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Hello and welcome to Noon Conference, hosted by Modality

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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You can access a recording of today's conference

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and previous noon conferences by creating a free account.

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Today's noon conference is provided by the France Foundation

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and we are honored to welcome Dr.

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Mary Salvato for a lecture entitled The Critical Role

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of the Radiologist and the Diagnosis

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and Surveillance of Patients with Bronchi ATIs.

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Dr. Salvato is the chair

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of radiology at Jacobi Medical Center in New York City.

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She specializes in thoracic radiology

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with a specific focus in interstitial lung diseases

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and patterns of fibrosis on ct.

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She's actively involved in research retrospectively

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reviewing well-established cts

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of usual interstitial pneumonia

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and looking at earlier exams

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to determine earlier CT manifestations of disease.

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Additionally, she has written a text on CT interpretation

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for non radiologists.

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Her ultimate goal is to affect

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as many people in a positive way as possible

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through education and a positive

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attitude at the end of her lecture.

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Please join her in a q

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and A session where she will address questions you

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may have on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

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Saboteur, please take it from here.

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Thank you so much for that, um, wonderful introduction.

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I'm so happy to be here today

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to speak about the critical role of the radiologist

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and diagnosing bronchiectasis thanks to the foundation for,

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um, providing this opportunity.

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Next slide please. Our steering committee members are

1:44

listed on this page.

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Next, our disclosures,

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our learning objectives for this um, conference are gonna be

1:54

to confirm the presidents of bronchiectasis via high

1:56

resolution CT scan to determine

1:59

how radiology imaging can help determine the etiology

2:01

and treatment for the bronchiectasis.

2:04

And to summarize the needs

2:05

for subsequent radiologic surveillance of patients

2:08

who are diagnosed with bronchiectasis.

2:14

In the beginning we'll speak about, um, an introduction

2:16

to bronchiectasis, how to make a bronchiectasis diagnosis,

2:22

the CT procedure to get the best diagnosis

2:24

of bronchiectasis, how important imaging is

2:28

for bronchiectasis etiology and, um, treatment

2:32

and a case presentation.

2:37

Please use your phone to scan the QR code once

2:40

and keep it open to response

2:42

to the questions throughout the presentations.

2:50

Introduction to bronchiectasis,

2:54

what is bronchiectasis?

2:56

As a radiologist, I call bronchiectasis maybe on

3:01

at least one 10th of the patients I see each day.

3:04

So it's a very common problem

3:06

and I use the term bronchiectasis when I see

3:09

that the bronchus is bigger than it's accompanying artery.

3:11

Like in this picture, we see the arteries may be about five

3:16

millimeters and the bronchus is about 10 millimeters.

3:18

So whenever the bronchus is bigger than it's accompanying

3:21

artery, we can use the term bronchiectasis

3:24

and it's permanent dilatation so it can,

3:26

it's irreversible dilatation

3:28

of the bronchus bigger than it's accompanying artery.

3:31

Bronchiectasis is a, a big problem

3:33

and it's getting, uh, it's increasing.

3:36

Compared to 2013, there were about 200 out

3:38

of a hundred thousand people with bronchiectasis,

3:40

and now in 2025 that number has more than doubled

3:45

to 478 per a hundred thousand people with bronchiectasis.

3:49

So a big problem and a great opportunity for radiologists

3:51

to be able to, um, diagnose the disease early.

4:02

What is the cause for bronchiectasis?

4:05

Bronchiectasis is frequently caused by a bacterial infection

4:09

and colonization.

4:10

When you have this infection, the body wants to rid the body

4:13

of that infection and neutrophils come to the rescue,

4:15

bring inflammation and they're corresponding ELAs stasis.

4:20

These elastases cause um,

4:22

airway destruction when they are excessive

4:24

and you can imagine as the airway gets destroyed

4:27

and um, larger in size that you're going

4:30

to accumulate more mucus,

4:31

which is gonna bring more neutrophils

4:33

and it has a continuous, um, vicious cycle

4:36

that propagates bronchiectasis.

4:39

Next slide. Not all

4:43

of bronchiectasis have neutrophils.

4:46

20% of them are associated with eosinophils.

4:49

The neutrophils though, are very important

4:51

because they bring along their ELAs stasis,

4:53

which cause destruction.

4:55

These ELAs stasis also create, um,

4:58

neutrophil extracellular traps where the infection is uh,

5:02

caught and eradicate from the body.

5:04

So as equally problematic as they are, they are are helpful,

5:08

the neutrophils in fighting infection.

5:12

Next slide.

5:17

How do we define a pulmonary exacerbation?

5:20

In general, it's a worsening of symptoms, um,

5:23

that we attribute to the underlying condition

5:25

of bronchiectasis.

5:27

But if you're doing a research protocol, you're gonna look

5:29

for certain, um, definition for what is an exacerbation

5:33

and typically they use that it's a

5:36

deterioration in at least three of these symptoms

5:38

that are listed below for longer than 48 hours

5:42

and they include, uh, worsening cough,

5:46

increased sputum volume

5:47

or thickening, um, more purulent, sputum, breathlessness,

5:51

inability to exercise fatigue, malaise or hemoptysis

5:56

and, and then the clinician determines if a change in the

5:59

treatment for their bronchiectasis is necessary.

6:01

This is what we consider it an exacerbation

6:03

of the bronchiectasis.

6:07

Next slide. This is our first question.

6:12

What do you know A patient presents

6:14

with a chronic productive cough for the past three years.

6:18

Which of the following would provide a diagnosis

6:21

of bronchiectasis?

