Correlation of CT findings with clinical evaluations in 261 patients with symptomatic bronchiectasis

Arsenic and non-malignant lung disease

Many aquifers in various parts of the world have been found to be contaminated with arsenic at concentration above 0.05 mg/L. However reports of large number of affected people in India and Bangladesh are unprecedented. Characteristic skin lesions (pigmentation, depigmentation and keratosis) are the hallmark signs of chronic arsenic toxicity. Emerging evidences show that ingestion of arsenic through drinking water may also lead to non-malignant respiratory effects. Early report of non-malignant pulmonary effect of chronic ingestion of arsenic was available from studies in children in Chile as early as 1970. However on the basis of case studies, respiratory effect of chronic arsenic toxicity in adults following drinking of arsenic contaminated water in West Bengal was first reported in 1997. Epidemiological studies carried out in West Bengal on a population of 7683 showed that the prevalence odds ratio (POR) estimates were markedly increased for participants with arsenic induced skin lesions who also had high levels of arsenic in their current drinking water source (> or = 0.5 mg/L) compared with individuals who had normal skin and were exposed to low levels of arsenic (< 0.05 mg/L). In participants with skin lesions, age-adjusted POR estimates for chronic cough were 7.8 for females (95% CI:3.1-19.5) and 5.0 for males (95% CI:2.6-9.9). In Bangladesh, similar study carried out on a population of 218 showed that the crude prevalence ratio for chronic bronchitis was found to be 10.3 (95% CI:2.4-43.1) for females and 1.6 (95% CI:0.8-3.1) for males. Reports of lung function tests were available from both hospital and population based studies. Results show evidences of restrictive, obstructive and combined obstructive and restrictive lung disease in different people having chronic lung disease associated with chronic arsenic toxicity. On the basis of clinical study, chest X-ray and HRCT done in Arsenicosis patients with features of chronic lung disease, the abnormalities observed were varied. Evidences of obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and bronchiectasis were found in some of the cases. Results of studies carried out on people showing features of Arsenicosis due to drinking arsenic contaminated water provide evidence that arsenic is a potent respiratory toxicant, even following ingestion.

Bronchiectasis: correlation of high-resolution CT findings with health-related quality of life

AIM

To evaluate the relationship between the severity of bronchiectatic diseases, as evident on high-resolution computed tomography (HRCT) and the patient's quality of life measured using the St George's Respiratory Questionnaire (SGRQ).

METHODS AND MATERIALS

Forty-six patients (25 women, 21 men, mean age: 63 years) with bronchiectatic disease as evident on recent HRCT examinations were recruited. Each patient completed the SGRQ and underwent respiratory function tests. HRCT findings were blindly and independently scored by two radiologists, using the modified Bhalla scoring system. The relationships between HRCT scores, SGRQ scores and pulmonary function tests were evaluated.

RESULTS

The patients' total CT score did not correlate with the SGRQ scores. However, patients with more advanced disease on HRCT, significantly differed in their SGRQ scores from patients with milder bronchiectatic disease. A significant correlation was found between the CT scores for the middle and distal lung zones and the activity, impacts and total SGRQ scores. No correlation was found between CT scores and respiratory function test indices. However, a significant correlation was found between the SGRQ scores and most of the respiratory function test indices.

CONCLUSION

A correlation between the severity of bronchiectatic disease as expressed in HRCT and the health-related quality of life exists in patients with a more severe bronchiectatic disease but not in patients with mild disease. Such correlation depends on the location of the bronchiectasis in the pulmonary tree.

Lung structure abnormalities, but normal lung function in pediatric bronchiectasis

BACKGROUND

Bronchiectasis is not considered to be uncommon in children anymore. The relationship between pulmonary function and severity of bronchiectasis is still controversial.

STUDY OBJECTIVES

To assess the extent and severity of bronchiectasis through high-resolution CT (HRCT) scan score, and to correlate it with clinical, microbiological, and functional data.

PATIENTS AND METHODS

Forty-three white children with HRCT-diagnosed bronchiectasis were studied. Bronchiectasis extent, bronchial wall thickening severity, and bronchial wall dilatation severity were evaluated using the Reiff score. Clinical, microbiological, and spirometry results were related to total HRCT scan score and to subscores as well.

