school-age children with CF., Competing Interests: Conflicts of interest: M. Stahl, S.Y. Graeber and S. Thee are participants of the Berlin Institute of Health (BIH)-Charité Clinician Scientist Program, and J. Röhmel is participant of the Case Analysis and Decision Support (CADS) program funded by Charité – Universitätsmedizin Berlin and the BIH. M. Stahl reports an Independent Research Innovation Award and honoraria for lectures and participation in advisory boards, all by Vertex Pharmaceuticals Incorporated, outside of the submitted work; she is Chairman of the German CF Research Council (FGM), Treasurer of the German Society of Paediatric Pulmonology (GPP) and was Secretary of the Group CF of the Paediatric Assembly of the ERS. M. Dohna is a participant of the Ellen-Schmidt Habilitationsförderung funded by the Hannover Medical School. S.Y. Graeber reports grants from the German CF Foundation and Vertex Pharmaceuticals Incorporated, and honoraria from Chiesi GmbH and Vertex Pharmaceuticals Incorporated for lectures and participation in advisory boards, outside of the submitted work. O. Sommerburg reports grants and honoraria from Vertex Pharmaceuticals Incorporated for lectures, outside of the submitted work. S.T. Pallenberg is a member of the Else-Kröner Forschungskolleg TITUS. A. Voskrebenzev reports a grant and honoraria for lectures from Siemens Healthineers, outside of the submitted work, holds a patent for a method of quantitative magnetic resonance lung imaging (Voskrebenzev, Gutberlet, Vogel-Claussen; number EP3107066, US-2016-0367200-Al 22.12.2016), and is a stockholder and CEO of BioVisioneers GmbH. K. Schütz reports payments for attending meetings and/or travel from Vertex Pharmaceuticals Incorporated, outside of the submitted work. G. Hansen reports receipt of consultation fees from Sanofi GmbH, outside of the submitted work. F. Doellinger reports payment or honoraria for lectures, presentations, manuscript writing or educational events from Bayer, Bayer Vital, Berlin-Chemie Menarini, Boehringer Ingelheim and Chiesi GmbH, payment for expert testimony from Calyx, and support for attending meetings from Bayer. E. Steinke reports grants from Berlin Institute of Health at Charité Berlin, and payment or honoraria for lectures, presentations, manuscript writing or educational events from Vertex Pharmaceuticals Incorporated. S. Thee reports honoraria for lectures and payment for attending meetings and/or travel from Vertex Pharmaceuticals Incorporated and Viatris, outside of the submitted work. J. Röhmel reports honoraria for lectures from Vertex Pharmaceuticals Incorporated, outside the submitted work; additionally, he is work package leader in BEAT-PCD (ERS-CRC). M.O. Wielpütz reports a grant from Vertex Pharmaceuticals Incorporated, and receipt of consulting fees and honoraria for lectures from Vertex Pharmaceuticals Incorporated and Boehringer Ingelheim, outside of the submitted work. L. Naehrlich reports receipt of fees for a data quality project of the German CF Registry. He is the medical lead of the German CF Registry, the pharmacovigilance study manager of the European Cystic Fibrosis Society Patient Registry and part of the Trial Steering Committee for CF STORM. He also reports grants from the German Center for Lung Research, Vertex Pharmaceuticals and Mukoviszidose Institute, and receipt of medical writing services from Articulate Science. J. Vogel-Claussen reports grants from BMBF, Siemens Healthineers, AstraZeneca, Boehringer Ingelheim and GSK, royalties or licenses from Siemens Healthineers, receipt of consulting fees from AstraZeneca, honoraria for lectures from Siemens Healthineers, AstraZeneca, Boehringer Ingelheim, GSK, Roche, Coreline Soft and Bayer, payments for attending meetings and/or travel from Vertex Pharmaceuticals Incorporated, Bayer, GSK and AstraZeneca, and holds a patent for a method of quantitative magnetic resonance lung imaging (Voskrebenzev, Gutberlet, Vogel-Claussen; number EP3107066, US-2016-0367200-Al 22.12.2016). B. Tümmler reports support for the present study from Bundesministerium für Forschung und Technologie, grants from the German Research Foundation (DFG; CRC 900; Excellence cluster “RESIST”), consultancy fees from Helmholtz Institut für Infektionsforschung, payment or honoraria for lectures, presentations, manuscript writing or educational events from Vertex Pharmaceutical (Germany) Incorporated, participation on a data and safety monitoring board or advisory board with Vertex Pharmaceuticals Incorporated, and leadership roles with Christiane Herzog Stiftung and the Microbiome/Metagenome Group of the German Center for Lung Research (DZL). M.A. Mall reports grants from the German Research Foundation (DFG; SFB-TR 84, and project 450557679) and the German Innovation Fund (01NVF19008), outside of the submitted work. Additionally, he reports receipt of consulting fees from AbbVie, Antabio, Arrowhead, Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotec, Prieris, Recode, Santhera, Splisense and Vertex Pharmaceuticals Incorporated, of honoraria for lectures from Vertex Pharmaceuticals Incorporated and participation in advisory boards from AbbVie, Antabio, Arrowhead, Boehringer Ingelheim, Enterprise Therapeutics, Kither Biotec, Pari and Vertex Pharmaceuticals Incorporated, and of payment for travel from Vertex Pharmaceuticals Incorporated and Boehringer Ingelheim, all outside of the submitted work. He is a Fellow of ERS (FERS). A-M. Dittrich reports support for the present study from the German Center for Lung Research (DZL), Vertex Pharmaceuticals Incorporated and European Cystic Fibrosis Society Clinical Trial Network (ECFS-CTN), grants from Vertex Pharmaceuticals Incorporated, ECFS-CTN, DFG and Christiane Herzog Stiftung, consultancy fees from the c4c consortium, GSK and European Cystic Fibrosis Society. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2024.)