6:23

Is it airway to artery diameter ratio

6:27

above a lower threshold of two, lack of airway tapering,

6:31

non-productive cough

6:33

or presence of an underlying condition such as asthma?

6:53

In order to make a diagnosis

6:54

of clinically significant bronchiectasis, you need radiology

6:58

and clinical correlation.

7:01

Clinically, the patient must have two

7:03

or more of the following symptoms, a cough most days

7:07

of the week, sputum production most days of the week

7:10

or a history of exacerbations of their bronchiectasis.

7:15

Radiographic confirmation is obtained by the presence of,

7:19

um, greater than or equal to one of the following, airway

7:22

to artery diameter greater than one,

7:25

but we feel more confident when it's closer to 1.5.

7:29

Um, and the pulmonologists tend to use 1.5,

7:31

whereas the radiologists say a pulmonary, um, the um,

7:35

bronchus to artery ratio greater than one.

7:38

A lack of tapering right as we go from central

7:40

to peripheral, the bronchi tend to get smaller.

7:43

If they don't get smaller, then that's another sign

7:45

of bronchiectasis and when we see airways

7:48

that are not traditionally seen in the periphery

7:50

of the lung, that might be a sign of bronchiectasis as well.

7:54

Next slide. A chest x-ray is not

7:59

sufficient for the diagnosis of bronchiectasis.

8:02

We may be get a hint that there are cystic changes

8:06

or T tram track lines,

8:07

but look at how much better we can see bronchiectasis

8:11

on the, the last image with the airway thickening

8:14

and the dilated airway bigger than its accompanying artery.

8:18

So CT scan is the mainstay for imaging of bronchiectasis

8:22

and chest x-ray is not sufficient.

8:28

Next slide. When do we suspect bronchiectasis?

8:32

It's hard clinically

8:33

because bronchiectasis can present in a way similar

8:36

to COPD and asthma.

8:38

We become more suspicious with certain congenital diseases

8:41

or autoimmune diseases.

8:43

Immunodeficiency and even inflammatory bowel disease can be

8:47

associated with bronchiectasis,

8:48

so we might have a high level of suspicion,

8:51

but it can be challenging clinically

8:52

because there's so much overlap.

8:57

Next slide please. What did you learn?

9:02

A patient presents with chronic productive cough

9:04

for the past three years.

9:06

Which of the following we provide a diagnosis

9:08

of bronchiectasis.

9:10

The answer is lack of airway, um, tapering

9:14

because the airway to artery diameter ratio

9:16

above a threshold is it should be one not of two.

9:20

And um, a non-productive cough is not specific

9:23

or the presence of an underlying condition.

9:25

So the lack of airway tapering is the correct answer.

9:31

Next slide please. So we do

9:36

see T scans so frequently now

9:39

and um, how should we do them in order

9:42

to get the best diagnosis for bronchiectasis?

9:46

It's important to use, um, to not have motion artifact.

9:49

That's probably the most important part

9:52

of having a good quality chest CT scan is

9:54

that the patient is not breathing during the exam

9:59

and so a non-contrast chest CT scan is very important.

10:02

When we give contrast, the patient feels warm all over

10:05

so they become more anxious

10:07

and they start breathing more quickly.

10:10

So non-contrast, chest CT scan, we wanna use thin slices.

10:14

When I first started doing my residency we had 10 millimeter

10:16

slice thickness and that would not, um, do well.

10:20

To diagnose bronchiectasis, we need

10:22

to have a slice thickness less than 1.5 millimeters

10:25

and in my institution we use 1.25 millimeters.

10:29

We wanna ask the patient

10:30

to take a full breath in and hold it.

10:32

That's very hard for some of our shorter breath patients.

10:35

So it might be wise for the technologist to practice

10:38

with the patient, correct breathing text, um, technique

10:41

and we're working on improving that at our institution

10:44

to help the patients to cooperate so

10:47

that we can get the best exams.

10:49

Expiratory images are important to see air trapping.

10:52

We don't do them on all of the um, CT scans

10:56

that the patient comes back for,

10:57

but on the first CT scan when we're trying to make um,

11:00

the diagnosis of air trapping,

11:02

we'll do an expiratory CT scan

11:04

and again, that quality is important as well.

11:06

Otherwise it becomes a double dose

11:08

of radiation without much benefit.

11:10

So we can practice that with our patients too

11:13

to blow out all their air

11:14

and hold it for an expiratory CT scan.

11:18

Next slide. I love the anatomy

11:23

of the lungs and I'd like

11:24

to just talk about the central airways

11:26

and um, so we could describe what airways are involved

11:29

with the bronchiectasis.

11:31

The right upper below bronchus has three parts.

11:33

It has an anterior, a posterior, and an apical.

11:37

When I look at the right up below bronchus, I can't help

11:39

but see a goldfish cracker.

11:41

I don't know if you've ever had goldfish crackers.

11:43

If you have, you'll never have.

11:45

Um, you'll never look at a goldfish cracker the same

11:48

after seeing that it looks like a right up below bronchus,

11:49

you'll never look at the right up below.

11:51

Bronchus the same. Now you know that it looks,

11:52

it looks like a goldfish cracker.

11:55

The right middle lobe is easy to recognize because the m

11:58

and the L and middle lobe stand are the same

12:01

as the um, subsegments.

12:03

So medial and lateral.

12:06

The right lower lobe looks like a compass to me instead

12:08

of anterior, um, instead of north, south, east

12:12

and west, it's anterior, posterior, medial,

12:16

lateral and superior.

12:18

So the right lung has 10 segments.

12:21

The left lung has to be smaller

12:23

because we have the heart occupying part of the left lung.

