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

ACR Appropriateness Criteria® Tracheobronchial Disease

A variety of thoracic imaging modalities and techniques have been used to evaluate diseases of the trachea and central bronchi. This document evaluates evidence for the use of thoracic imaging in the evaluation of tracheobronchial disease, including clinically suspected tracheal or bronchial stenosis, tracheomalacia or bronchomalacia, and bronchiectasis. Appropriateness guidelines for initial imaging evaluation of tracheobronchial disease and for pretreatment planning or posttreatment evaluation are included. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Postinfectious Pulmonary Complications: Establishing Research Priorities to Advance the Field: An Official American Thoracic Society Workshop Report

Continued improvements in the treatment of pulmonary infections have paradoxically resulted in a growing challenge of individuals with postinfectious pulmonary complications (PIPCs). PIPCs have been long recognized after tuberculosis, but recent experiences such as the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic have underscored the importance of PIPCs following other lower respiratory tract infections. Independent of the causative pathogen, most available studies of pulmonary infections focus on short-term outcomes rather than long-term morbidity among survivors. In this document, we establish a conceptual scope for PIPCs with discussion of globally significant pulmonary pathogens and an examination of how these pathogens can damage different components of the lung, resulting in a spectrum of PIPCs. We also review potential mechanisms for the transition from acute infection to PIPC, including the interplay between pathogen-mediated injury and aberrant host responses, which together result in PIPCs. Finally, we identify cross-cutting research priorities for the field to facilitate future studies to establish the incidence of PIPCs, define common mechanisms, identify therapeutic strategies, and ultimately reduce the burden of morbidity in survivors of pulmonary infections.

Chest computed tomography findings among adult Aboriginal Australians with bronchiectasis in the Top End Northern Territory of Australia

INTRODUCTION

There is limited evidence in the literature illustrating chest computed tomography (CT) characteristics among adult Aboriginal Australians with bronchiectasis. This retrospective study evaluates the radiological characteristics of bronchiectasis in Aboriginal Australians residing in the Top End, Northern Territory of Australia.

METHODS

Patients aged >18 years with chest CT-confirmed bronchiectasis between 2011 and 2020 were included. Demographics and relevant clinical parameters were collected. Alongside confirming bronchiectasis, chest CT reports were assessed for (i) lobar location (ii) unilateral or bilateral involvement and (iii) bronchiectasis type when available.

RESULTS

A total of 459 patients were identified with chest CT-confirmed bronchiectasis, with a median age of 47 years, and 55% were females. Bronchiectasis was predominantly recorded in the left lower lobe (LLL) (73%), followed by the right lower lobe (RLL) (62%) and the left upper lobe (LUL) was least common (22%). Females recorded the right middle lobe (RML) affected significantly more often than males (50 vs. 34%, P = 0.012). Bilateral involvement was common (74%), with the strongest pairwise correlation associated between the right upper lobe (RUL) and LUL (P < 0.001). Cylindrical (50%) and cystic (28%) types were most common. The RML and LLL showed positive correlation with cylindrical and LUL with cystic bronchiectasis. Neither lobar location nor bronchiectasis type showed any significant association with lung function parameters other than RML, Lingula and LUL involvement being associated with better percent predicted values of diffusing capacity for carbon monoxide. There were no significant associations between sputum culture and type or lobar locations of bronchiectasis except for non-Aspergillus fungus culture prevalence was higher with cystic or cylindrical types.

CONCLUSION

The results of this study may be an avenue to develop CT bronchiectasis severity scale in the future specific for Aboriginal Australians.

ECFS standards of care on CFTR-related disorders: Identification and care of the disorders

This is the third paper in the series providing updated information and recommendations for people with cystic fibrosis transmembrane conductance regulator (CFTR)-related disorder (CFTR-RD). This paper covers the individual disorders, including the established conditions - congenital absence of the vas deferens (CAVD), diffuse bronchiectasis and chronic or acute recurrent pancreatitis - and also other conditions which might be considered a CFTR-RD, including allergic bronchopulmonary aspergillosis, chronic rhinosinusitis, primary sclerosing cholangitis and aquagenic wrinkling. The CFTR functional and genetic evidence in support of the condition being a CFTR-RD are discussed and guidance for reaching the diagnosis, including alternative conditions to consider and management recommendations, is provided. Gaps in our knowledge, particularly of the emerging conditions, and future areas of research, including the role of CFTR modulators, are highlighted.

Biomarkers in bronchiectasis

Bronchiectasis is a heterogeneous disease with multiple aetiologies and diverse clinical features. There is a general consensus that optimal treatment requires precision medicine approaches focused on specific treatable disease characteristics, known as treatable traits. Identifying subtypes of conditions with distinct underlying biology (endotypes) depends on the identification of biomarkers that are associated with disease features, prognosis or treatment response and which can be applied in clinical practice. Bronchiectasis is a disease characterised by inflammation, infection, structural lung damage and impaired mucociliary clearance. Increasingly there are available methods to measure each of these components of the disease, revealing heterogeneous inflammatory profiles, microbiota, radiology and mucus and epithelial biology in patients with bronchiectasis. Using emerging biomarkers and omics technologies to guide treatment in bronchiectasis is a promising field of research. Here we review the most recent data on biomarkers in bronchiectasis.

COPD Assessment Test and risk of readmission in patients with bronchiectasis: a prospective cohort study

Introduction

Readmission following bronchiectasis exacerbation is a common and challenging clinical problem and few simple predictive tools exist. The COPD Assessment Test (CAT) is an easy-to-use questionnaire. This study aims to evaluate the predictive value of CAT scores in determining the risk of readmission in patients with bronchiectasis exacerbation.

Methods

We conducted a prospective cohort study in 106 bronchiectasis patients admitted with exacerbation. All patients completed the CAT at admission and at discharge. Patients were followed-up for 12 months to collect data on readmission. The area under the curve was used to measure the predictive value of CAT at admission, CAT at discharge and change in CAT for readmission due to bronchiectasis exacerbation.

Results

46 patients were readmitted for bronchiectasis exacerbation within 12 months. High CAT at admission was an independent risk factor for readmission within 12 months in patients with acute exacerbation of bronchiectasis (hazard ratio 3.201, 95% CI 1.065-9.624; p<0.038) after adjustment for confounding variables. The cut-off value of CAT at admission and CAT at discharge to predict 12-month readmission in patients with acute exacerbation of bronchiectasis was 23.5 (sensitivity 62.2%, specificity 83.6%) and 15.5 (sensitivity 52.2%, specificity 87.0%).

Conclusions

CAT at admission is a strong predictor of readmission in patients with bronchiectasis exacerbation.

Clinical characteristics, radiological features, and disease severity of bronchiectasis according to the spirometric pattern

Bronchiectasis show various ventilatory disorders in pulmonary function. The characteristics and severity of patients with bronchiectasis according to these pulmonary dysfunctions are still very limited. This study aimed to evaluate the clinical, radiologic feature and the disease severity of patients with bronchiectasis according to spirometric patterns. We retrospectively evaluated 506 patients with bronchiectasis who underwent pulmonary lung function test (PFT) at a referral hospital between 2014 to 2021. The results showed that cylindrical type was the most common (70.8%) type of bronchiectasis on chest Computed tomography (CT), and 70% of patients had bilateral lung involvement. On the other hand, obstructive ventilatory disorder was the most common (51.6%), followed by normal ventilation (30%) and restrictive ventilatory disorder (18.4%). The modified Medical Research Council (mMRC) was highest in patients with obstructive ventilatory disorders, Modified Reiff score [median (interquartile range)] [6 (3–10), P < 0.001], FACED (FEV₁, Age, Chronic colonization, Extension, and Dyspnea) score [3 (1–4), P < 0.001], and Bronchiectasis Severity (BSI) score [8 (5–11), P < 0.001] showed significantly highest values of obstructive ventilatory disorder rather than restrictive ventilatory disorder and normal ventilation. More than half of patients with bronchiectasis had obstructive ventilatory disorder. Bronchiectasis with obstructive ventilatory disorders has more dyspnea symptom, more disease severity and more radiologic severity. There was no significant association between spirometric pattern and radiologic type, but the more severe the radiologic severity, the more severe the lung function impairment.

