0:02

Hello and welcome to Noon Conference hosted by MRI Online

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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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and share ideas to help the community learn and grow.

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and previous noom conferences

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by creating a free MRI online account.

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Today's Noom conference is

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provided by the France Foundation.

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We're honored to welcome Dr.

0:34

Mary Salvato for a lecture entitled The Role

0:37

of the Radiologist in the Multidisciplinary Management

0:40

of Bronchiectasis.

0:42

Dr. Salvato is a professor

0:43

of radiology at Columbia University Irving Medical

0:45

Center in New York City.

0:47

She specializes in thoracic radiology

0:49

with a specific focus in interstitial lung diseases

0:52

and patterns of fibrosis on ct.

0:55

She's a passionate teacher

0:56

and has spoken throughout the country on the early

0:58

and correct diagnosis of IPF.

1:01

She's actively involved in research

1:02

and has written text on CT interpretation

1:05

for non radiologists.

1:06

Her ultimate goal is to affect as many people as possible

1:09

through education and a positive attitude.

1:12

And we're glad she's here today to share her expertise.

1:14

At the end of the lecture, please join her in a q

1:17

and A session, which will address questions you

1:19

may have on today's topic.

1:21

Please remember to use the q

1:22

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

1:24

as many as we can before our time is up.

1:26

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

1:29

Salur, please take it from here.

1:32

Thank you very much for your introduction.

1:34

It is my privilege to be here today to speak about the role

1:37

of radiologists in the multidisciplinary management

1:40

of bronchiectasis.

1:42

Thank you also to the France Foundation for this opportunity

1:45

to speak and, um, reach such a, uh, wonderful audience.

1:51

The learning objectives for today's talk is to be able

1:55

to differentiate the various forms

1:57

of bronchiectasis on high resolution CT scan

2:00

and to learn the role

2:01

of the radiologist in a multidisciplinary discussion.

2:07

We're gonna talk about what is bronchiectasis,

2:10

how imaging can help us decide what kind

2:12

of bronchiectasis the patient is suffering from.

2:15

How does imaging help us to make treatment decisions?

2:18

What is the role of imaging before, during, and

2:20

after treatment, and the future directions of imaging

2:23

for the diagnosis of bronchiectasis?

2:26

Let's start with a patient. This is a 61-year-old female.

2:30

She has a daily cough productive of yellow, green sputum,

2:34

frequent exacerbations treated with antibiotics.

2:37

She has bronchi with squeaks, no digital clubbing,

2:40

and her pulmonary function tests are compromised.

2:43

When I look at this chest x-ray,

2:45

I see at the lung basis there's either some ectasis

2:48

or scarring or consolidation

2:51

and I, um, I'm thinking I wish I could, could, um,

2:55

to know more about her from imaging.

2:58

What would you, um, this is a polling question now.

3:01

What would you recommend

3:02

as the next step in establishing

3:04

a diagnosis for this patient?

3:06

Would you do additional lung function testing?

3:09

Would you recommend sputum cultures, bronchoalveolar lavage,

3:13

or a chest ct?

3:18

And we'll give you a second to answer

3:20

that for a few seconds.

3:27

Thank you. So most of you would recommend a, um, CT scan

3:30

of the chest and the patient had a CT scan of the chest.

3:34

The patient, um, CT scan was done in prone position

3:37

and what we're seeing are dilated, um,

3:39

bronchi in the right middle lobe in the lingula.

3:42

The bronchi are bigger than their accompanying artery,

3:45

and this pattern in an older, um,

3:47

female is very characteristic

3:49

of mycobacterium avium intracellular.

3:52

When you see bronchiectasis in the right middle lobe

3:55

and lingular, it can occur elsewhere also,

3:58

but, um, predominantly it's usually in the right middle

4:00

lobe and lingular.

4:04

The definition of bronchiectasis is permanent dilatation

4:08

of the airway bigger than it's accompanying artery.

4:10

So here we see the artery,

4:11

the pulmonary artery and the bronchus.

4:13

And the bronchus is now bigger than the accompanying artery.

4:17

And um, we call that bronchiectasis.

