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. 2022 Apr;14(4):1042-1051.
doi: 10.21037/jtd-21-1755.

Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation

Rodrigo Vazquez Guillamet  1 , Maria C Vazquez Guillamet  1   2 , Ashraf Rjob  2 , Andrew Bierhals  3 , Irene Bello  4 , Alberto Jauregui Abularach  4 , Laneshia Tague  1 , Michael Wallendorf  5 , Gary F Marklin  6 , Chad Witt  1 , Derek E Byers  1 , Daniel Kreisel  7 , Ruben Nava  7 , Varun Puri  7 , Ramsey Hachem  1 , Elbert P Trulock  1
Affiliations

Uncertainty analysis of chest X-ray lung height measurements and size matching for lung transplantation

Rodrigo Vazquez Guillamet et al. J Thorac Dis. 2022 Apr.

Abstract

Background: Errors in measuring chest X-ray (CXR) lung heights could contribute to the occurrence of size-mismatched lung transplant procedures.

Methods: We first used Bland-Altman analysis for repeated measures to evaluate contributors to measurement error of chest X-ray lung height. We then applied error propagation theory to assess the impact of measurement error on size matching for lung transplantation.

Results: A total 387 chest X-rays from twenty-five donors and twenty-five recipients were measured by two raters. Individual standard deviation for lung height differences were independent of age, sex, donor vs. recipient, diagnostic group and race/ethnicity and all were pooled for analysis. Bias between raters was 0.27 cm (±0.03) and 0.22 cm (±0.06) for the right and left lung respectively. Within subject variability was the biggest contributor to error in measurement, 2.76 cm (±0.06) and 2.78 cm (±0.2) for the right and left lung height. A height difference of 4.4 cm or more (95% CI: ±4.2, ±4.6 cm) between the donor and the recipient right lung height has to be accepted to ensure matching for at least 95% of patients with the same true lung height. This difference decreases to ±1.1 cm (95% CI: ±0.9, ±1.3 cm) when the average from all available chest X-rays is used. The probability of matching a donor and a recipient decreases with increasing true lung height difference.

Conclusions: Individual chest X-ray lung heights are imprecise for the purpose of size matching in lung transplantation. Averaging chest X-rays lung heights reduced uncertainty.

Keywords: Lung transplantation; agreement; chest X-ray (CXR); error propagation; precision; size matching.

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1755/coif). DK serves as an unpaid editorial board member of Journal of Thoracic Disease. RVG reports that this research was supported by the Washington University Institute of Clinical and Translational Sciences Grant UL1TR002345 from the National Center for Advancing Translational Sciences (NCATS) of the National Institutes of Health (NIH). The content is solely the responsibility of the authors and does not necessarily represent the official view of the NIH. MW reports receiving salary support from Grant UL1TR002345 from the National Center for Advancing Translational Science NCATS of the National Institute of Health (NIH). GFM is the Medical Director at Mid America Transplant. DEB reports receiving research funding from Mid-America Transplant. RH reports receiving research funding from Bristol Myers Squibb and Mallinkrodt, gent funding from Mid America Transplant and personal fees from Transmedics, CareDx, Thevavance, and Vectura. The other authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Measurements. Solid line: RLH and LLH. Dotted line: right and left lung apex to ipsilateral costophrenic angle height (RCH, LCH). Dashed line: costophrenic angle to costophrenic angle, DW. RLH, right lung height; LLH, left lung height; DW, diaphragmatic width.
Figure 2
Figure 2
Bland-Altman plot for chest X-ray right lung height measured by two blinded readers from the right apex to the dome of the ipsilateral diaphragm. Individual measurements in the left panel, mean lung height in the right panel. The dashed black lines represent the mean difference or bias, and the limits of agreement with their 95% confidence intervals.
Figure 3
Figure 3
In the vertical axis percent probability of size matching donor and recipient according to: right lung height difference in the left panel, mean right lung height difference in the right panel, maximum allowed lung heights to match donor and recipient (dashed line =2 cm; dot line =4 cm; long dash =6 cm; dash, dot, dot =8 cm; solid line =10 cm.) and one or two chest X-ray readers (black =1; light grey =2). Until the apex of the curve reaches 100% donors and recipients with the same true lung height have a probability of not being matched equal to the distance between the apex and the 100% mark. The spread of the base equals the range of true lung heights differences that can be matched in each condition. When the apex becomes a plateau donor recipient pairs with true lung height difference equal to length of the plateau will be matched 100% of the time.
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