Impact of Emphysema Heterogeneity on Pulmonary

Function
Jieyang Ju1., Ruosha Li2., Suicheng Gu1, Joseph K. Leader1, Xiaohua Wang3, Yahong Chen3, Bin Zheng4,
Shandong Wu1, David Gur1, Frank Sciurba5, Jiantao Pu1,6*
1 Department of Radiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America, 2 Department of Biostatistics, University of Pittsburgh, Pittsburgh,
Pennsylvania, United States of America, 3 Peking University Third Affiliated Hospital, Beijing, Peoples Republic of China, 4 School of Electrical and Computer Engineering,
University of Oklahoma, Norman, Oklahoma, United States of America, 5 Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of
America, 6 Department of Bioengineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America

Abstract
Objectives: To investigate the association between emphysema heterogeneity in spatial distribution, pulmonary function
and disease severity.
Methods and Materials: We ascertained a dataset of anonymized Computed Tomography (CT) examinations acquired on
565 participants in a COPD study. Subjects with chronic bronchitis (CB) and/or bronchodilator response were excluded
resulting in 190 cases without COPD and 160 cases with COPD. Low attenuations areas (LAAs) (#950 Hounsfield Unit (HU))
were identified and quantified at the level of individual lobes. Emphysema heterogeneity was defined in a manner that
ranged in value from 2100% to 100%. The association between emphysema heterogeneity and pulmonary function
measures (e.g., FEV1% predicted, RV/TLC, and DLco% predicted) adjusted for age, sex, and smoking history (pack-years) was
assessed using multiple linear regression analysis.
Results: The majority (128/160) of the subjects with COPD had a heterogeneity greater than zero. After adjusting for age,
gender, smoking history, and extent of emphysema, heterogeneity in depicted disease in upper lobe dominant cases was
positively associated with pulmonary function measures, such as FEV1 Predicted (p,.001) and FEV1/FVC (p,.001), as well as
disease severity (p,0.05). We found a negative association between HI% , RV/TLC (p,0.001), and DLco% (albeit not a
statistically significant one, p = 0.06) in this group of patients.
Conclusion: Subjects with more homogeneous distribution of emphysema and/or lower lung dominant emphysema tend
to have worse pulmonary function.
Citation: Ju J, Li R, Gu S, Leader JK, Wang X, et al. (2014) Impact of Emphysema Heterogeneity on Pulmonary Function. PLoS ONE 9(11): e113320. doi:10.1371/
journal.pone.0113320
Editor: Harm Bogaard, VU University Medical Center, Netherlands
Received May 8, 2014; Accepted October 23, 2014; Published November 19, 2014
Copyright: 2014 Ju 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.
Data Availability: The authors confirm that all data underlying the findings are fully available without restriction. Raw data are available within the Supporting
Information files. Readers are welcome to ask for additional details from the corresponding Author.
Funding: This work is supported in part by grants from the National Institutes of Health (RO1 HL096613), the Bonnie J. Addario Lung Cancer Foundation, and the
National Health and Family Planning Commission of the R.R. China (No. 201402013). The funders had no role in study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing Interests: The authors have declared that no competing interests exist.
* Email: [email protected]
. These authors contributed equally to this work.

sensitive to depiction of the presence of emphysema. The extent of

parenchyma destruction is often quantified as the fraction of lung
voxels with Hounsfield Units (HU) value below a specific threshold
(e.g., ,2950 HU) [4]. Although pulmonary function and the
amount of emphysema are significantly correlated, there is
frequently a large variability in the computed fractional values of
emphysema at a specific pulmonary function value and vice verse
[5]. Hence, it is widely believed that spatial distribution and
pattern of emphysema may be important for understanding the
observed lack of concordance between pulmonary function and
the amount of diseased lung.
Emphysema is widely classified into three pathological phenotypes: centrilobular, panlobular, and paraseptal [67]. It has been