RESULTS

The percentages of affected lobes were as follows: right lower lobe, 65%; middle lobe, 56%; left lower lobe, 51%; right upper lobe, 37%; lingula, 30%; and left upper lobe, 30% (chi(2) = 18.4; p = 0.002). The mean (+/- SEM) HRCT score was 20 +/- 2.6. Total score or subscores of bronchiectasis extent, bronchial wall thickening severity, and bronchial wall dilatation severity were not significantly related to FEV(1) and FVC. Seventy-four percent of patients had asthma. The age at the onset of cough correlated with age at the time of the HRCT scan (p = 0.004) and with the presence of asthma (p = 0.01). Positive findings of deep throat or sputum cultures were found more frequently in atopic patients (p = 0.02) and asthmatic (p < 0.01) patients, and in children who were < 2 years of age at the onset of cough (p < 0.01).

CONCLUSIONS

Normal lung function may coexist with HRCT scan abnormalities and does not exclude damage to the bronchial structure. Pulmonary function is not an accurate method for assessing the severity of lung disease in children with bronchiectasis.

Bronchiectasis in Persons With Skin Lesions Resulting From Arsenic in Drinking Water

BACKGROUND

Arsenic is a unique human carcinogen in that it causes lung cancer by exposure through ingestion (in drinking water) as well as through inhalation. Less is known about nonmalignant pulmonary disease after exposure to arsenic in drinking water.

METHODS

We recruited 108 subjects with arsenic-caused skin lesions and 150 subjects without lesions from a population survey of over 7000 people in an arsenic-exposed region in West Bengal, India. Thirty-eight study participants who reported at least 2 years of chronic cough underwent high-resolution computed tomography (CT); these scans were read by investigators in India and the United States without knowledge of the presence or absence of skin lesions.

RESULTS

The mean (+/-standard deviation) bronchiectasis severity score was 3.4 (+/-3.6) in the 27 participants with skin lesions and 0.9 (+/-1.6) in the 11 participants without these lesions. In subjects who reported chronic cough, CT evidence of bronchiectasis was found in 18 (67%) participants with skin lesions and 3 (27%) subjects without skin lesions. Overall, subjects with arsenic-caused skin lesions had a 10-fold increased prevalence of bronchiectasis compared with subjects who did not have skin lesions (adjusted odds ratio=10; 95% confidence interval=2.7-37).

CONCLUSIONS

These results suggest that, in addition to being a cause of lung cancer, ingestion of high concentrations of arsenic in drinking water may be a cause of bronchiectasis.

High-resolution CT of the lung: patterns of disease and differential diagnoses

High-resolution CT (HRCT) of the lung is a powerful tool for the investigation of patients with acute or chronic respiratory symptoms or diffuse parenchymal lung disease. Detailed knowledge of normal pulmonary anatomy and an understanding of how normal anatomy is altered in disease states are required to appreciate fully HRCT findings in patients with pulmonary disease. Detailed knowledge of the technical aspects of HRCT examinations is required for optimal image quality. With the proper foundation, a pattern approach to HRCT interpretation may then be used successfully to provide accurate and reproducible interpretation.

Survival of patients with bronchiectasis after the first ICU stay for respiratory failure

STUDY OBJECTIVES

Respiratory failure (RF) is a frequent cause of death among patients with bilateral bronchiectasis. An ICU admission is commonly required, and neither short-term or long-term outcomes have been studied.

DESIGN

We performed a retrospective study over a 10-year period (January 1990 to March 2000). All patients with bilateral bronchiectasis admitted for the first time in the medical ICU for RF were reviewed. Patients with cystic fibrosis were excluded.