12:26

So things get combined instead of having an anterior

12:30

and a posterior in the right upper lobe, we have anterior,

12:34

posterior combined, I'm sorry, apical and posterior combined

12:37

and then an anterior instead of a medial

12:39

and lateral we have a superior

12:41

and an inferior in the left lower lobe, anterior

12:45

and medial combined.

12:46

So we have four segments.

12:48

So ultimately on the left side we have eight segments

12:51

and on the right side we have 10 segments.

12:54

Next slide. How does imaging help in determining

12:59

the etiology of the bronchiectasis?

13:01

So when we see on CAT scan, how specific can we be about

13:04

what is causing the bronchiectasis?

13:07

Next slide please. This is our question number two.

13:12

Please take a a moment.

13:14

A 52-year-old woman has worsening indigestion over the last

13:18

six to nine months as well as a persistent

13:20

and productive cough chest CT reveals diffuse

13:24

basal bronchiectasis.

13:25

Which of the following is most likely

13:28

to be an underlying cause of this patient's bronchiectasis?

13:32

Is it allergic broncho pulmonary aspergillosis,

13:36

bacterial pulmonary infection, chronic aspiration,

13:41

or undiagnosed cystic fibrosis?

13:43

Take a moment to answer that.

13:55

We can go to the next slide.

13:59

CT features can help us to differentiate different types

14:02

of bronchiectasis.

14:09

So when we think about allergic broncho pulmonary

14:12

aspergillosis, it's a very dilated bronchus more so than

14:15

with chronic aspiration

14:17

and it's more the central airways that are D are dilated

14:21

and in a characteristic finger in the glove appearance,

14:25

which we'll see on subsequent slides.

14:27

In contrast, chronic aspiration is maybe milder dilatation

14:31

of the bronchus usually in the basal regions of the lungs

14:34

because when you aspirate that's where the um, aspirated um,

14:39

materials go and you might see tree

14:41

and bud opacities, which are are more characteristic

14:44

of chronic aspiration than a BPA.

14:47

Next slide.

14:53

We talk about the degree of bronchiectasis

14:55

by using three terms.

14:57

Radiographically there is cylindrical bronchiectasis when

15:01

the bronchus is bigger than it's accompanying artery,

15:03

but there's relatively smooth dilatation.

15:07

In contrast, varicose bronchiectasis has an undulating

15:10

contour, so it's still a bronchus

15:12

that's bigger than it's accompanying artery,

15:14

but instead of being smooth, it's um, undulating

15:18

and weaving like a string of pearls.

15:20

And then cystic bronchiectasis would be considered the worst

15:23

kind of bronchiectasis.

15:24

These bronchi are very dilated

15:26

and if you were to do a VQ scan you would see

15:30

that there was no um, profusion to the area

15:32

where there were cystic bronchiectasis.

15:34

So it's not taking part in oxygen exchange.

15:39

Next slide please. So I love the

15:44

this article, um, from Dr. Lynn Reed.

15:47

It was written in 1950.

15:49

Can you imagine in 1950 Dr. Reed was doing dissections

15:53

and she saw that in normal, um, individuals

15:57

that their bronchi branched 16 times from the time

16:02

of the the trachea to the um, periphery of the lung.

16:07

We know now know that there are 26 branches,

16:10

or at least currently we believe that there are 26 branches.

16:13

So from the trachea

16:17

there are eight conducting airways that are segmental.

16:20

Then there are eight subsegmental conducting airways

16:24

and then there are eight respiratory segmental airways

16:29

and then there are sacks and ducks.

16:32

So a total of 26.

16:34

At her time in the 1950s she was able to see

16:38

the conducting airways,

16:39

the eight conducting segmental airways

16:41

and the eight conducting subsegmental airways

16:44

for a total of 16.

16:46

And she said that cylindrical bronchiectasis

16:51

maintains those 16 conducting aas.

16:54

But what happens when you have varicose bronchiectasis?

16:57

We we said was more undulating and more dilated.

17:00

You have some tation or pruning of the bronchi.

17:02

So instead of having 16 branches,

17:05

now you have eight branches and with sac

17:08

or cystic bronchiectasis the worst type of bronchiectasis,

17:10

you have further pruning to only four branches

17:13

and she identified that as the change that occurs

17:16

with bronchiectasis

17:17

and we still use her her grading system today

17:21

with cylindrical varicose and sac.

17:24

Next slide. So we can say

17:29

what type of bronchiectasis they have,

17:31

we can say its location,

17:32

but how do we get to

17:34

what disease is causing the bronchiectasis?

17:37

Well we have focal bronchiectasis gives us a narrow

17:40

differential diagnosis.

17:41

Most of the bronchiectasis are more diffuse

17:44

and then we have to look at the if they're essential

17:47

or peripheral and

17:48

that helps narrow down our differential diagnosis.

17:51

Let's look at a few cases next slide.

18:00

In this example we have a focal left lower

18:02

lobe bronchiectasis.

18:04

We see that the airways are bigger than their

18:06

accompanying artery.

18:07

The differential for this kind of pattern includes um,

18:11

the patient may have had an infection um, in the past

18:14

and left the bronchus dilated

18:17

because of the ELAs stasis

18:20

and that's gonna cause a focal bronchiectasis.

18:22

But that's not the only reason

18:23

that you can get focal bronchiectasis in children.

18:25

Oftentimes it is because of aspiration of a foreign body

18:29

or adults may be a tooth.

18:32

Um, bronchial stricture can cause focal bronchiectasis.

18:36

An end bronchial mass like a carcinoid tumor can cause focal

18:40

bronchiectasis distal to the obstructing mass.