Introduction
As the most common phenotype of chronic obstructive
pulmonary disease (COPD), emphysema is one of the leading
cause of disability and death in the United States and worldwide
[1]. This disease often goes undiagnosed for many years and
irreversibly destroys lung parenchyma (alveoli), causes hyperinflation, and reduces lung elasticity [2]. In clinical practice,
emphysema is typically diagnosed by pulmonary function tests
(PFTs), medical history, and physical examination. However,
traditional PFTs have a low sensitivity for diagnosing early stage
COPD. It was reported that 30% of patients may have
emphysema before exhibiting any detectable decline in pulmonary
function [3]. In contrast, computed tomography (CT) is highly
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Emphysema Heterogeneity

shown that panlobular emphysema was associated with alpha 1antitrypsin deficiency, while centrilobuar emphysema was associated with tobacco exposure [89]. Recently, by classifying a
population of 9,313 smokers into five subgroups in terms of
emphysema patterns (i.e., mild centrilobular, moderate centrilobular, severe centrilobular, panlobular, and paraseptal emphysema),
Castaldi et al. [10] showed that these phenotypes were strongly
associated with a wide range of respiratory physiology and
function measures. Other investigations assessed the spatial
distribution of emphysema in different patient groups by dividing
the lungs into: thirds [9], twelfths [8], and/or core and rind [11].
Different and at times conflicting findings have been reported [12
16]. However, all findings strongly and consistently suggest that
the distribution patterns of emphysema have significant clinical
implications and better understanding of the relationship between
different patterns and lung function may aid in more precise
patient stratification for optimal personalized management or
treatment.
Anatomically the human lungs are comprised of five lobes that
are serviced by their own of bronchovascular system and function
somewhat independently from a mechanical, ventilation, and
perfusion perspectives. Lobar independence may be what drives
the different relations between pulmonary function and emphysema distribution and patterns. In particular, there are anatomical
differences between the right and left lungs. For example, the right
lung consists of three lobes, while the left lung is slightly smaller
with only two lobes. Also, with respect to the trachea, the entering
(branching) angle of the right bronchus is typically smaller than
that of the left one because of the presence of the heart. Given the
close relationship between structure and function, it is interesting
to assess which lung tends to be more vulnerable to the disease. In
this study, we quantified emphysema by lobes and investigated the
possible impact of emphysema heterogeneity on pulmonary
function in a well characterized cohort of participants in a chronic
obstructive pulmonary disease (COPD) study.

chronic bronchitis (CB) or had no related information on CB

(Figure 1). CB was assessed based on series of questionnaires
completed by the subjects and determined by whether there is a
cough productive of sputum over three months duration during
two consecutive years and airflow obstruction. The demographics
of the 160 subjects with COPD and the 190 subjects without
COPD included in analysis are summarized in Table 1.

B. Acquisition of thin-section CT examinations

CT examinations were acquired without the use of radiopaque
contrast using a 64-detector CT scanner (LightSpeed VCT, GE
Healthcare, Waukesha, WI, USA) while subjects held their breath
at end inspiration. Scans were acquired using a helical technique
at the following parameters: 3260.625 mm detector configuration,
0.969 pitch, 120 kVp tube energy, 250 mA tube current, and 0.4-s
gantry rotation (or 100 mAs). Images were reconstructed to
encompass the entire lung field in a 5126512 pixel matrix using
the GE bone kernel at 0.625-mm section thickness and 0.625mm interval. Pixel dimensions ranged from 0.549 to 0.738 mm,
depending on participant body size. The bone kernel was used
because of its ability to visualize both parenchyma and airways
[19]. The subjects were instructed in breathing to reach TLC prior
to scanning; however, no real-time measures were employed to
ensure breathing compliance such as spirometry-gated CT
acquisition. The CT exams were reviewed to ensure compliance
with the above mentioned chest CT protocol and were reviewed
for artifacts that would contribute to poor image quality and/or
quantification (e.g., subject motion and/or metal artifacts).

