Bronchiectasis refers to abnormal dilatation of the bronchial tree and is seen in a variety of clinical settings. CT is the most accurate modality for diagnosis. It is largely considered irreversible.
As there are many causes of bronchiectasis, which may occur at essentially any age, no single demographic is particularly involved. Two groups make up the majority of cases: post-infectious and cystic fibrosis 3.
Bronchiectasis typically presents with recurrent chest infections, production of copious amounts of sputum and hemoptysis. The later is often the only symptom and is encountered in up to 50% of cases 9.
As is true for most lung pathology, bronchiectasis is the common response of bronchi to many different insults. Causes include 1-7,9:
- post-infective (most common)
- bronchial obstruction
- loss of surrounding lung volume
Mnemonic to remember common causes: CAPT KANGAROO HAS MOUNIER KUHN.
According to macroscopic morphology, three types have been described, which also represent a spectrum of severity 8:
- cylindrical bronchiectasis
- relatively uncommon
- beaded appearances where dilated bronchi have interspersed sites of relative narrowing
- severe form with cyst-like bronchi that extend to the pleural surface
- air-fluid levels are commonly present
Additionally bronchiectasis can result from the traction of fibrotic lung surrounding an airway. This is known as traction bronchiectasis.
There is dilation of bronchi and bronchioles due to elastic tissue and smooth muscle destruction.
Chest x-rays are usually abnormal, but are inadequate in the diagnosis or quantification of bronchiectasis. Tram-track opacities are seen in cylindrical bronchiectasis, and air-fluid levels may be seen in cystic bronchiectasis. Overall there appears to be an increase in bronchovascular markings, and bronchi seen end on may appear as ring shadows 8. Pulmonary vasculature appears ill-defined, thought to represent peribronchovascular fibrosis 8-9.
CT and HRCT especially excels at demonstrating the airways, and is able to a greater or lesser degree to distinguish some of the various underlying causes.
A number of features are helpful in diagnosing bronchiectasis 8-9:
- bronchus visualized within 1cm of pleural surface
- especially true of lung adjacent to costal pleura
- most helpful sign for early cylindrical change
- lack of tapering
- increased bronchoarterial ratio 9
- diameter of a bronchus should measure approximately 0.65-1.0 times that of the adjacent pulmonary artery branch
- between 1 and 1.5 may be seen in normal individuals, especially those living at high altitude
- greater than 1.5 indicates bronchiectasis
A number of anciliary findings are also recognized:
- bronchial wall thickening: normally wall of bronchus should be less than half the width of the accompanying pulmonary artery branch
- mucoid impaction
- air-trapping and mosaic perfusion
Signs described on CT include:
Treatment and prognosis
In general treatment of bronchiectasis is medical and involves promoting sputum clearance, using positional physiotherapy and early and aggressive treatment of pulmonary infections. In some cases chronic prophylactic administration of antibiotics may be required.
In cases where bronchiectasis is severe and significant morbidity is present, surgical resection of the affected lobe may be of benefit provided adequate repiratory reserve exists.
In cases where both lungs are extensively involved (e.g. cystic fibrosis) lung transplantation can be considered 10.
The differential is in two parts:
- causes of particular distribution of bronchiectasis
- mimics of bronchiectasis
Causes of particular distribution of bronchiectasis
- central bronchiectasis
- upper lobe bronchiectasis
- middle lobe bronchiectasis
- lower lobe bronchiectasis
Mimics of bronchiectasis
Conditions that may mimic cystic bronchiectasis include 8: