Bronchiectasis

Respiratory Tract Manifestations of Inflammatory Bowel Disease

Inflammatory bowel disease can manifest in many extraintestinal organ systems. The most frequently involved extraintestinal locations include the mucocutaneous, hepatobiliary, and ocular organ systems. The respiratory tract is less commonly involved and is therefore frequently overlooked. Consequently, it is believed that involvement of the respiratory tract in patients with inflammatory bowel disease is underreported. The pathogenesis is thought to be multifactorial, involving the common embryologic origin shared by the respiratory and luminal digestive tract, molecular mimicry, and immunologic interactions leading to immune-complex deposition in affected tissue. The spectrum of manifestations of the respiratory tract related to inflammatory bowel disease is broad. It not only includes direct involvement of the respiratory tract (ie, airways, interstitium, and pleura) but also can result as a consequence of systemic involvement such as in thromboembolic events. In addition, it may also be related to other conditions that affect the respiratory tract such as sarcoidosis and alpha-1 antitrypsin deficiency. Though some conditions related to respiratory tract involvement might be subclinical, others may have life-threatening consequences. It is critical to approach patients with suspected inflammatory bowel disease-related respiratory tract involvement in concert with pulmonology, infectious diseases, and any other pertinent experts, as treatments may require a multidisciplinary overlap of measures. Therefore, it is of paramount importance for the clinician to be aware of the array of respiratory tract manifestations of patients with inflammatory bowel disease, in addition to the possible spectrum of therapeutic measures.

Thin-section computed tomography findings and longitudinal variations of the residual pulmonary sequelae after discharge in patients with COVID-19: a short-term follow-up study

OBJECTIVES

This study analyzed and compared CT findings and longitudinal variations after discharge between severe and non-severe coronavirus disease (COVID-19) patients who had residual pulmonary sequelae at pre-discharge.

METHODS

A total of 310 patients were included and stratified into severe and non-severe COVID-19 groups. Cross-sectional CT features across different time periods (T0: pre-discharge, T1: 1-4 weeks after discharge, T2: 5-8 weeks after discharge, T3: 9-12 weeks after discharge, T4: > 12 weeks after discharge) were compared, and the longitudinal variations of CT findings were analyzed and compared in both groups.

RESULTS

The cumulative absorption rate of fibrosis-like findings in the severe and non-severe groups at T4 was 24.3% (17/70) and 52.0% (53/102), respectively. In both groups, ground-glass opacity (GGO) with consolidation showed a clear decreasing trend at T1, after which they maintained similar lower levels. The GGO in the severe group showed an increasing trend first at T1 and then decreasing at T4; however, the incidence decreased gradually in the non-severe group. Most fibrosis-like findings showed a tendency to decrease rapidly and then remained stable. Bronchial dilatation in the severe group persisted at an intermediate level.

CONCLUSIONS

After discharge, the characteristics and changing trends of pulmonary sequelae caused by COVID-19 were significantly different between the two groups. Pulmonary sequelae were more serious and recovery was slower in patients with severe/critical disease than in patients with moderate disease. A portion of the fibrosis-like findings were completely absorbed in patients with moderate and severe/critical diseases.

KEY POINTS

• Lung sequelae were more serious and recovery was slower in severe/critical COVID-19 patients. • Complete absorption of fibrosis-like findings after a short-term follow-up was observed in at least 17/70 (24.3%) of COVID-19 patients with severe/critical disease and 53/102 (52.0%) of COVID-19 patients with moderate disease. • The most common fibrosis-like findings was a parenchymal band; irregular interface was a nonspecific sign of COVID-19, and the percentage of bronchial dilatation in patients with severe/critical disease remained at a relatively stable medium level (range, 31.6 to 47.8%) at all stages.