MEASUREMENTS AND RESULTS

Forty-eight patients (mean age +/- SD, 63 +/- 11 years; mean simplified acute physiology score [SAPS] II, 32 +/- 12) of whom 25% received long-term oxygen therapy (LTOT) were identified. All the patients were treated with intensive medical care, associated with noninvasive ventilation in 13 patients (27%), and 26 patients (54%) required intubation. Nine patients (19%) died in the ICU. The 1-year mortality rate was 40%. Among the variables recorded at ICU admission, age > 65 years (p = 0.002), SAPS II score > 32 (p = 0.012), use of LTOT (p = 0.047), and intubation (p = 0.027) were associated with reduced survival in univariate analysis by Cox regression. Multivariate analysis by Cox proportional hazard model showed that age > 65 years (relative risk [RR], 2.70; 95% confidence interval [CI], 1.15 to 6.29) and use of LTOT (RR, 2.52; 95% CI, 1.15 to 5.54) were independently associated with reduced survival.

CONCLUSIONS

We performed the first study providing information related to the impact of the first ICU stay for RF on long-term outcomes for patients with bilateral bronchiectasis. Age > 65 years and prior use of LTOT were associated with reduced survival.

HRCT Findings of Proximal Interruption of the Right Pulmonary Artery

The purpose of this study is to present the characteristic HRCT findings of the lung parenchyma in patients with proximal interruption of the right main pulmonary artery. HRCT findings of proximal interruption of the right pulmonary artery demonstrated reticular opacities, septal thickening, subpleural consolidation, cystic lung changes, and pleural thickening in all 5 patients; bronchial dilation and bronchial wall thickening in 4 patients; and subpleural ground glass opacity (GGO) in 3 patients. The changes may be caused by absent pulmonary artery perfusion and development of systemic vessel collateralization.

Relationships between high-resolution computed tomography, lung function and bacteriology in stable bronchiectasis

To determine the relationship between high-resolution computed tomography (HRCT) findings, lung function, and bacteriology in bronchiectasis, we conducted a retrospective study of 49 Korean patients with stable bronchiectasis. To quantify the extent and severity of bronchiectasis, we used a CT scoring system consisting of bronchial dilatation, bronchial wall thickening, the number of bronchiectatic segments, the number of bulla, and the number of emphysema segments. The presence of air-fluid levels and lung consolidation were also evaluated. The results of CT scoring, spirometry and sputum culture were analyzed. Patients with cystic bronchiectasis had higher CT score, more dilated lumen and lower forced vital capacity (FVC), forced expiratory volume in 1 sec (FEV1), and FEV1/FVC than patients with cylindrical bronchiectasis. Patients with mixed ventilatory impairment had larger number of bronchiectatic segments than patients with obstructive ventilatory impairment. CT score and the number of bronchiectatic segments were significantly associated with FVC and FEV1, while CT score and the number of emphysema segments were significantly associated with FEV1/FVC. Twenty-one patients of 49 patients showed a positive sputum culture including 15 cases of Pseudomonas aeruginosa. The CT score was the most important predictor of lung function. The presence of air-fluid levels predicted bacterial colonization.

Bronquiectasias: aspectos diagnósticos e terapêuticos Estudo de 170 pacientes

INTRODUÇÃO: Bronquiectasias são freqüentemente encontradas na prática médica no Brasil, levando a significativa morbidez e comprometimento da qualidade de vida de seus portadores. OBJETIVOS: Analisar aspectos diagnósticos e terapêuticos em uma série de pacientes com bronquiectasias atendidos em um serviço de doenças pulmonares. MÉTODO: Sinais, sintomas, achados radiográficos e microbiológicos, e resultados terapêuticos foram estudados em 170 pacientes portadores de bronquiectasias hospitalizados no período de 1978 a 2001 - 62,4% do sexo feminino, 37,6% do masculino, com idade média de 37 anos, variando entre 12 e 88 anos. RESULTADOS: Antecedente de pneumonia na infância foi detectado em 52,5% dos pacientes, de tratamento tisiológico em 19,8%; 8,8% tinham asma brônquica, e dois tinham síndrome de Kartagener. Os sintomas mais comuns foram tosse (100%), expectoração (96%) e estertores pulmonares (66%). As lesões eram unilaterais em 46,5% dos casos. Pneumococo, H. influenzae ou flora mista estiveram presentes em 85% das amostras de escarro examinadas. Os 170 pacientes receberam inicialmente tratamento clínico à base de antibióticos e fisioterapia respiratória; 88 deles (52%) mais jovens, com lesões menores e boa reserva funcional foram submetidos à cirurgia de ressecção pulmonar (82 unilaterais e seis bilaterais). Ocorreram dois óbitos hospitalares entre os pacientes que receberam tratamento exclusivamente clínico. Os pacientes tratados cirurgicamente tiveram acentuada melhora dos sintomas, raramente necessitando ser reinternados. CONCLUSÕES: Os prolongados sintomas broncopulmonares foram permanentemente aliviados na maioria dos pacientes com bronquiectasias que puderam ir à cirurgia de ressecção pulmonar, diferentemente dos que seguiram com o tratamento clínico.

