Medial-basal segment (S7)-sparing right basal segmentectomy

The technique of medial-basal segment (S⁷)-sparing basal segmentectomy has not previously been reported. Herein we report the technical details of thoracoscopic anatomical basal segmentectomy preserving S⁷ in patients with B⁷ab branching pattern.

[Pneumonia: Does Ultrasound Replace Chest X-Ray?]

Pneumonia: Does Ultrasound Replace Chest X-Ray? Abstract. Pneumonic lung consolidations are characterized by typical changes in terms of sonomorphology: echopoor lesions with blurred margins, bronchoaerograms, regular vascularization, and parapneumonic effusions. Pneumonias may be first discovered at bedside. Reventilation is well correlated with clinical progression. Compared with CT in four metaanalyses, lung ultrasound shows accuracy with a sensitivity of 88-97 % and a specificity of 90-96 %. Chest x-ray on the other hand has a pooled sensitivity of 77 % and a specificity of 91 %. Thus, lung ultrasound should replace chest x-ray in the diagnosis of pneumonia aquired by out-patients.

The Correlation between Chest X-ray Scores and the Clinical Findings in Children and Adults with Mycoplasma pneumoniae Pneumonia

Objective To compare the radiological and laboratory data of children and adults with Mycoplasma pneumoniae pneumonia (MPP) and to evaluate the correlation between the total affected lung area and the clinical findings. Methods We retrospectively examined the data from MPP patients who visited our hospital during the period from April 2006 to July 2014. All data were retrieved at the time of the diagnosis of MPP and were analyzed to investigate the correlation between the clinical findings and the total affected lung area using a chest X-ray scoring system. Results We identified 71 children and 54 adults with MPP. The incidence of consolidation, which was the most common chest X-ray finding in both groups, was similar (children: n = 62, 87.3%; adults: n = 45, 83.3%). In contrast, air bronchogram, bronchial thickening, and atelectasis were observed significantly more frequently among children than among adults. In both groups, a chest X-ray scoring system revealed a zonal predominance of the affected area (middle-to-lower lung fields). The body temperature and serum data such as the C-reactive protein level, white blood cell count, and lactate dehydrogenase level were significantly higher in the child group than in the adult group. The total score did not significantly correlate with the above-mentioned inflammatory markers or the presence of hypoxemia in either group. Conclusion This study showed the first evidence of a correlation between the extent of lung abnormalities on chest X-ray (calculated as a total score) and the clinical findings, including the presence of hypoxemia, in children and adults with MPP.

[CLINICAL SIGNIFICANCE OF ANATOMICAL PECULIARITIES OF THE INTERMEDIATE BRONCHUS RAMIFICATION WHILE PERFORMANCE OF TYPICAL RIGHT-SIDED LOWER LOBECTOMY]

Different variants of the bronchial structures transsection, depending on peculiarities of the intermediate bronchus ramification, are possible while performance of typical resection of lower lobe of the right lung. Clinical significance and criteria of the intraoperative tactics choice in performance of typical lower lobectomy were studied. Trustworthy best results of separate transsection of apical segmental bronchus of lower lobe and of the basal bronchus in a cruciform ramification of intermediate bronchus were noted.

CT Characteristic of Early Local Recurrence After Resection of the Squamous Cell Carcinoma: Comparison With CT Characteristics of Stump Deformity or Granulation Tissue at Stump Site

The aim of this study is to compare the thin section computed tomography (CT) characteristics of the early local tumor recurrence with those of the stump deformity or granulation tissue after the resection of squamous cell carcinoma (SCC).Twenty-nine consecutive patients with local recurrence after definitive SCC operation from April 2006 to September 2012 were included in our study. Pre- and postoperative CT findings from these patients were retrospectively reviewed and compared with those in the age- and sex-matched 29 patients with the stump deformity or granulation tissue at stump site after definitive SCC operation, by 2 radiologists. We evaluated the initial tumor stage, tumor size, and tumor location in relation with the bronchus on preoperative CT scan. On postoperative CT scan, we evaluated the size, CT characteristics, and involvement pattern of the suspected soft tissue around the stump site, and the distance between surgical staples and soft tissue at the stump site.Tumor stage, tumor size, and tumor location in relation with the bronchus on preoperative CT scan were not significantly different between 2 groups, while lymph node stage was more advanced in the local recurrence group. On postoperative CT scan, the size of suspected soft tissue at stump site is significantly larger, and the distance between stump staples and suspected soft tissue was significantly longer in the local recurrence group than control group (median; 19 mm and 3 mm; 18 mm and 0 mm, respectively, P < 0.001). The univariate analysis showed that the size of soft tissue and the distance between soft tissue and stump site on postoperative CT scan were associated with the predictive factors of local recurrence (P < 0.001). On the receiver-operating characteristic analysis, the optimal cutoffs of the size of soft tissue and the distance between soft tissue and stump staples for determining local tumor recurrence were 6 and 5 mm, respectively.The proper knowledge CT characteristics of local tumor recurrence including the soft tissue size (cut-off, 6 mm) and the distance (cut-off, 5 mm) between soft tissue and stump site will help us achieve the early diagnosis and higher diagnostic rate of locally recurred SCC.