C. Heterogeneity of emphysema distribution in different

lobes
In-house developed software was used to segment the lungs and
the lobes [2022]. Similar to other investigations [2324], low
attenuation area (LAA) was defined as the volume of image voxels
with HU values lower than 2950 HU [25]. The percentage of low
attenuation areas (%LAA) was computed as the sum of LAAs
divided by the lung volume, and values were computed for the
entire lung and each lobe. Small LAA clusters were removed to limit
possible over-estimation of emphysema due to image noise and/or
artifacts. Considering that CT images are reconstructed in a sliceby-slice manner and in-plane image pixel size ranges typically from
approximately 0.65 mm to 0.90 mm, low attenuation areas with

Methods and Materials

A. Study population
We initially collected a dataset consisting of 565 CT exams from
an NIH-sponsored Specialized Center for Clinically Oriented
Research (SCCOR) in COPD at the University of Pittsburgh. The
CT exams originate from the baseline data collection of the first
565 SCCOR participants who were recruited from those
previously enrolled in the Pittsburgh Lung Screening Study
(PLuSS) cohort [17]. The inclusion criteria for SCCOR were
age .40 years and at least a 10 pack-year history of tobacco
exposure. SCCOR participants underwent pre- and post-bronchodilator spirometry and plethysmography, measurement of lung
diffusion capacity by single breath carbon monoxide (DLco), a
chest CT examination and answered demographic as well as
medical history questionnaires. The guidelines [18] published by
American Thoracic Society were followed when performing these
lung function tests. All data acquisition procedures and the CT
scans were performed under a University of Pittsburgh Institutional Review Board-approved protocol (#0612016) with written
informed consent obtained from all participants. The dataset
included 346 subjects with COPD as defined by the Global
Initiative for Obstructive Lung Disease (GOLD), and 219 subjects
without COPD (Figure 1). Among the subjects with COPD, 137
had bronchodilator response (BR) and were excluded. An increase
of 12% and 200 ml in the forced expiratory volume in one second
(FEV1) was considered as a positive response to bronchodilator.
We also excluded 49 patients who were either diagnosed with
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Figure 1. Flowchart illustrating how the final dataset analytic

sample was obtained in which COPD by was defined by GOLD
classification. (BR: subjects with bronchodilator response, and CB:
subjects with chronic bronchitis).
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Emphysema Heterogeneity

Table 1. Patient characteristics.

characteristics

Sex: male
Age (yrs)

A
B

Pack years, N = 287

FEV1%Predicted (%)B
FEV1/FVC% (%)
RV/TLC (%)

DLco Predicted (%)

LAA%
HI%

GOLD classification

All

COPD

non-COPD

N = 350

N = 160

N = 190

201(57%)

104(65%)

97(51%)

64(61,69)

67(61,70)

63(60,67)

50(35,70)

57(40,77)

45(32,63)

91(74,101)

71(48,85)

98(91,105)

72(62,77)

61(44,66)

77(75,81)

38(34,43)

43(35,53)

36(33,40)

74(58,86)

61(42,75)

82(71,90)

1.2(0.5,4.4)

4.5(1.5,12.2)

0.5(0.2,1.3)

17(4,36)

23(2,42)

14(4,27)

None COPD

190(54%)

0(0%)

190(100%)

Gold I

55(16%)

55(34%)

0(0%)

Gold II

64(18%)

64(40%)

0(0%)

Gold IIIIV

41(12%)

41(26%)

0(0%)

Categorical variables were summarized by frequency (%). Continuous variables were summarized by medians and interquartile ranges (IQR).
A
Summarized by frequency (%);
B
Summarized by median (IQR).
Abbreviations:
FVC functional vital capacity.
FEV1% forced expiratory volume in one second percent predicted.
RV residual volume.
TLC total lung capacity.
DLco% diffusing lung capacity of carbon monoxide percent.
doi:10.1371/journal.pone.0113320.t001

in-plane area less than 3 mm2 (approximately 4,5 pixels in an

image slice) were discarded and were not included in the %LAA
computation. Considering that a median filter or other smoothing
filters may alter pixel values, we chose not to use any smoothing
filter. The clustering operation was performed after application of a
threshold.
After the identification of regions associated with emphysema
regions, an emphysema heterogeneity index (HI) between upper
and lower lobes was computed (Eq. (1)), which results in values
ranging from -100% to +100%. For the right lung, %LAAupper
was computed as the sum of emphysema volume in the right upper
and middle lobes. For the entire lung, %LAAupper was computed
as the combination of the emphysema in the left upper, right
upper, and right middle lobes, while %LAAlower was the summed
values for the left lower and right lower lobes. When emphysema is
equally distributed among the lobes or its computed extent in the
entire lung is less than 1%, HI has a zero value.