4:20

It's considered a rare disease affecting 566 people per

4:25

100,000 on average,

4:26

but it's increasing with a 40% increase over

4:30

the past 10 years.

4:32

This, um, sign is called a signet ring sign

4:34

because the bronchus is bigger than the artery

4:36

and it looks like a a ring.

4:40

Lynn Reed was one of the early people

4:42

who described bronchiectasis in 1950.

4:44

She wrote an important article

4:46

and she said that the mildest form

4:48

of bronchiectasis is cylindrical bronchiectasis,

4:51

where the bronchi is bigger than the accompanying artery,

4:54

but it's relatively smooth.

4:56

She said the um, next more significant type

4:58

of bronchiectasis is Vera Rao bronchiectasis,

5:01

where there's areas of narrowing

5:03

and dilatation resembling a varicose vein.

5:07

And the worst type of bronchiectasis was cystic

5:10

bronchiectasis, which looked like a cluster of grapes.

5:13

And um, of course she wasn't seeing this on cat scan.

5:16

She was seeing this on, um, uh, physical exam.

5:19

She was doing an autopsy series.

5:22

When we think about how long it take,

5:24

how many branches the airways have from the trachea

5:27

to the periphery of the lung, the airways branch, 26 times,

5:31

there are eight conducting segmental airways from the

5:35

trachea to more the, the periphery of the lung.

5:38

Then there's eight more, um,

5:41

subsegmental conducting airways carrying the air,

5:45

and then there are eight subsegmental respiratory airways.

5:48

So they're up to 24.

5:49

And then the last two are the, the ducts and the sacs.

5:53

And so for a total of, um, 26,

5:57

and when we think about the conducting airways,

5:59

there are 16 of them.

6:01

And um, Lynn Reed saw that in people

6:04

with cylindrical bronchiectasis,

6:06

they maintained having 16 conducting airways.

6:10

In contrast, what happens with veo bronchiectasis is

6:12

that there's pruning of the branches.

6:15

So instead of having 16 branches,

6:17

now there are only eight branches.

6:19

And further in secular bronchiectasis

6:22

or cystic bronchiectasis, there's further pruning

6:24

and only four branches in the conducting airways.

6:29

And her grading system still holds

6:31

true today we're using it.

6:32

Um, when we describe bronchiectasis radiographically,

6:36

although she described it um, at autopsy,

6:40

where this lecture today is not talking about the type

6:42

of bronchiectasis that's pulled open because of fibrosis.

6:46

Um, we call that traction bronchiectasis.

6:48

Um, we're talking about bronchis, uh, bronchitis,

6:51

that bronchiectasis, that's an intrinsic prob problem

6:54

with the bronchus itself.

6:57

How does imaging help in determining the etiology

6:59

of bronchiectasis?

7:02

We're gonna do a pretest question now.

7:03

If you could answer, how should a CT scan for evaluation

7:07

of bronchiectasis be performed?

7:09

Should it be performed in full inspiration

7:13

with thick collation using intravenous contrast

7:17

or prone imaging only?

7:21

We're not gonna go over this answer now

7:24

and we'll go to the next slide.

7:29

Here's how a CT scan should be done for bronchiectasis.

7:33

We never use contrast.

7:34

I don't know if you've ever had a CT scan with contrast.

7:37

It makes you feel warm all over

7:39

and you become a little bit anxious

7:41

because you're not used to that feeling.

7:43

And so the patient becomes t knick

7:45

and that's the enemy of having a good CT scan is

7:48

to have motion artifact due to respiration.

7:51

The slice technician be as thin as possible,

7:53

ideally less than 1.5 millimeters.

7:56

And we want the patient to have a full inspiratory effort,

8:00

a big breath in and hold it.

8:02

Um, sometimes we do expiratory images on the first time

8:05

we're seeing a patient to see if there is air trapping.

8:12

Let's review some of the anatomy of the airways.

8:15

When thinking about the right up below bronchus,

8:17

I can't help but see a goldfish cracker.

8:19

You see how much the right up

8:21

below bronchus looks like a goldfish cracker.

8:24

Now you'll never look at a goldfish cracker the same

8:26

or a right up below bronchus

8:28

and there is an anterior branch, a posterior branch,

8:31

and from the top an apical branch.