Optimizing parameters of an open-source airway segmentation algorithm using different CT images

BACKGROUND

Computed tomography (CT) helps physicians locate and diagnose pathological conditions. In some conditions, having an airway segmentation method which facilitates reconstruction of the airway from chest CT images can help hugely in the assessment of lung diseases. Many efforts have been made to develop airway segmentation algorithms, but methods are usually not optimized to be reliable across different CT scan parameters.

METHODS

In this paper, we present a simple and reliable semi-automatic algorithm which can segment tracheal and bronchial anatomy using the open-source 3D Slicer platform. The method is based on a region growing approach where trachea, right and left bronchi are cropped and segmented independently using three different thresholds. The algorithm and its parameters have been optimized to be efficient across different CT scan acquisition parameters. The performance of the proposed method has been evaluated on EXACT'09 cases and local clinical cases as well as on a breathing pig lung phantom using multiple scans and changing parameters. In particular, to investigate multiple scan parameters reconstruction kernel, radiation dose and slice thickness have been considered. Volume, branch count, branch length and leakage presence have been evaluated. A new method for leakage evaluation has been developed and correlation between segmentation metrics and CT acquisition parameters has been considered.

RESULTS

All the considered cases have been segmented successfully with good results in terms of leakage presence. Results on clinical data are comparable to other teams' methods, as obtained by evaluation against the EXACT09 challenge, whereas results obtained from the phantom prove the reliability of the method across multiple CT platforms and acquisition parameters. As expected, slice thickness is the parameter affecting the results the most, whereas reconstruction kernel and radiation dose seem not to particularly affect airway segmentation.

CONCLUSION

The system represents the first open-source airway segmentation platform. The quantitative evaluation approach presented represents the first repeatable system evaluation tool for like-for-like comparison between different airway segmentation platforms. Results suggest that the algorithm can be considered stable across multiple CT platforms and acquisition parameters and can be considered as a starting point for the development of a complete airway segmentation algorithm.

Radiological findings and outcomes of bronchial artery embolization in cryptogenic hemoptysis

Management of cryptogenic massive hemoptysis is difficult, and conservative treatment may be inadequate to stop the hemorrhage. Surgery is not a reasonable option because there is no underlying identifiable pathology. This study aimed to investigate the radiologic findings and bronchial artery embolization outcomes in cryptogenic hemoptysis, and to compare the results with non-cryptogenic hemoptysis. We evaluated 26 patients with cryptogenic hemoptysis and 152 patients with non-cryptogenic hemoptysis. A comparison of the bronchial artery abnormalities between the cryptogenic and non-cryptogenic hemoptysis groups showed that only extravasation was more statistically significant in the cryptogenic hemoptysis group than in the non-cryptogenic hemoptysis group, while the other bronchial artery abnormalities, such as bronchial artery dilatation, hypervascularity, and bronchial-to-pulmonary shunting, showed no significant difference between groups. Involvement of the non-bronchial systemic artery was significantly greater in the non-cryptogenic hemoptysis group than in the cryptogenic hemoptysis group. While 69.2% of patients with cryptogenic hemoptysis also had hypervascularity in the contralateral bronchial arteries and/or ipsilateral bronchial artery branches other than the bleeding lobar branches, this finding was not detected in non-cryptogenic hemoptysis. Embolization was performed on all patients using polyvinyl alcohol particles of 355-500 µm. Hemoptysis ceased in all patients immediately after embolization. While recurrence of hemoptysis showed no statistically significant difference between the cryptogenic and non-cryptogenic hemoptysis groups, it was mild in cryptogenic hemoptysis in contrast to mostly severe in non-cryptogenic hemoptysis. Transarterial embolization is a safe and effective technique to manage cryptogenic hemoptysis.