exhibit any detectable decline in pulmonary function [3],

subgroups with COPD and without COPD were analyzed
separately. We investigated the distribution of HI% and differences in HI% values between left lung and right lung using
histograms. A one-sample chi-square test was used to examine
whether the proportion of subjects with positive HI% was different
from 50%. We used the sign test of location to examine whether
the median difference in HI% values between the left and right
lungs was different from zero.
The post-bronchodilator measurements used in the analyses
include: (1) FEV1% predicted, (2) FEV1/FVC, (3) RV/TLC, and
DLco%. We compared the distributions of these four pulmonary
function measures between subjects with upper lung dominant
emphysema (i.e., HI%.0%) and those with lower lung dominant
emphysema (i.e., HI%#0%) using the nonparametric Wilcoxon
rank-sum test. In addition, we combined the GOLD classification
score into two categories (I and II combined vs. III and IV
combined) and compared the differences in distributions, if any,
between the two groups.
To investigate the univariate association between HI% and lung
function measures, we used piecewise linear regression method
with a knot at 0, by defining HI%+ = max (0%, HI%) and
HI%2 = min(HI%, 0%). The piecewise linear regression is a
generalization of the conventional linear regression method, which
corresponds to situations where the slopes of HI%+ and HI%2 are
equivalent. Note that a piecewise linear regression model provides
more flexibility in characterizing the relationship between HI%
and outcomes of interest when compared to the conventional
linear regression model. Next, we performed multiple linear
regression modeling between HI% and the four lung function
measures respectively, adjusting for age, sex, smoking history, and

8
0%,
if the total LAA% is less than 1%
>
<
1
HI%~
>
: %LAAupper {%LAAlower |100%,
otherwise
%LAAupper z%LAA
lower

D. Statistical analyses
We summarized the patient characteristics using the frequencies
and proportions for categorical variables (e.g., sex and GOLD
classification score) and median values and quartiles for continuous variables (e.g., age and FEV1% predicted). Considering that
a large portion of patients may have emphysema but do not
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cantly lower than non-COPD subjects (Table 2). When HI was

greater than zero (i.e., upper lobe dominant emphysema) it was
significantly and directly correlated with FEV1 % predicted (p,
0.001) and FEV1/FVC% (p = 0.002) and significantly and
inversely correlated with RV/TLC% (p,0.001) among subjects
with COPD (Figure 3). COPD subjects with lower lung dominant
emphysema (i.e., HI%,0%) did not have a statistically significant
correlation with lung function measures.
Emphysema heterogeneity in COPD subjects significantly
contributed to linear regression models of lung function that
included overall emphysema (LAA%), HI, age, gender, and
smoking history. Heterogeneity index significantly and positively
contributed to the linear model of FEV1% predicted (p,.001) and
FEV1/FVC% (p = 0.002) and significantly and negatively to the
linear model of RV/TLC% (p,.001) among COPD subjects with
upper lung dominant emphysema (Table 3). A one percent
increase in HI was associated with 0.28% (95% CI 0.140.42%)
increase in FEV1% predicted. For GOLD classification score, in a
multiple logistic regression model of GOLD COPD classification
including overall emphysema (LAA%), HI, age, gender, and
smoking history, HI significantly and negatively contributed to
GOLD classification with the probability of having higher GOLD
classification scores (i.e. III or IV) among COPD subjects with
upper lung dominant emphysema (Table 4). A one percent
increase in HI resulted in decreasing the odds of having high
GOLD classification score by a multiplicative factor of 0.953 (95%
CI 0.910.99, p = 0.03). In a multiple linear regression model of
subjects without COPD that included overall emphysema, HI,
age, gender, and smoking history, HI% significantly and

overall emphysema (LAA%). A multiple logistic regression model

was adopted to model the odds of having higher GOLD
classification results for GOLD III and IV combined, and the
results were summarized in terms of odds ratios (OR). Statistical
significance was defined by p,.05 (two sided). Analyses were
performed using SAS (SAS Institute Inc, NC), version 9.3.

