Bronchiectasis – StatPearls – NCBI Bookshelf

Continuing Education Activity

Bronchiectasis is a chronic lung disease characterized by persistent and lifelong widening of the bronchial airways and weakening of the function mucociliary transport mechanism owing to repeated infection contributing to bacterial invasion and mucus pooling throughout the bronchial tree. This activity reviews the evaluation and management of bronchiectasis and reviews the role of the interprofessional team in improving care for patients with this condition.

Objectives:

• Identify the etiology of bronchiectasis.

• Summarize the role of airway obstruction, infection, and peribronchial fibrosis in the pathophysiology of bronchiectasis.

• Outline the evaluation of bronchiectasis.

• Review the importance of collaboration and communication among the interprofessional team to enhance the delivery of care for patients with this condition.

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Introduction

Initially, bronchiectasis was described in the early 19th century by Laennec. Bronchiectasis is a chronic lung disease characterized by persistent and lifelong widening of the bronchial airways and weakening of the function mucociliary transport mechanism owing to repeated infection contributing to bacterial invasion and mucus pooling throughout the bronchial tree.[1][2][3] Bronchiectasis is responsible for the significant loss of lung function and one that can result in considerable morbidity and even early mortality.

Etiology

Historically, the most common cause of bronchiectasis was thought to be an antecedent respiratory infection, often during childhood. The causes are idiopathic, acquired, or infection-related.

Bacterial Infections

• Mycobacterium: Tuberculosis and atypical

• Haemophilus influenzae

• Pseudomonas aeruginosa

• Staphylococcus aureus

• Mycoplasma and HIV

Viral Infections

Fungal Infections

Bronchial obstruction

• Foreign body

• Mucus plug

• Tumors

• Hilar lymphadenopathy (right middle lobe syndrome: extrinsic compression from postinfectious adenopathy)

Postinflammatory pneumonitis

Congenital/Genetic

• Cystic fibrosis

• Young syndrome

• PCD: primary ciliary dyskinesia (Kartenger Syndrome)

• immunodeficiency (hypogammaglobulinemia)

• Alpha1-antitrypsin deficiency (AAT)

• Mounier-Kuhn syndrome

Inflammatory diseases

Pulmonary Diseases

• Asthma 

• Bronchomalacia

• Cronic-obstructive pulmonary disease (COPD) (reported in up to 50% of patients with moderate-to-severe COPD)

• Diffuse panbronchiolitis

• Idiopathic pulmonary fibrosis (traction bronchiectasis)

Altered immune response

• Allergic Bronchopulmonary Aspergillosis

• Hypersensitivity pneumonitis

Others

• Yellow nail syndrome (yellow nails, lymphedema, pleural effusion, bronchiectasis 40% first described in 1964)

Epidemiology

Bronchiectasis predominance is not clearly understood. Global statistics suggest that the incidence of bronchiectasis has risen over the past few years. It can exist in any age group. However, it generally occurred in childhood during the pre-antibiotic period.[4] Recent evidence shows that bronchiectasis disproportionately affects women and older individuals, and may be contributing to an increasing healthcare burden.

Pathophysiology

The three most important mechanisms that contribute to the pathogenesis of bronchiectasis are recurrent infections, airway obstruction, and peribronchial fibrosis.

Neutrophils dominate airway inflammation in bronchiectasis, driven by high concentrations of neutrophil chemoattractants such as interleukin-8 (CXCL-8), and leukotriene B4. Airway bacterial colonization occurs because of impaired mucociliary clearance and because of the failure of neutrophil opsonophagocytic killing. Other mechanisms of immune dysfunction include the inability to clear apoptotic cells and invasion of T-cells, with recent reports leading to Th27 cells playing a significant role. Histologic changes in bronchiectasis include cartilage destruction and fibrosis, mucosal and mucous gland hyperplasia, inflammatory cell infiltration, and increased mucous and exudate.

History and Physical

History of a long-standing cough with purulence is typical of bronchiectasis. Patients may report repetitive pulmonary infections that require antibiotics over several years. Patients can also present with progressive dyspnea, intermittent wheezing, hemoptysis, pleuritic chest pain, and associated fatigue and weight loss. The hemoptysis is mild and manifested by blood flecks in the patient’s usual purulent sputum, which is occasionally life-threatening. Often patients are diagnosed after many years of symptoms when a chronic cough or hemoptysis becomes debilitating.

Cough: 98%, sputum: 78% (sputum is typically mucoid and relatively odorless), dyspnea: 62%, haemoptysis: 56% to 92%, and pleuritic chest pain: 20% (secondary to chronic coughing).

Physical: Findings are nonspecific.

General findings may include digital clubbing (2% to 3%), cyanosis, plethora, wasting, and weight loss.

• Local chest examination:  Most commonly crackles and wheezes on auscultation.

• Crackles: 75%, usually bi-basal.

• Wheezing: 22% (wheezing may be due to airflow obstruction from secretions)

Clinical Features of Associated Causative condition: 

• Connective tissue diseases: Arthritis Sicca syndrome

• ABPA: Prominent wheezing

• Bronchial obstruction: localized wheezing

• PCD, CF, Young Syndrome: Recurrent sinus disease, infertility

• Features of acute exacerbation of bronchiectasis: Change in sputum production, increased dyspnea, increased cough, fever, increased wheezing, and reduced pulmonary function.

Evaluation

The recommendations of the British Thoracic Society (BTS) suggest checking for underlying factors involving immunoglobulin tests (IgA, IgM, IgG, and IgE), and testing to exclude ABPA (specific IgE to Aspergillus, IgG to Aspergillus, and eosinophil count). [5][6][7][8] Sputum culture to exclude nontuberculous mycobacteria (NTM) and assessment of autoantibodies are also suggested. Testing for cystic fibrosis (CF) (sweat test and/or screening for common CF mutations) is recommended for patients aged younger than 40 years or with recurrent Pseudomonas aeruginosa and Staphylococcus aureus isolation, or upper lobe predominant disease irrespective of age.

Alpha-1 Antitrypsin level, Ciliary function analysis, and Serology for HIV  if indicated.

Imaging: 

Chest radiography is usually the initial study performed in suspected bronchiectasis.

Signs on chest x-ray include the identification of parallel linear densities, tram-track opacities, or ring shadows reflecting thickened and abnormally dilated bronchial walls.

Signs of complications/exacerbations, such as patchy densities due to mucoid impaction (mucus may become of high density due to chronic inspissation) and consolidation, volume loss secondary to mucoid bronchial obstruction or chronic cicatrization are also seen.

In comparison to chest x-ray, CT is both more sensitive and provides more specific information. In addition to making the diagnosis, the pattern of disease on HRCT may enable one to limit the differential to a single/few specific causative entities.

The CT chest signs of bronchiectasis were first described by NAIDICH et al. in 1982. Multidetector computed tomography (MDCT) is preferred over high-resolution computed tomography (HRCT) as it can obtain thin sections of 1 mm (high resolution). HRCT is performed when MDCT is not available.