Pulmonary imaging abnormalities in an adult case of congenital lobar emphysema

Congenital lobar emphysema is mainly diagnosed in infants, although rare cases are reported in adults. A 20-yr-old female with acute dyspnea, chest pain and left upper lobe (LUL) chest x-ray hyperlucency underwent 3He magnetic resonance imaging (MRI) for ventilation and apparent diffusion coefficient (ADC) measurements, as well as CT for emphysema and airway wall measurements. Forced expiratory volume in 1s, residual volume, and airways-resistance were abnormal, but there was normal carbon-monoxide-diffusing-capacity. The LUL relative area of the density histogram <-950 HU and airway morphology were highly abnormal compared with the other lobes and coincident with highly abnormal MRI-derived acinar duct dimensions. CT also identified bronchial atresia and congenital lobar emphysema as the source of symptoms in this case where there was also functional imaging evidence of collateral ventilation from the fissure (and not the abnormally terminated airway) into the emphysematous LUL.

Case of combined paratracheal air cyst and accessory cardiac bronchus

Paratracheal air cyst (PTAC) is rather frequently detected on thoracic multi-detector computed tomography (MDCT) in daily practice. Accessory cardiac bronchus (ACB) is a rare anomaly; however, the incidence rate is increasing with the use of recent high quality MDCT scanners. We report a case of combined PTAC and ACB that was incidentally detected by MDCT. Three dimensional CT images revealed anatomical details.

Changes in CT scan-estimated airway dimensions during an acute exacerbation of asthma

Asthma is a chronic airway disease characterized by reversible airflow limitation with airway wall thickening. Although some studies have reported changes in airway dimensions estimated on chest CT in patients with chronic asthma, little is known about dynamic changes in airway dimensions between acute exacerbations of asthma and recovery. Our case documents significant changes in the bronchial wall, as estimated on serial chest CT scans, over a short-term interval during an exacerbation of asthma.

[New method of scoring lung changes using computed tomography in patients with cystic fibrosis]

AIM

1. Introducing our own modification of the scoring system in high resolution computed tomography (HRCT) to evaluate changes in the lungs of patients with cystic fibrosis. 2. Comparison between scoring systems based on conventional chest radiography and HRCT in our own modification.

MATERIAL AND METHODS

The material consists of 50 children: 28 girls and 22 boys aged 5-17 years. Chest X-rays in P-A projection and HRCT (Picker PQS) were performed in all the children. Chest X-rays were evaluated using the Brasfield and Northern scores. In the Brasfield scoring system both lungs are assessed together. The Northern scoring system assesses each lung separately. In our own modification of the HRCT scoring system each lung was divided into six parts. Bronchiectases, bronchial wall thickness, mucous plugs, atelectases, emphysema, cysts and mosaic perfusion were assessed in each part of the lungs.

RESULTS

The analysis using the Brasfield score showed: minimal changes in 9 patients (18%; grading scale 20-24 points), mild changes in 23 (46%; 15-19 points), acute findings in 18 (36%; 7-14 points). The analysis using the Northern score showed: no changes in 1 patient (2%; grading scale 0 points), pathological findings were seen in the right lung in 49 patients (98%), while in the left lung in 48 (96%). Pathological changes in both lungs were seen in 96% of the patients. HRCT exams were evaluated based on our own modification of Bhalla and Maffesanti scores. Bronchial wall thickening was seen in all the patients examined, bronchiectases in 40 (80%), atelectasis, emphysema, bullas in 34 (68%), mosaic perfusion in 20 (40%). Central mucous plugs were seen in 34 patients (68%), peripheral plugs in 40 (80%). Both central and peripheral mucous plugs were observed in 33 patients (66%). There were no mucous plugs in 9 children (18%). The extent of lung lesions was compared using the Brasfield score and the HRCT score in our own modification. There were no extensive changes in 8 patients (16%) on chest X-ray evaluated by Brasfield score and only in 1 patients (2%) on HRCT. Using the Northern score 1 patient was assessed as having normal lungs. In HRCT assessment there was no patient with normal lungs. There were no mucous plugs in 23 patients (46%) on chest X-ray evaluation. In HRCT mucous plugs were not found only in 9 patients (18%). 8 children had two HRCT exams in 1-6 year intervals. In all of them the progression of lung lesions was observed on HRCT. In conventional radiography the progression of the disease was seen in 3 patients evaluated in the Northern score and in 4 children evaluated using the Brasfield score.

