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Assessment of Bronchiectasis by Computed Tomography

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Assessment of Bronchiectasis by Computed Tomography Thorax: first published as 10.1136/thx.40.12.920 on 1 December 1985. Downloaded from Thorax 1985;40:920-924 Assessment of bronchiectasis by computed tomography IM MOOTOOSAMY, RH REZNEK, J OSMAN, RSO REES, MALCOLM GREEN From the Departments of Diagnostic Radiology and Chest Medicine, St Bartholomew's Hospital, London ABSTRACT Computed tomography and bronchography were used to assess the distribution of bronchiectasis in 15 lungs from eight patients with clinical features of the disease. Of the 36 lobes adequately displayed by bronchography, 22 were found to have bronchiectasis and 14 were found to be normal by both techniques. Cystic disease was readily identified by computed tomography but the cylindrical and varicose types of bronchiectasis could not be distinguished. Segmental local- isation was less accurate, with agreement between computed tomography and bronchography in 116 out of 130 segments. It is concluded that with a modern high resolution scanner computed tom- ography provides a useful method of assessing lobar distribution in bronchiectasis. The incidence of bronchiectasis in the United King- placing bronchography in a substantial number, dom has decreased since the advent ofantibiotic treat- Muller et al found correspondence in only about half ment and the decline in severe respiratory disease in the lungs studied. childhood. Nevertheless, it still occurs as the result of The purpose of this study is to assess the place of severe pulmonary infections and in association with modern high resolution computed tomography scan-copyright. immune deficiency, cystic fibrosis, and other condi- ners in the clinical management ofpatients with bron- tions. chiectasis and to investigate the accuracy with which The disease is defined as irreversible abnormal di- lobar and segmental disease and the type of disease latation of the bronchi and has been classified by present can be predicted. Reid' into three types-cystic, varicose, andcylindri- cal. Although the plain chest film may provide a clue, Patients and methods http://thorax.bmj.com/ particularly in the cystic type, bronchography is still the definitive investigation. It is indicated when it is Eight patients with a clinical diagnosis of bronchi- necessary to confirm the clinical diagnosis or, if the ectasis were included in the study, all of whom had disease is localised, to exclude the disease in other posteroanterior, lateral, and supine chest films; bron- parts of the lungs if lobectomy is contemplated. Bron- chograms; and computed tomography scans. Bilateral chography is an unpleasant, potentially dangerous,23 bronchograms were obtained in seven of the patients and invasive investigation that requires considerable (aqueous dionosil being used), three via a fibreoptic skill and even when expertly performed it may leave bronchoscope and four by transnasal tracheal intu- on September 27, 2021 by guest. Protected areas of lung inadequately examined owing to tech- bation. In one patient a right bronchogram only was nical or other difficulties. available as the examination had to be abandoned Computed tomography scanners with their im- before the left side was examined owing to the proved resolution provide a potential means of de- patient's distress. tecting or excluding bronchiectasis and so avoiding Computed tomography scans were performed with bronchography. Naidich et al4 described the appear- a GE 9800 scanner with a two second scan time, 512 ances of bronchiectasis on computed tomography in matrix, and 10mm scan thickness. The patients were six patients and recently Muller et al presented re- examined supine with slices at I cm intervals through sults obtained in 11 patients. Whereas Naidich et al the lungs. Scans were also obtained with the patient were optimistic about computed tomography re- prone where indicated to differentiate dependent pul- monary vessels. The interval between computed tom- Address for reprint requests: Dr IM Mootoosamy, Department of ography and bronchography was less than six months Diagnostic Radiology, St Bartholomew's Hospital, London in all patients except patient I (with cystic bronchi- ECIA 7BE. ectasis), who was scanned at 12 months. Accepted 8 July 1985 The chest radiographs were examined indepen- 920 Thorax: first published as 10.1136/thx.40.12.920 on 1 December 1985. Downloaded from Assessment ofbronchiectasis by computed tomography 921 R k Fig 1 (Above) Computed tomography scan of lungs showing bronchial wall thickening and dilatation in both lower lobes, with "tramline" appearance in the right anterior segment and in the left lower lobe (arrowed). copyright. (Right) Bronchogram from the same patient: oblique view ofright lower lobe showing