8:33

When I think about the right middle lobe, there are two

8:36

branches and I think remember them because of the initials.

8:39

Middle lobe ML are the same as medial and lateral.

8:44

The right lower lobe has five branches

8:46

and they look like a compass just like north,

8:48

southeast, and west.

8:50

The right lo lobe bronchi are anterior posterior, medial

8:55

lateral and superior from the top.

8:59

So there are 10 branches in total, 10 primary

9:02

branches in the right lung

9:04

and in the left lung there are more truncated

9:07

things are combined together.

9:08

So in the left upper the lobe, instead

9:09

of having three branches and anterior and apical

9:12

and posterior, the apical

9:14

and the posterior combined leaving two branches

9:17

and the lingula has superior

9:19

and inferior instead of medial and lateral.

9:22

In the left lower lobe, the anterior

9:24

and medial are combined leaving four branches

9:26

for the left lower lobe

9:27

and a total of eight branches on the left side

9:30

and 10 branches on the right side.

9:35

Let's take this next patient, a 62-year-old female.

9:38

So pretend we're at work today

9:39

and we have this patient we're seeing, um,

9:42

they're hemoptysis, which has led

9:44

to the CAT scan of the chest.

9:46

They report having a pneumonia at age 12.

9:48

They had bronchitis during pregnancy. During pregnancy.

9:52

On the CT scan of the chest,

9:53

we see focal bronchiectasis in the left lower lobe.

9:56

Notice the bronchus is bigger than the accompanying arteries

9:59

and the microbiology shows pseudomonas.

10:02

So this is a focal, um, bronchiectasis

10:06

and there's a narrow differential for focal bronchiectasis,

10:10

which includes infections from bio, um,

10:12

bacterial infections, viral infections

10:15

and mycobacterial infections.

10:17

But also in young people,

10:18

things like foreign body aspiration is very common.

10:22

Bronchials stricture can occur

10:23

and a bronchial masses like um, broncho artis is when

10:28

a calcified lymph node erodes into the bronchus

10:31

and causes downstream obstruction

10:33

or an endobronchial tumor like an endobronchial carcinoid.

10:37

And bronchial atresia congenitally acquired stricture

10:41

of the bronchus with mucoid impaction usually

10:43

and surrounding air trapping.

10:45

So these are the reasons you might think about

10:47

for focal bronchiectasis infection.

10:50

Um, broncho ssis, bronchial atresia and bronchial carcinoid.

10:56

But most of the bronchiectasis we see is not

10:58

focal bronchiectasis.

11:00

It's more diffuse. We said previously

11:02

that there are 1 2 26 branches of the, from the trachea

11:06

to the periphery of the lung.

11:08

Right now we're gonna talk about the central bronchiectasis,

11:10

the bronchiectasis that affects the

11:12

first to the eighth branch.

11:16

Here is a pretest question.

11:19

Which upper low predominant central bronchiectasis is

11:22

associated with asthma?

11:25

Is it dism modal CLIA aspiration,

11:30

MAI or allergic broncho pulmonary aspergillosis?

11:37

I'll give you a second to answer

11:39

and then we'll go to the next slide.

11:44

When we think about central bronchiectasis,

11:47

we think about moon year Koon's disease.

11:50

Koon's disease is also called tracheal bromely,

11:53

and I reserve thinking about moona c***s

11:56

until the trachea measures three

11:59

centimeters in transverse dimension.

12:01

This is a rare disease

12:02

and in my 25 years,

12:03

I think I've seen it three times at most.

12:06

So we have tracheal bromely is moona konz,

12:09

there are sometimes tracheal diverticulum as well.

12:13

The next disease is more, um, common

12:18

allergic bronchopulmonary aspergillosis

12:21

allergic bronchopulmonary aspergillosis gives what's called

12:23

a hand and a glove appearance.

12:25

It's dilatation of the first to the fourth branch.

12:28

So we said that there's 26.

12:30

This is very proximal, the first to the fourth branch.

12:33

So the big bronchi are dilated and contain mucus.

12:36

Give the hand in glove, the hand is the mucus

12:39

and the glove is the dilated bronchus

12:41

and it's seen in patients who have asthma

12:43

and cystic fibrosis.