Current state of the art MRI for the longitudinal assessment of cystic fibrosis

Pulmonary MRI can now provide high-resolution images that are sensitive to early disease and specific to inflammation in cystic fibrosis (CF) lung disease. With specificity and function limited via computed tomography (CT), there are significant advantages to MRI. Many of the modern MRI techniques can be performed throughout life, and can be employed to understand changes over time, in addition to quantification of treatment response. Proton density and T1 /T2 contrast images can be obtained within a single breath-hold, providing depiction of structural abnormalities and active inflammation. Modern radial and/or spiral ultrashort echo-time (UTE) techniques rival CT in resolution for depiction and quantification of structure, for both airway and parenchymal abnormalities. Contrast perfusion MRI techniques are now utilized routinely to visualize changes in pulmonary and bronchial circulation that routinely occur in CF lung disease, and noncontrast techniques are moving closer to clinical translation. Functional information can be obtained from noncontrast proton images alone, using techniques such as Fourier decomposition. Hyperpolarized-gas MRI, increasingly using 129 Xe, is now becoming more widespread and has been demonstrated to have high sensitivity to early airway obstruction in CF via ventilation MRI. The sensitivity of 129 Xe MRI promises future use in personalized medicine, management of early CF lung disease, and in future clinical trials. By combining structural and functional techniques, with or without hyperpolarized gases, regional structure-function relationships can be obtained, giving insight into the pathophysiology of disease and improved clinical management. This article reviews the modern MRI techniques that can routinely be employed for CF lung disease in nearly any large medical center. Level of Evidence: 4 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2019.

Respiratory care in familial dysautonomia: Systematic review and expert consensus recommendations

BACKGROUND

Familial dysautonomia (Riley-Day syndrome, hereditary sensory autonomic neuropathy type-III) is a rare genetic disease caused by impaired development of sensory and afferent autonomic nerves. As a consequence, patients develop neurogenic dysphagia with frequent aspiration, chronic lung disease, and chemoreflex failure leading to severe sleep disordered breathing. The purpose of these guidelines is to provide recommendations for the diagnosis and treatment of respiratory disorders in familial dysautonomia.

METHODS

We performed a systematic review to summarize the evidence related to our questions. When evidence was not sufficient, we used data from the New York University Familial Dysautonomia Patient Registry, a database containing ongoing prospective comprehensive clinical data from 670 cases. The evidence was summarized and discussed by a multidisciplinary panel of experts. Evidence-based and expert recommendations were then formulated, written, and graded using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Recommendations were formulated for or against specific diagnostic tests and clinical interventions. Diagnostic tests reviewed included radiological evaluation, dysphagia evaluation, gastroesophageal evaluation, bronchoscopy and bronchoalveolar lavage, pulmonary function tests, laryngoscopy and polysomnography. Clinical interventions and therapies reviewed included prevention and management of aspiration, airway mucus clearance and chest physical therapy, viral respiratory infections, precautions during high altitude or air-flight travel, non-invasive ventilation during sleep, antibiotic therapy, steroid therapy, oxygen therapy, gastrostomy tube placement, Nissen fundoplication surgery, scoliosis surgery, tracheostomy and lung lobectomy.

CONCLUSIONS

Expert recommendations for the diagnosis and management of respiratory disease in patients with familial dysautonomia are provided. Frequent reassessment and updating will be needed.

Diffuse bronchiectasis as the primary manifestation of endobronchial sarcoidosis

Sarcoidosis is an idiopathic disease that most commonly involves the lungs and is characterized by granulomatous inflammation. Bronchiectasis is one pulmonary manifestation of sarcoidosis, although it is almost always observed as traction bronchiectasis in the setting of fibrotic lung disease. A 50-year-old woman was evaluated for chronic cough and bronchiectasis with a small amount of peripheral upper lobe honeycombing and no significant pulmonary fibrosis or lymphadenopathy. After an extensive laboratory and imaging evaluation did not identify a cause of her bronchiectasis, bronchoscopy was performed to assess for primary ciliary dyskinesia and revealed a diffuse cobblestone appearance of the airway mucosa. Endobronchial biopsies and lymphocyte subset analysis of bronchoalveolar lavage fluid were consistent with a diagnosis of sarcoidosis. We believe endobronchial sarcoidosis should be included in the differential diagnosis of patients presenting with bronchiectasis.