Background: Preserved Ratio Impaired Spirometry (PRISm) is considered to be a precursor of chronic obstructive pulmonary disease. Radiomics nomogram can effectively identify the PRISm subjects from non-COPD subjects, especially when during large-scale CT lung cancer screening., Methods: Totally 1481 participants (864, 370 and 247 in training, internal validation, and external validation cohorts, respectively) were included. Whole lung on thin-section computed tomography (CT) was segmented with a fully automated segmentation algorithm. PyRadiomics was adopted for extracting radiomics features. Clinical features were also obtained. Moreover, Spearman correlation analysis, minimum redundancy maximum relevance (mRMR) feature ranking and least absolute shrinkage and selection operator (LASSO) classifier were adopted to analyze whether radiomics features could be used to build radiomics signatures. A nomogram that incorporated clinical features and radiomics signature was constructed through multivariable logistic regression. Last, calibration, discrimination and clinical usefulness were analyzed using validation cohorts., Results: The radiomics signature, which included 14 stable features, was related to PRISm of training and validation cohorts (p < 0.001). The radiomics nomogram incorporating independent predicting factors (radiomics signature, age, BMI, and gender) well discriminated PRISm from non-COPD subjects compared with clinical model or radiomics signature alone for training cohort (AUC 0.787 vs. 0.675 vs. 0.778), internal (AUC 0.773 vs. 0.682 vs. 0.767) and external validation cohorts (AUC 0.702 vs. 0.610 vs. 0.699). Decision curve analysis suggested that our constructed radiomics nomogram outperformed clinical model., Conclusions: The CT-based whole lung radiomics nomogram could identify PRISm to help decision-making in clinic., (© 2024. The Author(s).)

Background: Traumatic pulmonary pseudocyst is a rare "cystlike" lung lesion that typically develops following blunt chest trauma. It differs from lung cancer associated with cystic airspaces in terms of pathogenic mechanisms, clinical manifestations, and radiological features. Furthermore, there are few reports of the diagnostic bias between traumatic pulmonary pseudocyst and lung cancer associated with cystic airspaces. Here, we present a rare case of lung cancer associated with cystic airspaces that mimicks traumatic pulmonary pseudocyst., Case Presentation: A 61-year-old man with no chest medical or surgical history, no chest radiologic examination within the last five years, and no smoking history had an air-filled "cystlike" lesion surrounded by solid components and ground-glass opacities in the middle third of the right upper lobe of the lung during a computed tomography evaluation following blunt chest trauma. He was initially diagnosed with traumatic pulmonary pseudocyst and treated conservatively. On the third post-trauma day, he experienced hemoptysis, which was successfully treated with intravenous hemostatic medication. On the ninth post-trauma day, he exhibited a significant hemoptysis and a moderate dyspnea. A subsequent chest computed tomography scan demonstrated that the solid components had entered the lesion's cavity and significantly expanded, and the surrounding ground-glass opacities had slightly enlarged. A contrast-enhanced chest computed tomography scan and a three-dimensional reconstruction computed tomography image confirmed that the solid components were a hematoma caused by damage to the right upper pulmonary vein. A right upper lobectomy was performed based on the concern about severe intrapulmonary bleeding. An intraoperative frozen section analysis showed significant bleeding in the lung parenchyma. Adenosquamous carcinoma was unexpectedly identified during the postoperative pathological examination of the resected specimen. A diagnosis of primary lung adenosquamous carcinoma was made. He was discharged on the seventh postoperative day and followed up for two years without any recurrence., Conclusions: The potential of lung cancer associated with cystic airspaces should be considered for "cystlike" lung lesions discovered in elderly patients after blunt chest trauma. A comprehensive review of the medical history, meticulous analysis of the radiological findings, and close monitoring can help clinicians reduce the risk of diagnostic bias., (© 2024. The Author(s).)