12:46

The next patient has William Campbell's disease.

12:51

William Campbell's disease affects the fifth

12:53

to the eighth branch of the um, bronchi.

12:57

So it you'll have normal, very central bronchi.

13:00

The peripheral bronchi will be normal,

13:01

but the bronchi in the middle will be dilated

13:03

and gives this very like a mini type of appearance

13:06

where when you see it, you know

13:08

that it's William's Campbell.

13:10

And in order to prove it, you do an expiratory CT scan

13:13

and these bronchi will collapse

13:16

because they don't have cartilage.

13:19

So the central bronchiectasis are going to be, um, Nia Kuns,

13:23

allergic bronchopulmonary aspergillosis

13:25

associated with asthma.

13:27

And then Williams Campbell,

13:29

we talked about focal, we talked about central.

13:31

And now we have another pretest question.

13:33

What is the most common location

13:35

of post-primary tuberculosis?

13:38

Is it in the back of the upper lobes?

13:41

Is it in the front of the lower lobes?

13:45

Is it in the lingula and right middle lobe

13:47

or is it in the upper lobes and anteriorly located?

13:59

Okay, we'll go to the next slide.

14:01

We talked about focal bronchiectasis,

14:03

central bronchiectasis,

14:04

but most of the bronchiectasis are more diffuse

14:07

that we see on a day-to-day basis.

14:09

And then we think about whether it is upper lobe

14:11

or lower predominant, upper low predominant bronchiectasis.

14:15

We can think about sarcoidosis, cystic fibrosis

14:18

and tuberculosis.

14:20

Sarcoidosis, you know, has four stages, um,

14:23

or five if you include no sarcoidosis.

14:26

Stage one affects just the lymph nodes become big.

14:29

I think about stage one.

14:30

One thing is sick, the lymph nodes are sick.

14:33

Stage two, two things are sick.

14:34

The patient has lymph nodes and nodules that are enlarged.

14:38

And stage three, the lymph nodes start to involute

14:42

and the nodule stay.

14:43

Stage three and stage four is fibrosis.

14:46

The fibrosis of sarid prefers the back

14:49

of the upper lungs very characteristically.

14:53

Cystic fibrosis is uh, another bronchiectasis

14:56

that affects the upper lobes.

14:57

It was, um, described at Columbia by Dr. Dorothy Anderson,

15:02

who noticed babies with salty skin were dying from lung

15:05

diseases and she coined the term cystic fibrosis.

15:08

And we see dilated bronchi in the upper lungs,

15:12

bronchiectasis in the upper lungs.

15:15

Tuberculosis affects the upper lungs as well.

15:17

And just like sarcoidosis, tuberculosis affects the back

15:20

of the upper lungs as opposed

15:22

to diseases like chronic hypersensitivity.

15:24

Pneumonitis affect the, the front, um,

15:27

tuberculosis affects the back

15:30

and it tends to have more mucus

15:31

and secretions than sarcoidosis.

15:36

Here we have another pretest question.

15:39

For an elderly female with cough and right middle lobe

15:43

and lingular bronchiectasis,

15:44

what is the most likely diagnosis?

15:46

Is it cystic fibrosis in an elderly female MAI

15:51

tuberculosis or DYS modal clia

16:04

lower low bronchiectasis has a specific

16:06

differential diagnosis.

16:07

Probably most commonly in a hospital setting we see

16:10

aspiration pneumonia with dilated bronchi

16:14

and um, mucus in the bronchi

16:16

and consolidation from aspiration

16:19

another relatively lower lobe predominant middle lobe

16:22

and lingular bronchiectasis is MAI

16:27

and MAI, like we had said previously affects the um,

16:31

right middle lobe in the lingular

16:33

with bronchiectasis bigger than it's accompanying artery.

16:36

Usually the patient will be an older female

16:39

and it's supposedly caused from not having a rigorous cough.

16:43

My mother's 85

16:44

and when she coughs, I tell her to cough more rigorously.

16:47

The term for this is Lady Windermere syndrome

16:49

because um, she was portrayed in the movies

16:52

as a polite older woman.