Imaging of Diseases of the Large Airways

Imaging of the large airways is key to the diagnosis and management of a wide variety of congenital, infectious, malignant, and inflammatory diseases. Involvement can be focal, regional, or diffuse, and abnormalities can take the form of masses, thickening, narrowing, enlargement, or a combination of patterns. Recognition of the typical morphologies, locations, and distributions of large airways disease is central to an accurate imaging differential diagnosis.

Imaging of Cystic Fibrosis and Pediatric Bronchiectasis

1. CT is superior to pulmonary function tests and chest radiography for the assessment and monitoring of cystic fibrosis (CF)-related lung disease and, also, of pediatric bronchiectasis not caused by CF (hereafter referred to as non-CF bronchiectasis). 2. Low-dose CT protocols that impart radiation doses similar to those used in chest radiography are feasible for the surveillance of patients with bronchiectasis. 3. Chest radiography is still most commonly used as the first-line imaging examination of choice for the assessment of acute complications related to bronchiectasis. 4. Pulmonary MRI, with or without the use of inhaled hyperpolarized gas, can be performed to obtain functional information, and, in dedicated centers, it may yield imaging results comparable to those obtained by CT. 5. Gastrointestinal and pancreaticobiliary manifestations of CF are observed with greater frequency in adults, because of increased life expectancy.

Mucociliary clearance: pathophysiological aspects

Mucociliary clearance has long been known to be a significant innate defence mechanism against inhaled microbes and irritants. Important knowledge has been gathered regarding the anatomy and physiology of this system, and in recent years, extensive studies of the pathophysiology related to lung diseases characterized by defective mucus clearance have resulted in a variety of therapies, which might be able to enhance clearance from the lungs. In addition, ways to study in vivo mucociliary clearance in humans have been developed. This can be used as a means to assess the effect of different pharmacological interventions on clearance rate, to study the importance of defective mucus clearance in different lung diseases or as a diagnostic tool in the work-up of patients with recurrent airway diseases. The aim of this review is to provide an overview of the anatomy, physiology, pathophysiology, and clinical aspects of mucociliary clearance and to present a clinically applicable test that can be used for in vivo assessment of mucociliary clearance in patients. In addition, the reader will be presented with a protocol for this test, which has been validated and used as a diagnostic routine tool in the work-up of patients suspected for primary ciliary dyskinesia at Rigshospitalet, Denmark for over a decade.

Chronic atelectasis of the left lower lobe: a clinicopathological condition equivalent to middle lobe syndrome

OBJECTIVES

Middle lobe syndrome is a well-known clinical condition. In this retrospective study, we report our experience with a similar clinicopathological condition affecting the left lower lobe.

METHODS

The data of 17 patients with atelectasis or bronchiectasis of the left lower lobe who underwent lobectomy during the period from January 2000 to December 2011 were reviewed. Demographic, clinical, radiological and surgical data were collected.

RESULTS

Seventeen patients were included in this study, only one adult male patient of 52 years and 16 children. The paediatric patients were 10 boys and 6 girls, their age ranged from 2 to 11 years, mean 6.19 ± 2.6 years. Most patients presented with recurrent respiratory infection 15/17 (88.2%). The lag time before referral to surgery ranged from 3 to 48 months, mean 17.59 ± 13.1 months. Radiological signs of bronchiectasis were found in 11 (64.7%) patients. Bronchoscopy showed patent lower lobe bronchus in all patients. The criteria for lobectomy were evidence of bronchiectasis [11 (64.71%) patients], persistent atelectasis of the lobe after bronchoscopy and intensive medical therapy for a maximum of 2 months [6 (35.29%) patients]. Histopathological examination showed bronchiectasis in 11 (64.71%) patients, fibrosing pneumonitis in 4 (23.53%) patients and peribronchial inflammation in 2 (11.76%) patients. Most patients were doing well 1 year after surgery.