Background: This study aimed to investigate the radiological changes in patients with nontuberculous mycobacterial pulmonary disease (NTM-PD) having bronchiolitis patterns on computed tomography (CT)., Methods: We retrospectively reviewed the final diagnosis and radiologic changes of patients suspected of having NTM-PD without cavity or bronchiectasis on CT image, between January 1, 2005 and March 31, 2021. NTM-PD was diagnosed based on the American Thoracic Society and Infectious Diseases Society of America criteria. The initial and final CT findings (bronchiectasis, cellular bronchiolitis, cavity formation, nodules, and consolidation) were compared between patients diagnosed with and without NTM-PD., Results: This study included 96 patients and 515 CT images. The median CT follow-up duration was 1510.5 (interquartile range: 862.2-3005) days. NTM-PD was recognized in 43 patients. The clinical variables were not significantly different between patients with and without NTM-PD, except for underlying chronic airway disease (P < 0.001). Nodule and consolidation were more frequently observed on the initial CT scans of patients with NTM-PD compared with those without (P < 0.05). On the final follow-up CT scan, bronchiectasis (P < 0.001), cavity (P < 0.05), nodule (P < 0.05), and consolidation (P < 0.05) were more frequently observed in patients with NTM-PD. Among the 43 patients with NTM-PD, 30 showed a radiological progression on CT, with bronchiectasis (n = 22) being the most common finding. The incidence of bronchiectasis increased over time., Conclusion: The bronchiolitis pattern on CT images of patients with NTM-PD showed frequent radiological progression during the follow-up period., (© 2024. The Author(s).)

Background: Lung cancer is one of the most common malignant tumors at present. This study aimed to compare the diagnostic accuracy, complication rates, and predictive values of computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and electronic bronchoscopy-guided transbronchial lung biopsy (TBLB) for patients with central pulmonary lesions (CPLs) with a diameter ≥ 3 cm., Methods: We retrospectively included 110 patients with CPLs with a diameter ≥ 3 cm who underwent preoperative PTNB and TBLB examinations and ultimately underwent surgery to remove CPLs and obtained pathological results. Detailed information was collected in order to compare whether there was a difference between two groups. Data were processed using SPSS software (Version 26.0; IBM Corp). Data were compared by t-test or chi-square test. p < 0.05 was considered statistically significant., Results: All patients underwent surgical treatment at the department of thoracic surgery and obtained a final pathological diagnosis. The rate of positive predictive value (PPV) was comparable between the two methods, and the negative predictive value (NPV) was significantly higher in the PTNB group compared with the TBLB group (p < 0.05). In addition, PTNB was more sensitive and accurate than TBLB (p < 0.05). However, the PTNB group had a higher probability of complications, and TBLB was a relatively safer examination method., Conclusion: PTNB demonstrated a higher accuracy and sensitivity than TBLB in the treatment of CPLs with a diameter ≥ 3 cm, but the complication rates of PTNB are relatively high. These methods exhibited different diagnostic accuracies and therefore should be selected based on different medical conditions., (© 2024 The Author(s). The Clinical Respiratory Journal published by John Wiley & Sons Ltd.)