18:43

Also, something that we don't see too commonly now is

18:45

broncho ssis.

18:46

So the calcified lymph node in the mediastinum can erode the

18:50

mediastinum and go into the bronchus and cause broncho ssis

18:55

and then congenital bronchial atresia with dilatation

18:58

of the bronchus due to um, an obstruction

19:01

with mu nuclear infection.

19:02

And the hallmark of that is surrounding air trapping.

19:06

Next slide. More commonly we see diffuse

19:10

bronchiectasis and then we can think about

19:13

narrowing our differential.

19:15

We said that there's 26 branches

19:18

of the airways from central to peripheral.

19:21

Well what if a bronchiectasis affects the

19:23

more proximal airways?

19:24

It's gonna narrow down our differential.

19:28

Koon's disease is tracheal bromely.

19:30

So when we see a dilated trachea

19:33

and central bronchi,

19:35

we can think about munya Koon's disease.

19:37

Very rare. The trachea has

19:39

to be bigger than three centimeters in size.

19:41

I think I've seen this twice in my um, 25 years

19:43

of doing chest radiology.

19:46

In contrast, allergic broncho pulmonary aspergillosis is

19:49

much more common and we see it frequently in patients

19:53

that have asthma and cystic fibrosis.

19:56

These are dilated airways

19:58

that are from the first to the fourth branch.

20:01

So we said that there is 20 so branches when the first

20:04

to the fourth branch are dilated, we think about a BPA.

20:07

And since these are are central bronchi,

20:10

they're a bigger bronchi.

20:11

There is um,

20:12

oid impaction in these dilated bronchi giving the classic

20:16

hand or finger and glove appearance

20:18

where the glove is the dilated bronchus

20:20

and the finger is the mucus that's impacted inside of it.

20:24

If we don't remove that mucus, it becomes desiccated

20:27

and calcified over time.

20:30

Another disease, excuse me,

20:34

that affects the central airways is Williams Campbell,

20:37

I'm just gonna take a drink for a second, I'm sorry.

20:42

Williams Campbell, unlike A BPA, which affects the first

20:45

to the fourth, affects the fifth to the eighth branch

20:49

of the airway and there's a lack of cartilage.

20:53

So when you see the central airway being normal in size

20:57

and the middle airway being larger

20:59

and the distal airway being normal in size,

21:01

think about Williams Campbell.

21:03

When the patient breathes out with Williams Campbell the

21:08

because of the lack of cartilage, the airways collapse

21:12

and it gives a characteristic appearance

21:14

of Williams Campbell.

21:16

The next slide please.

21:20

Here's an example of Nia C***s.

21:22

You get trache bromely

21:24

but you also get um, bronchial diverticulum.

21:28

Next slide please. We talked about broncho

21:33

pulmonary aspergillosis allergic

21:35

bronchopulmonary aspergillosis.

21:37

There are four types of aspergillosis infection.

21:40

The mild is asperger occurring in a preexisting cavity.

21:44

This A BPA is associated with asthma

21:48

and then we have invasive and semi invasive aspergillosis in

21:51

immunocompromised patients.

21:53

Next slide. Williams Campbell, if you suspect it,

21:57

you do an expiratory CT scan

21:59

and show that the bronchiectasis collapses.

22:02

Next slide. Now we're talking about

22:07

more diffuse bronchiectasis, not just in the central airways

22:10

but more diffuse and we think about upper

22:13

lobe bronchiectasis.

22:14

When I see bronchiectasis in the upper lobes,

22:16

especially if it's in the back of the upper lobes,

22:18

I think about sarcoidosis if it's in the upper lobes

22:23

and there's associated with a lot of mucor impaction

22:25

and a younger person.

22:27

I think about cystic fibrosis which was first described by

22:30

Dorothy Anderson when she noticed that people children with

22:34

salty skin were dying from respiratory infections

22:40

and um, upper lobe bronchiectasis,

22:42

just like sarcoid in the back,

22:43

tuberculosis is a bronchiectasis

22:45

that affects the upper lobes in the back.

22:49

Next slide please. Thank you.

22:55

What about if the bronchiectasis is in the lower lobes

22:58

and not in the lower lobes?

22:59

We have an excellent example of chronic aspiration.

23:02

We can see even that there's debris within the right

23:04

lower lobe bronchus.

23:06

Often they get tree

23:07

and bud nodularity, lady Windermere syndrome.

23:12

The next case is NTM Nontuberculous mycobacteria infection.

23:17

They get the classic dilated bronchi in the right middle

23:21

lobe and the lingula,

23:22

the bronchus is bigger than it's accompanying artery.

23:25

This is usually an older women, we see this maybe one third

23:28

of the women that we see have, um,

23:30

this lady Windermere type syndrome.

23:32

They're usually thinner

23:34

with dilated bronchi in the right middle lobe

23:36

and the lingula, but it can be in the lower lobes

23:39

or it could be diffusely.

23:41

And then finally, if I see a young patient,

23:43

oftentimes a male patient in in their twenties

23:45

who has a history of recurrent infection

23:49

and I see a lower lung bronchiectasis,

23:51

bronchial wall thickening,

23:53

I think about dism modal CLIA syndrome.

23:56

If their heart is on the right side instead of the left,

23:59

we call it cartas.

24:01

If they have yellow nails, um,

24:04

and dys, modal clia, we call it yellow nail syndrome.

24:07

If they have azos permia, we call it young syndrome.

24:10

So disodium is CLIA is the broad category,

24:13

but there are subcategories as well.

24:16

Next slide please.

24:22

And so here we have another example of um,

24:25

lady Windermere syndrome with the dilated bronch

24:28

and we can see them really well here.