16:54

I think she was only 26 in the movies.

16:55

So not characteristic of a typical patient with MAI,

16:58

but dilated bronchi in the right men lobe and lingula.

17:02

We think about, um, MAI

17:05

and I see this probably three times a day.

17:07

So very common. Um, disease in in New York,

17:12

dys modal CLIA is rare.

17:14

This disease, I think about when I see someone who's a young

17:17

person usually in their twenties who has a history

17:20

of recurrent pneumonia.

17:21

And when we do the CT scan,

17:23

they have dilated lower low bronchi with thickening

17:26

of the um, walls.

17:29

Um, very characteristic dism,

17:30

modal cilia is the broad category.

17:32

If they have a right-sided heart, we call it cartas.

17:36

If they have yellow nails, we call it yellow nail syndrome.

17:39

If they have azoospermia, we call it young syndrome.

17:41

So the broad category is dism modal cilia.

17:44

So just to regroup the things that we talked about, we said

17:48

that in, uh, if you have focal bronchiectasis,

17:51

we're gonna think about an infection.

17:53

We're gonna think about broncho LSIs, bronch atresia,

17:56

bronchial carcinoid.

17:58

If you have central bronchiectasis,

18:00

we're gonna think about Nia Koons, allergic broncho,

18:03

pulmonary aspergillosis and Williams Campbell.

18:06

If we have upper lung bronchiectasis,

18:08

we're gonna think about sarcoid and tb.

18:10

They look very similar and cystic fibrosis

18:13

and more lower lung bronchiectasis.

18:15

We're gonna think about aspiration MAI and dism, modal CLIA

18:19

and um, some clinical information is gonna be helpful in

18:22

differentiating those.

18:24

Here's another example of MAI look how it's affecting, um,

18:28

the right middle lobe characteristically

18:30

with thick walled dilated bronchi,

18:33

cylindrical type bronchiectasis bigger than the

18:34

accompanying artery.

18:37

And this is another patient

18:38

with dism modal clia more diffuse lower lobe

18:41

bronchiectasis, a younger patient.

18:45

Secondary features of um, people

18:47

with airways disease is mosaic attenuation and air trapping

18:51

and those terms are challenging, um, to work with.

18:54

When we have an inspiratory CT scan, we look

18:58

and we see, we use the word mosaic attenuation

19:00

and all it really means is heterogeneity.

19:02

So most of the CAT scans we see, we can say

19:04

that there's mosaic attenuation, heterogeneity.

19:07

Um, a little bit of mosaic attenuation is expected in normal

19:11

people when it affects more than two lobes,

19:14

I usually call it mosaic attenuation.

19:16

And um, so we see areas that are darker

19:19

and areas that are lighter,

19:21

but the challenge then is deciding whether this darker area

19:25

is the sick area or the wider area is the sick area.

19:30

The way that you do that is you look at the darker area

19:32

and if the blood vessels in the darker area are smaller than

19:36

the blood vessels in the wider area,

19:38

then the darker area is the sick area

19:40

and the patient either has pulmonary artery hypertension

19:43

causing pruning of these vessels,

19:45

or they have air trapping causing relative hypoxia

19:48

that's making the vessels smaller

19:50

because the blood is shunting elsewhere to

19:52

where it's more oxygen available.

19:54

If the blood vessels are the same size and the blood area

19:57

and the white area,

19:58

then the white area has ground glass opacity.

20:02

So usually even on the inspiratory CT scan,

20:05

I can narrow the differential diagnosis down.

20:08

If I see that the vessels in this patient are smaller in the

20:11

dark area compared to the white area,

20:13

then I can just look at the pulmonary artery size

20:15

and if it is normal, assume that this is related to um,

20:19

small airways disease.

20:22

Um, when I measure the pulmonary artery size, I used

20:25

to use 33 millimeters transverse as the, um,

20:30

diameter that I would call, um, suspicious

20:32

for pulmonary artery hypertension

20:33

and recommend an echocardiogram.

20:35

But now I have, um, I wait

20:38

until the pulmonary artery is bigger than the aorta.

20:42

Um, and the pulmonary artery

20:44

to aorta ratio is greater than one to call

20:47

to suggest pulmonary artery hypertension.