Bronchial dilation, the cardinal sign of bronchiectasis, is characterized: 

• A broncho arterial ratio (BAR) of more than 1

• Lack of bronchial tapering (normal airways diminish in caliber as they extend toward the lung periphery)

• Visibility of airways within 1 cm of the pleural surface (normal airways should not be visualized this far out in the lung periphery) or abutting the mediastinal pleural surface.

Usual Pattern on CT scan of the Chest

Cylindrical (tram track sign): Dilated airways seen in a horizontal orientation.

Signet-ring: The dilated airway lies adjacent to a pulmonary artery branch giving the appearance of a ring (internal bronchial diameter greater than that of the adjacent pulmonary artery).

Varicose: Implies non-uniform bronchial dilatation. The bronchi resemble varicose veins. The luminal dilatation is characterized by alternating areas of luminal dilatation and constriction, creating a beaded appearance, and the wall thickening is irregular. This varicose bronchiectasis serves as an intermediate step before the development of grossly dilated cystic airways.

Cystic or saccular: A cluster of thin-walled cystic spaces.

Mosaic lung attenuation: The terminology is used to characterize heterogeneous lung density in the damaged lung segments owing to air trapping and hence has a geographic distribution. On expiration, this result can be produced or exaggerated.

Dilated bronchial arteries: These are best-demonstrated post administration of intravenous contrast. These tortuous vessels extend along the central airways toward the hila. It is these vessels that are often responsible for hemoptysis.

Other Findings:

Lobar collapse

Mycetoma formation (Fungus ball): Aspergillus fumigatus (a fungus) may colonize dilated airways or bullae/cavities. It is a major source of hemoptysis.

Decreased Lung function:

Airflow obstruction: FEV1 decreased

Air trapping: Residual volume increased

Treatment / Management

Bronchiectasis is treatable but rarely curable.

Treatment Goals:

1. Identifying and treating the underlying cause

2. Improve tracheobronchial clearance

3. Control infection

4. Reverse airflow obstruction

General Management

1. Identifying and treating the underlying cause: Immunoglobulin replacement, steroids, antifungals for ABPA, treatment for NTM, and CF all represent opportunities to treat the underlying cause specifically, and systematic testing of all patients is recommended in consensus guidelines.[9][10][11]

2. Improve tracheobronchial clearance: Most physicians recommend mucus clearance as the mainstay of therapy in bronchiectasis, Postural drainage consists of adopting a position in which the uppermost lobe is drained, and should be performed for a minimum of 5 to 10 minutes twice a day. Efficiently performed, this is of great value both in reducing the amount of cough and sputum and in preventing recurrent episodes of bronchopulmonary infection.

Deep breathing followed by forced expiratory maneuvers (the “active cycle of breathing” technique) is of help in allowing secretions in the dilated bronchi to gravitate towards the trachea, from which vigorous coughing can clear them. “Percussion” of the chest wall with cupped hands may help to dislodge sputum, and a number of mechanical devices are available, which cause the chest wall to oscillate, thus achieving the same effect.

3. Control infection: The choice of antibiotic should primarily be based on the results of culture and sensitivity. When no specific pathogen is identified, and the patient is not seriously ill, an oral agent like amoxicillin, co-amoxiclav, or macrolides for 2 weeks is sufficient.

Use a higher dose of oral amoxicillin 1 gm twice per day for 2 weeks, especially if colonized with H. influenza. If pseudomonas-colonized, then a 2-week course of ciprofloxacin 750 mg twice per day (with cautious use in the elderly) is reasonable.

For patients with moderate-to-severe symptoms, parenteral antibiotics, such as an aminoglycoside (gentamicin, tobramycin), antipseudomonal synthetic penicillin, a third-generation cephalosporin, or a fluoroquinolone, may be indicated.

Treatment for Pseudomonas isolates 2 weeks of intravenous (IV) antipseudomonal antibiotics, nebulized colistin for 3 months, or nebulized colistin for 3 months with an additional 4 weeks of oral ciprofloxacin.

Maintenance therapy with intermittent antibiotics is not used routinely in patients with non-CF bronchiectasis, and the decision to use long-term antibiotics should be individualized.

Inhaled aminoglycosides can be of benefit in chronic non-CF bronchiectasis; however, the treatment needs to be of sustained duration.

4. Control reverse airflow obstruction: In patients with airflow obstruction, inhaled bronchodilators and corticosteroids should be used to enhance airway patency.

5. Lifestyle modifications: As with other respiratory diseases, patients with bronchiectasis should be encouraged to stop smoking. Vaccination against influenza and pneumococcal disease is also recommended.

Adjunctive Surgical Treatment:

• Surgery is only indicated in a small proportion of cases. These are usually young patients in whom the bronchiectasis is unilateral and confined to a single lobe or segment, as demonstrated by CT.

• Surgery is an important adjunct to therapy in some patients with advanced or complicated disease.

• Single- or double-lung transplantation has been used as a treatment of severe bronchiectasis, predominantly when related to CF. In general, consider patients with CF and bronchiectasis for lung transplantation when FEV falls below 30% of the predicted value. Female patients and younger patients may need to be considered sooner.

• Massive hemoptysis: Bronchial artery embolization and/or surgery is first-line therapy for the management of massive hemoptysis.

Differential Diagnosis

• Asthma

• Bronchitis

• Cystic Fibrosis

• Emphysema

• Tuberculosis

Pearls and Other Issues

Bronchiectasis complications include pneumonia, lung abscess, empyema, septicemia, cor pulmonale, respiratory failure, secondary amyloidosis with nephrotic syndrome, and recurrent pleurisy.

Prognosis

The disease is progressive when associated with ciliary dysfunction and cystic fibrosis, and eventually causes respiratory failure in other patients. The prognosis can be relatively good if postural drainage is performed regularly, and antibiotics are used judiciously.

Enhancing Healthcare Team Outcomes

Bronchiectasis is a progressive disorder with no cure. Hence it is best managed by an interprofessional team that includes the primary care physician, nurse practitioner, pulmonologist, infectious disease expert, thoracic surgery, and an internist. The key is to improve symptoms and prevent relapses.[12][13] These patients often develop respiratory infections that require antibiotics. At some point, most patients develop complications that include pneumonia, lung abscess, empyema, septicemia, cor pulmonale, respiratory failure, secondary amyloidosis with nephrotic syndrome, and recurrent pleurisy.

The disease is progressive when associated with ciliary dysfunction and cystic fibrosis and eventually causes respiratory failure. In other patients, the prognosis can be relatively good if postural drainage is performed regularly, and antibiotics are used judiciously.[7]

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Figure

Chest CT showing upper lobe bronchiectasis in a patient with bronchial asthma, consistent with ABPA. Contributed by Moiz Salahuddin, MD

References

1.

