The radiographic diagnosis of emphysema.

There are many findings of emphysema by conventional radiography, but the most reliable and reproducible is that of overinflation, which is best judged by the height and contour of the hemidiaphragm. Even in expert hands, the diagnosis of emphysema by conventional radiography is 65% to 80% accurate, depending to a large degree on the clinical population studied. Although most patients with severe emphysema are diagnosed correctly, only half of those patients with mild-to-moderate levels of parenchymal destruction are detected. Emphysema is identified by CT as focal, unmarginated, hypodense areas unassociated with fibrosis. Emphysema also may be detected by computer programs selecting pixels with abnormally low attenuation values. By either method, CT is superior to chest radiography in detection of mild and moderate degrees of emphysema and has detection rates of more than 90% and correlation with extent and severity of disease in more than 80% of patients. CT may be more sensitive to the presence of mild emphysema than pulmonary function tests, which are global indications of lung function. HRCT appears to offer a small, but real, advantage over 10-mm collimation in identification of small areas of emphysema, but areas of emphysema smaller than 0.5 cm in diameter are commonly missed, even with HRCT. Wider use of CT for investigation of relatively asymptomatic smokers may allow early diagnosis of emphysema and provide more information of the natural history of this disease, information that is sorely lacking at this time. Assessment of potential therapy such as smoking cessation or antioxidants will only be possible with widespread use of a method that is of relatively low risk, easy to duplicate, and accurate.