Risk Factors Associated with Impairment in Pulmonary Diffusing Capacity among Patients with Noncystic Fibrosis Bronchiectasis

This study aims to investigate the risk factors associated with impaired pulmonary diffusing capacity among patients with noncystic fibrosis bronchiectasis (NCFB) and compare the predictive value of several scoring systems for the impairment in these patients. Between July 2019 and June 2021, patients who were admitted to the hospital and diagnosed with NCFB were included in this study. Clinical data were collected and analyzed retrospectively. A total of 175 NCFB patients were included in the analysis. Multivariate logistic regression analysis revealed that impaired pulmonary diffusing capacity diagnosed by carbon monoxide diffusing capacity (DLCO) <80% prediction was associated with age, Reiff score, body mass index (BMI), comorbid chronic obstructive pulmonary disease (COPD), and interstitial lung disease (ILD). Disease duration, frequency of exacerbation, hemoglobin level, and COPD were independent risk factors for impaired pulmonary diffusing capacity diagnosed by DLCO/alveolar volume (VA) <80% prediction. Age, Reiff score, and smoking status were independent risk factors for decreased VA diagnosed by VA <80% prediction. The areas under the curve (AUC) for discrimination of DLCO <80% prediction were 0.822 (0.760-0.885) for Bronchiectasis Severity Index (BSI), 0.787 (0.718-0.856) for FACED, 0.795 (0.729-0.863) for E-FACED, and 0.767 (0.694-0.839) for modified Medical Research Council (mMRC) scores; the AUC for discrimination of DLCO/VA <80% prediction was 0.803 (0.727-0.880) for BSI, 0.752 (0.669-0.835) for FACED, 0.757 (0.676-0.839) for E-FACED, and 0.762 (0.679-0.845) for mMRC, respectively. The BSI had the largest AUC, but the differences between those scoring systems had no statistical significance (P=0.181 for DLCO <80% prediction and P=0.105 for DLCO/VA <80% prediction). The mMRC score (up to 2 grades) showed a high specificity for discriminating diffusing dysfunction (88.3% for DLCO <80% prediction and 76.1% for DLCO/VA <80% prediction). In NCFB patients, several factors such as age, Reiff score, BMI, exacerbation frequency, disease duration, and comorbid COPD and ILD were associated with impaired pulmonary diffusing capacity, which requires more attention in managing those patients. In addition, several scoring methods, including a simple index of mMRC, showed a comparable and moderate performance for predicting pulmonary diffusing impairment and would facilitate the systematic evaluation of the diffusing capacity of NCFB patients.

Impact of bronchial wall thickness on airflow obstruction in bronchiectasis

The association between airflow obstruction and bronchial dilation has been researched in bronchiectasis. However, the impact of bronchial wall thickening on airflow obstruction has not been thoroughly investigated. This study assessed the underlying mechanism of airflow obstruction in bronchiectasis due to abnormal bronchial wall thickening using oscillometry. A total of 98 patients with bronchiectasis were retrospectively reviewed. At the time of diagnosis, spirometric and oscillometric parameters, high-resolution computed tomography scores, and clinical characteristics were collected. The bronchial diameter, bronchial wall thickness, and extent of emphysema were evaluated semi-quantitatively. Correlations between patient data and characteristics were analyzed. Thirty-three patients with airflow obstruction showed higher respiratory resistance, more negative respiratory reactance (Xrs) at 5 Hz (X5), and higher bronchial wall thickness score than those without airflow obstruction. The bronchial wall thickness score negatively affected forced expiration volume in 1 s /forced vital capacity and X5. Abnormal bronchial wall thickening might make Xrs more negative and progress airflow obstruction in bronchiectasis.

Imaging in non-cystic fibrosis bronchiectasis and current limitations

Non-cystic fibrosis bronchiectasis represents a heterogenous spectrum of disorders characterised by an abnormal and permanent dilatation of the bronchial tree associated with respiratory symptoms. To date, diagnosis relies on computed tomography (CT) evidence of dilated airways. Nevertheless, definite radiological criteria and standardised CT protocols are still to be defined. Although largely used, current radiological scoring systems have shown substantial drawbacks, mostly failing to correlate morphological abnormalities with clinical and prognostic data. In limited cases, bronchiectasis morphology and distribution, along with associated CT features, enable radiologists to confidently suggest an underlying cause. Quantitative imaging analyses have shown a potential to overcome the limitations of the current radiological criteria, but their application is still limited to a research setting.

In the present review, we discuss the role of imaging and its current limitations in non-cystic fibrosis bronchiectasis. The potential of automatic quantitative approaches and artificial intelligence in such a context will be also mentioned.

USE OF COMPUTED TOMOGRAPHY (CT) TO DETERMINE THE SENSITIVITY OF CLINICAL SIGNS AS A DIAGNOSTIC TOOL FOR RESPIRATORY DISEASE IN BORNEAN ORANGUTANS (PONGO PYGMAEUS)

Orangutans are noteworthy among great apes in their predilection for chronic, insidious, and ultimately fatal respiratory disease. Termed Orangutan Respiratory Disease Syndrome (ORDS), this cystic fibrosis-like disease is characterized by comorbid conditions of sinusitis, mastoiditis, airsacculitis, bronchiectasis, and recurrent pneumonia. The aim of this retrospective study was to determine the sensitivity of clinical signs in the diagnosis of ORDS in Bornean orangutans (Pongo pygmaeus) compared with the gold standard for diagnosis via computed tomography (CT). We retrospectively compared observed clinical signs with CT imaging in a population of clinically affected animals at an orangutan rescue center in southeastern Borneo. From August 2017 to 2019, this center housed 21 ORDS-affected animals, all of which underwent CT imaging to delineate which areas of the respiratory tract were affected. We reviewed clinical signs recorded in medical records and keeper observation notes for each individual for the period of 2 years prior to the date of the CT scan. A chi-square test of association was used to assess whether the observed clinical signs could predict the results of CT imaging. Results show that clinical signs may not be sensitive indicators in predicting respiratory disease identified by CT imaging. Based on the results of this study, clinical signs appear to be very poor predictors of underlying respiratory pathology in orangutans, based on high P-values, low sensitivity, and low specificity. This result is observed even with clinical signs data gathered over a full 24-mo period prior to CT scan performance. The findings of this study suggest the need for advanced imaging to properly diagnose and manage the most common health issue of captive orangutans.