CONCLUSIONS

Chronic atelectasis of the left lower lobe is a clinicopathological condition equivalent to middle lobe syndrome. Impaired collateral ventilation together with airway plugging with secretion is an accepted explanation. Surgical resection is indicated for bronchiectatic lobe or failure of 2-month intensive medical therapy to resolve lobar atelectasis.

Kartagener's syndrome--anaesthetic considerations for ENT surgery

Kartagener's syndrome is a rare autosomal recessive disorder presenting a triad of sinusitis, bronchicetasis and situs inversus with dextrocardia. It occurs in 50% of patients with situs inversus. The most important anesthetic implications of Kartegener's syndrome surgery are assessement of pulmonary and cardiac structure and function. We present a case of 43-year-old woman with chronic rhinosinusitis with polyps and bilateral sectetory otitis media. The chest radiograph and CT scans showed dextrocardia and situs inversus with chronic bronchitis without bronchiectasis. Spirometry showed forced expiratory volume in one second (FEV1) of 2.66 L and forced vital capacity (FVC) of 3.62 L. Electroechography showed no cardiac abnormalities with 55-60% of EF. The anesthetic implications of Kartagener's syndrome are varied. The regional or general anesthesia might be involved with sinus surgery, ear surgery, pulmonary surgery, infertility or abdominal and cardiac surgery. The main anesthetic considerations among patients with Kartagener's syndrome are related to the pulmonary function which include preoperative respiratory infections due to bronchiectasis. We should also monitor potentially occluded congenital heart diseases. Kartagener's syndrome is a rare disease and when the patient need an operation we have to consider surgery with regional or general anesthesia. The general anesthesia would be safe after complete preanaesthetic examination of the patient. The ECG, chest CT scans, spirometry and echocardiography are mandatory before the operation.

Middle lobe syndrome: a review of clinicopathological features, diagnosis and treatment

Middle lobe syndrome (MLS) is a rare but important clinical entity that has been poorly defined in the literature. It is characterized by recurrent or chronic collapse of the middle lobe of the right lung but can also involve the lingula of the left lung. Pathophysiologically, there are two forms of MLS, namely obstructive and nonobstructive. Obstructive MLS is usually caused by endobronchial lesions or extrinsic compression of the middle lobe bronchus such as from hilar lymphadenopathy or tumors of neoplastic origin, resulting in postobstructive atelectasis and pneumonitis. In the nonobstructive type, no obstruction of the middle lobe bronchus is evident during bronchoscopy or with computerized tomography of the chest. The etiology of the nonobstructive form is not completely understood. Inefficient collateral ventilation, infection and inflammation in the middle lobe or lingula are thought to play a role, and bronchiectasis is the most common histological finding. Patients with proven endobronchial lesions or malignancy are usually offered surgical resection directly. This contrasts with nonobstructive MLS, where most patients respond to medical treatment consisting of bronchodilators, mucolytics and broad-spectrum antibiotics. However, some patients do not respond to conservative treatment and may suffer irreversible damage of the middle lobe or lingula, in addition to having recurrent symptoms of infection or inflammation. These selected patients can be offered surgical resection of the middle lobe or lingula, which is associated with a low mortality rate and favorable outcome.

Bronchiectasis: new approaches to diagnosis and management

Non-cystic fibrosis (CF) bronchiectasis is a common, potentially serious, condition. Further investigations should be performed in an attempt to identify the underlying cause because it may lead to a change in therapy and have significant prognostic implications. MRI is being investigated as a radiation free alternative to high-resolution CT scan of the chest. Many of the treatment recommendations for non-CF bronchiectasis have not been studied in randomized controlled trials but have been extrapolated from the management recommendations for CF. Studies are beginning to inform decisions regarding the management of non-CF bronchiectasis, and an understanding of the best treatment options is beginning to emerge.

