The fissure: interlobar collateral ventilation and implications for endoscopic therapy in emphysema

Figures & data

Figure 1 Three different pathways for collateral ventilation.

Notes: Interalveolar ventilation through the pores of Kohn. Bronchiole–alveolar ventilation through channels of Lambert. Interbronchiolar ventilation through channels of Martin.

Figure 2 Collateral ventilation.

Notes: Schematic figure illustrating the role of intra- and interlobar collateral ventilation, and the implications for bronchoscopic lung volume reduction using one-way endobronchial valves. The interlobar collateral ventilation from the left upper to the left lower lobe, impedes the desired atelectasis of the lower lobe. Because all segments of the left lower lobe have endobronchial valves, intralobar collateral ventilation does not influence the development of atelectasis.

Table 1 Prevalence of incomplete fissures

Author (year)	Subjects (N)	Research	Measurement	Incomplete (%)	Patient group/remarks
Aziz et al^Citation21 (2004)	622	HRCT	Not described	RMF: 48 LMF: 43 MF: 63	No pulmonary disease
Koenigkam-Santos et al^Citation28 (2013)	247	MDCT	• Two radiologists • Consensus#	RMF: 81 LMF: 50 MF: 89	Varying population. No statistical difference between GOLD stages
Koenigkam-Santos et al^Citation29 (2012)	35	MDCT	• Two pneumologists and three radiologists • Consensus#	RMF: 85 LMF: 65–74 MF: 88–91	COPD GOLD III/IV
Gülsün et al^Citation23 (2006)	144	HRCT	• Two radiologists • Consensus#	RMF: 63 LMF: 60 MF: –	No pulmonary disease
Heřmanová et al^Citation30 (2014)	250	HRCT	• Medical student • Diagnostic criteria*	RMF: 35 LMF: 24 MF: 74	Varying population, no significant pathological changes
Cronin et al^Citation31 (2010)	150	MDCT	• Two radiologists • Consensus#	RMF: 34 LMF: 25 MF: 48	No pulmonary disease
Mahmut and Nishitani^Citation32 (2007)	1,000	MDCT	• Medical student • Diagnostic criteria*	RMF: 17 LMF: 19 MF: 20	Exclusion: lung lesions around interlobar fissures
Ozmen et al^Citation33 (2010)	307	MDCT	• Two radiologists • Consensus#	RMF: 70 LMF: 48 MF: 87	Exclusion: advanced fibrosis, kyphoscoliosis, chest deformity, massive pleural fluid, atelectasis, consolidation, or giant pleural bullae
Guan et al^Citation34 (2015)	208	MDCT	• Two radiologists • Diagnostic criteria*	RMF: 41 LMF: 46 MF: 62	No pulmonary disease
Pu et al^Citation35 (2014)	573	HRCT	• Computerized	RMF: 74 LMF: 75 MF: 86	Healthy population and COPD-patients

Notes:

* Diagnostic criteria: 1) neither a clear avascular zone nor interlobar line is observed; 2) vascular images in adjacent lobes cross over the interlobar region; 3) pulmonary blood vessels, particularly the pulmonary vein, penetrate the interlobar region; 4) the pulmonary vein is observed in the interlobar region and is related to the vascular images in adjacent lobes.

# Consensus: individual evaluation of fissure and classified as complete or incomplete, consensus with colleagues.

Abbreviations: HRCT, high-resolution computed tomography; MDCT, multidetector computed tomography; RMF, right major fissure/right oblique fissure; LMF, left major fissure/left oblique fissure; MF, minor fissure/horizontal fissure; COPD, chronic obstructive pulmonary disease; GOLD, Global initiative for chronic Obstructive Lung Disease.

Figure 3 Chartis measurement.

Notes: (A) The Chartis balloon at the distal tip of the catheter. (B) Bronchoscopic view of the Chartis balloon blocking the entrance to the right lower lobe to measure collateral ventilation to this lobe. (C) Example of a negative Chartis measurement with absence of collateral ventilation, measured in spontaneous breathing patient. The orange pattern shows the expired flow (mL/min). The decrease of the flow pattern indicates there is no collateral flow. The blue pattern shows the negative intrapleural pressure (cmH₂O) and indicates the quality of the occlusion by the balloon. (D) Example of a positive Chartis measurement with collateral ventilation, as there is no decline in the expired flow. (E) Example of a negative Chartis measurement with absence of collateral ventilation, measured in a sedated patient with positive pressure ventilation. Therefore, only the decreasing flow pattern is shown, indicating there is no collateral flow.
Abbreviations: F, flow; P, pressure.

Figure 4 Implanted one-way endobronchial valve.

Notes: (A) Open valve, allowing trapped air and fluids to escape. (B) Closed valve, no air or fluids can enter the valve.

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