Chronic Obstructive Pulmonary Disease as a Phenotype of Bronchiectasis for Long-Term Clinical Presentation and Treatment

Background and Objectives: Bronchiectasis and chronic obstructive pulmonary disease (COPD) often coexist, although the causality is not currently clear. Currently, the clinical influence of COPD on patients with major bronchiectasis over time has not yet been investigated. Material and Methods: This retrospective study recruited consecutive patients with bronchiectasis from outpatient clinic between January 2006 and December 2007. Under the setting of quantification with HRCT, patients who should undergo multiple pulmonary function and exercise tests with regularclinic follow-up were included. The final analysis consisted of 66 eligible patients who were evaluated for clinical status, treatment, and sputum culture from up to 10-year electronic medical records. Results: Of these 66 patients, 45 (68%) had bronchiectasis without COPD and 21 (32%) had COPD. Patients with COPD group had a higher bronchiectasis extent score (32.21 ± 13.09 points vs. 21.89 ± 10.08 points, p = 0.001). Sputum production was reported more frequently by patients with COPD; however, no significant difference was observed after 3 years of follow-up (82.4% vs. 81.6%, p = 0.945). Bronchiectasis extent score correlated with positive sputum culture with Pseudomonas without a synergistic effect from COPD (odds ratio: 1.06, confidence interval: 1.00–1.12, p = 0.031). Regardless of COPD, after 10 years, the proportion of patients using inhaled corticosteroids and/or long-acting β2-agonist between the two groups was not significantly different. Conclusion: COPD aggravated bronchiectasis extension, which was correlated with chronic Pseudomonas aeruginosa colonisation. Moreover, COPD would affect the medium-term (in 3–5 years) bronchiectasis treatment. Therefore, the COPD phenotype of bronchiectasis could be a clinical predictor of the course of treatment.

Quality of life and its determinants in patients with noncystic fibrosis bronchiectasis

Background:

Promoting quality of life (QoL) in patients with bronchiectasis, as a chronic disease, is a part of therapeutic principles. This study aimed to investigate QoL and its determinants in patients with noncystic fibrosis (CF) bronchiectasis.

Materials and Methods:

This cross-sectional study was conducted on 62 patients (38.7% male, mean age: 44) with non-CF bronchiectasis and involvement of ≥2 lobes in Qazvin, Iran. QoL was evaluated using the St. George's Respiratory Questionnaire (SGRQ). The relationships of QoL subscales with clinical (cough, dyspnea, and sputum volume) and paraclinical (spirometry, computerized tomography scan, sputum microbiology, and 6-min walk test [6-MWT]) were assessed using Pearson's correlation coefficient and multiple linear regression analyses.

Results:

The mean SGRQ total score was 53.1 (standard deviation 19.8) out of 100. The level of dyspnea (r = 0.543, P < 0.001), cough (r = −0.594, P < 0.001), 6-MWT (r = −0.520, P < 0.001), sputum volume (r = 0.423, P = 0.002), and number of exacerbations (r = 0.446, P = 0.009) had significant correlation with SGRQ total score. In multiple regression analysis, forced expiratory volume in 1 s was an independent predictor of the symptom (β = −0.22, P = 0.048) and activity (β = −0.43, P = 0.03) subscales, whereas cough was an independent predictor of the symptom subscale (β = −2.1, P = 0.002).

Conclusion:

In patients with non-CF bronchiectasis, the extent of lung impairment has a lower effect on the QoL than clinical symptoms. It seems that the QoL can be improved through the proper treatment of clinical symptoms and rehabilitation for promoting 6-MWT.

Clinical features associated with a doctor-diagnosis of bronchiectasis in the Severe Asthma Network in Italy (SANI) registry

BACKGROUND

Several severe asthma comorbidities have been identified: an emerging one is bronchiectasis. We evaluated the frequency of bronchiectasis on severe asthma in a real-life setting, through the 'Severe Asthma Network Italy' (SANI) registry.

METHODS

SANI registry encompasses demographic, clinical, functional and inflammatory data of Italian severe asthmatics. Data obtained by the enrolled patients were analyzed, focusing the attention on those patients with concomitant clinically relevant bronchiectasis.

RESULTS

About 15.5% patients have bronchiectasis. Bronchiectasis diagnosis was associated with a higher prevalence of chronic rhinosinusitis with nasal polyps (54.6% vs. 38%, p = 0.001) and higher serum IgE levels (673.4 vs. 412.1 kUI/L, p = 0.013). Patients with bronchiectasis had worse asthma control (ACT: 16.7 vs 18.2, p = 0.013), worse quality of life (AQLQ: 4.08 vs. 4.60, p = 0.02) and lower lung function (FEV₁% predicted 67.3 vs. 75.0, p = 0.002). A higher rate of severe asthma exacerbations in the previous 12 months (85.2% vs. 61.5%, p < 0.001) was found in patients with bronchiectasis.

CONCLUSION

severe asthma associated with bronchiectasis represents a particularly severe asthma variant, possibly driven by an eosinophilic endotype. We, therefore, suggest that bronchiectasis should necessarily be assessed in severe asthmatic patients.

Characterization of the severity of dyspnea in patients with bronchiectasis: correlation with clinical, functional, and tomographic aspects

OBJECTIVE

To characterize a population of patients with bronchiectasis, correlating clinical, radiological, and functional aspects with the severity of dyspnea.

METHODS

This was a cross-sectional study involving adult patients with HRCT-confirmed bronchiectasis, categorized according to the severity of dyspnea (as being mildly or severely symptomatic, on the basis of the modified Medical Research Council scale). We correlated the severity of dyspnea with clinical parameters, functional parameters (spirometry values, lung volumes, and DLCO), and CT parameters.

RESULTS

We evaluated 114 patients, 47 (41%) of whom were men. The median age (interquartile range) was 42 years (30-55 years). The most common form was idiopathic bronchiectasis. Of the 114 patients, 20 (17.5%) were colonized with Pseudomonas aeruginosa and 59 (51.8%) were under continuous treatment with macrolides. When we applied the Exacerbation in the previous year, FEV1, Age, Colonization, Extension, and Dyspnea score, the severity of dyspnea was categorized as moderate in 54 patients (47.4%), whereas it was categorized as mild in 50 (43.9%) when we applied the Bronchiectasis Severity Index. The most common lung function pattern was one of obstruction, seen in 95 patients (83.3%), and air trapping was seen in 77 patients (68.7%). The prevalence of an obstructive pattern on spirometry was higher among the patients with dyspnea that was more severe, and most functional parameters showed reasonable accuracy in discriminating between levels of dyspnea severity.

CONCLUSIONS

Patients with bronchiectasis and dyspnea that was more severe had greater functional impairment. The measurement of lung volumes complemented the spirometry data. Because bronchiectasis is a complex, heterogeneous condition, a single variable does not seem to be sufficient to provide an overall characterization of the clinical condition.

Diagnosis and quantification of bronchiectasis using computed tomography or magnetic resonance imaging: A systematic review

BACKGROUND

Bronchiectasis is an irreversible dilatation of the airways caused by inflammation and infection. To diagnose bronchiectasis in clinical care and to use bronchiectasis as outcome parameter in clinical trials, a radiological definition with exact cut-off values along with image analysis methods to assess its severity are needed. The aim of this study was to review diagnostic criteria and quantification methods for bronchiectasis.

METHODS

A systematic literature search was performed using Embase, Medline Ovid, Web of Science, Cochrane and Google Scholar. English written, clinical studies that included bronchiectasis as outcome measure and used image quantification methods were selected. Criteria for bronchiectasis, quantification methods, patient demographics, and data on image acquisition were extracted.

RESULTS

We screened 4182 abstracts, selected 972 full texts, and included 122 studies. The most often used criterion for bronchiectasis was an inner airway-artery ratio ≥1.0 (42%), however no validation studies for this cut-off value were found. Importantly, studies showed that airway-artery ratios are influenced by age. To quantify bronchiectasis, 42 different scoring methods were described.