24:30

The artery is smaller than the accompanying bronchus

24:34

with a signet ring sign in the right middle lobe,

24:37

especially very characteristic of Lady Windermere.

24:41

Next slide. Here we see a wonderful

24:46

example of lower lobe bronchiectasis in a patient with

24:50

dism modal CLIA syndrome, A young patient.

24:53

Next slide. An important thing

24:58

is air trapping.

24:59

It can be very confusing

25:00

and challenging to make the right diagnosis.

25:04

When we look at the first CT scan, we,

25:07

this is an inspiratory CT scan.

25:10

We see heterogeneity

25:13

and um, that heterogeneity we call mosaic attenuation.

25:16

On an inspiratory CT scan we see areas that are darker

25:20

and areas that are wider.

25:22

And the thing that we have to do on this CT scan is then

25:25

to look at the darker areas like we see in the right lower

25:28

lobe and ask ourselves,

25:31

are the blood vessels smaller in the darker area?

25:35

If the blood vessels are smaller in the darker area,

25:38

it means that the darker area is the sick area.

25:41

If the blood vessels are the same size in the darker area

25:45

compared to the wider area, it means

25:46

that the wider area is the sick area

25:49

and the patient has ground glass opacity.

25:52

In this case, the darker area has smaller vessels,

25:57

so it is sick and it means

25:59

that the patient either has pulmonary artery hypertension

26:02

or small airways disease.

26:04

We do the expiratory CT scan, which is the second CT scan

26:08

and we see that the heterogeneity has increased

26:12

and that means that there is airway trapping consistent

26:15

with small airways disease.

26:17

But even if we weren't to do the expiratory CT scan

26:22

on the inspiratory CT scan, we can look

26:25

to see if the bronchial walls are thickened

26:27

and suggest that the finding is likely due

26:29

to small AOIs disease

26:31

or we can measure the size of the pulmonary artery.

26:34

And if it's normal then it's probably not pulmonary

26:37

artery hypertension.

26:39

Thank you. Next slide. What, what did you learn?

26:43

Number two, A 52-year-old woman

26:47

has worsening the indigestion over six to nine months.

26:51

Persistent productive cough.

26:53

The chest CT reveals diffuse basal bronchiectasis.

26:57

And what is the most likely diagnosis?

26:59

We know when it's lower lung predominant.

27:00

We think about chronic aspiration and, um, MAI

27:05

and um, dism modal Celia.

27:09

And for a 52-year-old,

27:10

the most likely diagnosis would be chronic aspiration given

27:13

her, um, history of indigestion and productive cough.

27:19

Next slide. How can imaging help to determine

27:23

what treatment for bronchiectasis,

27:25

how is it benefiting the clinician?

27:27

Our findings on chest ct,

27:31

a 3-year-old man with asthma presents with dyspnea.

27:36

A CT scan reveal central bronchiectasis with mucus plugging

27:41

in a hand in glove pattern consistent with A BPA.

27:47

What treatment would you recommend based on this diagnosis?

27:50

Corticosteroids chronic macrolides,

27:55

CFTR, modulator therapy or suppressive antibiotics.

28:11

The goals for treating bronchiectasis include relieving

28:15

patient symptoms, minimizing progression,

28:20

minimizing complications due to exacerbations

28:22

and improving the patient's quality of life.

28:26

Next slide.

28:31

There is, um, important

28:33

to have targeted treatments in patients with cystic fibrosis

28:38

to treat the underlying cause of the disease

28:40

if that's possible.

28:41

Like um, recurrent aspiration to treat comorbidities

28:48

and to target the pathophysiology.

28:51

Next slide. When patients have

28:56

increased wall thickness

28:57

or mucus plugging,

29:00

the best treatments include airway clearance therapies, um,

29:04

such as chest physical therapy

29:08

or nebulized saline to help break up the viscous secretions.

29:17

Next slide.

29:26

And if the patient has micro nodules like tree

29:29

and bud, the best treatments will be chronic macrolides

29:33

and antibiotics suppressive antibiotics.

29:38

Next slide. If a patient has central bronchiectasis like

29:43

a B, p, a, inhaled, bronchodilators

29:46

and corticosteroids would be the best treatment.

29:49

So our imaging features help to guide treatment

29:53

for the patient and are important for us

29:55

to describe in our report.

29:58

Next slide. So a 3-year-old

30:03

man with a diagnosis of asthma presents with dyspnea.

30:08

A CT scan reveals central bronchiectasis

30:12

with mucus plugging

30:13

and hand in glove pattern consistent with A BPA.

30:17

What treatment would recommend, um, based on this diagnosis

30:24

and corticosteroids?

30:29

Next slide. Should we follow up patients

30:34

with imaging when they have bronchiectasis?

30:36

How often should we follow up patients

30:38

with bronchiectasis is the discussion for for this section?

30:43

Next slide. Which statement reflects recommendations

30:48

or needs for CT imaging throughout the course

30:50

of bronchiectasis?

30:53

Guidelines Only specify use in diagnosis.

30:58

It should not be used except for people

31:00

that are deteriorating.

31:02

It is part of the risk severity scoring systems result

31:06

of two variable for monitoring therapeutic response.

31:17

Next slide.

31:22

We can do, um, subsequent imaging for a multitude

31:25

of reasons, including surveillance to see

31:27

how the patient is progressing if they responded

31:30

to an intervention by the clinician,

31:32

if they're having worsening symptoms

31:34

and also for patient education.

31:38

Next slide please. In this case we

31:43

have a patient with MAI who has um,

31:47

sputum cultures but limited symptoms

31:50

and this imaging six months later show

31:53

progression and cavitation.

