L. Renata Thronson, HMS III
Gillian Lieberman, MD
Oct/Nov 2003
Radiologic Findings in
Bronchiectasis
L. Renata Thronson, Harvard Medical School Year III
Gillian Lieberman, MD
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Bronchiectasis
Bronchiectasis is an irreversible, chronic
dilatation of diseased airways.
2
L. Renata Thronson, HMS III
Gillian Lieberman, MD
A 64 year-old male
with recurrent
pneumonia
A 44 year-old
woman with
cough and rales
and
PACS, BIDMC
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Pathogenesis of Bronchiectasis
Environmental
insult
Defective mucociliary
clearance
Microbes persist in
bronchi
Genetic
susceptibility
Tissue damage
Colonization
Progressive
lung damage
Chronic
inflammation
Adapted from Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Menu of tests
• Bronchography
– The “gold standard”
• High-resolution CT
– 1-2 mm collimation
– Grenier et al: Se 96%; Sp 93%
– Young et al: Se 98%; Sp 99%
• Chest x-ray
– Inferior sensitivity and specificity
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Bronchography
• Requires local
anesthetic and
bronchographic
medium
 potential for allergic
reaction
• Exam limited to
airways
http://radiology.rsnajnls.org
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
CXR: Findings
• Indistinct vessel
margins
• Tram lines
• Ring shadows
• Volume loss
– Elevated left
hemidiaphragm
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7
L. Renata Thronson, HMS III
Gillian Lieberman, MD
HRCT: Findings
• Dilatation
– Signet ring sign
– Non-tapering airways
• Indirect signs
– Mucous plugging
– Lobar volume loss
– Wall thickening
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8
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Signet Ring Sign
Airway
Pulmonary
artery
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9
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Non-tapering airways
• Airways visible
within 1 cm of
the visceral
pleura
• Tram lines
• Flaring
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10
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Mucous plugging
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
11
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Morphologies of Bronchiectasis
• Cylindrical
• Cystic
• Varicoid
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Morphologies of Bronchiectasis
• Cylindrical
• Cystic
• Varicoid
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13
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Morphologies of Bronchiectasis
• Cylindrical
• Cystic
• Varicoid
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Morphologies of Bronchiectasis
• Cylindrical
• Cystic
• Varicoid
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
DDX of Bronchiectasis
• Postinfectious
–
–
–
–
Bacterial
Mycobacterial
Viral
Fungal
• Post-transplantation
– Chronic rejection
– GVHD
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
DDX of Bronchiectasis
• Postinflammatory
– Aspiration
– Toxic inhalation
• Postobstructive
– Tumor
– Foreign body
– Stricture
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
DDX of Bronchiectasis
• Impaired mucociliary clearance
– Dyskinetic cilia syndromes
– Cystic Fibrosis
• Inherited cellular or molecular defects
– Alpha-1-antitrypsin deficiency
– Cystic Fibrosis
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
DDX of Bronchiectasis
• Immune deficiency
– Inherited
– Acquired
• Collagen Vascular Disease
–
–
–
–
–
Rheumatoid arthritis
Sjogren’s syndrome
Ankylosing spondylitis
Marfan syndrome
IBD
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
DDX of Bronchiectasis
• Congenital bronchial abnormalities
– Mounier-Kuhn syndrome
– Williams-Campbell syndrome
– Bronchopulmonary sequestration
• Miscellaneous
– Asthma
– Yellow-nail syndrome
– Sarcoidosis
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Diagnostic Pitfalls
Bronchiectasis
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Interstitial disease
http://www.hospitalist.net/case1.html
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Diagnostic Pitfalls
Signet ring?
Tram lines?
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
22
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Diagnostic Pitfalls
Branching airway
Double shadow: heart and vessels
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126
23
L. Renata Thronson, HMS III
Gillian Lieberman, MD
64 year-old man with recurrent
pneumonia
PACS, BIDMC
24
L. Renata Thronson, HMS III
Gillian Lieberman, MD
64 year-old man with recurrent
pneumonia
Ring shadow
PACS, BIDMC
Tram lines
25
L. Renata Thronson, HMS III
Gillian Lieberman, MD
64 year-old man with recurrent
pneumonia
Airways
visible at
pleural
margin
Varicoid
dilatation
Mucous
plugging
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26
L. Renata Thronson, HMS III
Gillian Lieberman, MD
44 year-old woman with cough
Varicoid dilatation
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Cystic dilatation
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27
L. Renata Thronson, HMS III
Gillian Lieberman, MD
44 year-old woman with cough
Tracheal margins
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Tracheal margins
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Mounier-Kuhn syndrome
• Congenital bronchial
abnormality
• ?Autosomal recessive
• Findings
– Tracheomegaly
– Bronchomegaly
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Bronchiectasis and Situs Inversus
Courtesy of Phillip Boiselle, MD
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Kartagener syndrome
• Primary ciliary
dismotility
– Recurrent respiratory
infections
– Decreased fertility
• Findings on CXR
– Bronchiectasis
– Situs inversus
Courtesy of Phillip Boiselle, MD
31
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Cystic Fibrosis
• Upper lobe
predilection
• Panlobar disease
• Marked cystic
dilatation
– Air-fluid levels
may be seen within
cysts
Courtesy of Phillip Boiselle, MD
32
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Cystic Fibrosis
• Upper lobe
predilection
• Panlobar disease
• Marked cystic
dilatation
– Air-fluid levels
may be seen within
cysts
Courtesy of Phillip Boiselle, MD
33
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Postinfectious Varicoid
Bronchiectasis
Focal bronchiectasis
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Summary
• DDX of bronchiectasis is broad, but the diseases
share a common pathogenesis
• Morphologies reflect degrees of severity
– Cylindrical
– Cystic
– Varicoid
• Tests available
– Bronchography
– CXR
– HRCT
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Summary
• Radiologic findings
– CXR
• Volume loss
• Mucous plugging
– “gloved finger”
• Inflammation
– Indistinct vessel margins
– Tram lines
– Ring shadows
36
L. Renata Thronson, HMS III
Gillian Lieberman, MD
Summary
• Radiologic findings
– HRCT
•
•
•
•
Wall thickening
Mucous plugging
Crowded bronchilobar volume loss
Airway dilatation
– Signet ring sign
– Non-tapering small airways
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
References
•
•
•
•
•
Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.
McGuinness G, Naidich DP. CT of Airways Disease and Bronchiectasis. Radiologic Clinics of
North America 2002; 40:1-19.
Friedman, PJ. Chest Radiographic Findings in Adults with Cystic Fibrosis. Seminars in
Roentgenology 1987; 22:114-124.
Grenier P, Maurice R, Musset D, et al. Bronchiectasis: Assessment by thin-section CT.
Radiology 1986; 161:95-99.
Young K, Aspestrand F, Kolbenstvedt. High resolution CT and bronchography in the
assessment of bronchiectasis. Acta Radiology 1991; 32:439-441.
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L. Renata Thronson, HMS III
Gillian Lieberman, MD
Acknowledgements
•
•
•
•
•
•
Andru Bageac, MD
Eric Niendorf, MD
Phillip Boiselle, MD
Gillian Lieberman, MD
Larry Barbaras
Pamela Lepkowski
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