Results
In the participants with COPD, median age was 67, 65% were
male, median pack-years was 57, median FEV1% predicted was
71%, and median FEV1/FVC% was 61%. Forty-one (26%) of the
COPD subjects had a GOLD classification scores greater than II
(Table 1). In the participants without COPD, median age was 63,
51% were male, median pack-years was 45, median FEV1%
predicted was 98%, and median FEV1/FVC% was 77%. Upper
lobe dominant emphysema (positive HI%) was significantly more
prevalent in both subjects with COPD (129/160 or 80.6%) and
without COPD (161/190 or 84.7%) compared to lower lobe
dominant emphysema (p,0.05 in both sets of subjects) (Figures 2A and 2C). The HI between the left and right lungs was not
significantly different (p.0.05) in both sets of subjects (Figure 2B
and 2D).
Lung function in COPD subjects was significantly correlated
with upper lobe dominant emphysema. Subjects with COPD and
upper lung dominant emphysema (i.e., HI%.0) had significantly
higher FEV1% predicted (p = 0.01) and, consequently, lower
GOLD scores (p = 0.02) than COPD subjects with lower lung
dominant emphysema (Table 2). In subjects without COPD and
upper lobe dominant emphysema DLco% predicted was signifi-

Figure 2. Distributions of computed HI% (left) and differences in computed HI% between the left and the right lungs (right). The top
row represents the COPD patients (N = 160), and the bottom row represents the non-COPD patients (N = 190).
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Table 2. Pulmonary function measures and COPD classification of subjects classified as having lower and upper lung dominant
emphysema, stratified by emphysema heterogeneity and disease severity.

COPD, N = 160

FEV1% Predicted (%)

non-COPD, N = 190

HI, = 0%

HI.0%

N = 31

N = 129

p-value

HI, = 0%

HI.0%

N = 29

N = 161

p-value

55(32,80)

74(55,88)

0.01

99(91,108)

98(92,104)

0.8

FEV1/FVC (%)B

53(34,66)

62(51,66)

0.1

78(76,81)

77(75,81)

0.3

RV/TLC (%)B

45(39,57)

42(35,52)

0.1

35(34,40)

36(33,40)

0.9

56(42,76)

62(43,75)

0.7

89(83,92)

79(70,89)

0.01

DLco Predicted (%)

GOLD classification

0.02

GOLD III

18(58%)

101(78%)

GOLD IIIIV

13(42%)

28(22%)

Summarized by frequency (%);

Summarized by median (IQR).
doi:10.1371/journal.pone.0113320.t002
B

Figure 3. Scatter plots of pulmonary function measures and emphysema heterogeneity (HI%) for COPD patients. The grey line
represents the estimated pulmonary function as a function of HI%. p1 denotes the p-value of HI%2 = min(0%, HI%) in the piecewise linear regression,
and p2 corresponds to the p-value of HI%+ = max (0%, HI%).
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Table 3. Multiple linear regression results for different pulmonary function measures among subjects with COPD (n = 160).