Ho T, Cusack RP, Chaudhary N, Satia I, Kurmi OP. Under- and over-diagnosis of COPD: a global perspective. Breathe (Sheff). 2019 Mar;15(1):24-35. [PMC free article: PMC6395975] [PubMed: 30838057]

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Ferri S, Crimi C, Heffler E, Campisi R, Noto A, Crimi N. Vitamin D and disease severity in bronchiectasis. Respir Med. 2019 Mar;148:1-5. [PubMed: 30827468]

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Guan WJ, Han XR, de la Rosa-Carrillo D, Martinez-Garcia MA. The significant global economic burden of bronchiectasis: a pending matter. Eur Respir J. 2019 Feb;53(2) [PubMed: 30819807]

4.

Goeminne PC, Hernandez F, Diel R, Filonenko A, Hughes R, Juelich F, Solomon GM, Upton A, Wichmann K, Xu W, Chalmers JD. The economic burden of bronchiectasis – known and unknown: a systematic review. BMC Pulm Med. 2019 Feb 28;19(1):54. [PMC free article: PMC6393984] [PubMed: 30819166]

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Schoovaerts K, Lorent N, Goeminne P, Aliberti S, Dupont L. National Survey on the Management of Adult Bronchiectasis in Belgium. COPD. 2019 Feb;16(1):72-74. [PubMed: 30786778]

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O’Neill K, O’Donnell AE, Bradley JM. Airway clearance, mucoactive therapies and pulmonary rehabilitation in bronchiectasis. Respirology. 2019 Mar;24(3):227-237. [PubMed: 30650472]

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Patel S, Cole AD, Nolan CM, Barker RE, Jones SE, Kon S, Cairn J, Loebinger M, Wilson R, Man WD. Pulmonary rehabilitation in bronchiectasis: a propensity-matched study. Eur Respir J. 2019 Jan;53(1) [PubMed: 30578381]

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Kocurek EG, Jagana R. Noncystic fibrosis bronchiectasis management: opportunities and challenges. Curr Opin Pulm Med. 2019 Mar;25(2):192-200. [PubMed: 30640187]

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Bell SC, Elborn JS, Byrnes CA. Bronchiectasis: Treatment decisions for pulmonary exacerbations and their prevention. Respirology. 2018 Nov;23(11):1006-1022. [PubMed: 30207018]

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Mitchelmore P, Wilson C, Hettle D. Risk of Bacterial Transmission in Bronchiectasis Outpatient Clinics. Curr Pulmonol Rep. 2018;7(3):72-78. [PMC free article: PMC6096922] [PubMed: 30148050]

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Visser SK, Bye P, Morgan L. Management of bronchiectasis in adults. Med J Aust. 2018 Aug 20;209(4):177-183. [PubMed: 30107772]

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Dalrymple RA, Kenia P. European Respiratory Society guidelines for the diagnosis of primary ciliary dyskinesia: a guideline review. Arch Dis Child Educ Pract Ed. 2019 Oct;104(5):265-269. [PubMed: 30076157]

13.

Polverino E, Dimakou K, Hurst J, Martinez-Garcia MA, Miravitlles M, Paggiaro P, Shteinberg M, Aliberti S, Chalmers JD. The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions. Eur Respir J. 2018 Sep;52(3) [PubMed: 30049739]

Disclosure: Kim Bird declares no relevant financial relationships with ineligible companies.

Disclosure: Jawedulhadi Memon declares no relevant financial relationships with ineligible companies.

Bronchiectasis – Causes – NHS

Bronchiectasis is caused by the airways of the lungs becoming damaged and widened. This can be the result of an infection or another condition, but sometimes the cause is not known.

Your lungs are continually exposed to germs, so your body has sophisticated defence mechanisms designed to keep the lungs free of infection.

If a foreign substance (such as bacteria or a virus) gets past these defences, your immune system will attempt to stop the spread of any infection by sending white blood cells to the location of the infection.

These cells release chemicals to fight the infection, which can cause the surrounding tissue to become inflamed.

For most people, this inflammation will pass without causing any further problems.

But bronchiectasis can occur if the inflammation permanently destroys the elastic-like tissue and muscles surrounding the bronchi (airways), causing them to widen.

The abnormal bronchi then become filled with excess mucus, which can trigger persistent coughing and make the lungs more vulnerable to infection.

If the lungs become infected again, this can result in further inflammation and further widening of the bronchi.

As this cycle is repeated, the damage to the lungs gets progressively worse.

How quickly bronchiectasis progresses can vary significantly. For some people, the condition will get worse quickly, but for many the progression is slow.

In around half of all cases of bronchiectasis, no obvious cause can be found. 

These are some of the more common triggers that have been identified.

Childhood infections

Around 1 in 3 cases of bronchiectasis in adults are associated with a severe lung infection in childhood, such as:

• severe pneumonia
• whooping cough
• tuberculosis (TB)
• measles

But as there are now vaccinations available for these infections, it’s expected that childhood infections will become a less common cause of bronchiectasis in the future.

Immunodeficiency

Some cases of bronchiectasis occur because a person has a weakened immune system, which makes their lungs more vulnerable to tissue damage.

The medical term for having a weakened immune system is immunodeficiency.

Some people are born with an immunodeficiency because of problems with the genes they inherit from their parents.

It’s also possible to acquire an immunodeficiency after an infection such as HIV.

Allergic bronchopulmonary aspergillosis (ABPA)

Some people with bronchiectasis develop the condition as a complication of an allergic condition known as allergic bronchopulmonary aspergillosis (ABPA).

People with ABPA have an allergy to a type of fungi known as aspergillus, which is found in a wide range of different environments across the world.

If a person with ABPA breathes in fungal spores, it can trigger an allergic reaction and persistent inflammation, which can progress to bronchiectasis.  

Aspiration

Aspiration is the medical term for stomach contents accidentally passing into your lungs, rather than down into your gastrointestinal tract.

The lungs are very sensitive to the presence of foreign objects, such as small samples of food or even stomach acids, so this can trigger inflammation leading to bronchiectasis.

Cystic fibrosis

Cystic fibrosis is a genetic disorder, where the lungs become clogged up with mucus.

The mucus then provides an ideal environment for a bacterial infection to take place, leading to the symptoms of bronchiectasis.

Cilia abnormalities

Cilia are the tiny hair-like structures that line the airways in the lungs. They’re designed to protect the airways and help move away any excess mucus.

Bronchiectasis can develop if there’s a problem with the cilia that means they’re unable to effectively clear mucus from the airways.

Conditions that can cause problems with the cilia include:

• Young’s syndrome – a rare condition only affecting males thought to be caused by exposure to mercury in childhood
• primary ciliary dyskinesia – a rare condition caused by inheriting faulty genes

Regulations regarding the use of mercury are now much stricter, so it’s expected that Young’s syndrome will become a much less common cause of bronchiectasis in the future.

Connective tissue diseases

Certain conditions that cause inflammation in other areas of the body are sometimes associated with bronchiectasis.

These include:

• rheumatoid arthritis
• Sjögren’s syndrome
• Crohn’s disease
• ulcerative colitis

These conditions are usually thought to be caused by a problem with the immune system, where it mistakenly attacks healthy tissue.

