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

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

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish
Pages (from-to)1042-1051
Number of pages10
JournalJournal of Thoracic Disease
Issue number4
StatePublished - Apr 2022


  • Lung transplantation
  • agreement
  • chest X-ray (CXR)
  • error propagation
  • precision
  • size matching


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