Sensory functions of motile cilia and implication for bronchiectasis

Cilia are specialized organelles that extend from the cell surface into the local environment. Cilia of the airway epithelia are motile to provide mucociliary clearance. On other cells, solitary cilia are specialized to detect chemical or mechanosensory signals. Sensory proteins in motile cilia have recently been identified that detect fluid flow, bitter taste and sex hormones. The relationship of these sensory functions in motile cilia to disease is now being revealed. An example are the polycystin-1 and polycystin-2 proteins that function as a flow sensor in kidney cilia and are mutated in autosomal dominant polycystic kidney disease (ADPKD). These polycystins are also expressed in motile cilia, potentially operating as sensors in the lung. Computed tomography studies from patients with ADPKD reveal evidence of bronchiectasis, suggesting polycystins are important in lung function. The motile cilia expression of this protein complex, as well as sensory channel TRPV4, bitter taste and sex hormones receptors, indicate that the cilia is wired to interpret environmental cues. Defective signaling of sensory proteins may result in a ciliopathy that includes lung disease.

Surgery for bronchiectasis: The effect of morphological types to prognosis

BACKGROUND

Although the incidence has declined over the past years in societies with high socioeconomic status, bronchiectasis is still an important health problem in our country.

AIM

To review and present our cases undergoing surgery for bronchiectasis in the past 12 years and their early and late term postoperative outcomes and our experience in bronchiectasis surgery and the effect of morphological type on the prognosis.

METHODS

The medical records of 62 cases undergoing surgical resection for bronchiectasis in the Clinics of Thoracic and Pediatric Surgery were evaluated retrospectively. The disease was on the left in 33 cases, on the right in 26 and bilateral in three cases. The most common surgical procedure was lobectomy. Forty one patients underwent pneumonectomy, lobectomy and complete resection including bilobectomy. Twenty-one (33.87%) cases underwent incomplete resection, of whom 11 (17.74%) underwent segmentectomy and 10 (16.13%) underwent lobectomy + segmentectomy.

RESULTS

It was found that the rate of being asymptomatic was significantly higher in patients undergoing complete resection compared to those undergoing incomplete resection. Spirometric respiratory function tests were performed to assess the relationship between morphological type and the severity of disease. All parameters of respiratory function were worse in the saccular type and FEV(1)/FVC showed a worse obstructive deterioration in the saccular type compared to the tubular type.

CONCLUSION

The success rate of the procedure increases with complete resection of the involved region. The morphological type is more important than the number and extension of the involved segments in showing the disease severity.

Bronchoscopic and high-resolution CT scan findings in children with chronic wet cough

BACKGROUND

Chronic wet cough strongly suggests endobronchial infection, which, if left untreated, may progress to established bronchiectasis. Our aim was to compare the effectiveness of chest high-resolution CT (HRCT) scanning and flexible bronchoscopy (FB) in detecting airway abnormalities in children with chronic wet cough and to explore the association between radiologic and bronchoscopic/BAL findings.

METHODS

We retrospectively evaluated a selected population of 93 children (0.6-16.4 years) with wet cough for > 6 weeks who were referred to a specialized center and deemed unlikely to have asthma. All patients were submitted to hematologic investigations, chest radiographs (CXRs), HRCT scanning, and FB/BAL. HRCT scans were scored with the Bhalla method, and bronchoscopic findings of bronchitis were grouped into five grades of severity.

RESULTS

Positive HRCT scan findings were present in 70 (75.2%) patients (P = .76). A positive correlation was found between Bhalla score and duration of cough (ρ = 0.23, P = .028). FB/BAL was superior to HRCT scan in detecting abnormalities (P < .001). The Bhalla score correlated positively with type III (OR, 5.44; 95% CI, 1.92-15.40; P = .001) and type IV (OR, 8.91; 95% CI, 2.53-15.42; P = .001) bronchoscopic lesions; it also correlated positively with the percentage of neutrophils in the BAL (ρ = 0.23, P = .036).