Page last reviewed: 27 July 2021
Next review due: 27 July 2024

ᐈ How to treat bronchiectasis? ~【Diagnostics in Kyiv】

In case of severe wheezing, coughing and pain in the chest, we recommend that you urgently contact the MEDICOM clinic for a consultation with a pulmonologist. We offer accurate diagnostics, comfortable stay in the center and the most effective treatment for our patients. We employ highly qualified experienced specialists who know how to treat bronchiectasis, constantly improve their level of competence and are guided by world medical practices and WHO standards.

Bronchiectasis is an expansion of the walls of large bronchi with their subsequent inflammation and destruction. The cause of the disease are chronic infections and inflammatory processes.

A respiratory disease that causes bronchiectasis is called bronchiectasis. This medical problem occurs in 2-4% of the population. In most cases, it is detected in people under the age of 20 years. Statistics indicate that adult men have bronchiectasis more often than women. In childhood, the disease manifests itself with the same frequency in both sexes.

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Types of bronchiectasis

There are several signs by which the types of bronchiectasis are differentiated:

• according to the clinical course – an exacerbation phase or a remission phase;
• by origin – congenital and acquired;
• by prevalence – unilateral or bilateral lung disease.

According to the nature of changes in the lungs, bronchiectasis can be divided into the following types:

• fusiform;
• bagged;
• mixed;
• cylindrical;
• cystic.

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According to the areas of distribution, bronchial lesions are divided into peripheral and central.

It is possible to clarify the location of bronchiectasis by examining the method of bronchoscopy and CT.

There is a differentiation of bronchiectasis pathologies according to the level of their severity:

• Mild illness.
  It is characterized by long remissions during which the patient is fully functional. Exacerbations occur no more than 2 times a year.
• Medium shape.
  Sputum production is 50–100 ml per 24 hours, the remission phase is characterized by the presence of a wet cough, a moderate decrease in working capacity, slight respiratory disturbances. Exacerbations occur more often than 2 times a year.
• Heavy duty.
  The remission phase is observed infrequently, performance is constantly reduced. Exacerbations are prolonged, with abundant sputum production (more than 200 ml per day).

Due to the occurrence of bronchiectasis, they are divided into:

• post-infectious – appear after illnesses;
• obstructive – occur as a result of external compression or blockage of the lungs by a foreign body;
• associated with inhalation injuries – they are provoked by the inhalation of toxic substances;
• aspiration – appear as a result of an irritating secret entering the lungs;
• associated with chronic lung diseases – for example, sarcoidosis.

Such an important examination as a chest x-ray helps to identify changes that indirectly indicate the presence of bronchiectasis. To clarify the diagnosis and characteristics of the disease, it will be necessary to undergo an extended course of diagnostics.

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Causes of bronchiectasis

Among the causes of bronchiectasis, inflammation of the end sections of the bronchi can be called the main one.

Bronchiectasis sometimes results from a previous respiratory infection.

Bronchial dilatation can be caused by pathogens of the genus Mycobacteriaceae (tuberculous and non-tuberculous).

Sometimes the cause of bronchiectasis is congenital genetic malformations of the lungs Mycobacteriaceae.

Bronchiectasis inevitably occurs in people with cystic fibrosis (cystic fibrosis). Pathologies of the functioning of the epithelial cells lining the respiratory organs cause structural disorders of the bronchi.

Most often, with cystic fibrosis, the expansion occurs immediately on both sides of the respiratory tract, bronchiectasis affects a large area of ​​the lungs. The patient’s condition is complicated by chronic inflammation of the nasal sinuses and pancreas.

In addition to the above reasons, aspiration (inhalation) of foreign bodies, nasopharyngeal secretions, chemicals and toxins can cause bronchiectasis.

Immune disorders contribute to the occurrence of structural changes in the branches of the windpipe. Also, bronchiectasis can be a consequence of improper treatment of acute pulmonary inflammation that occurs against the background of local disorders of the bronchial structure.

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The course of bronchiectasis

As a result of the destruction of elastic fibers and muscle tissue of the respiratory tract, their expansion occurs. This leads to disturbances in the processes of breathing. Stagnation of sputum provokes a strong cough and blockage of the terminal sections of the bronchi. Lack of air in certain parts of the lungs causes tissue compaction, which worsens blood supply.

Often the appearance of bronchiectasis is associated with the spread of inflammatory lesions of the lungs. Inflammation reduces the elasticity of the bronchial walls, causing its thinning, protrusion.

As a result of the disease, the level of protection of the bronchial tree against pathogens is significantly reduced. As a result, a biofilm containing pathogens appears on the surface of the respiratory epithelium.

Bronchiectasis occurs in three stages:

• the first stage is characterized by slight changes in the small bronchi, with their filling with a viscous fluid;
• the second – is manifested by inflammation and suppuration, with the destruction of tissues lining the airways from the inside, while scars form in them;
• third – characterized by a strong expansion of the bronchi, filled with purulent masses; destructive processes flow into the lung tissues surrounding the bronchi with the appearance of scars.

Chronic intoxication with suppuration results in malnutrition of the myocardium.

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Symptoms of bronchiectasis

This pathology is chronic. Its undulation is noticeable: alternation of aggravation of symptoms (acute form) with relief of the condition (remission).

Most often, the structure of the bronchi located in the lower parts of the respiratory organs is disturbed. Pathology can spread both to one lung, and to both at once. Determining the localization of bronchiectasis is important for choosing the right therapy.

Symptoms of bronchiectasis:

• Wheezing, shortness of breath.
  If the pathological process has spread widely through the tissues, and bronchial obstruction has joined the current disease, wheezing, whistling sounds in the chest, and shortness of breath are noted during breathing.
• Cough.
  An integral main symptom of bronchiectasis. Coughing attacks are chronic, accompanied by sputum discharge. During the period of relief, the liquid departs in small quantities, mainly in the morning. In the phase of aggravation of symptoms, the amount of sputum increases, it is separated throughout the day. There are cases of dry bronchiectasis, without discharge of fluid.
• Decreased performance.
  Respiratory failure causes a lack of oxygen in the blood, which affects the patient’s well-being in the form of weakness, fatigue.
• Chest pain.
  In an acute course of the disease, pain in the chest area may occur, sometimes combined with a feeling of fullness or pressure, discomfort. Sometimes chills, hyperthermia, sweating join the pain.
• Fingers of Hippocrates.
  With a long course of the disease, such a peculiar symptom appears as a flask-shaped thickening of the terminal finger phalanges on the hands. The fingers become similar in appearance to drumsticks.
• developmental delay.
  Atypical symptom that manifests itself against the background of congenital anomalies of the respiratory system.

People often see a doctor with suspected asthma or other lung problems. They may be disturbed by episodes of expectoration of blood, severe shortness of breath, recurrent pneumonia. All of the above can be a sign of bronchiectasis.