CONCLUSION

Different diagnostic criteria for bronchiectasis are being used, but no validation studies were found to support these criteria. To use bronchiectasis as outcome in future studies, validated and age-specific cut-off values are needed.

Diagnostic imaging in adult non-cystic fibrosis bronchiectasis

Radiology plays a key role in the diagnosis of bronchiectasis, defined as permanent dilatation of the bronchial lumen. Volumetric thin-section multidetector computed tomography is an excellent noninvasive modality to evaluate bronchiectasis. Bronchiectasis is categorised by morphological appearance. Cylindrical bronchiectasis has a smooth tubular configuration and is the most common form. Varicose bronchiectasis has irregular contours with alternating dilating and contracting lumen. Cystic bronchiectasis is the most severe form and exhibits saccular dilatation of bronchi. Bronchial dilatation is the hallmark of bronchiectasis and is evaluated in relation to the accompanying pulmonary artery. A broncho–arterial ratio exceeding 1:1 should be considered abnormal. Normal bronchi are narrower in diameter the further they are from the lung hila. Lack of normal bronchial tapering over 2 cm in length, distal from an airway bifurcation, is the most sensitive sign of bronchiectasis. Findings commonly associated with bronchiectasis include bronchial wall thickening, mucus plugging and tree-in-bud opacities. Bronchiectasis results from a myriad of conditions, with post-infectious bronchiectasis being the most common. Imaging can sometimes discern the cause of bronchiectasis. However, in most cases it is nonspecific or only suggestive of aetiology. While morphological types are nonspecific, the distribution of abnormality offers clues to aetiology.

Bronchiectasis is a chronic progressive condition with significant disease burden and frequent exacerbations for which the diagnosis relies on cross-sectional imaginghttp://bit.ly/2NxOLky

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.

High-Resolution Computed Tomography and Pulmonary Function Findings of Occupational Arsenic Exposure in Workers

Background:

The number of studies where non-malignant pulmonary diseases are evaluated after occupational arsenic exposure is very few.

Aims:

To investigate the effects of occupational arsenic exposure on the lung by high-resolution computed tomography and pulmonary function tests.

Study Design:

Retrospective cross-sectional study.

Methods:

In this study, 256 workers with suspected respiratory occupational arsenic exposure were included, with an average age of 32.9±7.8 years and an average of 3.5±2.7 working years. Hair and urinary arsenic levels were analysed. High-resolution computed tomography and pulmonary function tests were done.

Results:

In workers with occupational arsenic exposure, high-resolution computed tomography showed 18.8% pulmonary involvement. In pulmonary involvement, pulmonary nodule was the most frequently seen lesion (64.5%). The other findings of pulmonary involvement were 18.8% diffuse interstitial lung disease, 12.5% bronchiectasis, and 27.1% bullae-emphysema. The mean age of patients with pulmonary involvement was higher and as they smoked more. The pulmonary involvement was 5.2 times higher in patients with skin lesions because of arsenic. Diffusing capacity of lung for carbon monoxide was significantly lower in patients with pulmonary involvement.

Conclusion:

Besides lung cancer, chronic occupational inhalation of arsenic exposure may cause non-malignant pulmonary findings such as bronchiectasis, pulmonary nodules and diffuse interstitial lung disease. So, in order to detect pulmonary involvement in the early stages, workers who experience occupational arsenic exposure should be followed by diffusion test and high-resolution computed tomography.

Surgery for predominant lesion in nonlocalized bronchiectasis

OBJECTIVE

Patients with nonlocalized bronchiectasis are encountered commonly; however, there is little information regarding surgical intervention in this patient population. The aim of this study was to evaluate symptomatic response and safety of anatomic resection of the predominant lesion via the use of lobectomy for the management of nonlocalized bronchiectasis.

METHODS

We reviewed the medical records of 37 consecutive patients who underwent lobectomy via thoracotomy for nonlocalized bronchiectasis between 2010 and 2013. The main surgical indications were nonlocalized bronchiectasis with one predominant lesion, failure of medical treatment, and adequate cardiopulmonary reserve. The predominant lesion was determined by preoperative computed tomography and/or bronchoscopy. Preoperative symptoms were compared with postoperative symptoms and analyzed by the use of paired techniques.

RESULTS

The mean patient age was 54.5 ± 6.4 years. There was no operative mortality. Postoperative complications occurred in 8 (21.6%) patients, including 1 with empyema, 1 with persistent air leak, and 6 with minor transient complications, all of which were manageable without any reoperation. After lobectomy, the median extent of residual bronchiectatic areas in the remaining lungs was 25% (range, 12.5%-42.9%). The frequency of acute infection (5.3 ± 2.1/year vs 1.8 ± 2.3/year) and hemoptysis (4.9 ± 2.8/year vs 1.1 ± 0.7/year) decreased significantly and the amount of sputum also decreased (37.1 ± 3.4 mL/day vs 10.7 ± 4.6 mL/day). Twenty-three (62.2%) patients were asymptomatic after surgery, 10 (27.0%) were symptomatic with clinical improvement, and 4 (10.8%) had no change or worsened.

CONCLUSIONS

Lobectomy for the predominant lesion is a safe procedure in the surgical treatment of nonlocalized bronchiectasis and leads to significant relief of symptoms with good rates of satisfaction.

A morphologic study of the airway structure abnormalities in patients with asthma by high-resolution computed tomography

BACKGROUND

Airway structure changes, termed as airway remodeling, are common in asthma patients due to chronic inflammation, which can be assessed by high-resolution computed tomography (HRCT). Considering the controversial conclusions in the correlation of morphologic abnormalities with clinical feature and outcome, we aimed to further specify and evaluate the structural abnormalities of Chinese asthmatics by HRCT.

METHODS

From August 2012 to February 2015, outpatients with asthma were recruited consecutively in the Asthma Center of West China Hospital, Sichuan University. Standard HRCT and pulmonary function test (PFT) were performed to collect information of bronchial wall thickening, bronchial dilatation, mucus impaction, emphysema, mosaic perfusion, atelectasis, and spirometric parameters. We reported the incidence of each structural abnormality in HRCT and compared it among different asthmatic severities.

RESULTS

A total of 123 asthmatics were enrolled, among which 84 (68.3%) were female and 39 (31.7%) were male. At least one structural abnormality was detected by HRCT in 85.4% asthmatics, and the incidence of bronchial wall thickening, bronchial dilatation, mucus impaction, emphysema, mosaic perfusion, and atelectasis was 57.7%, 51.2%, 22%, 24.4%, 5.7% and 1.6%, respectively. The incidences of bronchial wall thickening, bronchial dilation and emphysema were significantly increased by asthma severity (P<0.05), while incidences of mucus impaction (26/27, 96.30%), mosaic perfusion (6/7, 85.71%) and atelectasis (2/2, 100%) were mainly found in severe asthma. We found a longer asthma history (28.13±18.55 years, P<0.001, P=0.003), older age (51.30±10.70 years, P=0.022, P=0.006) and lower predicted percentage of forced expiratory volume in one second (FEV₁%) (41.97±15.19, P<0.001, P<0.001) and ratio of forced expiratory volume to forced vital capacity (FEV₁/FVC) (48.01±9.55, P<0.001, P<0.001) in patients with severe bronchial dilation compared with those in none and mild bronchial dilation. A negative correlation was also found between the extent of bronchial dilation and FEV₁% as well as FEV₁/FVC (r=-0.359, P=0.004; r=-0.266, P=0.035, respectively).

