Background Pulmonary microvasculature alterations are implicated in emphysema pathogenesis, but the association between pulmonary microvascular blood volume (PMBV) and emphysema has not been directly assessed at scale, and prior studies have used non-specific measures of emphysema.

Methods The Multi-Ethnic Study of Atherosclerosis Lung Study invited participants recruited from the community without renal impairment to undergo contrast-enhanced dual-energy CT. Pulmonary blood volume was calculated by material decomposition; PMBV was defined as blood volume in the peripheral 2 cm of the lung. Non-contrast CT was acquired to assess per cent emphysema and novel CT emphysema subtypes, which include the diffuse emphysema subtype and small-airways-related combined bronchitic-apical emphysema subtype. Generalised linear regression models included age, sex, race/ethnicity, body size, smoking, total lung volume and small airway count.

Results Among 495 participants, 53% were never-smokers and the race/ethnic distribution was 35% white, 31% black, 15% Hispanic and 18% Asian. Mean PMBV was 352±120 mL; mean per cent emphysema was 4.95±4.75%. Lower PMBV was associated with greater per cent emphysema (−0.90% per 100 mL PMBV, 95% CI: −1.29 to –0.51). The association was of larger magnitude in participants with 10 or more pack-years smoking and airflow obstruction, but present among participants with no smoking history or airflow limitation, and was specific to the diffuse CT emphysema subtype (−1.48% per 100 mL PMBV, 95% CI: −2.31 to –0.55).

Conclusion In this community-based study, lower PMBV was associated with greater per cent emphysema, including in participants without a smoking history or airflow limitation, and was specific to the diffuse CT emphysema subtype.