Background Incidental extrapulmonary findings are commonly detected on chest CT scans and can be clinically important. Purpose To integrate artificial intelligence (AI)-based segmentation for multiple structures, coronary artery calcium (CAC), and epicardial adipose tissue with automated feature extraction methods and machine learning to detect extrapulmonary abnormalities and predict all-cause mortality (ACM) in a large multicenter cohort. Materials and Methods In this post hoc analysis, baseline chest CT scans in patients enrolled in the National Lung Screening Trial (NLST) from August 2002 to September 2007 were included from 33 participating sites. Per scan, 32 structures were segmented with a multistructure model. For each structure, 15 clinically interpretable radiomic features were quantified. Four general codes describing abnormalities reported by NLST radiologists were applied to identify extrapulmonary significant incidental findings on the CT scans. Death at 2-year and 10-year follow-up and the presence of extrapulmonary significant incidental findings were predicted with ensemble AI models, and individualized structure risk scores were evaluated. Area under the receiver operating characteristic curve (AUC) analysis was used to evaluate the performance of the models for prediction of ACM and extrapulmonary significant incidental findings. The Pearson χ 2 test and Kruskal-Wallis rank sum test were used for statistical analyses. Results A total of 24 401 participants (median age, 61 years [IQR, 57-65 years]; 14 468 male) were included. In 3880 of 24 401 participants (16%), 4283 extrapulmonary significant incidental findings were reported. During the 10-year follow-up, 3389 of 24 401 participants (14%) died. CAC had the highest feature importance for predicting the three study end points. The 10-year ACM model demonstrated the best AUC performance (0.72; per-year mortality of 2.6% above and 0.8% below the risk threshold), followed by 2-year ACM (0.71; per-year mortality of 1.13% above and 0.3% below the risk threshold) and prediction of extrapulmonary significant incidental findings (0.70; probability of occurrence of 25.4% above and 9.6% below the threshold). Conclusion A fully automated AI model indicated extrapulmonary structures at risk on chest CT scans and predicted ACM with explanations. ClinicalTrials.gov Identifier: NCT00047385 © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Yanagawa and Hata in this issue.

Introduction: There is still a lack of clinical evidence comprehensively evaluating the effectiveness of antiviral treatments for COVID-19 hospitalized patients., Methods: A retrospective cohort study was conducted at Beijing You'An Hospital, focusing on patients treated with nirmatrelvir/ritonavir or azvudine. The study employed a tripartite analysis-viral dynamics, survival curve analysis, and AI-based radiological analysis of pulmonary CT images-aiming to assess the severity of pneumonia., Results: Of 370 patients treated with either nirmatrelvir/ritonavir or azvudine as monotherapy, those in the nirmatrelvir/ritonavir group experienced faster viral clearance than those treated with azvudine (5.4 days vs. 8.4 days, p < 0.001). No significant differences were observed in the survival curves between the two drug groups. AI-based radiological analysis revealed that patients in the nirmatrelvir group had more severe pneumonia conditions (infection ratio is 11.1 vs. 5.35, p = 0.007). Patients with an infection ratio higher than 9.2 had nearly three times the mortality rate compared to those with an infection ratio lower than 9.2., Conclusions: Our study suggests that in real-world studies regarding hospitalized patients with COVID-19 pneumonia, the antiviral effect of nirmatrelvir/ritonavir is significantly superior to azvudine, but the choice of antiviral agents is not necessarily linked to clinical outcomes; the severity of pneumonia at admission is the most important factor to determine prognosis. Additionally, our findings indicate that pulmonary AI imaging analysis can be a powerful tool for predicting patient prognosis and guiding clinical decision-making., (© 2024 The Author(s). Influenza and Other Respiratory Viruses published by John Wiley & Sons Ltd.)

Background/aims: To compare the effects of abatacept and conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) on the progression and development of rheumatoid arthritis-associated interstitial lung disease (RA-ILD)., Methods: This multi-center retrospective study included RA patients receiving abatacept or csDMARDs who underwent at least two pulmonary function tests and/or chest high-resolution computed tomography (HRCT). We compared the following outcomes between the groups: progression of RA-ILD, development of new ILD in RA patients without ILD at baseline, 28-joint Disease Activity Score with the erythrocyte sedimentation rate (DAS28-ESR), and safety. Longitudinal changes were compared between the groups by using a generalized estimating equation., Results: The study included 123 patients who were treated with abatacept (n = 59) or csDMARDs (n = 64). Nineteen (32.2%) and 38 (59.4%) patients treated with abatacept and csDMARDs, respectively, presented with RA-ILD at baseline. Newly developed ILD occurred in one patient receiving triple csDMARDs for 32 months. Among patients with RA-ILD at baseline, ILD progressed in 21.1% of cases treated with abatacept and 34.2% of cases treated with csDMARDs during a median 21-month follow-up. Longitudinal changes in forced vital capacity and diffusing capacity for carbon monoxide were comparable between the two groups. However, the abatacept group showed a more significant decrease in DAS28-ESR and glucocorticoid doses than csDMARDs group during the follow-up. The safety of both regimens was comparable., Conclusion: Abatacept and csDMARDs showed comparable effects on the development and stabilization of RA-ILD. Nevertheless, compared to csDMARDs, abatacept demonstrated a significant improvement in disease activity and led to reduced glucocorticoid use.