CONCLUSIONS

1. Our own modification of the HRCT scoring system in patients with cystic fibrosis simplified the evaluation of the lung lesions and made it possible to adapt it to the practical needs of physiotherapists. The assessment of the central and peripheral mucous plugs is very important for planning individual physiotherapy for every child. 2. HRCT has an advantage over conventional chest X-rays in the evaluation of the stage and progression of lung disease in patients with cystic fibrosis. Plain films do not allow exact evaluation of the mucous plugs that obstruct the bronchial tree. 3. In spite of this advantage, due to the radiation dose involved in CT, one should carefully assess the indications to use this method in routine evaluation of the disease in children with cystic fibrosis.

[Difficulty in left-sided double-lumen tube placement in patients undergoing surgical graft replacement of the descending aorta is predicted from tracheobronchial compression]

BACKGROUND

In surgical graft replacement of the descending aorta graft, one-lung ventilation (OLV) is required to provide adequate surgical view and to allow removal of blood from the left lung. It is best to use a double-lumen tube (DLT) to assure OLV but it is sometimes difficult to place the left-sided DLT due to thoracic aneurysm or the dissection lumen. We retrospectively investigated tracheobronchial anatomy by chest X-ray and chest computed tomography (CT) in 29 cases of descending aorta replacement to determine how best to manage difficult placement of the left-sided DLT.

METHODS

From our database of 29 patients who had undergone descending aorta replacement between February 1, 2005, and December 31, 2009, we investigated the association between difficulty in placing the left-sided DLT and tracheobronchial anatomy by chest X-ray and CT.

RESULTS

We could not place a left-sided DLT in 3 of 29 cases. Two of these cases were planned surgery for aortic aneurysm and the other was an emergency operation for acute aortic dissection. We could manage the two cases safely using a right-sided DLT. We compared chest X-ray and chest CT images of these 3 cases with the other 26 cases and found that compression of the tracheobronchial tree was prevalent in the cases of difficult placement of the left-sided DLT.

CONCLUSIONS

We experienced difficulty in placement of the left-sided DLT in 3 of 29 cases of descending aorta replacement. We can predict difficulty of left-sided DLT placement by the presence of compression of the tracheobronchial tree on chest CT.

Diagnostic accuracy of chest x-ray in tracheobronchial foreign body aspiration in paediatric patients

OBJECTIVE

To evaluate the diagnostic value of chest X-Ray in tracheobronchial foreign body aspiration among group of children in southern Punjab.

METHODS

The Cross sectional/comparative diagnostic procedural study was conducted in the Department of Radiology, Nishtar Medical College and Children Hospital Complex. Multan from January 2009-January 2011. Chest CT was performed in 45 consecutive children with suspected foreign body aspiration, and plain chest X-ray was evaluated at the same time. Multi-planar reformatted imaging with virtual bronchoscopy was carried out after Multidetector CT examination. Findings on plain X-Ray and CT scan chest were noted in each patient.

RESULTS

All 42 (100%) patients with tracheobronchial foreign bodies were identified by chest CT. Three patients avoided unnecessary operations due to negative CT scan for foreign body with alternate diagnosis. Right main stem bronchus was the most common location of foreign body 20 (47.6%) and air trapping was the most common associated finding (28.5%). Sixteen of the 45 (35.5%) patients had no abnormalities on plain X-Ray. The difference between Multi-detector CT and plain X-Ray results was statistically significant (p < 0.001). The sensitivity, specificity, positive predictive value (PPV). negative predictive value (NPV), and accuracy of chest X-Ray in this study were 66.6%, 50%, 89.6%, 18.7% and 64.4% respectively.

CONCLUSION

Chest X-Ray is not specific for diagnosis of foreign body aspiration and a normal chest X-Ray does not always rule out the diagnosis of foreign body aspiration in patients with a history suggestive of foreign body aspiration and positive physical examination.

Endobronchial aspergilloma: report of 10 cases and literature review

PURPOSE

A retrospective investigation of the clinical and radiologic features as well as the bronchoscopic appearance was carried out in patients with endobronchial aspergilloma.

MATERIALS AND METHODS

Ten patients with endobronchial aspergilloma diagnosed by bronchoscopy and histological examination were identified at the Gyeongsang University Hospital of Korea, from May 2003 to May 2009.