CONCLUSIONS

The incidences of structural abnormalities detected by HRCT are fairly high in Chinese asthma populations, especially the bronchial wall thickening and bronchial dilation, which are significantly increased in severe asthma, and are potential risk factors of pulmonary function decline in asthmatics.

Phenotyping Adults with Non-Cystic Fibrosis Bronchiectasis: A 10-Year Cohort Study in a French Regional University Hospital Center

BACKGROUND

Data concerning phenotypes in bronchiectasis are scarce.

OBJECTIVE

The aim of this study was to describe the clinical, functional and microbiological phenotypes of patients with bronchiectasis.

METHODS

A monocentric retrospective study in a university hospital in France was conducted over 10 years (2002-2012). Non-cystic fibrosis patients with tomographic confirmation of bronchiectasis were included. The clinical, functional and microbiological data of patients were analyzed relying on the underlying etiology.

RESULTS

Of the 311 included patients, an etiology was found for 245 of them. At the time of diagnosis, the median age was 61 years and the mean FEV1 was 63% of predicted. The main causes of bronchiectasis were post-infectious (50%, mostly related to tuberculosis), chronic obstructive pulmonary disease (COPD; 13%) and idiopathic (11%). Other causes were immune deficiency (6%), asthma (4%), autoimmunity (3%), tumor (2%) and other causes (4%). The comparison of phenotypic traits shows significant differences between COPD, congenital and idiopathic groups in term of sex (p = 0.0175), tobacco status (p < 0.0001), FEV1 (p = 0.0412) and age at diagnosis (p < 0.001), Pseudomonas aeruginosa (PA) colonization (p = 0.0276) and lobectomy (0.0093). Functional follow-up was available in 30% of patients with a median duration of 2.7 years. Presence of PA was associated with a lower median FEV1 at diagnosis (43% p < 0.003) but not with a faster rate of decline in FEV1.

CONCLUSION

Distinctive clinical, functional and microbiological features were found for idiopathic, congenital and COPD-related bronchiectasis. A prospective follow-up of these subgroups is necessary to validate their relevance in the management of bacterial colonization and specific complications of these bronchiectases.

Non CF-bronchiectasis: Aetiologic approach, clinical, radiological, microbiological and functional profile in 277 patients

BACKGROUND AND OBJECTIVES

Non-Cystic Fibrosis (CF) bronchiectasis is common in Greece but little attention has been paid to the investigation of its aetiology, clinical, radiological, microbiological and lung function profile.

METHODS

We prospectively evaluated patients with non-CF bronchiectasis confirmed by high resolution computed tomography (HRCT) of the chest. Aetiology, clinical data, radiology score, microbiological profile and lung function were investigated.

RESULTS

We evaluated 277 patients (170 women) with bronchiectasis (mean age: 60.5 ± 16 years), 64% of them being non-smokers. Post-infectious (25.2%) and past tuberculosis (TB) (22.3%) were the most commonly identified underlying conditions, while no cause was found in 34% of the patients. The main symptoms were cough (82%), mucopurulent sputum (80%), dyspnea (60%) and haemoptysis (37%). Mean duration of symptoms was 9.7 (SD 10.7) years. Infectious exacerbations were observed in 67.5% of the patients with a mean frequency of 2.3 (SD 1.4) per year. The most frequent lung function pattern was the obstructive (43.1%) while 38% of the patients had normal spirometry. Pseudomonas aeruginosa was the most common pathogen yielded in sputum cultures (43%) followed by Haemophilus influenzae (12.6%). Patients with P. aeruginosa had a more long-standing disease and worse lung function. Radiological severity of the disease was mainly related to impaired lung function, P. aeruginosa isolation in sputum and frequent exacerbations.

CONCLUSION

Data indicate that in Greece, "past" tuberculosis remains an important cause of bronchiectasis. P. aeruginosa was the predominant pathogen in the airways, associated with disease severity, while the most common lung function impairment was obstruction.

Tolerability and Pharmacokinetic Evaluation of Inhaled Dry Powder Tobramycin Free Base in Non-Cystic Fibrosis Bronchiectasis Patients

Rationale

Bronchiectasis is a condition characterised by dilated and thick-walled bronchi. The presence of Pseudomonas aeruginosa in bronchiectasis is associated with a higher hospitalisation frequency and a reduced quality of life, requiring frequent and adequate treatment with antibiotics.

Objectives

To assess local tolerability and the pharmacokinetic parameters of inhaled excipient free dry powder tobramycin as free base administered with the Cyclops dry powder inhaler to participants with non-cystic fibrosis bronchiectasis. The free base and absence of excipients reduces the inhaled powder dose.

Methods

Eight participants in the study were trained in handling the device and inhaling correctly. During drug administration the inspiratory flow curve was recorded. Local tolerability was assessed by spirometry and recording adverse events. Serum samples were collected before, and 15, 30, 45, 60, 75, 90, 105, 120 min; 4, 8 and 12 h after inhalation.

Results and Discussion

Dry powder tobramycin base was well tolerated and mild tobramycin-related cough was reported only once. A good drug dose-serum concentration correlation was obtained. Relatively small inhaled volumes were computed from the recorded flow curves, resulting in presumably substantial deposition in the central airways—i.e., at the site of infection.

Conclusions

In this first study of inhaled dry powder tobramycin free base in non-cystic fibrosis bronchiectasis patients, the free base of tobramycin and the administration with the Cyclops dry powder device were well tolerated. Our data support further clinical studies to evaluate safety and efficacy of this compound in this population.

An analysis of etiology, causal pathogens, imaging patterns, and treatment of Japanese patients with bronchiectasis

BACKGROUND

Bronchiectasis (BE), a syndrome that presents with persistent or recurrent bronchial sepsis related to irreversibly damaged and dilated bronchi, has not been well-characterized in Asians. This study aims to review the etiology, causal pathogens, imaging patterns, and treatment of BE and to define the prognostic factors for acute exacerbation in a Japanese population.

METHODS

We performed a retrospective cohort study of 147 patients (104 women; median age, 73 years; range, 30-95 years) with BE at our institution using high-resolution computed tomography to identify imaging patterns and the area of pulmonary involvement.

RESULTS

Common BE etiologies were idiopathic (N=50 [34%]), sinobronchial syndrome (N=37 [25%]), non-tuberculous mycobacteriosis (NTM; N=26 [18%]), and previous respiratory infection (N=21[14%]). Pseudomonas aeruginosa was the most common causal pathogen (24%). Common imaging patterns were cylindrical (66%) and mixed including cylindrical pattern (47%). The median number of involved lobes was 2; 49% of the patients had ≥ 3 involved lobes, and 49% had middle lobe and left lingula dominant BE. Patients with predominantly lower lobe BE comprised 4% of the NTM group and 48% of the non-NTM group (P<0.001). In multivariate analysis, cystic BE was a predictor for frequent exacerbations in non-NTM patients (OR=7.947; P=0.004) which led to increased hospital admissions (OR=4.691; P=0.004).

CONCLUSIONS

Idiopathic and sinobronchial syndrome were common causes of BE. Etiology did not contribute to imaging pattern or predictors of exacerbations. Cystic BE was a predictor for frequent exacerbations in the non-NTM BE patients.

Chest computed tomography predicts microbiological burden and symptoms in pulmonary Mycobacterium xenopi

BACKGROUND AND OBJECTIVE

The development of computed tomography (CT) findings usually precedes the diagnosis of pulmonary nontuberculous mycobacterial infection. The utility of specific CT scan features, although often available long before respiratory sample cultures, is not fully understood. We sought to assess associations among CT features, symptoms and microbiological disease criteria in pulmonary Mycobacterium xenopi isolation.