Background Data on the diagnostic accuracy of ultralow-dose (ULD) CT protocols for periodic surveillance in recipients of lung transplant are lacking. Purpose To assess the potential for radiation dose reduction using ULD photon-counting CT (PCT) to detect lung abnormalities in recipients of lung transplant during repeat CT follow-up. Materials and Methods Consecutive adult recipients of lung transplant undergoing same-day standard-of-care low-dose (LD) and ULD PCT from March 2023 to May 2023 were prospectively included. The ULD protocols were performed with two target effective doses comprising 20% (hereafter, ULD1) and 10% (hereafter, ULD2) of the standard LD protocol. The 1-mm reconstructions were reviewed by three readers. Subjective image quality, the visibility of certain anatomic structures (using a five-point Likert scale), and the presence of lung abnormalities were independently assessed. The χ 2 or t tests were used to evaluate differences between the ULD1 and ULD2 protocols. Results A total of 82 participants (median age, 64 years [IQR, 54-69 years]; 47 male) were included (41 participants for each ULD protocol). The mean effective doses per protocol were 1.41 mSv ± 0.44 (SD) for LD, 0.26 mSv ± 0.08 for ULD1, and 0.17 mSv ± 0.04 for ULD2. According to three readers, the subjective image quality of the ULD images was deemed diagnostic (Likert score ≥3) in 39-40 (ULD1) and 40-41 (ULD2) participants, and anatomic structures could be adequately visualized (Likert score ≥3) in 33-41 (ULD1) and 34-41 (ULD2) participants. The detection accuracy for individual lung anomalies exceeded 70% for both ULD protocols, except for readers 1 and 3 detecting proximal bronchiectasis and reader 3 detecting bronchial wall thickening and air trapping. No evidence of a statistically significant difference in noise ( P = .96), signal-to-noise ratio ( P = .77), or reader accuracy (all P ≥ .05) was noted between the ULD protocols. Conclusion ULD PCT was feasible for detecting lung abnormalities following lung transplant, with a tenfold radiation dose reduction. © RSNA, 2024 Supplemental material is available for this article . See also the editorial by Ciet in this issue.

Background It is increasingly recognized that interstitial lung abnormalities (ILAs) detected at CT have potential clinical implications, but automated identification of ILAs has not yet been fully established. Purpose To develop and test automated ILA probability prediction models using machine learning techniques on CT images. Materials and Methods This secondary analysis of a retrospective study included CT scans from patients in the Boston Lung Cancer Study collected between February 2004 and June 2017. Visual assessment of ILAs by two radiologists and a pulmonologist served as the ground truth. Automated ILA probability prediction models were developed that used a stepwise approach involving section inference and case inference models. The section inference model produced an ILA probability for each CT section, and the case inference model integrated these probabilities to generate the case-level ILA probability. For indeterminate sections and cases, both two- and three-label methods were evaluated. For the case inference model, we tested three machine learning classifiers (support vector machine [SVM], random forest [RF], and convolutional neural network [CNN]). Receiver operating characteristic analysis was performed to calculate the area under the receiver operating characteristic curve (AUC). Results A total of 1382 CT scans (mean patient age, 67 years ± 11 [SD]; 759 women) were included. Of the 1382 CT scans, 104 (8%) were assessed as having ILA, 492 (36%) as indeterminate for ILA, and 786 (57%) as without ILA according to ground-truth labeling. The cohort was divided into a training set ( n = 96; ILA, n = 48), a validation set ( n = 24; ILA, n = 12), and a test set ( n = 1262; ILA, n = 44). Among the models evaluated (two- and three-label section inference models; two- and three-label SVM, RF, and CNN case inference models), the model using the three-label method in the section inference model and the two-label method and RF in the case inference model achieved the highest AUC, at 0.87. Conclusion The model demonstrated substantial performance in estimating ILA probability, indicating its potential utility in clinical settings. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Zagurovskaya in this issue.