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Features of bronchiectasis in children

The main manifestation of bronchiectasis in children is chronic bronchitis. The first alarming symptoms can be noticed already at the age of 3-4 years. In this case, the disease progresses quite actively, remissions are rare.

Children with bronchiectasis often develop hypovitaminosis, in some cases there is a deformity of the chest. Otherwise, the symptoms are the same as in adults.

Pathology is treated mainly by conservative methods.

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Complications of bronchiectasis

Prolonged bronchiectasis, often turning into complications, can lead to secondary pathologies.

Possible complications of bronchiectasis:

• chronic respiratory failure;
• septicemia – infection of the blood;
• pleural empyema – accumulation of pus in the pleural cavity;
• increase in the right parts of the heart – “cor pulmonale”;
• pneumosclerosis – manifested with widespread lesions of the bronchi;
• abscess formation – accumulation and distribution of purulent contents in the respiratory organs;
• spontaneous pneumothorax – a sudden rupture of lung tissue with air entering the pleural cavity;
• pulmonary hemorrhages – are quite rare, hemoptysis is a more common problem;
• amyloidosis – accumulation in the tissues of a certain protein that provokes their destruction, the complication is extrapulmonary.

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Diagnosis of bronchiectasis

The purpose of the diagnosis of bronchiectasis is to establish the etiology of the disease, localization and nature of lesions. The first stage of diagnosis is a consultation with an ENT doctor. He sees patients with chronic sinusitis, a frequent comorbidity of bronchiectasis.

Obligatory examination of the patient in case of suspicion of bronchial dilatation. With a prolonged course of the disease, the specialist will immediately note the presence of Hippocratic fingers and a slight deformity of the chest. This is followed by auscultation of the lungs with a phonendoscope. The doctor recognizes the characteristic sounds that appear in patients during breathing.

The next diagnostic step is laboratory testing. What tests should be done if bronchiectasis is suspected:

• sputum analysis, to determine the presence of pathogens;
• urinalysis, to detect amyloidosis;
• blood test to determine the level of red blood cells, white blood cells, hemoglobin, C-reactive protein.

Examinations using modern equipment, the main of which is computed tomography, help to make a final diagnosis. This diagnostic method allows you to determine the nature of the spread of lesions, the presence of fluid in the lung tissues, scars, abscesses.

X-ray of the lungs makes the picture of the disease more clear. In the picture, the specialist recognizes the types of tissue deformation, the places of their scarring and thinning.

Bronchoscopy will help clarify the diagnosis if it is possible to take material for analysis directly from the patient’s mucosa.

In order to prescribe the most adequate inhalation therapy, a study of respiratory function with a bronchodilator test is carried out.

Previously used bronchography is currently not used for diagnosis due to invasiveness and poor tolerance by patients.

Every year, patients with bronchiectasis undergo an electrocardiogram to detect heart problems.

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Treatment of bronchiectasis

The changes caused to the airways by the disease are incurable. Therefore, the treatment of bronchiectasis is reduced mainly to the fight against inflammation and the provision of pulmonary drainage.

Medication administration

The most convenient and safest way to administer drugs to the lungs is by inhalation using a nebulizer. By spraying, mucolytics are delivered to the bronchi – drugs that thin sputum. There are medicines for the introduction of which a nebulizer is not required.

In the acute phase of the disease, patients are recommended to use antibacterial drugs. Only the attending physician should deal with the selection of the remedy and the appointment of the dosage.

Bronchiectasis: surgical treatment

If the disease is severe, a series of bronchoscopies can be performed under local anesthesia. This will help to quickly alleviate the patient’s condition.

Operations for bronchiectasis are indicated in the following cases:

• in the absence of stable remission within 2–3 years;
• when local destruction of the tissues of the respiratory organs provokes bleeding;
• if localized cirrhosis develops;
• when pulmonary hemorrhage does not respond to drug therapy for longer than 24 hours;
• for bleeding from the lungs, which exceeds 200 ml in volume.

Surgery is available for patients of all ages.

Other methods of patient support

It is quite possible for a person with bronchial damage to achieve long-term remission and improve their condition. To do this, the patient must follow proper nutrition. There is a special diet for patients – with an increased amount of protein. Be sure to include foods rich in vitamins in your diet.

In chronic respiratory failure, the patient is prescribed oxygen therapy.

UHF therapy and electrophoresis are used during the acute course of the disease. After the onset of relief, UV irradiation and inhalation of mucolytics are performed. To activate the process of sputum removal, the patient undergoes a vibration massage procedure.

To improve respiratory processes, experts recommend exercise therapy for children and adults. Therapeutic exercise increases the pressure in the lumen of the bronchi, increases the movement of the diaphragm and intercostal muscles.

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Control of cure

Since bronchial disease is not treatable, medical control over the patient’s condition is to maintain a stable remission. Patients annually pass tests, undergo studies of the respiratory and cardiovascular systems. This allows you to identify and stop the progression of bronchiectasis in time.

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Prevention of bronchiectasis

Prevention of deterioration in bronchiectasis is the timely treatment of infectious diseases. The patient must be vaccinated against dangerous diseases caused by pathogens.

Despite the fact that the quality of life of people with bronchiectasis is significantly reduced, it is possible to live with this pathology for a long time. In recent years, statistics on the level of life expectancy of patients and their general condition have significantly improved.

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Q&A

What does bronchiectasis look like?

Forms of bronchiectasis can be seen on computed tomography and radiography. Bronchiectasis appears irregularly opaque on CT scans, with many round or linear opacities, or round and oval thin-walled cavities. Bronchiectasis on x-rays are shown as a more or less pronounced increase and deformation of the lung pattern.

What is traction bronchiectasis?

Traction bronchiectasis occurs in patients with pulmonary fibrosis as the fibrous tissue pulls against the bronchial wall. The disease can be diagnosed by bronchoscopy. And to determine the subtype of bronchiectasis, you need to undergo a CT scan. On computed tomography, it looks like bronchiectasis with an uneven contour. The term is applied to intralobular bronchioles when the airways are enlarged at the periphery of the lung.

What is left lower lobe bronchiectasis?

Bronchiectasis in the lower lobe on the left is the displacement of the left root downwards, and the heart – to the left. At the same time, the lung field narrows, darkening and a decrease in the size of the lowest lobe occur. The scale of the affected area is specified during the diagnosis. A pulmonologist gives a referral for ultrasound and other research methods.

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The article is for informational purposes only. Please remember: self-medication can harm your health.

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The author of the article:

Gancheva Elena Anatolyevna

Therapist of the highest category, gastroenterologist of the second category

Expert in the direction:

Ovchinnikova Natalia Nikolaevna

Head of the consultative, diagnostic and therapeutic department of the hospital, general practitioner of the highest category

Which doctor treats bronchiectasis?

How to treat bronchiectasis in children, the pediatrician will most likely answer. For adults, the physician’s office should be the first hospital instance. You may also need to consult an ENT doctor and a pulmonologist. Specialists of all these areas practice the treatment of bronchiectasis in Kyiv. The departments of the MEDICOM clinic in Obolon and Pechersk are waiting for their patients. Do you have any questions? Request a call or write to us.