31:55

So this was a very important imaging finding

31:58

for the clinician and for us to report

32:00

that the patient is progressing.

32:03

Next slide. Here's another patient

32:08

with mycobacterium.

32:10

The images are obtained before initiation of therapy and

32:13

after therapy we can see much improvement.

32:16

So the follow-up imaging was helpful to know

32:18

that we are on the right track

32:19

and giving the medication

32:21

that's most beneficial to the patient.

32:26

Next slide please. It's really important

32:31

to recognize the severity of disease early

32:33

because then we can talk about prognosis

32:37

and um, whether we need to monitor the patient closer

32:40

and um, change the therapy.

32:43

We should do CT scan when patients are having deteriorating

32:46

symptoms to see what's the reason for the deterioration.

32:49

Is it the primary bronchiectasis

32:51

or a secondary pro problem that has occurred?

32:57

How do we quantify the amount of of symptoms?

33:02

The clinical quantification is considered mild if the

33:05

patient has um, a lower number of symptoms

33:08

or a less intense system symptoms such

33:10

as negative sputum cultures

33:12

and sputum only once in a while

33:14

where we consider it moderate clinically.

33:16

If the symptoms are persistent

33:18

and the patient needs antibiotics

33:20

between exacerbations and then severe.

33:22

If there's a large amount of purulent secretions

33:26

with frequent exacerbations in positive cultures,

33:29

we consider that severe clinically.

33:31

Next slide Radiographically.

33:35

We can also quantify the amounts of bronchiectasis

33:39

and multiple systems have been developed,

33:41

which is probably the challenge

33:43

that there's not one uniform system to use

33:46

the bronchiectasis radio.

33:48

Um, radiology index. CT score.

33:50

The BRI score is a simplified version of the Bala scoring.

33:55

Mild is a BRI one, moderate is a Brix two

33:58

or three severe as a Brix four or five.

34:01

So it's a score of zero to five, zero no bronchiectasis.

34:04

Five, a lot of bronchiectasis.

34:06

The zero to three component is the amount of dilatation

34:09

of the bronchus and then emphysema is

34:12

considered as a part of it as well.

34:13

Giving the extra two points to get to a level of five

34:18

severity is important to, um, for the patient to know so

34:22

that you can counsel the patient about

34:23

the importance of treatment.

34:26

Next slide. Other radiology scoring system.

34:30

Inclu includes the reef scoring system

34:33

and this one looks at the number of lobes involved

34:36

and it continues the lingula as a lobe.

34:38

So it has six lobes

34:40

and you score one if the bronchiectasis is cylindrical.

34:43

Two if it's Veracode, and three if it's cystic.

34:46

So you can get a score from zero to 18.

34:48

A score of zero to six is considered mild radiographic

34:51

bronchiectasis moderate to seven to 12

34:55

and severe is 13 to 18.

34:57

The reef scoring system is relatively straight. Um, forward.

35:02

Next one. Some other scoring systems that are um, combined

35:07

with um,

35:09

radiology include the bronchiectasis severity index index

35:13

and this is a score of less than three.

35:16

If less than three lobes are involved, you give a zero.

35:18

If more than three lobes are involved, you give one point.

35:22

The faced scoring system gives if one

35:24

to two lobes are involved,

35:25

you give zero greater than two lobes.

35:27

You give one point and then the e faced adds if the patient

35:31

has exacerbation.

35:32

So these are so many different scoring systems,

35:36

but the goal is to assess in predicting

35:39

how bad does this patient's bronchiectasis,

35:41

how likely are they to have an exacerbation,

35:44

are they gonna be hospitalized

35:45

and is they, do they have an increased risk of mortality?

35:48

All the clinical and radiology scoring systems are,

35:51

their aim is to side, um, how, how sick this patient is

35:54

and what they have to do so that they, um, stay well.

35:59

Next slide please. And knowing

36:03

what the imaging shows can be helpful

36:05

to the patient as well.

36:06

This patient is saying if somebody came along

36:08

and said to me, if you don't do airway clearance every

36:11

morning and night, you're gonna get worse.

36:13

You bronchiectasis is gonna get worse.

36:16

It would probably have frightened me into doing better.

36:18

So sometimes patients having that knowledge of

36:20

how severe their bronchiectasis helps 'em

36:22

to be more compliant with treatment.

36:27

Next slide please. Which statement reflects

36:31

recommendations and are needs

36:32

for CT imaging throughout the course of bronchiectasis?

36:38

And the answer for this

36:42

is it is included in risk severity scoring systems.

36:49

Now we'll talk about a case to consider.

36:54

A 56-year-old woman presents to the primary care

36:57

with bronchitis productive cough,

37:00

difficulty taking deep breaths.

37:03

She had flu three years ago

37:05

and she's having increasingly frequent

37:07

and severe cases of bronchitis since that time.

37:11

Her primary care physician put her on antibiotic therapy

37:15

and she's referred to radiology for a suspected pneumonia.

37:20

Next slide please. I'd like you

37:24

to think about the answer to this question.

37:27

We are in your practice,

37:28

have you seen delays in confirming bronchiectasis diagnosis?

37:33

Have you noted that maybe people are unlikely

37:35

or unwilling to call bronchiectasis early?

37:42

Next slide please. The initial

37:47

imaging of our patient shows bronchiectasis.

37:50

We see this is patient is prone,

37:52

they're laying on their stomach.

37:55

We see significant bronchiectasis in the right middle lobe

37:59

and the lingula with increased wall thickness

38:03

because of its distribution

38:06

and the patient's age, we think about, um, NI infection

38:11

and the severity index was considered, um, five

38:14

with moderate bronchiectasis.