Congenital lung anomaly (CLA) refers to a rare group of malformations that are typically identified prenatally or in early childhood. However, a significant proportion of cases evade detection until adulthood and either are incidentally discovered or manifest with symptoms of recurrent respiratory infection or pulmonary hemorrhage. While most CLAs have characteristic imaging findings at CT and MRI, they remain a diagnostic challenge due to the infrequency with which they are encountered in adults. Radiologists frequently play a pivotal role in suggesting the diagnosis and guiding appropriate management strategies, and recognition of characteristic imaging patterns is crucial for accurate diagnosis. The authors examine the imaging appearances and clinical manifestations in adult patients with CLA, with a focus on patients who have bronchopulmonary involvement and those with combined bronchopulmonary and vascular anomalies. Entities discussed include bronchogenic cyst, bronchial atresia, congenital lobar overinflation, congenital pulmonary airway malformation, proximal interruption of the pulmonary artery, bronchopulmonary sequestration, hypogenetic lung syndrome, placental transmogrification of the lung, and hybrid lesions. Common complications that may arise in these patients are discussed and illustrated. © RSNA, 2024 Supplemental material is available for this article.

Radiation recall pneumonitis is an inflammatory reaction of previously radiated lung parenchyma triggered by systemic pharmacological agents (such as chemotherapy and immunotherapy) or vaccination. Patients present with non-specific symptoms such as cough, shortness of breath, or hypoxia soon after the initiation of medication or vaccination. Careful assessment of the patient's history, including the thoracic radiation treatment plan and timing of the initiation of the triggering agent, in conjunction with CT findings, contribute to the diagnosis. Once a diagnosis is established, treatment includes cessation of the causative medication and/or initiation of steroid therapy. Differentiating this relatively rare entity from other common post-therapeutic complications in oncology patients, such as recurrent malignancy, infection, or medication-induced pneumonitis, is essential for guiding downstream clinical management., Competing Interests: The authors have no potential conflicts of interest to disclose., (Copyright © 2024 The Korean Society of Radiology.)

Objective: This study aimed to explore the value of preoperative and postoperative computed tomography (CT)-based radiomic signatures and Δ radiomic signatures for evaluating the early efficacy of microwave ablation (MWA) for pulmonary malignancies., Methods: In total, 115 patients with pulmonary malignancies who underwent MWA treatment were categorized into response and nonresponse groups according to relevant guidelines and consensus. Quantitative image features of the largest pulmonary malignancies were extracted from CT noncontrast scan images preoperatively (time point 0, TP0) and immediately postoperatively (time point 1, TP1). Critical features were selected from TP0 and TP1 and as Δ radiomics signatures for building radiomics models. In addition, a combined radiomics model (C-RO) was developed by integrating radiomics parameters with clinical risk factors. Prediction performance was assessed using the area under the receiver operating characteristic curve (AUC) and decision curve analysis (DCA)., Results: The radiomics model using Δ features outperformed the radiomics model using TP0 and TP1 features, with training and validation AUCs of 0.892, 0.808, and 0.787, and 0.705, 0.825, and 0.778, respectively. By combining the TP0, TP1, and Δ features, the logistic regression model exhibited the best performance, with training and validation AUCs of 0.945 and 0.744, respectively. The DCA confirmed the clinical utility of the Δ radiomics model., Conclusions: A combined prediction model, including TP0, TP1, and Δ radiometric features, can be used to evaluate the early efficacy of MWA in pulmonary malignancies., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Advancements in computational technology have led to a shift towards automated detection processes in lung cancer screening, particularly through nodule segmentation techniques. These techniques employ thresholding to distinguish between soft and firm tissues, including cancerous nodules. The challenge of accurately detecting nodules close to critical lung structures such as blood vessels, bronchi, and the pleura highlights the necessity for more sophisticated methods to enhance diagnostic accuracy. This paper proposed combined processing filters for data preparation before using one of the modified Convolutional Neural Networks (CNNs) as the classifier. With refined filters, the nodule targets are solid, semi-solid, and ground glass, ranging from low-stage cancer (cancer screening data) to high-stage cancer. Furthermore, two additional works were added to address juxta-pleural nodules while the pre-processing end and classification are done in a 3-dimensional domain in opposition to the usual image classification. The accuracy output indicates that even using a simple Segmentation Network if modified correctly, can improve the classification result compared to the other eight models. The proposed sequence total accuracy reached 99.7%, with 99.71% cancer class accuracy and 99.82% non-cancer accuracy, much higher than any previous research, which can improve the detection efforts of the radiologist.