METHODS

We reviewed 70 consecutive immunocompetent patients with pulmonary M. xenopi isolation and classified them according to the American Thoracic Society (ATS) diagnostic criteria for disease. 'Definite disease' patients (n = 16) met modified ATS criteria. 'Possible disease' patients (n = 10) met microbiological criteria, had abnormal CT scans, but data regarding symptoms were unavailable. 'No disease' patients (n = 44) had only one positive sputum culture, or were asymptomatic or had no relevant CT findings. Two radiologists, without knowledge of the clinical or microbiological information, independently reviewed the scans.

RESULTS

The mean (standard deviation) age of all patients was 63 (16) years, and 39% were women. Patients with 'definite disease' usually had nodules (88%) and cavities (63%), but less often bronchiectasis (50%) and tree-in-bud (50%). Patients with 'possible' or 'no disease', respectively, had nodules (100% or 80%), bronchiectasis (40% or 18%) or tree-in-bud (40% or 11%). Cavitation (P ≤ 0.0001) and nodules ≥ 5 mm (P = 0.0002) were associated with fulfilled microbiological criteria for disease. Bronchiectasis (P = 0.02) and nodules <5 mm (P = 0.002) were associated with symptoms of infection.

CONCLUSIONS

Among immunocompetent patients with pulmonary M. xenopi isolation, cavitation and large nodules predict fulfilling microbiological disease criteria, while bronchiectasis and small nodules predict symptoms.

Description and validation of a scoring system for tomosynthesis in pulmonary cystic fibrosis

OBJECTIVES

To design and validate a scoring system for tomosynthesis (digital tomography) in pulmonary cystic fibrosis.

METHODS

A scoring system dedicated to tomosynthesis in pulmonary cystic fibrosis was designed. Three radiologists independently scored 88 pairs of radiographs and tomosynthesis examinations of the chest in 60 patients with cystic fibrosis and 7 oncology patients. Radiographs were scored according to the Brasfield scoring system and tomosynthesis examinations were scored using the new scoring system.

RESULTS

Observer agreements for the tomosynthesis score were almost perfect for the total score with square-weighted kappa >0.90, and generally substantial to almost perfect for subscores. Correlation between the tomosynthesis score and the Brasfield score was good for the three observers (Kendall's rank correlation tau 0.68, 0.77 and 0.78). Tomosynthesis was generally scored higher as a percentage of the maximum score. Observer agreements for the total score for Brasfield score were almost perfect (square-weighted kappa 0.80, 0.81 and 0.85).

CONCLUSIONS

The tomosynthesis scoring system seems robust and correlates well with the Brasfield score. Compared with radiography, tomosynthesis is more sensitive to cystic fibrosis changes, especially bronchiectasis and mucus plugging, and the new tomosynthesis scoring system offers the possibility of more detailed and accurate scoring of disease severity.

KEY POINTS

Tomosynthesis is more sensitive than conventional radiography for pulmonary cystic fibrosis changes. The radiation dose from chest tomosynthesis is low compared with computed tomography. Tomosynthesis may become useful in the regular follow-up of patients with cystic fibrosis.

Effect of radiological extent and severity of bronchiectasis on pulmonary function

Background

The aim of this study was to ascertain the effect of the extent and severity of bronchiectasis as determined with high-resolution computed tomography (HRCT) on lung function in patients with pure bronchiectasis, bronchiectasis and asthma, and bronchiectasis and chronic obstructive pulmonary disease (COPD).

Methods

One hundred nineteen patients (71 with pure bronchiectasis, 25 asthmatic patients with bronchiectasis, and 23 COPD patients with bronchiectasis) underwent HRCT and pulmonary function tests. Computed tomography features were scored by the consensus of 2 radiologists.

Results

There were no statistically significant differences among the 3 patient groups regarding the extent of bronchiectasis, bronchial dilatation degree, bronchial wall thickening, decreased attenuation in the lung parenchyma, or presence of mucus in the large and small airways. In the pure bronchiectasis group, a negative correlation was found between forced vital capacity (FVC) % of predicted, forced expiratory volume in 1 sec (FEV₁) % of predicted, the FEV₁/FVC ratio and the extent of bronchiectasis, bronchial wall thickening, bronchial wall dilatation, and decreased attenuation. At multivariate analysis the main morphologic changes associated with impairment of FVC and FEV₁ were the extent of bronchiectasis and a decreased attenuation in the lung parenchyma. The decrease in the FEV₁/FVC ratio was associated with bronchial wall dilatation. No correlation was found between morphologic changes and indices of pulmonary function in the asthma and COPD patients.

Conclusions

Morphologic changes associated with bronchiectasis do not influence lung function in patients with asthma and COPD directly, although they do play a role in impairing pulmonary function in patients with bronchiectasis alone.

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.

Clinical, radiologic, and functional evaluation of 304 patients with bronchiectasis

BACKGROUND

Bronchiectasis continues to be one of the major causes of morbidity and mortality in developing countries, with a probably underestimated higher prevalence than in developed countries.

OBJECTIVE

To assess the clinical profile of adult patients with bronchiectasis.

METHODS

We retrospectively reviewed the clinical, radiologic, and physiologic findings of 304 patients with bronchiectasis confirmed by high-resolution computed tomography.

RESULTS

Mean age of participants (45.7% males, 54.3% females) was 56 ± 25 years and 65.8% of them were lifetime non-smokers. Most common identified causes of bronchiectasis were childhood disease (22.7%), tuberculosis (15.5%), and pneumonia (11.5%). The predominant symptoms were productive cough (83.6%), dyspnea (72%), and hemoptysis (21.1%). The most common findings on chest examination were crackles (71.1%) and rhonchi (28.3%). Types of bronchiectasis were cylindrical in 47%, varicose in 9.9%, cystic in 45.1%, and multiple types in 24.3%. Involvement was multilobar in 75.3% and bilateral in 62.5%. Of 274 patients, 20.8% displayed normal pulmonary function test results, whereas 47.4%, 8% and 23.7% showed obstructive, restrictive, and mixed pattern, respectively. Patients with cystic disease had a higher frequency of hemoptysis (42%) and a greater degree of functional impairment, compared to other types.

CONCLUSION

In patients with bronchiectasis from southern Turkey, generally presenting with recurrent productive cough, hemoptysis, dyspnea, and persistent bibasilar rales, the etiology remains mainly idiopathic. Post-infectious bronchial destruction is one of the major identified underlying pathological processes. The clinical picture and the deterioration of the pulmonary function test might be more severe in patients with cystic type bronchiectasis.

HRCT score in bronchiectasis: correlation with pulmonary function tests and pulmonary artery pressure

BACKGROUND:

High-resolution CT scan (HRCT) and its score have an important role in delineating pathological changes and pulmonary functional impairment in patients with bronchiectasis.

AIMS:

To assess pulmonary function tests (PFTs) in patients with cystic and cylindrical bronchiectasis. To correlate HRCT score with PFTs and systolic pulmonary artery pressure (SPAP) in both radiological types.

MATERIALS AND METHODS:

A cross-sectional study of patients with bronchiectasis diagnosed by HRCT was conducted at King Khalid University Hospital, Riyadh, Saudi Arabia. PFTs, HRCT score and SPAP were measured in both types.