RESULTS

The patients included 9 men and 1 woman, and the age of the patients ranged from 36 to 76 (median, 58 years). The associated diseases or conditions were: previous pulmonary tuberculosis in 7 patients, lung cancer in 2 patients, pulmonary resection in 1 patient, and foreign body of the bronchus in 1 patient. The chest radiologic finding showed fibrotic changes as a consequence of previous tuberculosis infection in 6 patients and a mass-like lesion in 2 patients. Two patients had a co-existing fungus ball, and an endobronchial lesion was suspected in only 2 patients on the CT scan. The bronchoscopic appearance was a whitish to yellow necrotic mass causing bronchial obstruction in 7 patients, foreign body with adjacent granulation tissue and whitish necrotic tissue in 1 patient, whitish necrotic tissue at an anastomosis site in 1 patient, and a protruding mass with whitish necrotic tissue in 1 patient.

CONCLUSION

An endobronchial aspergilloma is a rare presentation of pulmonary aspergilosis and is usually incidentally found in immunocompetent patients with underlying lung disease. It usually appears as a necrotic mass causing bronchial obstruction on bronchoscopy and can be confirmed by biopsy.

Consideration of dose limits for organs at risk of thoracic radiotherapy: atlas for lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus

PURPOSE

To review the dose limits and standardize the three-dimenional (3D) radiographic definition for the organs at risk (OARs) for thoracic radiotherapy (RT), including the lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus.

METHODS AND MATERIALS

The present study was performed by representatives from the Radiation Therapy Oncology Group, European Organization for Research and Treatment of Cancer, and Soutwestern Oncology Group lung cancer committees. The dosimetric constraints of major multicenter trials of 3D-conformal RT and stereotactic body RT were reviewed and the challenges of 3D delineation of these OARs described. Using knowledge of the human anatomy and 3D radiographic correlation, draft atlases were generated by a radiation oncologist, medical physicist, dosimetrist, and radiologist from the United States and reviewed by a radiation oncologist and medical physicist from Europe. The atlases were then critically reviewed, discussed, and edited by another 10 radiation oncologists.

RESULTS

Three-dimensional descriptions of the lung, proximal bronchial tree, esophagus, spinal cord, ribs, and brachial plexus are presented. Two computed tomography atlases were developed: one for the middle and lower thoracic OARs (except for the heart) and one focusing on the brachial plexus for a patient positioned supine with their arms up for thoracic RT. The dosimetric limits of the key OARs are discussed.

CONCLUSIONS

We believe these atlases will allow us to define OARs with less variation and generate dosimetric data in a more consistent manner. This could help us study the effect of radiation on these OARs and guide high-quality clinical trials and individualized practice in 3D-conformal RT and stereotactic body RT.

[Change of the bronchial morphology, supine to lateral position on the 3DCT]

BACKGROUND

It is more difficult to intubate the double-lumen bronchial tube into the left bronchus than the right bronchus, and it is more difficult in a left decubitus position than normal position. And it is most difficult in the flexional decubitus position.

METHODS

We examined the cause of the difficulty in intubation of the left main bronchus which is solved by 3DCT.

RESULTS

The cause of the difficulty was the increase in size of the divergence angle of the left bronchus. Once the double-lumen left bronchial tube in the left bronchus has been pulled out, it is difficult to return the tube back to the left bronchus in the flexional position. For returning the tube to the bronchus, we place the head higher and change the flexional position to the extended position.

CONCLUSIONS

We examined the cause of difficulty in intubation of the left bronchus in the decubitus position with 3DCT. We concluded that the cause is the increase in the size of the angle, and for the tube to be intubated in the left bronchus, the patient position must be changed from the flexional position.

Bronchial compression as adverse effect of left pulmonary artery stenting in a patient with hypoplastic left heart syndrome

A 5-year-old child with hypoplastic left heart syndrome (HLHS) was noted to have left pulmonary artery stenosis after Glenn shunt placement. Therefore, a stent was implanted into the left pulmonary artery to relieve stenosis. After redilatation of the pulmonary artery stent, wheezing, fatigue, asymmetric bronchial sound, and desaturation was noted. Computed tomography, bronchoscopy, and bronchography confirmed critical left main bronchus compression as a consequence of the mass effect of the dilated stent. Balloon plasty of the left bronchus successfully relieved bronchial stenosis. Tracheobronchial obstruction is a possible adverse effect of vascular stenting in children with congenital heart defects. Balloon plasty seems to be a safe and efficient therapeutic option in those cases.