Background: Pulmonary dysfunction in thoracic kyphoscoliosis has been correlated with chest wall distortion, uneven trunk growth and restrictive pattern. The study aims to analyse the variation in thoracic inlet measurements on pulmonary dysfunction with varying curve magnitude and thoracic cage parameters., Methods: In a non-randomised, prospective case-control study, 80 consecutive patients with thoracic kyphoscoliosis were divided into 3 groups based on Cobb angle: Group 1 (31-50), Group 2 (51-80) and Group 3 (> 80). Thoracic inlet measurement was calculated by thoracic inlet index (TI) on MRI at the sternal level. Pulmonary function and thoracic cage parameters [hemi thorax height, rib-apex distance, AP chest diameter at sternal level and transverse thoracic diameter] were documented. TI values were compared with 20 age-matched asymptomatic controls. Multivariate correlation and regression analysis were performed to investigate the correlations., Results: The mean age of the study cohort was 14.1 ± 4.4 years, including Group 1 (6 patients), Group 2 (55 patients) and Group 3 (19 patients) versus 12.9 ± 2.2 years in controls. The mean TI was 2.8 ± 0.56 in Group 1, 3.7 ± 0.9 in Group 2 and 4.0 ± 1.12 in Group 3 versus 2.6 ± 0.43 in controls. Pulmonary dysfunction was severe with TI > 7.1 (p < 0.001) in Group 3 patients with thoracic hypokyphosis. Multivariate regression for thoracic parameters and TI > 5.6 showed significant correlation of pulmonary dysfunction in Group 2 and 3 curves with apex between T1 and T4, whereas transverse thoracic diameter, rib-apex distance and hemi thorax height were weakly associated., Conclusion: Thoracic inlet index (TI), a neglected pre-operative variable associated with pulmonary dysfunction in thoracic kyphoscoliosis, can be evaluated on MRI without an additional cost and radiation., (© 2024. The Author(s), under exclusive licence to Scoliosis Research Society.)

Purpose: Rapid on-site-evaluation (ROSE) is a technique aimed at improving the diagnostic performance of computed tomography (CT)-guided core needle biopsy (CNB) in lung cancer. The aim of this retrospective study was to investigate the impact of ROSE on the rate of nondiagnostic specimens and on accuracy computed on diagnostic specimens., Materials and Methods: During a 3-year period, 417 CT-guided CNBs were performed at our center. The biopsies were retrospectively classified into 2 groups: 141 procedures were assisted by ROSE and 276 were not. All of them were reviewed for clinical, procedural, and pathological data. Pathology results were classified as diagnostic (positive or negative for malignancy) or nondiagnostic. The results were compared with the final diagnosis after surgery or clinical follow-up. Nondiagnostic rate, sensitivity/specificity/negative predictive value/positive predictive value for the ROSE and non-ROSE groups were calculated. Finally, procedural complications and the adequacy of the specimens for the molecular analysis were recorded., Results: The study evaluated 417 CNBs (mean patients' age 71 years, 278 men). Nondiagnostic rates with and without ROSE were 4% (6/142) and 11% (29/276), respectively ( P = 0.028). Sensitivity/specificity/negative predictive value/positive predictive value with and without ROSE did not show statistically significant differences, and no difference in major/minor complication rates was observed between the 2 groups. The adequacy of specimen for subsequent molecular analysis was 100% with (42/42) and 82% without ROSE (51/62)., Conclusions: Rapid on-site-evaluation reduced the rate of nondiagnostic specimens by 50% with no change in complication rates or accuracy and increased by 20% the chances of a successful subsequent molecular analysis., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: The present study aims to explore the application value of the air bronchogram (AB) sign and other computed tomography (CT) signs in the early diagnosis of lung adenocarcinoma (LUAD)., Method: The pathological information and CT images of 130 patients diagnosed with N 0 and M 0 solitary pulmonary nodules (diameter ≤3 cm) and treated with surgical resection in our hospital between June 2021 and June 2022 were analyzed., Results: The patients were divided into the benign pulmonary nodule (BPN) group (14 cases), the AIS group (30 cases), the MIA group (10 cases), and the IAC group (76 cases). Among the 116 patients with AIS and LUAD, 96 showed an AB sign. Among the 14 patients with BPN, only 4 patients showed an AB sign. The average CT value and maximum diameter were significantly higher in the IAC group than in the AIS and MIA