RESULTS:

We studied 94 patients with bronchiectasis; 62 were cystic and 32 were cylindrical. Their mean age was 53.4 ± 17.5 SD years. Forced vital capacity (FVC%) and forced expiratory volume in 1 second (FEV1%) were significantly lower in cystic patients (P < 0.0001) as compared with cylindrical patients; and diffusion capacity of carbon monoxide (DLCO%) was also significantly lower (P < 0.01). In the cystic group, PaO₂ was significantly lower; and PaCO₂, higher (P < 0.0001). HRCT score was correlated with FEV1% (r = −0.51). HRCT score was significantly lower in the cystic group (P = 0.002) and correlated with SPAP (r = 0.23). Global HTCT score of 10.3 ± 2.5 was associated with SPAP ≥40 mm Hg (P = 0.011).

CONCLUSION:

Patients with cystic bronchiectasis have significantly higher impairment of pulmonary physiology as compared with those with cylindrical bronchiectasis patients. HRCT score correlated with PFTs and SPAP.

Quantitative airway assessment on computed tomography in patients with alpha1-antitrypsin deficiency

The relationship between quantitative airway measurements on computed tomography (CT) and airflow limitation in individuals with severe alpha (1)-antitrypsin deficiency (AATD) is undefined. Thus, we planned to clarify the relationship between CT-based airway indices and airflow limitation in AATD. 52 patients with AATD underwent chest CT and pre-bronchodilator spirometry at three institutions. In the right upper (RUL) and lower (RLL) lobes, wall area percent (WA%) and luminal area (Ai) were measured in the third, fourth, and fifth generations of the bronchi. The severity of emphysema was also calculated in each lobe and expressed as low attenuation area percent (LAA%). Correlations between obtained measurements and FEV(1)% predicted (FEV(1)%P) were evaluated by the Spearman rank correlation test. In RUL, WA% of all generations was significantly correlated with FEV(1)%P (3rd, R = -0.33, p = 0.02; 4th, R = -0.39, p = 0.004; 5th, R = -0.57, p < 0.001; respectively). Ai also showed significant correlations (3rd, R = 0.32, p = 0.02; 4th, R = 0.34, p = 0.01; 5th, R = 0.56, p < 0.001; respectively). Measured correlation coefficients improved when the airway progressed distally from the third to fifth generations. LAA% also correlated with FEV(1)%P (R = -0.51, p < 0.001). In RLL, WA% showed weak correlations with FEV(1)%P in all generations (3rd, R = -0.34, p = 0.01; 4th, R = -0.30, p = 0.03; 5th, R = -0.31, p = 0.03; respectively). Only Ai from the fifth generation significantly correlated with FEV(1)%P in this lobe (R = 0.34, p = 0.01). LAA% strongly correlated with FEV(1)%P (R = -0.71, p < 0.001). We conclude therefore that quantitative airway measurements are significantly correlated with airflow limitation in AATD, particularly in the distal airways of RUL. Emphysema of the lower lung is the predominant component; however, airway disease also has a significant impact on airflow limitation in AATD.

[Bronchial diseases: CT imaging features]

Multidetector row computed tomography (MDCT) is the imaging modality of reference for the diagnosis of bronchiectasis. MDCT may also detect a focal stenosis, a tumor or multiple morphologic abnormalities of the bronchial tree. It may orient the endoscopist towards the abnormal bronchi, and in all cases assess the extent of the bronchial lesions. The CT findings of bronchial abnormalities include anomalies of bronchial division and origin, bronchial stenosis, bronchial wall thickening, lumen dilatation, and mucoid impaction. The main CT features of bronchiectasis are increased bronchoarterial ratio, lack of bronchial tapering, and visibility of peripheral airways. Other bronchial abnormalities include excessive bronchial collapse at expiration, outpouchings and diverticula, dehiscence, fistulas, and calcifications.

Qualitative analysis of high-resolution CT scans in severe asthma

BACKGROUND

High-resolution CT (HRCT) scanning is part of the management of severe asthma, but its application varies between centers. We sought to describe the HRCT scan abnormalities of a large severe asthma cohort and to determine the utility of clinical features to direct the use of HRCT scanning in this group of patients.

METHODS

Subjects attending our Difficult Asthma Clinic (DAC) between February 2000 and November 2006 (n = 463) were extensively re-characterized and 185 underwent HRCT scan. The HRCT scans were analyzed qualitatively and the interobserver variability was assessed. Using logistic regression we defined clinical parameters that were associated with bronchiectasis (BE) and bronchial wall thickening (BWT) alone or in combination.

RESULTS

HRCT scan abnormalities were present in 80% of subjects and often coexisted with BWT (62%), BE (40%), and emphysema (8%). The interobserver agreement for BE (kappa = 0.76) and BWT (kappa = 0.63) was substantial. DAC patients who underwent HRCT scanning compared with those who did not were older, had longer disease duration, had poorer lung function, were receiving higher doses of corticosteroids, and had increased neutrophilic airway inflammation. The sensitivity and specificity of detecting BE clinically were 74% and 45%, respectively. FEV(1)/FVC ratio emerged as an important predictor for both BE and BWT but had poor discriminatory utility for subjects who did not have airway structural changes (FEV(1)/FVC ratio, >or= 75%; sensitivity, 67%; specificity, 65%).

CONCLUSION

HRCT scan abnormalities are common in patients with severe asthma. Nonradiologic assessments fail to reliably predict important bronchial wall changes; therefore, CT scan acquisition may be required in all patients with severe asthma.

Irreversiblity of remodeled features on high-resolution computerized tomography scans of asthmatic patients on conventional therapy: a 6-year longitudinal study

Airway remodeling can be assessed using high-resolution computerized tomography (HRCT) scanning of both parenchymal-and airway abnormalities in patients with asthma. The aim of this study was to examine structural changes in large and small airways of asthmatic patients using HRCT to determine if remodeling changes had occurred after prolonged use of conventional anti-asthma therapy. HRCT scans were evaluated prospectively for evidence of the following abnormalities: bronchial wall thickening (BWT), bronchiectasis, mucoid impactions, small centrilobular opacities, thick linear opacities, focal hyperlucency, and emphysema. Fifty mild and moderate asthmatics were enrolled in the study group. These abnormalities were re-evaluated in the patients after the passage of 6 years of regular anti-asthma medication. Forty-six of the patients completed the study. The probability of finding at least one abnormality by HRCT investigation was statistically higher in the second scan than in the first (26 patients [56.5%] versus 18 patients [39.1%], p = 0.02]. Irreversibility ratios of abnormalities were 80%, 100%, 75%, 87.7%, 77.8%, and 100% for BWT, bronchiectasis, small centrilobular opacities, focal hyperlucency, thick linear opacity, and emphysema, respectively. The ratios for newly detected structural abnormalities were 25%, 2.5%, 0%, 7.9%, 8.1%, and 0% for BWT, bronchiectasis, small centrilobular opacities, focal hyperlucency, thick linear opacity, and emphysema, respectively. New occurrences and progression in BWT are associated with the duration of asthma affliction (p = 0.03). The results of our study indicate that HRCT remodeling features, once occurring, are irreversible in most of the patients, and new remodeling features also occur despite administering the standard asthma treatment.

Effect of early versus late intervention with inhaled corticosteroids on airway wall thickness in patients with asthma

BACKGROUND AND OBJECTIVE

The aim of this study was to determine whether early versus late initiation of long-term inhaled corticosteroid (ICS) therapy decreases airway wall thickness in patients with asthma.

METHODS

One hundred and eighty-one patients with asthma not previously treated with ICS were given inhaled budesonide for 1 year. These patients were divided into five groups according to the duration of their asthma symptoms, which ranged from less than 1 year to more than 10 years. High-resolution CT images and post-bronchodilator FEV1 were examined before and 1 year after treatment.