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06/09/2021 22:25

Igor Valentinovich

Everything you need to know. Thank you.

15.04.2021 10:11

Evgeniya

Correctly, the author is well done

26.02.2021 15:36

Toma Voronina 900 03

Thanks for the article, it helped a lot.

06.02.2021 20:03

Emilia

The child has frequent colds, spasms, thanks for the advice.

12/15/2020 12:49

Roman Oleksiyovych

The site is already good, rich in basic information, don’t know the clinic, can you help.

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I am not a robot

Pathology of small bronchi

00:00

Igor Evgenievich Tyurin Doctor of Medicine:

– I am pleased to give the floor to Irina Alexandrovna to continue the conversation about the pathology of the small bronchi. Please.

Irina Alexandrovna Sokolina , Candidate of Medical Sciences:

– Good day, dear colleagues!

Today my message will be devoted to two pathological conditions: bronchiectasis and related pathological conditions and pathology of the small bronchi.

Let’s start with bronchiectasis. We partly touched on this topic at our last meeting, but let me remind you once again that bronchiectasis is defined as local and irreversible dilatation of the bronchi.

Primary bronchiectasis is distinguished, which develops mainly in early childhood. They are caused by acute infectious diseases of the bronchopulmonary system. The left lung is affected 1.5 – 2 times more often than the right. A third of patients may experience bilateral lesions.

The most common localization of primary bronchiectasis is the basal segments of the lower lobes, or the middle lobe and lingular segments.

In practice (especially in adult patients), secondary bronchiectasis is more common, which form and develop as complications of other pathological processes of the respiratory system. These are, first of all, tuberculous processes, inflammatory processes.

Secondary bronchiectasis includes the so-called atelectatic bronchiectasis, which Igor Evgenievich referred to. They occur in the zone of partial or complete atelectasis and develop as a result of infection of the bronchial secretion, distal to the site of obstruction.

02:00

Radiographic signs of bronchiectasis depend on the condition of the surrounding lung parenchyma. It may not be changed, the airiness may be disturbed, it may be, on the contrary, compacted.

Most often, we detect the expansion of the lumen of the bronchi, if, for example, there are compactions of the lung tissue around, due to inflammatory or fibrotic changes, as in the right picture. The expansion of the lumen of the bronchi is revealed: their walls look like thick parallel lines, and in the cross section, bronchiectasis usually look like annular cells with a diameter of up to 1 centimeter.

If the lung tissue remains airy, it is difficult to detect bronchiectasis, especially if they are limited. We see local areas of cellular and severe deformation of the pulmonary pattern.

Here we see that in direct projection, behind the shadow of the heart, these changes are not visible. They are better detected in the study in the lateral projection, which is why it is necessary to take pictures in two projections. This is a standard research technique for the pathology of the chest organs.

With a significant expansion, with the formation of cystic or saccular bronchiectasis, we can see thin-walled cavities of a round or oval shape. This is more common in congenital pathological conditions such as cystic fibrosis.

In such large bronchiectasis during exacerbation, inflammation, we can see horizontal levels of fluid. This is an important sign of bronchiectasis.

Thus, we can divide the radiological signs of bronchiectasis into direct and indirect symptoms.

Of course, a change in bronchial patency in one way or another affects the airiness of the lung tissue. This may show up:

• share reduction,
• convergence of the lumen of segmental bronchi,
• thickening of their walls,
• formation of peribronchial sclerosis,
• depletion of the lung pattern in neighboring lobes due to compensatory increase in airiness,
• deformation of the contours of the diaphragm and interlobar fissures.

04:42

For a long time, bronchography was the method of diagnosing bronchiectasis. But now, in connection with the introduction of computed tomography, this has become the main method for diagnosing bronchiectasis.

They are detected by computed tomography in almost 100% of cases. Especially with high-resolution computed tomography, which we discussed in great detail at our last meeting.

The main CT signs of bronchiectasis are the expansion of the lumen of the bronchus, the absence of a normal decrease in its diameter towards the periphery, and visible lumen of the bronchi in the cortical parts of the lungs.

There are three types of bronchiectasis according to the form.

Cylindrical bronchiectasis. We can talk about them when the ratio of the diameter of the bronchus to the diameter of the artery is greater than one. This is usually manifested by a symptom which has a very poetic name: the symptom of the “ring with a stone.”

The air ring itself is the bronchi (here we see it on both slides). The stone is the pulmonary artery. Most often, such bronchiectasis is formed in chronic bronchitis. Infectious processes play an important role in their formation.

Varicose (fusiform) bronchiectasis have the form of uneven (varicose) expansion of the bronchial lumen. Moreover, the walls of bronchiectasis, as a rule, are thickened due to chronic recurrent inflammatory processes. That is due to peribronchial sclerosis.

More often, fusiform bronchiectasis may end in a cystic expansion of its lumen: the so-called saccular bronchiectasis. Often they reveal horizontal levels of liquid.

The three main types of bronchiectasis that we detect.

07:10

Direct pathological processes that are associated with the formation of bronchiectasis.

Of these, primarily cystic fibrosis (cystic fibrosis, as it is also defined). This is a hereditary disease that is characterized by a systemic lesion of the exocrine glands, causing a violation of the respiratory system in combination with a disease of the digestive system.

There are several clinical forms. Including a mixed pulmonary-intestinal form, which is observed in the vast majority of patients, and an isolated bronchopulmonary form.

In the pathogenesis of the formation of bronchiectasis in this pathology: low water content in bronchial secretion, impaired mucociliary clearance, stagnation of secretion in the bronchi, development of secondary recurrent inflammation.

It must be said that cystic fibrosis is a two-way process. It is more often localized in the upper lobe of the right lung. Multiple bronchiectasis are determined – mixed and varicose. In later stages – cystic or saccular. Retention cysts, bronchiolectasias.

Since the process is characterized by recurrent exacerbations, a secret often stagnates in them. We see these changes in the form of filled bronchi. Of course, this is accompanied by uneven airiness of the lung tissue with areas of valvular swelling.

Pseudomonas aeruginosa is often a relapse and exacerbation of the infectious process in such patients.

Computed tomography is of great importance in cystic fibrosis. Especially when observing patients in dynamics, since it allows you to determine the activity of the inflammatory process.

The second congenital pathology, which is associated with the formation of bronchiectasis and due to impaired mucociliary clearance, is Kartagener’s syndrome. It is characterized by the reverse arrangement of internal organs.

We see bronchiectasis in this patient. On the right – pronounced changes in the lower lobe of the right lung, volume reduction, the presence of bronchiectasis, bronchiolectasis with signs of inflammation. Some of them are filled with content. There are also changes in the upper lobe of the left lung.

09:49

Detection of bronchiectasis is of great importance in patients with long-term asthma because they may be a reflection of a complication that may occur in these patients – allergic bronchopulmonary aspergillosis (ABPA).