bronchial dilatation. dently by one radiologist (RSOR) without knowledge bronchography was recorded to include its type (cys- http://thorax.bmj.com/ of other findings. The lobar distribution of changes tic, varicose, or cylindrical), lobar distribution within consistent with bronchiectasis was recorded from the each lung, and, within each lobe, disease of individual plain films. The presence of bronchiectasis as seen on segments. The computed tomography scans were as- on September 27, 2021 by guest. Protected Fig 2 Computed tomography scan of lungs showing bronchial dilatation and bronchial wall thickening in the left lower lobe and in the lingula (arrowed). A dilated, thick walled bronchus cut transversely is seen in the posterior segment of the left lower lobe as a circular lucency (open arrow). Thorax: first published as 10.1136/thx.40.12.920 on 1 December 1985. Downloaded from 922 Mootoosamy, Reznek, Osman, Rees, Green Comparison of results of computed tomography and bronchography Patient 1 2 3 4 5 6 7 8 CT B CT B CT B CT B CT B CT B CT B CT B Right upper lobe Apical - v. .- - - Posterior + Anterior + v. - - - - Right middle lobe Medial + + - - c + - - + + + v + * Lateral + + - - + + . - .+- v - * Right lower lobe ) Apical c c Medial c c + + + + - + v - + Anterior c c - - 0 + - v + v Lateral c e - + - + + +- -v Posterior c c + v + + + v + + + v + + Left upper lobe Apical + - - Antenor - Superior lingula + + v - - - - + - o Inferiorlingula * v - - - - + + + + Left lower lobe 0 Apical - v * Posterior + v + + + * + + + + + + + + X Lateral + v + + + * + - + + + + + + Anterior - v * + + + + + + Zz X CT = computed tomography scan; B = bronchogram; + = cylindrical bronchiectasis; v = varicose bronchiectasis; c = cystic bronchiectasis; - = normal; 0 = consolidation; * = underfilling; ® = lobes where bronchiectasis changes seen on plain radiograph. sessed independently by another radiologist (RHR), Results copyright. also without knowledge of other findings. Normal bronchi can be seen on computed tom- The chest radiographs were thought to be normal in ography only in the central portions ofthe lung paren- five patients and to show changes consistent with chyma in or adjacent to the hila."6 The peribronchial bronchiectasis in three. Patient I showed cystic fibrosis, however, associated with bronchiectasis6 changes in the right lower lobe, patient 6 showed with resultant bronchial wall thickening and di- tramline shadows in the left lower lobe, and patient 7 http://thorax.bmj.com/ latation renders bronchi visible in more peripheral showed tramline shadows in the right middle and parts of the lung,6 and thickening of the wall com- lower lobes (table). bined with the lack of peripheral tapering suggests the Bronchography was performed in eight patients; in diagnosis. When cut longitudinally these abnormal one patient only one side could be examined, so that bronchi appear as "tramlines" (fig la). When cut 15 lungs were available for comparison. Part of the transversely they appear as circular or oval lucencies middle lobe was underfilled in one patient and part of (fig 2) and the lack of tapering can be confirmed by the left lower lobe in another; of the 36 remaining bron- examination of two or more contiguous slices. In the lobes, 22 were assessed as showing evidence of on September 27, 2021 by guest. Protected cylindrical type of disease the walls have a smooth chiectasis and 14 were normal. Independent assess- outline, whereas in the varicose type they are said to ment of the computed tomography scans indicated have a "beaded" appearance.6 Cystic disease is that the same 22 lobes showed bronchiectasis, while readily recognisable on computed tomography, the the other 14 were considered to be free of disease. The cysts being arranged in clusters or strings. two lobes that were underfilled in the bronchogram The presence or absence of bronchiectasis on the also showed evidence of disease on computed tom- computed tomography scans was recorded according ography. There was extensive cystic disease in the to these criteria, and after the lobar distribution and right lower lobe of one patient, which was obvious on the type of disease had been established an attempt bronchography (fig 3a). This correlated well with the was made to predict whether particular segments were computed tomography findings (fig 3b). Otherwise the affected within each lobe. On computed tomography, disease appeared on the bronchograms to be mostly of pulmonary lobes can be recognised easily by locating the cylindrical type, but varicose changes were noted the main fissures.78 Segmental anatomy, although not in some parts of six lobes. The differences between so easy, can be identified by locating the segmental varicose and cylindrical bronchiectasis could not be bronchi and pulmonary vessels.89 distinguished on computed tomography.
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