Endotracheal tuberculous stenosis: ventilation rescue and bronchography guided stenting

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

[Three cases of removal of intrabronchial metal nails]

We describe the successful extraction from an airway of foreign bodies metal nails in three cases. They were all carpenters, and often held nails between their lips. Case 1: a 72-year-old man had aspirated a nail three months earlier, but did not seek medical assistance at the time. A chest X-ray film and CT examination revealed a nail in the peripheral S7 region of the right lower lobe. The nail could not be extracted with forceps via bronchoscopy, so video-assisted thoracic surgery was performed. During surgery, the nail moved to the truncus intermedius, then it was extracted using bronchoscopy forceps. The extracted nail was rust-proof, and no rust was observed. Case 2 : a 76-year-old man visited our hospital with a history bloody sputum with a slightly dry cough for two months. A chest X-ray film showed a nail in the right hilum. Bronchoscopy revealed the nail covered with mucinous secretion in the right B7, and it was extracted by forceps. It was a rust-proof type nail, and no granulation tissue was observed in the bronchus. Case 3: a 74-year-old man visited our hospital because of dry cough for two months. A chest X-ray revealed a nail in the right hilus and bronchoscopy showed the nail was buried in reactive granulation tissue in the right middle lobe bronchus and could not be observed from the surface. Tranilast (n-[3,4-dimethoxycinnamoyl] anthranilic acid) at 300 mg/day and Methylprednisolone at 250 mg/day were prescribed for 4 days, followed by a reduction of the corticosteroid to 40 mg/day for 3 days. Seven days later, the granulation tissue and mucosal edema had diminished, and the nail was successfully extracted. The extracted nail was not rust-proof and had swollen with rust. These nails were found a few months after aspiration. The reason why these were not defected was possibly that the long and narrow shape did not obstruct the segmental bronchus and the symptoms can be less severe compared with other foreign bodies. The rust-proof nails were covered with mucinous secretion, but the nail without coating had rusted and caused reactive granulation tissue and swelling observed. Corticosteroid and Tranilast are thought to be effective in reducing such granulation tissue in airways.

Thoracic high resolution computed tomography (HRCT) in asthma

INTRODUCTION

High-resolution computed tomography (HRCT) is a widespread medical imaging method for the study of thoracic diseases. In asthma it is very useful particularly when it is difficult to achieve an effective control of disease, and in severe deterioration.

AIM

It was intended to evaluate the imaging changes by HRCT in asthmatic patients and to assess the expression according to the symptoms and duration of disease.

MATERIAL AND METHODS

Thirty three patients from the Outpatient Department, with asthma classified in the different clinical severity stages according to GINA, were randomly included. They were submitted to HRCT (Somaton Plus-4, Siemens). The lesions were classified in reversible (mucoid impaction, acinar pattern centrilobular nodules and lobar collapse) and irreversible (bronchiectasis, bronchial wall-thickening, sequellar line shadows and emphysema).

RESULTS

The 33 asthmatic patients (20 female) had an average age of 44.76 +/- 16.98 years and a mean disease evolution time of 23.39 +/-14.83 years. 30% had mild persistent asthma, 43% moderate persistent asthma and 27% severe persistent asthma. All the patients were under inhaled corticotherapy. Only 6 patients had normal HRCT 4 with mild persistent asthma (4 to 25 years of duration of disease) and 2 with moderate persistent (10 to 48 years of duration of disease). 81.81% of the patients had changes in HRCT, being the irreversible lesions the most frequent. The most important irreversible lesions were observed in severe asthma patients with longer duration of disease. All the patients with reversible lesions had also irreversible changes. Most of the bronchiectasis were centrally located and were found in severe asthma patients. Irreversible changes were identified in 3 patients with mild asthma and a maximum of 6 years of duration of disease.

DISCUSSION

HRCT findings were related with asthma severity and long lasting disease but there are some asthmatics that also present early abnormalities, even in milder forms. All the groups of asthmatic patients presented all types of imaging changes, including the irreversible ones. In asthma these changes can be the result of individual patterns of response to frequent exacerbations, leading to a persistent chronic inflammatory process that will determine airway remodelling, even in early stages of disease and/or mild asthma.

