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J Clin Invest. 2018 Oct 29. pii: 120693. doi: 10.1172/JCI120693. [Epub ahead of print]

Airway fractal dimension predicts respiratory morbidity and mortality in COPD.

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Division of Pulmonary, Allergy and Critical Care Medicine.
UAB Lung Imaging Core, and.
UAB Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Department of Radiology, University of California, San Diego, California, USA.
Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa, USA.
Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA.
Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama, USA.
Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan, USA.
Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachussetts, USA.
Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachussetts, USA.
The COPDGene Investigators are detailed in the Supplemental Acknowledgments.



Chronic obstructive pulmonary disease (COPD) is characterized by airway remodeling. Characterization of airway changes on computed tomography has been challenging due to the complexity of the recurring branching patterns, and this can be better measured using fractal dimensions.


We analyzed segmented airway trees of 8,135 participants enrolled in the COPDGene cohort. The fractal complexity of the segmented airway tree was measured by the Airway Fractal Dimension (AFD) using the Minkowski-Bougliand box-counting dimension. We examined associations between AFD and lung function and respiratory morbidity using multivariable regression analyses. We further estimated the extent of peribronchial emphysema (%) within 5 mm of the airway tree, as this is likely to affect AFD. We classified participants into 4 groups based on median AFD, percentage of peribronchial emphysema, and estimated survival.


AFD was significantly associated with forced expiratory volume in one second (FEV1; P < 0.001) and FEV1/forced vital capacity (FEV1/FVC; P < 0.001) after adjusting for age, race, sex, smoking status, pack-years of smoking, BMI, CT emphysema, air trapping, airway thickness, and CT scanner type. On multivariable analysis, AFD was also associated with respiratory quality of life and 6-minute walk distance, as well as exacerbations, lung function decline, and mortality on longitudinal follow-up. We identified a subset of participants with AFD below the median and peribronchial emphysema above the median who had worse survival compared with participants with high AFD and low peribronchial emphysema (adjusted hazards ratio [HR]: 2.72; 95% CI: 2.20-3.35; P < 0.001), a substantial number of whom were not identified by traditional spirometry severity grades.


Airway fractal dimension as a measure of airway branching complexity and remodeling in smokers is associated with respiratory morbidity and lung function change, offers prognostic information additional to traditional CT measures of airway wall thickness, and can be used to estimate mortality risk.

TRIAL REGISTRATION: identifier: NCT00608764.


This study was supported by NIH K23 HL133438 (SPB) and the COPDGene study (NIH Grant Numbers R01 HL089897 and R01 HL089856). The COPDGene project is also supported by the COPD Foundation through contributions made to an Industry Advisory Board comprised of AstraZeneca, Boehringer Ingelheim, Novartis, Pfizer, Siemens, Sunovion and GlaxoSmithKline.


COPD; Pulmonology

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