20:51

And um, we can do an expiratory CT scan if we have one.

20:54

Um, uh, done.

20:56

The way that we should look at it is if it becomes more

20:59

pronounced the, um, heterogeneity,

21:01

then we consider it to be air trapping.

21:03

Pulmonary artery hypertension shouldn't become more

21:05

pronounced, the heterogeneity on expiration.

21:11

How can imaging help in determining treatment

21:13

for bronchiectasis?

21:15

The goals of treatment for bronchiectasis is

21:17

to relieve the symptoms of cough.

21:19

The cough, um, the, um, shortness

21:21

of breath prevent the progression of disease

21:23

and prevent complications like exacerbations.

21:27

What is an exacerbation?

21:28

Exacerbation is when you have 48 hours

21:31

of worsening symptoms, at least 48 hours of worsening cough,

21:35

more perial and sputum, more volume

21:38

of sputum hemoptysis.

21:40

And a clinician determines

21:42

that the treatment needs to be changed.

21:46

There are no medications approved, um, in the United States

21:50

for the treatment of bronchiectasis

21:52

to reverse bronchiectasis except for cystic fibrosis.

21:55

They have new treatments available.

21:57

Um, so you're gonna treat the underlying cause if you can.

21:59

Like if a patient is aspirating, you're gonna try to, um,

22:03

help with the aspiration.

22:04

Um, treat comorbid conditions like GERD and target.

22:09

The essential aspects of the pathophysiology

22:12

of the bronchiectasis bronchiectasis is so, um,

22:16

interesting when you think about it, a patient gets a

22:18

bacterial infection, the neutrophils come to the rescue

22:21

to try to clear the infection

22:22

but bring with them elastases, which destroy the airway.

22:26

The airway gets destroyed

22:27

and distorted, which becomes a setup for more mucus

22:29

to settle in that area.

22:31

And then a secondary infection,

22:33

which brings more neutrophils and elastases

22:36

and it just perpetuates the cycle, an ongoing

22:39

and worsening cycle.

22:42

The treatment of it involves things like

22:44

airway clearance techniques.

22:46

I had been a physical therapist before I became a doctor

22:48

and we used to do chest percussion on patients

22:50

and see how the mucus would clear hypertonic saline,

22:54

ne nebulized, macrolides suppressive antibiotics,

22:58

bronchodilators and corticosteroids the

23:00

mainstreams of treatment.

23:02

And here is a question for you.

23:04

For a female with bronchiectasis

23:06

and frequent exacerbations,

23:09

she has sputum cultures growing pseudomonas, MAC

23:12

and IgE is normal.

23:14

What would be the treatment alternative

23:15

to reduce exacerbations?

23:17

Is it chronic macrolides, inhaled tobramycin,

23:21

prednisone or albuterol?

23:36

Here we have a CT scan with dilated bronchi,

23:40

thick wall bronchi mucoid impaction,

23:43

and the treatments will be airway clearance therapies

23:46

to get up this mucus

23:47

and nebulize saline to make the secretions less viscous.

23:52

In patients with, um, nodules, uh,

23:56

that might be pseudomonas we treat with chronic macrolides

23:59

and suppressive antibiotics like tobramycin.

24:07

In patients that have central bronchiectasis,

24:10

we're gonna use inhaled bronchodilators and corticosteroids.

24:16

When do we decide to follow up imaging?

24:18

So we do an imaging, we see the patient has bronchiectasis.

24:20

How often do we need to follow up the imaging?

24:23

This is a polling question for you maybe in your practice

24:26

how you would think to follow it up best when monitoring

24:29

for progression of disease, what is the appropriate interval

24:32

for follow-up imaging when you wanna look for, not

24:35

that they're having an exacerbation,

24:36

but um, if they are progressing, is it one month,

24:41

three months, six months, or 12 months?

24:43

So

24:54

there's variable and I think that is so true

24:55

that we do have variable patterns

24:57

for following up bronchiectasis to see, um,

25:00

how it is evolving in our institution,

25:05

I think from six to 12 months, we do for following up

25:08

of patients that are not having an acute exacerbation.

25:12

So we do subsequent, um, imaging

25:14

to see if the patient is progressing.