38:17

Next slide. Another question for you to reflect on.

38:22

How often do you consider the potential impact

38:25

of neutrophil inflammation on disease progression in

38:29

patients with bronchiectasis and persistent infection?

38:33

Do you, do you think about that?

38:34

I,

38:39

next slide please.

38:43

The patient improved after appropriate treatment

38:45

and started airway clearance therapy at three months.

38:50

Um, they were doing better.

38:52

They had improved CT scan, reduced mucus plugging

38:55

and their symptoms were improved as well.

38:57

So really pointing in a positive

38:59

direction after three months.

39:02

In the next slide please.

39:05

But after one year the patient felt relatively well

39:09

for five months, but then started feeling

39:11

tired and coughing.

39:13

She dropped off on her airway clearance therapy

39:15

because she became too busy.

39:19

The physician requested a follow-up CT scan,

39:22

which on the first to three month follow-up

39:24

there was improvement.

39:26

And now on the later follow-up there's progression.

39:30

So there's an important for following up

39:32

and being consistent

39:33

with your patient's airway clearance therapy.

39:38

Next slide please. Another question for you to reflect on.

39:44

How often do you share the CT scans with patients

39:46

who have bronchiectasis?

39:48

Do you review them with them so that they can see

39:51

how much their bronchiectasis is?

39:54

I have the opportunity sometimes as a radiologist to talk

39:57

to our lung cancer screening patients

39:59

and when I show them their results

40:01

or their images, they are so much more likely

40:03

to stop smoking or to improve their, um,

40:07

diet and exercise.

40:09

And so the image can go a long way

40:12

for a patient's wellbeing.

40:15

Next slide. The takeaway points

40:20

for this lecture include the radiologist needs to be aware

40:23

of the clinical characteristics of bronchiectasis

40:26

as a chronic respiratory disease so that HRCT can be used

40:31

for confirmation.

40:33

The chest patterns of bronchiectasis can provide insight

40:36

into the etiology and suggest appropriate treatments.

40:41

Chest CT can be look used to assess severity

40:44

but also to follow up

40:46

to see if the treatment is working well

40:48

and for educations of patients.

40:52

Next slide. Future directions.

40:56

What are we gonna do in the future?

40:57

What, what can we look forward to for bronchiectasis?

41:04

I love the idea of this, um, new MRI that's very fast

41:09

with respiratory gating holds the potential of being able to

41:14

do imaging without radiation exposure.

41:17

This is a healthy volunteer where we use this new technique.

41:21

It took 2.5 minutes to perform

41:26

this patient was healthy,

41:27

but there's a respiratory gating, so even if they were short

41:30

of breath, we would be able to, um,

41:32

have less motion artifacts and excellent quality images.

41:37

Next slide. And

41:42

then there's functional MRI image, which gives you like a VQ

41:46

scan result where we can look at, um,

41:49

what areas are being ventilated,

41:51

what areas are being perfused,

41:52

and identify areas of mismatch.

41:56

Next slide. MRI also offers us the opportunity

42:01

to see if our treatments are working.

42:04

The top row shows pre-treatment

42:07

and the second row shows post-treatment

42:10

and we can see the improvement in, um,

42:13

lung function in certain areas after treatment

42:15

and get validation that our treatments are working.

42:19

So lots to look forward to in the future. Next slide.

42:25

Thank you. Sincerely, it's a pleasure

42:27

to be here today with you.

42:28

I'm sorry for my intermittent coughing.

42:30

It's very cold here in the New York.

42:34

Thank you so much for sharing this lecture. Dr. Salvatore?

42:37

Yes. We will open the floor now for some questions.

42:41

If you've got any, please put them in the q

42:43

and a box so we can try to get through as many

42:45

as we can before we close.

42:48

We've got a couple in here already.

42:50

So can a patient have a BPA

42:54

without bronchiectasis?

42:56

I cannot say that word. Apologies.

42:59

I think that they can, um, I have not seen a patient like

43:03

that to be, to be truthful.

43:05

I think that there must be an early time

43:08

where the bronchis is not so dilated.

43:10

Um, but they always have bronchiectasis.

43:12

In my experience with the,

43:14

the question is oftentimes is can they have a BPA without

43:17

having asthma and cystic fibrosis?

43:20

And that's who would be an exception

43:21

to the rule and not the rule.

43:23

Thank you for your question.

43:26

Can you please help to differentiate

43:27

between cystic bronchiectasis and cystic lung disease?

43:31

Hmm, very interesting question.

43:33

And um, cystic bronchiectasis tends

43:37

to be more localized when we think about

43:40

cystic lung diseases.

43:41

We think about, um, when we think about the diffuse ones,

43:45

we can think about lymph angio.

43:46

Leiomyomatosis doesn't have as thick walls

43:49

as the cystic bronchiectasis, um,

43:52

lymphocytic interstitial pneumonitis, which the,

43:55

the cysts are not as thick walled.

43:57

Um, so I think that one of the main differences is the,

44:01

the wall thickness of bronchiectasis compared

44:03

to the cystic lung diseases,

44:05

whether they're d be diffuse or focal.

44:08

And uh, great question. Thank you.

44:12

This one says could you please review the slide on the

44:15

distribution of bronchiectasis and treatment again.

44:19

So when there is wall thickness

44:21

and mucus plugging, then anything to bring

44:24

that mucus up, um, would be helpful.

44:26

Like, um, nebulized saline makes the secretions less thick.