Retrospective review of children presenting with non cystic fibrosis bronchiectasis: HRCT features and clinical relationships

Non cystic fibrosis (CF) bronchiectasis in children presents with a spectrum of disease severity. Our aims were to document the extent and severity of disease in children with non-CF bronchiectasis, to review the inter- and intraobserver agreement for the high-resolution computed tomography (HRCT) features examined, and to assess correlations between HRCT features and clinical measures of severity. We performed a retrospective review of 56 children from the Starship Children's Hospital. HRCT scans were scored by a modified Bhalla system, and the chest X-rays using the Brasfield score. Scores were correlated with demographics, number of hospitalizations, disease duration, pulmonary function, clinical examination, and chronic sputum infection. The bronchiectasis seen was widespread and severe, particularly in Maori and Pacific Island children. The kappa coefficient for intraobserver agreement was better than that for interobserver agreement. Comparisons between HRCT scan and lung function parameters showed that the strongest relationships were between forced expiratory volume in 1 sec (FEV(1)) and forced expiratory flow between 25-75% of forced vital capacity (FEF(25-75)) with the extent of bronchiectasis, bronchial wall thickening, and air trapping. Children with digital clubbing and chest deformity showed significantly higher scores for extent of bronchiectasis, bronchial wall dilatation and thickness, and overall computed tomography (CT) score. No relationship was demonstrated between chronic sputum infection and CT score. The HRCT score demonstrated a stronger correlation between the extent and severity of bronchiectasis, and spirometry values, than the chest X-ray score. In conclusion, pediatric non-CF bronchiectasis in Auckland is extensive and severe. The good intraobserver ratings mean that consistency of scoring is possible on repeated scans. This study cannot comment on the relationships of CT and less severe disease.

Changing paradigms in the diagnosis and management of bronchiectasis

The face of bronchiectasis may have changed in recent years but individual cases continue to pose difficult challenges. As childhood infection becomes less of a problem, alternative causes of bronchiectasis are increasingly recognized which themselves offer new problems of diagnosis and management. Evolving concepts of pathogenesis suggest alternative strategies for treatment but as yet the evidence base on which to make firm decisions is lacking. Antibacterial regimens are not universally applicable and individualized protocols with parenteral, nebulized or continuous antibacterial therapy are increasingly used in the treatment of patients with bronchiectasis. Despite the theoretical appeal of using mucolytic or anti-inflammatory drugs their roles are still uncertain and have yet to be examined in adequate clinical trials. The factors determining disease progression are still poorly understood but in some patients worsening airflow obstruction heralds the onset of ventilatory failure. The management of the latter requires bronchodilators and controlled oxygen therapy, and strategies including non-invasive ventilation are increasingly an option. Changing indications for surgery are evident with fewer palliative resections but a developing role for transplantation.

CT of airways disease and bronchiectasis

High-resolution CT is accepted as an accurate noninvasive means of diagnosing bronchiectasis. A wide spectrum of abnormalities may be identified at HRCT in patients with airway disease, including various distinctive patterns of bronchiectasis in specific clinical settings, such as ABPA, MAC infection, AIDS, and CF. Characteristic CT findings occasionally suggest a specific diagnosis that may not have been under clinical consideration. HRCT also provides significant clinical use in assessing the degree and extent of airway disease, and allows noninvasive monitoring of disease progression, regression, or response to therapy.