In the pathogenesis of ABPA, fungal colonization of the respiratory tract (usually medium-sized bronchi), vascular damage with eosinophilic infiltration and the formation of bronchocentric granulomas are important. As a result, the development of bronchiectasis, bronchial obstruction, pneumofibrosis.

In the diagnostic criteria for ABPA, as we see, in addition to clinical and laboratory data, the identification of proximal bronchiectasis is of great importance. The use of computed tomography in this situation is of great clinical importance, since these changes are well detected using this method.

In this case, an example of a patient with bronchial asthma is given – a long-term sufferer, who is on glucocorticosteroid therapy. Plain radiograph shows changes in the upper lobe of the right lung. Here’s what they look like on x-rays.

We see that these changes are in the form of a V-shaped filled structure. On the tomograms, it is very clearly visible just the dilated and filled bronchi. In this case, by the type of retention cyst.

This is what confirmed ABLA cases look like. Proximal bronchiectasis is revealed – dilated segmental and subsegmental bronchi. Some of them may be filled with pathological contents.

When eosinophils in the blood become heavier and increase in patients with bronchial asthma, it is advisable to perform a computed tomography study to detect proximal bronchiectasis, which may be a reflection of ABPA.

I would also like to draw attention to such a pathology as atypical mycobacterial infection (not tuberculosis mycobacterial infection). These are processes that develop in patients of the older age group: older than 45-50 years. They are characterized by recurrent bronchopulmonary pathology. The most common pathogen causing bronchiectasis is Mycobacterium avium.

Mostly such processes are localized in the middle lobe and in the reed segments. A recurrent bronchopulmonary process with localization in these segments may suggest that this may be caused by a non-tuberculous (atypical) mycobacterial infection and requires clarification.

13:10

In this patient, we see changes in the middle lobe of the right lung, which are manifested by a cellular-severe deformity of the lung pattern, some volumetric decrease in the middle lobe. Computed tomography shows varicose and cystic bronchiectasis with severe peribronchial inflammatory and sclerotic changes.

I wanted to draw your attention to bronchiectasis. Of course, it is logical that post-inflammatory and post-tuberculosis processes lead to this. But in these two conditions – non-tuberculous mycobacterial infection and ABPA – the use of computed tomography in the diagnosis of this pathology is of great importance.

Bronchiolitis or pathology of the small bronchi.

Bronchiolitis is defined as an exudative or productive sclerotic inflammation of the small airways (bronchioles) that results in partial or complete obstruction.

Anatomy of bronchioles.

Bronchioles are small bronchi, from which the terminal and respiratory bronchioles are isolated. The diameter of the bronchioles does not exceed 2-3 mm. A feature of the anatomical structure of bronchioles is that their wall does not contain cartilaginous plates.

At the same time, terminal and respiratory bronchioles are isolated. Terminal bronchioles regulate airflow. These are the airways. Respiratory bronchioles are involved in gas exchange.

15:03

(Slide show) .

There are several classifications of bronchiolitis. But from the point of view of radiation diagnostics, the so-called pathohistological classification of bronchiolitis, in which acute (exudative) bronchiolitis is isolated, will be most acceptable to us. The main reason for their formation are infectious processes, inhalation of gases. Morphologically, epithelial necrosis, edema and infiltration of the wall occur there. Such bronchiolitis in the clinical picture is characterized by an acute onset. With inadequate treatment, chronicity of the process may occur, or inflammation may involute (if the treatment is timely).

Chronic (or productive sclerotic) bronchiolitis. There are constrictive and proliferative. Constrictive bronchiolitis is characterized by peribronchiolar fibrosis and narrowing of the lumen. It includes such histological forms as obliterating, respiratory, follicular bronchiolitis, panbronchiolitis. This form of damage to the small bronchi occurs with systemic diseases of the connective tissue, post-infectious conditions with inadequate treatment, the state after transplantation of organs and tissues.

Proliferative bronchiolitis is characterized by productive inflammation and proliferation of granulation tissue or organizing exudate. Proliferative bronchiolitis is bronchiolitis obliterans with organizing pneumonia. This form of bronchiolitis can occur with interstitial connective tissue diseases, or idiopathic.

(Slide show) .

Clinical manifestations of bronchiolitis. Basically, there are two leading symptoms – progressive shortness of breath and non-productive cough. But in the diagnosis of this condition, of course, the data of the anamnesis are of great importance. Indication of acute respiratory diseases, inhalation of toxic gases, organic, inorganic dust. Taking medication. The presence of concomitant pathology, such as collagenoses, bronchial asthma.

As for the ethnic factor, the so-called diffuse panbronchiolitis is described, which develops among the inhabitants of the Pacific region in connection with the migration of the population. This may be true in other geographic areas as well.

17:52

Physical findings are very poor in bronchiolitis. It may be dry wheezing. Spirometry – these functions of external respiration depend on the genetic form of bronchiolitis. So, basically, constrictive bronchiolitis, which are characterized by peribronchiolar fibrosis. They are characterized by the development of obstructive disorders. Moreover, in practice, such patients do not respond or respond poorly to a test with bronchodilators. And with the proliterative form of bronchiolitis, the restrictive nature of the violation of the function of external respiration is usually encountered.

(Slide show) .

Unfortunately, X-ray changes are detected in no more than half of the patients, mainly in severe forms. They can be manifested either by areas of increased airiness of the lung tissue (as we see in the right picture), or by areas of compaction of the lung tissue, or by an increase in the lung pattern.

(Slide show) .

Therefore, of course, high-resolution computed tomography plays a leading role in the diagnosis of bronchiolitis. We mention this pathology more and more often, we talk about bronchiolitis precisely in connection with the development of computed tomography, since we have been able to identify these changes.

Let me remind you that in a standard examination, with high-resolution computed tomography, we do not see small bronchi, bronchioles. We begin to see them when some pathological process occurs there.

(Slide show) .

We can divide the symptoms of bronchiolitis into direct symptoms when we directly see these altered bronchioles. This can occur due to the thickening of their walls, making a gap on the contents. Or centrilobular foci.

Finally, indirect signs of bronchiolitis are uneven airiness of the lung tissue.

20:15

(Slide show) .

A direct sign of bronchiolitis is the symptom of “tree in bud” or “willow twig”. This symptom is literally translated from English and has no analogue in Russian yet. It has an appearance on computed tomograms in the form of Y-, -V-structures, which are detected at a distance of 2–5 millimeters from the costal pleura. The morphological basis of this symptom is the thickening of the wall of the bronchioles or the accumulation of secretions in the lumen of the bronchioles.

Unfortunately, we can state that such changes are taking place there. But the etiology of this secret (fungal, tuberculous, bacterial), unfortunately, we cannot differentiate. Based on the totality of some signs and changes in the lung tissue, anamnesis, we can assume this. And the sign of damage to the bronchi, bronchioles, the symptom of a “tree in the kidneys” looks like these Y- and -V-structures.

(Slide show) .