RESULTS

Before treatment, airway wall thickness was increased relative to the duration of asthma. Disease severity improved with ICS treatment even in patients who had suffered asthma symptoms for more than 10 years. Post ICS treatment, airway wall thickness decreased in patients with a duration of symptoms less than 3 years, and a minor response was seen in patients with a duration of symptoms from 3 to 5 years. However, there was no change in airway wall thickness in patients who had suffered asthma for more than 5 years. Post-bronchodilator FEV1 improved only in patients who had suffered asthma for less than 3 years.

CONCLUSIONS

ICS therapy may improve asthma control in all asthma patients despite the disease duration, but early ICS treatment may be critical to reverse airway wall thickening associated with asthma.

High resolution computed tomography and pulmonary function in common variable immunodeficiency

Patients with common variable immunodeficiency (CVID) have impaired production of immunoglobulins and hence recurrent airway infections, which in turn may lead to radiological changes and impaired lung function. Uncertainty exists about the nature and frequency of the radiological and the physiological abnormalities, and how they relate to each other. We reassessed high resolution computed tomography (HRCT) images in 65 patients, reported results from previously measured lung function tests, and studied relations between radiology, function and clinical variables. Airway obstruction, ventilatory restriction and impaired gas diffusion was found in 40, 34 and 21% of the patients, respectively. HRCT abnormalities were present in 94% of the subjects, mild changes being the most common. Bronchial wall thickening, found in two thirds of the patients, was related to airway obstruction and impaired gas diffusion. Linear and/or irregular opacities, the most frequent interstitial abnormality, was related to impaired gas diffusion. Bronchiectasis was found in more than half, but only severe bronchiectasis was related to airway obstruction. Since bronchial wall thickening and linear and/or irregular opacities are both frequent and important determinants of impaired pulmonary function, more attention should be given to these features in the follow up of CVID patients.

Bronchiectasis

Bronchiectasis, which was once thought to be an orphan disease, is now being recognized with increasing frequency around the world. Patients with bronchiectasis have chronic cough and sputum production, and bacterial infections develop in them that result in the loss of lung function. Bronchiectasis occurs in patients across the spectrum of age and gender, but the highest prevalence is in older women. The diagnosis of bronchiectasis is made by high-resolution CT scans. Bronchiectasis, which can be focal or diffuse, may occur without antecedent disease but is often a complication of previous lung infection or injury or is due to underlying systemic illnesses. Patients with bronchiectasis may have predisposing congenital disease, immune disorders, or inflammatory disease. The treatment of bronchiectasis is multimodality, and includes therapy with antibiotics, antiinflammatory agents, and airway clearance. Resectional surgery and lung transplantation are rarely required. The prognosis for patients with bronchiectasis is variable given the heterogeneous nature of the disease. A tailored, patient-focused approach is needed to optimally evaluate and treat individuals with bronchiectasis.

Factors associated with lung function decline in adult patients with stable non-cystic fibrosis bronchiectasis

BACKGROUND

Bronchiectasis remains a major public health problem, but factors influencing its natural history are not well characterized. The objective of our study was to explore modifiable and nonmodifiable factors associated with lung function decline in a clinical cohort of patients with stable non-cystic fibrosis (CF) bronchiectasis.

METHODS

Seventy-six stable adult patients (mean age, 69.9 years; 48.7% men) with bronchiectasis were included. The diagnosis of bronchiectasis was established in all cases by high-resolution CT scanning. Baseline data were collected on clinical history, symptoms, disease extension, treatment, sputum volume, microbiological aspects, laboratory findings, and exacerbations. All patients were invited to attend the clinic every 6 months for 24 months to conduct full spirometry and microbiological analysis of sputum, and to report the number of exacerbations.

RESULTS

Overall, the group experienced a rate of decline of lung function (FEV1) of 52.7 mL per year. Independent factors associated with an accelerated decline of lung function were chronic colonization with Pseudomonas aeruginosa (PA) [odds ratio (OR), 30.4; 95% confidence interval (CI), 3.8 to 39.4; p=0.005], more frequent severe exacerbations (OR, 6.9; 95% CI, 2.3 to 10.5; p=0.014), and more systemic inflammation (OR, 3.1; 95% CI, 1.9 to 8.9; p=0.023). Regrettably, none of the long-term treatment strategies evaluated, including the use of long-acting inhaled bronchodilators, inhaled or oral steroids, oxygen therapy, secretion clearance maneuvers, or antibiotics had a significant effect on FEV1 decline.

CONCLUSION

Chronic colonization by PA, severe exacerbations, and systemic inflammation are associated with disease progression in non-CF bronchiectasis.

Obliterative Bronchiolitis

Obliterative bronchiolitis (OB) is a condition characterized by inflammation and fibrosis of the bronchiolar walls resulting in narrowing or obliteration of the bronchiolar lumen. The most common causes are childhood lower respiratory tract infection, hematopoietic stem cell or lung and heart-lung transplantation, and toxic fume inhalation. The most frequent clinical manifestations are progressive dyspnea and dry cough. Pulmonary function tests demonstrate airflow obstruction and air trapping. Radiographic manifestations include reduction of the peripheral vascular markings, increased lung lucency, and overinflation. The chest radiograph, however, is often normal. High-resolution CT is currently the imaging modality of choice in the assessment of patients with suspected or proven OB. The characteristic findings on high-resolution CT consist of areas of decreased attenuation and vascularity (mosaic perfusion pattern) on inspiratory scans and air trapping on expiratory scans. Other CT findings of OB include bronchiectasis and bronchiolectasis, bronchial wall thickening, small centrilobular nodules, and three-in-bud opacities. Recent studies suggest that hyperpolarized ³He-enhanced magnetic resonance imaging may allow earlier recognition of obstructive airway disease and therefore may be useful in the diagnosis and follow-up of patients with OB.

Dissociation of lung function, dyspnea ratings and pulmonary extension in bronchiectasis

Bronchiectasis is a heterogeneous disease in terms of its clinical and functional presentation. Some isolated parameters have been used to assess the severity of bronchiectasis or its response to treatment. A study was undertaken to evaluate whether lung function, dyspnea and extension of the disease are separate entities in the impact of bronchiectasis upon patients using factor analysis. Patients with bronchiectasis diagnosed by high-resolution computed tomography (HRCT) and airflow obstruction defined by FEV1/FVC<70% were included. Data were collected relating to clinical history, three different clinical ratings of dyspnea (Medical Research Council (MRC), Borg scale and Basal Dyspnea Index), the extent of bronchiectasis and functional variables. A total of 81 patients (mean age (SD): 69.5 (8.7)) years were included. The degree of dyspnea (MRC) was 1.9 (0.8). Mean FEV1 was 1301 ml (56.9% pred.). Four factors were found that accounted for 84.1% of the total data variance. Factor 1 (45.6% of the data variance) included the three measurements of dyspnea. Factor 2 (16% variance) comprised airflow obstruction parameters (FEV1, FEV1/FVC and PEF). Factor 3 (13.8% variance) included RV/TLC and RV (lung hyperinflation). Factor 4 (8.6% variance) included bronchiectasis extent. Dyspnea was more closely correlated with lung hyperinflation (r:0.33-0.54) than with airflow obstruction parameters (r:0.17-0.26).

CONCLUSIONS

Airflow obstruction, dyspnea, lung hyperinflation and the lung extent of the bronchiectasis are four independent entities in the impact of bronchiectasis upon patients.