44:31

I was a physical therapist before I became a doctor

44:33

and I used to go into patient's room

44:35

and do chest percussion like this

44:37

and that would help bring up secretions.

44:39

The patient in the picture had a vest on which helped, uh,

44:42

um, to bring up the secretions as well.

44:46

In contrast, the next slide,

44:50

when patients have tree

44:52

and bud like nodules, we think about um,

44:56

antibiotics and um, macrolides

45:00

and the next slide for a BPA, bronchodilators

45:04

and corticosteroids are recommended.

45:07

I think more from a radiologic perspective, diagnosing,

45:11

describing the pattern is important

45:13

so the clinician can make the best

45:16

decision as to the treatment. Thank you.

45:21

That feels like a good segue to this question.

45:23

How do you recommend reporting the severity

45:25

of bronchiectasis in our CT reports?

45:28

So I think although we have all these different, uh,

45:31

grading systems, um,

45:33

what most people use are Lin Reed's original 1950s grading

45:38

of whether it's cylindrical, meaning it's smoothly dilated

45:41

versus um, ricard where it's undulating and then cystic.

45:46

When it looks like a cluster of grapes,

45:49

that might be a little bit unsatisfying

45:50

because it doesn't show extent.

45:52

It only shows severity of one bronchus being dilated.

45:57

Probably the best, um, scoring systems

46:02

would be like the reef system that says

46:04

how many lobes are involved

46:06

and how dilated each, um, bronchis.

46:10

And that was on a score of zero to um, 18

46:13

and I think that's a very good way

46:14

of looking at bronchiectasis.

46:20

Got two more questions.

46:21

When is prone CT recommended to you?

46:24

Do use, when is it recommended to you as prone ct?

46:28

Thank you for this question.

46:30

I, I rarely have um, used prone CT scan.

46:33

I think it's more of uh,

46:34

useful in pulmonary fibrosis when it's very early pulmonary

46:38

fibrosis and you wonder if it's dependent atelectasis

46:42

or um, true fibrosis.

46:45

Um, when patients lay on the CT scan table getting

46:49

intravenous contrast, it could be that they're there

46:51

for maybe 15 minutes.

46:53

And so I only use prone positioning when I think it could be

46:56

early interstitial lung disease versus atelectasis.

47:02

So I'm looking for dilated bronchi.

47:04

If the bronchodilate in the prone position, then I know

47:07

that it is um,

47:08

or even in the supine position, I know that it is fibrosis

47:11

and not um, atelectasis.

47:16

Fantastic. All right, one more we might have to hunt

47:20

through the slides on this one.

47:21

Can you review the section on arterial bronchial di diameter

47:25

changes based on GG O versus small decal vessel disease?

47:29

Uh, that's a great uh, and a complicated slide.

47:32

So um, we can try. Where was that slide?

47:36

It was after the end

47:37

of the different patterns of bronchiectasis.

47:40

I think we should go backwards. I think it'll be there.

47:54

There it is. Perfect. So one forward from here.

47:58

Do you see um, that's the one.

48:03

Do you see my mouse when I move?

48:07

No, No, we don't

48:09

See yours.

48:10

Okay. So when we look at the first CT scan image, we see

48:14

behind the right major fissure, there's an area of lucency.

48:21

Now you can say on the CT scan

48:23

that this is mosaic attenuation

48:24

'cause there's an area of lucency

48:26

and there's an area of normal lung

48:28

and mosaic just means heterogeneous.

48:30

Now when you look at the area of lucency,

48:33

are the blood vessels small in that area?

48:37

More small than the area that are less lucin

48:41

and I think that they are.

48:43

So you have small blood vessels in that area.

48:45

They're either small

48:46

because the of pruning from pulmonary artery hypertension

48:52

or they're small because of the relative hypoxia of

48:56

that area due to air trapping.

48:59

So when you see that the blood vessels are smaller in the

49:01

dark area, your patient either has pulmonary artery

49:04

hypertension or small airways disease.

49:08

Now you could just stick with this x-ray and the CT scan

49:11

and how can you exclude pulmonary artery hypertension?

49:15

Look at the size of the pulmonary artery.

49:17

If it's smaller than the aorta,

49:19

then they don't have pulmonary artery hypertension.

49:22

And this lucency must because, be

49:25

because of small airways disease.

49:28

If the pulmonary artery is big, it may be

49:31

that they have pulmonary artery hypertension

49:33

and small airways disease.

49:35

If the bronchial walls are thickened, it's probably

49:38

that they have small airways disease.

49:40

But many people will do an expiratory CT scan,

49:45

which is also helpful if it's good quality.

49:48

And if the heterogeneity becomes more significant,

49:52

then it's small airways disease.

49:54

And if it doesn't then it's pulmonary artery hypertension.

49:57

So those are the steps. First you look at the inspiratory

50:00

and the size of the vessels

50:02

and if they're small then the black area sick.

50:05

If they are equal, then the white area sick

50:07

and the patient has ground glass opacity from

50:12

infection, hemorrhage, edema, all the different causes.

50:15

Thank you for your question.

50:16

Thank you for the opportunity to say that again.

50:20

Well, thank you so much for answering those questions.

50:22

We've gotten through them all

50:24

and thank you so much for being here

50:25

and giving this awesome lecture, Dr. Salvato.

50:27

Thank you. My pleasure. Have a great day today everybody.

50:30

Thank you for participating.

50:32

Yes, uh, everyone thank you for those great questions

50:35

and for participating in our NOOM conference.

50:37

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50:38

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50:40

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50:42

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50:46

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50:49

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50:51

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50:54

Imaging of Acute Abdominal

50:56

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50:58

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51:00

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51:05

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