[Tracheobronchial foreign body aspirations]

BACKGROUND

Determining and removing aspirated foreign bodies from the airways is important in preventing complications. Foreign body aspiration is usually seen in childhood but can occur at any age. Complete or partial obstruction of the main bronchial system produces different findings, and death can result if emergency treatment is not given. We analyzed patients treated for foreign body aspiration in our clinic.

METHODS

In this report, 96 cases were examined in our clinic for aspiration of foreign bodies between 1995 and 2007. Patients were aged between 10 months and 70 years. Most cases were in the pediatric age group. Sixty-two (62%) patients were female and 34 (38%) were male. The period between aspiration and treatment varied from 1 hour to 10 years.

RESULTS

Bronchoscopies were established with controlled ventilation under general anesthesia. The foreign bodies were seen and extracted in 83 patients (86.5%) using foreign body forceps. Thirteen (13.5%) cases underwent thoracotomy. In the late period, pulmonary resection was performed in 5 (5.2%) cases because of irreversible pathology.

CONCLUSION

This study reports that foreign body aspiration is important in adults as well as in children, and suspicion and history are the most important diagnostic criteria. Radiologic findings with physical examination are of great importance in the evaluation of these patients.

[Quantitative evaluation of airway involvement in a patient with relapsing polychondritis using computed tomography]

A 63-year-old woman was admitted to our hospital because of auricular chondritis, conjunctivitis, polyarthralgia, productive cough and dyspnea. On admission, pulmonary function test demonstrated an obstructive pattern, and flow-volume curve (FVC) revealed a constrictive upper airway flow pattern. Chest CT showed a thickened tracheal wall and narrowing of the airway. The laboratory findings revealed an elevation of CRP and high titer of anti-type II collagen antibody. She was diagnosed as relapsing polychondritis (RP) according to Damiani's criteria. After the initiation of the therapy with 32 mg/day of methylprednisolone, her symptoms, pulmonary function, FVC and CT findings ameliorated promptly, and the titer of anti-type II collagen antibody became normalized. Moreover, we measured the airway wall thickness, percentage wall area (WA%) and percentage wall thickness (WT%), by CT and HRCT, and also evaluated the airway involvement quantitatively. Both WA% and WT% were inversely correlated with FEV1.0%. The airway inlolvement is most important prognostic factor in patients with RP, and sequential evaluation of airway manifestation are necessary. We suggest that a quantitative evaluation of bronchial structures by sequential CT is useful for the evaluation of RP as well as pulmonary function tests.

Chest computed tomography findings in familial dysautonomia patients: a model for aspiration

BACKGROUND

Lung disease in patients with familia dysautonomia is caused mainly by recurrent aspiration of gastric contents, food and liquids swallowed incorrectly.

OBJECTIVE

To describe chest computed tomography findings in patients with familial dysautonomia.

METHODS

A retrospective analysis of chest CT findings was performed for 34 FD patients (15 females, 19 males) with a mean age of 18 +/- 12.8 years.

RESULTS

The CT revealed bronchial wall thickening (in 94% of the patients), atelectasis (in 73%), ground glass opacities (in 53%), focal hyperinflation (in 44%), fibrosis (in 29%) and bronchiectasis (in 26%). The extrapulmonary abnormalities were scoliosis (79%) and esophageal dilatation (35%). Silent fractures were noted in two vertebral bodies and one rib.

CONCLUSIONS

Pulmonary changes were consistent with chronic inflammation in the bronchi and interstitial tissues. Ground glass opacities and fibrosis support the theory that these changes could be due to gastric aspiration. Bronchiectasis is less frequent. Esophageal dilatation with fluid overflow adds to aspiration. Fractures can be asymptomatic and are often missed.

A 77 year old male with peripheral eosinophilia, pulmonary infiltrates and a small pleural effusion

The presence of peripheral eosinophilia with lung infiltrates poses a diagnostic challenge for the clinician. The differential diagnosis includes a wide spectrum of diseases. In some of them (for example vasculitis, lymphoma) eosinophilic pneumonia represents just another "symptom" and not the final diagnosis. A thorough diagnostic procedure is required to examine all related clinical entities in order to establish a firm diagnosis. In particular, Idiopathic Chronic Eosinophilic Pneumonia (ICEP) is a rare disorder. In the majority of cases, it is characterized by peripheral eosinophilia, lung infiltrates, bronchoalveolar lavage eosinophilia (above 25%), exclusion of other possible causes and last but not least an impressive improvement under steroid therapy. Relapses are common but they do not seem to be related with ICEP associated mortality.