groups. In the BPN group, 5 patients had an average CT value of >80 HU. Among all LUAD-based groups, there was only 1 patient with a CT value of >60 HU., Conclusions: The identification of the AB sign based on CT imaging facilitates the differentiation between benign and malignant nodules. The CT value and maximum diameter of pulmonary adenocarcinoma nodules increase with the increase of the malignancy degree. The nodule type, CT value, and maximum diameter are useful for predicting the pathological type and prognosis. If the average CT value of pulmonary nodules is >80 HU, LUAD may be excluded., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Non-invasive and sensitive clinical endpoints are needed to monitor onset and progression of early lung disease in children with cystic fibrosis (CF). We compared lung clearance index (LCI), FEV 1 , functional and structural lung magnetic resonance imaging (MRI) outcomes in Swiss children with CF diagnosed following newborn screening., Methods: Lung function (LCI, FEV 1 ) and unsedated functional and structural lung MRI was performed in 79 clinically stable children with CF (3 - 8 years) and 75 age-matched healthy controls. Clinical information was collected throughout childhood., Results: LCI, ventilation and perfusion defects, and structural MRI scores were significantly higher in children with CF compared with controls, but FEV 1 was not different between groups. Lung MRI outcomes correlated significantly with LCI (morphology score (r = 0.56, p < 0.001); ventilation defects (r = 0.43, p = 0.001); perfusion defects (r = 0.64, p < 0.001), but not with FEV 1 . Lung MRI outcomes were more sensitive to detect impairments in children with CF (abnormal ventilation and perfusion outcomes in 47 %, morphology score in 30 %) compared with lung function (abnormal LCI in 21 % and FEV 1 in 4.8 %). Pulmonary exacerbations, respiratory hospitalizations, and increase in patient-reported cough was associated with higher LCI and higher structural and functional MRI outcomes., Conclusions: The LCI and lung MRI outcomes non-invasively detect even mild early lung disease in young children with CF diagnosed following newborn screening. Pulmonary exacerbations and early respiratory symptoms were risk factors for structural and functional impairment in childhood., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Prof. P. Latzin reports the followind COIs: - Grants from Vertex and OM Pharma paid to the institution - Participation on data safety monitoring boards or advisory boards of Polyphor, Santhera DMC, Vertex, OM Pharma, Vifor, Sanofi Aventis - Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Vertex, Vifor, OM Pharma Jakob Usemann reports: Grants from - Swiss lung foundation - Palatin Foundation, Basel, Switzerland Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: - Vertex - Zurich Lung foundation Support for attending meetings and/or travel from Vertex Kathryn Ramsey reports: Support for the present manuscript form: -Swiss National Science Foundation Ambizione Research Grant (168173), paid to the institution Leadership or fiduciary role in other board, society, committee or advocacy group, unpaid Global Lung Initiative MBW Task Force Elisabeth Kieninger reports: Payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events: Sanofi-Aventis., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Methods: This prospective study included 92 patients who underwent BLVR with quantitative SPECT/CT study pre- and post-procedure between November 2018 and June 2023. The mean age was 70 years (range 56-85). with 51 males and 41 females. SPECT/CT quantified perfusion for each lobe, and the lowest counts/volume ratio determined the procedural target. Postprocedure SPECT/CT assessed total atelectasis and perfusion shifts. The 6-minute walk test and pulmonary function tests were compared pre- and post-BLVR., Results: SPECT/CT-guided BLVR showed clinical benefits (decreased oxygen requirements) and physiological improvements in total lung capacity, forced expiratory volume, and forced vital capacity ( P < 0.05). Significant perfusion shifts were observed away from the target lobe, with unique patterns noted for ipsilateral and contralateral nontarget lobes ( P < 0.05)., Conclusion: Quantitative lobar SPECT/CT in preprocedural guidance for BLVR proved useful in identifying suitable targets in multi-lobe homogeneous emphysema, resulting in physiological and clinical improvements for this patient group. The perfusion shift information provided by SPECT/CT offers valuable insights for pulmonologists., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)