FEV1% Predicted Coef (CI)

FEV1/FVC% Coef (CI)

RV/TLC% Coef (CI)

DLCO% Coef (CI)

21.43 (21.67, 21.18)***

LAA%

21.54 (21.83,21.26)

21.09 (21.22, 20.97)***

0.58 (0.43,0.74)***

HI%+

0.28 (0.14,0.42)***

0.09 (0.03,0.15)**

20.15 (20.23, 20.08)***

20.11 (20.23,0.01)

HI%2

0.02 (20.29,0.33)

20.03 (20.17,0.11)

0.16 (20.01,0.34)

0.19 (20.08,0.46)

Age (yrs)

0.73 (0.17,1.29)*

0.06 (20.18,0.31)

0.05 (20.26,0.36)

0.18 (20.3,0.66)

Male

9.53 (3.37,15.68)**

2.47 (20.22,5.16)

27.3 (210.71, 23.88)***

6.46 (1.17,11.75)*

Packyear

20.02 (20.1,0.06)

0.00 (20.04,0.03)

20.02 (20.07,0.02)

20.01 (20.08,0.06)

The cells represent the regression coefficients and estimated 95% confidence intervals (in parentheses).
*means 0.01#p,0.05,
** means 0.001#p,0.01, and *** means p,0.001.
doi:10.1371/journal.pone.0113320.t003

negatively contributed to RV/TLC%, but was not significantly

associated with other lung function metrics (Table 5).

predominant emphysema. Also, subjects with or without COPD

had similar levels of emphysema in the right versus left lungs
despite the relatively large differences in anatomical structure.
Our findings agreed with Tanabe et al. [6] who reported that a
more homogeneous distribution of emphysema was associated
with an accelerated decline in FEV1 independently of baseline
pulmonary function and overall emphysema severity. In their
study, 131 male patients were involved. Similarly, Haraguchi et al.
[27] reported similarly that uniformity of emphysema distribution
correlated with severity of airway obstruction in pulmonary
embolism (PE) patients, which is consistent with our finding in that
subjects with lower lung dominant emphysema had significantly
worse pulmonary function. According to this observation, the
chance of a rapid decline in lung function is relatively lower in
subjects with upper dominant and heterogeneous emphysema. In
contrast, Gietema et al. [7] observed that an apical distribution
was associated with more severe air-flow impairment when the
emphysema was quantified at a threshold of 2910 HU, but they
found no significant impact when emphysema was quantified at a
threshold of 2950 HU.
As Tanabe et al. [6] explained, it is not easy to identify the exact
factors behind the variety of emphysema distribution among
smokers and explain why homogeneous distribution and lower
lung dominant emphysema is critical for lung function. However,
on the basis of previous investigations [1314], where specific
genes (e.g., MMP-9) were found to associate with upper lung
dominant emphysema, we believe that specific genes could be
associated with susceptibility to homogeneous emphysema. Also,
given the close relationship between structure and function in the
biological system, the morphology of specific structures (e.g.,
airway tree) that affect airflow could contribute to emphysema
distribution as well, because airway morphology, which could be

Discussion
The importance of emphysema distribution has been widely
recognized. Accurate phenotypic description of emphysema may
aid in predicting prognosis of emphysema and designing efficacy
personalized therapy or management for preventing disease
progression. In 1957, Leopold et al. [26] differentiated emphysema into two categories: centrilobular and panlobular. Presently,
paraseptal emphysema is considered a third category of emphysema. This classification is based on the lobular locations of
emphysema in the lungs. Castaldi et al. [10] found that
emphysema phenotypes were strongly associated with respiratory
physiology and function. Other investigators subdivided the lungs
into varying number of zones and compared lung function across
the zones [89,11]. In contrast, we quantified emphysema by lobes
and assessed the association between inter-lobar heterogeneity,
COPD severity, and lung function. Unlike the traditional
gravitational division of the lungs, this strategy takes the unique
lung anatomy into account when characterizing the emphysema
distribution. Three-hundred and fifty subjects were included in our
analysis after exclusion of subjects with CB and positive
bronchodilator response, which consisted of 160 subjects with
and 190 subjects without COPD by GOLD classification. As
compared to previous investigation [67,27], this exclusion may
enable more reliable assessment of the impact of emphysema on
lung function. In our cohort, subjects with or without COPD and
upper lobe dominant emphysema had significantly better pulmonary function compared with subjects with lower lobe dominant
emphysema. However, smokers do not always have upper

Table 4. Multiple logistic regression model for GOLD classification score among subjects with COPD (n = 160).