It is this symptom that usually occurs in infectious bronchiolitis and is caused by infectious processes, which may include bacterial infections (more often we see this with mycoplasmal pneumonia), with tuberculosis and non-tuberculous mycobacterial infections. Viral etiology is usually found in adenoviruses, respiratory syncyal viruses. In children, this virus is usually one of the causes of such acute infectious bronchiolitis. With a fungal infection – bronchopulmonary aspergillosis.

Tree bud symptom is very common in infectious bronchiolitis.

(Slide show) .

It must be said that this symptom is potentially reversible with adequate treatment. Here we see the involution of pathological changes. Here are signs of bronchiolitis, and, by the way, bronchiectasis – the so-called incoming bronchiectasis, which occur during inflammation. Already against the background of adequate treatment, we see that most of the so-called bronchiectasis is no longer detected. And bronchiectasis is an irreversible change. Therefore, usually, if we see such pronounced inflammatory changes, then we write about bronchiectasis with caution, because then this may simply not be detected.

23:01

(Slide show) .

Such changes, the symptom of “a tree in the kidneys” can also occur in congenital pathology, in which bronchioles are also involved in the process. This is also a symptom of Kartagener (which we talked about) and cystic fibrosis.

(Slide show) .

Diffuse panbronchiolitis is a rare disease in the Pacific. It is characterized by the development of an immune response. There is a mononuclear infiltration of bronchioles, alveolar ducts and alveoli. Clinically manifested by cough, sputum, shortness of breath. Usually characterized by the addition of a bacterial infection.

Here we see such pronounced changes, which are caused by inflammation of the bronchioles and small bronchi, and bronchi of medium caliber. This is manifested by thickening of the walls of the bronchi, the expansion of their lumen, the expansion of the lumen of the bronchioles. Here, the arrow shows how almost near the pleura we see what a wide lumen of bronchioles, thickening of the walls. Bronchial lumens are filled with contents.

(Slide show) .

The two symptoms (as I said) are the tree-in-bud symptom and centrilobular ground-glass lesions. They have the appearance of poorly defined centrilobular foci of low density. Their morphological basis is areas of peribronchiolar inflammation.

“Tree in buds” – this is mainly inside the bronchi and wall. Here it is peribronchial inflammation without signs of lumen expansion and filling with bronchial secretions. Pathological processes that can lead to this are hypersensitivity pneumonia, respiratory bronchiolitis, follicular bronchiolitis.

24:59

(Slide show) .

Hypersensitivity pneumonitis (or, as we called it, exogenous allergic alveolitis) is in most cases a disease that develops as an allergic reaction to the inhalation of gases, some kind of toxic damaging factor of an allergic reaction. As a rule, bronchioles are also involved in the process. Most often, we see in the acute-subacute or acute phase multiple centrilobular foci of low density, with blurry contours, like ground glass. This is a very characteristic sign of hypersensitivity pneumonitis.

(Slide show) .

Follicular bronchiolitis is more common in children. It is characterized by hyperplasia of lymphoid tissue in the walls of bronchioles with the formation of follicles. May also be seen in patients with rheumatoid arthritis.

(Slide show) .

Respiratory bronchiolitis is bronchiolitis that develops in smokers. It must be said that in the initial stage, these changes do not manifest themselves in any way and are detected only with computed tomography. The median age at which this bronchiolitis develops is 35 years. The disease (as I said) is associated with smoking.

There is an ingrowth of granulation tissue into the respiratory bronchioles, which contains pigmented alveolar macrophages. Computed tomography reveals such small centrilobular ground-glass lesions. They are indicated (some of them) by arrows. They are multiple-multiple. If you look, there are a lot of these centers here. At the same time, we see that the walls of the bronchi are completely normal. They may be slightly thickened, but not thickened.

These changes, as a rule, are localized in the upper parts of the lungs, but can also be combined with centriacinar emphysema. This bronchiolitis develops (as I said), mainly in smokers and is detected only with a CT scan.

27:10

(Slide show) .

Finally, an indirect sign of bronchiole damage is the so-called mosaic density, or mosaic perfusion, which looks like a combination of areas of increased and decreased density in the lung tissue. It occurs as a result of changes in the small bronchi, followed by reflex vasoconstriction and redistribution of blood to healthy areas of the lung tissue. These changes must be differentiated from the ground glass symptom. We haven’t talked about this symptom yet. I think in the future we will touch on this symptom in the differential diagnosis.

(Slide show) .

Exhaled. With such an uneven airiness of the lung tissue, these changes are better detected during an exhalation examination in the form of the so-called “air trap” symptom.

(Slide show) .

This symptom is very characteristic of bronchiolitis obliterans, in which we see an uneven mosaic density of the lung tissue, which is due to areas of swelling, and is clearly visible on exhalation.

(Slide show) .

In case of post-inflammatory changes, with chronicity of the process, changes in the type of obliterating bronchiolitis may occur. The type of Swyer-James syndrome that develops in children after a viral infection. As a rule, these changes are characterized by unilateral lesion and lobar lesion. These changes must, of course, be differentiated from emphysema, because they are based not on the destruction of lung tissue, but on the development of this bronchiolitis and subsequent increased airiness of the lung parenchyma.

In this case (we see) it usually manifests itself radiographically, by an increase in the airiness of the lung tissue. We see the same thing in computed tomography, that in this case there is a lesion of the lower lobe of the left lung. The volume of the share has been increased. Air is increased. The vascular bed is disreduced. Separate cylindrical bronchiectasis can occur against this background.

29:22

(Slide show) .

The last thing I would like to touch upon is bronchiolitis obliterans with organizing pneumonia. In 70% of the development of this condition, the cause, as a rule, is not established. In 30%, similar changes can occur with systemic diseases of the connective tissue, with drug therapy.

The mean age of development of this pathology is 55 years. There is an overgrowth of polypoid granulation tissue in the bronchioles. Clinically characterized by unproductive cough, shortness of breath. It can be detected in the form of subfebrile fever (especially with drug therapy).

Computed tomography shows bilateral areas of lung tissue compaction, which are located mainly in the cortical regions of the lungs. The thickening of the walls of the bronchi, the expansion of their lumen in the areas of compaction can be detected.

The main distinguishing feature of bronchiolitis obliterans with organizing pneumonia from protracted pneumonia is usually bilateral changes and the absence of the effect of antibiotic therapy.

(Slide show) .

This is an example of bronchiolitis obliterans with organizing pneumonia. We see bilateral changes, mainly in the form of areas of compaction of the lung tissue in the subpleural regions. The degree of these changes may be different against the background of these compacted areas. We see the air gaps of the bronchi. Against the background of conventional antibiotic therapy, involution of such changes does not occur.

(Slide show) .

Thus, in the differential diagnosis of bronchiolitis, the data of anamnesis, clinical picture, data, first of all, of the function of external respiration are of great importance. High-resolution computed tomography plays a decisive role in detection and differential diagnosis. Here, differential diagnosis is already built on a predominant basis.