Improving Contrast Enhancement in Pulmonary CTA: The value of breathing maneuvers

Abstract

Purpose To investigate contrast dynamics and artifacts associated with different breathing maneuvers during pulmonary computed tomography angiography (pCTA) in a prospective randomized clinical trial. Method Three different breathing maneuvers (inspiration, expiration, Mueller) were randomly assigned to 146 patients receiving pCTA for suspected pulmonary embolism (PE). Contrast enhancement of central and peripheral arteries and imaging quality of lung parenchyma were compared and analyzed. Results were compared by using the analysis of variances (ANOVA) and Kruskal-Wallis-Test. Results Mean enhancement in the pulmonary trunk was highest during breath-hold in inspiration (293 HU, range 195–460 HU) compared to Mueller (259 HU, range 136–429 HU, p = 0022) and expiration (267 HU, range 115–376 HU). This was similar for the right pulmonary artery (inspiration 289 HU, range 173–454 HU; Mueller 250 HU, range 119–378 HU; p = 0.007; expiration 257 HU, range 114–366 HU; p = 0.032) and left pulmonary artery (inspiration 280.3 HU, range 170–462 HU; Mueller 245 HU, range 111–371 HU; p = 0.016; expiration 252 HU, range 110–371 HU). Delineation of peripheral arteries was significantly better in inspiration vs Mueller (p = 0.006) and expiration (p = 0.049). Assessment of the lung parenchyma was significantly better in inspiration vs Mueller (p = 0.013) or expiration (p < 0.001). Conclusions Resting inspiratory position achieved the highest enhancement levels in central and peripheral pulmonary arteries and best image quality of the pulmonary parenchyma in comparison to other breathing maneuvers. It is necessary to train the maneuver prior to the examination in order to avoid deep inspiration with the risk of suboptimal opacification of the pulmonary arteries.

Canadian Society of Thoracic Radiology/Canadian Association of Radiologists Best Practice Guidance for Investigation of Acute Pulmonary Embolism, Part 2: Technical Issues and Interpretation Pitfalls

“…[1][2][3] Patients at risk should be instructed in breath suspension and should not be asked to ''take a big breath in and hold it.'' 4,5 On fast scanners, it may be possible to obtain adequate imaging without any interruption of breathing.…”

“…Acute pulmonary embolism (PE) is an important cause of cardiovascular morbidity and mortality in Canada. [1][2][3][4] It is a difficult clinical diagnosis to make and thus leads to thousands of computed tomography pulmonary angiogram (CTPA) studies being performed every year in patients in emergency departments and on inpatient wards. 1 CTPA plays a vital role in the diagnosis of acute PE while also helping to guide management due to its ability to identify imaging features that confer worse outcomes such as right heart enlargement and strain and central distribution of pulmonary emboli.…”

“…1 CTPA plays a vital role in the diagnosis of acute PE while also helping to guide management due to its ability to identify imaging features that confer worse outcomes such as right heart enlargement and strain and central distribution of pulmonary emboli. [2][3][4][5][6][7][8][9] Additional benefits of accessibility, accuracy, identification of alternate diagnoses and rapid reporting turn-around time have helped establish CTPA as the current standard of care imaging for acute PE.…”

Corrigendum to “Improving contrast enhancement in pulmonary CTA: The value of breathing maneuvers” [Eur J Radiol Open 7 (2020) 100280]

“…The authors regret that in Eur J Radiol Open 2020 "Improving Contrast Enhancement in Pulmonary CTA: The value of breathing maneuvers" [1] it was not explicitly stated, that our device used to control Mueller Maneuver to improve pulmonary contrast enhancement as proposed by Gutzeit A. et al [2,3] was custom-made in analogy to [2,3], but was not identical with it, since the original device was not commercially available at the time.…”

“…Furthermore, we would like to point out that figure 2 [1] was adapted from figure 3 [2] and figure 6 [3]. The author [2,3] agreed afterwards to use parts of the images.…”