CONCLUSIONS

HRCT scanning detected airway wall thickening and bronchiectasis, and the severity of the findings correlated positively with the length of clinical symptoms and the intensity of neutrophilic inflammation in the airways. However, HRCT scanning was less sensitive than FB/BAL in detecting airway abnormalities. The two modalities should be considered complementary in the evaluation of prolonged wet cough.

Respiratory bacterial pathogens in the nasopharynx and lower airways of Australian indigenous children with bronchiectasis

OBJECTIVE

To test the hypothesis that bacterial density, strain diversity, and concordance of pathogens between upper and lower airways are higher in children with bronchiectasis than in those with non-bronchiectatic conditions.

STUDY DESIGN

Nasopharyngeal (NP) swabs and bronchoalveolar lavage (BAL) fluid were cultured from 45 Indigenous children with bronchiectasis and 30 non-Indigenous children with non-bronchiectatic respiratory symptoms. Lower airway infection was defined as >10(4) colony-forming units of respiratory bacteria/mL of BAL fluid. Concordance was determined by phenotype or genotype.

RESULTS

NP carriage of Streptococcus pneumoniae, nontypable Haemophilus influenzae (NTHi), and Moraxella catarrhalis, and lower airway infection by NTHi (47% vs 3%), were detected significantly more often in the children with bronchiectasis than in those without this condition. BAL specimens from the infected Indigenous children also showed greater strain diversity (71% vs 0%). Strain concordance in NP and BAL cultures was high in both infected subgroups.

CONCLUSIONS

The high density and diversity of respiratory bacteria, along with strain concordance between upper and lower airways, found in Indigenous children with bronchiectasis suggest a possible pathogenic role of recurrent aspiration of NP secretions.

Motion artifact on high-resolution CT images of pediatric patients: comparison of volumetric and axial CT methods

OBJECTIVE

The purpose of this study was to address the controversy whether the quality of volumetric high-resolution CT (HRCT) images is as good as that of axial nonvolumetric HRCT images by assessing the degree of motion artifact on images acquired with the two methods at MDCT of pediatric patients with known or suspected lung disease.

MATERIALS AND METHODS

A search of the hospital information system was conducted to identify the cases of pediatric patients with clinically suspected or known interstitial lung disease who underwent 16-MDCT of the chest with both volumetric and axial HRCT acquisitions (both 1.25-mm slice thickness) from March 2005 to July 2008. Two pediatric radiologists reviewed the images for the presence of motion artifacts at three anatomic levels (upper, middle, and lower lung zones). Motion artifacts were given numerical grades representing no artifact to severe artifact, and the paired Student's t test was used to compare the scores for the two acquisition methods. A total motion score for each acquisition was calculated by summing the scores for each of the three lung zones, and the scores for the two imaging methods were compared. Correlation between degree of motion artifact and age was evaluated. Effective radiation doses were estimated for volumetric and axial CT acquisitions.

RESULTS

The study population consisted of 54 children (28 boys, 26 girls; mean age, 11.7 +/- 3.8 years; range, 5-18 years; eight inpatients, 46 outpatients) who underwent a total of 54 MDCT chest studies with volumetric and axial HRCT acquisitions. Motion artifact scores were higher for axial than for volumetric HRCT images of the upper (1.2 vs 1.0), middle (1.6 vs 1.2), and lower (2.2 vs 1.5) lung zones (p < 0.05 at each level). The total motion score of the axial HRCT images (mean, 5; range, 1-9) was higher than that of the volumetric HRCT images (mean, 3.6; range, 1-8) (p < 0.05). Younger age correlated with higher motion artifact score on axial HRCT images (r = -0.36, p < 0.01), whereas no correlation was found between age and motion artifact score on volumetric HRCT images (r = -0.12, p = 0.38). The effective radiation doses were 0.57 mSv for axial HRCT acquisition and 7.6 mSv for volumetric acquisition. The addition of axial acquisition increased the total radiation dose of the MDCT examination 7.1%.

CONCLUSION

At CT of pediatric patients, reconstructed HRCT images from volumetric MDCT acquisition have significantly less motion artifact than images obtained with traditional axial acquisition.