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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.

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

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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.

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

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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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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L. Renata Thronson, HMS III


Gillian Lieberman, MD

Signet Ring Sign


Airway

Pulmonary
artery
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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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L. Renata Thronson, HMS III


Gillian Lieberman, MD

Mucous plugging

Hansell DM. Bronchiectasis. Radiologic Clinics of North America 1998; 36:107-126.

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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

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

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
Sjogrens 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

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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

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L. Renata Thronson, HMS III


Gillian Lieberman, MD

64 year-old man with recurrent


pneumonia

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L. Renata Thronson, HMS III


Gillian Lieberman, MD

64 year-old man with recurrent


pneumonia

Ring shadow

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Tram lines

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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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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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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

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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

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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

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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
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L. Renata Thronson, HMS III


Gillian Lieberman, MD

Summary
Radiologic findings
HRCT

Wall thickening
Mucous plugging
Crowded bronchilobar 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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