OR (CI)
LAA%

1.28 (1.16, 1.41)***

HI%+

0.95 (0.91, 0.99)*

HI%2

1.03 (0.94, 1.13)

Age (yrs)

0.88 (0.76, 1.02)

Male

0.25 (0.05, 1.29)

packyear

1.00 (0.98, 1.03)

The cells represent the estimated odds ratio (OR) and the corresponding confidence intervals.
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Table 5. Multiple linear regression model for pulmonary function measures among subjects without COPD (n = 190).

FEV1% Predicted

FEV1/FVC%

RV/TLC%

DLCO%

Coef (CI)

Coef (CI)

Coef (CI)

Coef (CI)

LAA%

20.82 (22.17,0.53)

20.78 (21.23, 20.32)***

0.54 (20.05,1.13)

21.37 (22.96,0.23)

HI%+

0.08 (20.04,0.19)

20.04 (20.08,0)

20.06 (20.11, 20.01)*

20.11 (20.24,0.03)

HI%

20.4 (20.88,0.09)

20.03 (20.2,0.13)

20.01 (20.22,0.21)

20.6 (21.18, 20.02)*

Age (yrs)

0.47 (0.04,0.9)*

20.16 (20.3, 20.01)*

0.43 (0.24,0.62)***

20.27 (20.78,0.24)

Male

2.27 (21.57,6.1)

20.3 (21.59,0.99)

25.38 (27.06, 23.7)***

5.21 (0.66,9.76)*

Packyear

20.04 (20.11,0.03)

0 (20.02,0.03)

0 (20.03,0.03)

20.09 (20.17, 20.01)*

The cells represent the regression coefficients and estimated 95% confidence intervals (in parentheses).
doi:10.1371/journal.pone.0113320.t005

the result of specific genes, may alter the interaction between the
harmful chemicals in the air and lung tissues. Therefore, in our
opinion, a fully understanding of the variety of emphysema
distribution may need multi-disciplinary investigative effort
involving both imaging and genetics.
We note that there are limitations with this study. First, our
study was performed at a single institution with a modest number
of subjects and may or may not be generalizable to other cohorts
or institutions. Although 350 subjects were included, the variety of
emphysema extent and disease heterogeneity is still very limited.
Non-smokers were not included. This data selection bias may
somewhat affect the conclusion. To largely alleviate this issue, we
proposed to exclude the asthmatic and CB patients to enable a
relatively reliable analysis of the impact of emphysema heterogeneity on lung function. Second, the heterogeneity index may have
oversimplified the complexity of heterogeneous distribution
patterns of emphysema. Hence, more precise strategy for
quantifying 3D distribution patterns of emphysema in the lung
may be needed for improved phenotyping of emphysema. Third,
we removed very small clusters of voxels below the threshold
under the assumption they represent image noises or artifacts.
However, further effort may be needed to assess whether the
approach taken is optimal for this purpose. Fourth, the number of
subject with lower lobe dominant emphysema was relatively small
in both the COPD (n = 31) and non-COPD (n = 29) subjects,
which may have hinder this phenotype from reaching statistical
significance in some of the analyses. Finally, this retrospective

cross-sectional study did not consider the impact of longitudinal

changes in emphysema distribution patterns on pulmonary
function or disease progression, but was outside the scope of this
preliminary study.

Conclusions
We investigated the association between inter-lobar heterogeneity of emphysema and pulmonary function measures. Our
primary observation was that upper lone dominant emphysema
was associated with significantly better lung function and
significantly milder COPD compared to subjects with lower lobe
dominant emphysema in both COPD and non-COPD subjects.
We conclude that the chance of a rapid decline in lung function is
relatively lower in subjects with upper dominant and heterogeneous emphysema.

Supporting Information
Data S1

Raw data in CSV format.

(CSV)

Author Contributions
Conceived and designed the experiments: JP DG FS. Performed the
experiments: SG JJ RL. Analyzed the data: RL JP SG JJ YC XW.
Contributed reagents/materials/analysis tools: SW BZ JL YC XW. Wrote
the paper: JJ RL JL BZ DG.

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