25:17

Here's a patient that has, um, mycobacterium avium complex

25:22

with um, characteristic lingular

25:25

and right middle low bronchiectasis and some consolidation

25:29

and then a follow-up imaging six months later shows

25:32

that they have progressed and have more cavitation.

25:35

So follow-up was important for this patient.

25:40

Another reason is

25:41

to see if they're responding well to treatment.

25:43

We might do a follow-up imaging if we did a new

25:45

treatment intervention.

25:47

Here's a cystic fibrosis patient that's on CFTR modulators

25:50

for their cystic fibrosis.

25:51

And look at how beautifully it cleared on follow-up imaging

25:55

showing that the treatment was working

26:01

a patient with, um, mycobacterium who's, uh, received, uh,

26:04

treatment is also shows significant improvements.

26:07

So we see if our interventions are having a positive effect

26:12

or if the patient develops an acute illness,

26:14

we might use imaging

26:15

to see if there are complications like pneumonia or empaa.

26:21

What does the future hold for bronchiectasis?

26:23

What should we be working at as um, as

26:27

to help these patients more?

26:29

What can we do to, to help these patients?

26:32

I think, um, a grading system that included the extent

26:35

of bronchiectasis, not just the amount of dilatation

26:38

of an individual bronchus would be helpful.

26:41

Um, maybe there are many systems described in the

26:43

literature, but one that everyone adapts would be helpful

26:45

for we for communication with each other.

26:48

And I'm very hopeful about, um,

26:50

MRI being used on these patients more frequently.

26:54

Now we have what would be the limitation of MRI

26:57

as it is the standard of care.

26:58

We have people who are very short of breath,

27:00

who are coughing, having

27:02

to spend a long time in an MRI would be very difficult

27:05

for them lying flat.

27:07

But these new techniques using ZTE, which is so fast,

27:11

it's less than five millimeter minutes in size, sorry,

27:14

sorry, five minutes long.

27:16

And, um, and we put a a belt on the patient

27:19

for respiratory gating.

27:20

So there's very little motion artifact.

27:23

This was a healthy volunteer,

27:24

but you could see how good the quality of the images are

27:27

and how the, um, how well we see the, um, blood vessels.

27:32

And you can imagine if the patient

27:33

of bronchiectasis we would see it.

27:34

Well another thing that's helpful with MRI imaging is

27:38

that we can differentiate nodules from mucus on,

27:41

um, T two weighted imaging.

27:44

So I'm optimistic about the future for that.

27:47

So the takeaway points, the definition

27:49

of bronchiectasis is irreversible dilatation

27:51

of the airways bigger than their accompanying artery.

27:54

We need to be able to differentiate traction bronchiectasis,

27:57

which is a fibrotic lung disease from intrinsic

28:00

bronchial disease.

28:02

The pattern of bronchial involvement helps us

28:04

to differentiate and give a more narrow differential for

28:07

what the etiology might be

28:09

and the proper CT skin is important in order

28:11

to make the the best diagnosis.

28:17

We have some, um, post-test questions now.

28:21

Um, so if you would please answer these.

28:23

Which upper low predominant central bronchiectasis is

28:27

associated with asthma?

28:30

Is it dys modal CLIA aspiration, MAI

28:35

or allergic broncho pulmonary aspergillosis.

28:49

So allergic bronchopulmonary aspergillosis is associated

28:53

with, um, asthma as the majority of you said.

29:00

How should a CT scan for the evaluation

29:02

of bronchiectasis be performed in full inspiration

29:06

with thick collation using intravenous contrast

29:11

or prone imaging Only

29:31

full inspiration.

29:32

Exactly. For an elderly female

29:37

who has cough, a right middle lobe

29:40

and a lingular bronchiectasis,

29:42

what is the most likely diagnosis?

29:44

Is it cystic fibrosis MAI

29:49

tuberculosis or dism modal CLIA

29:52

syndrome in an elderly female.

30:08

Very good. The majority of you said MAI, which is the

30:11

right diagnosis for the right middle lobe

30:13

and lingula in an elderly female.

30:17

What is the most common location

30:19

of post-primary tuberculosis?

30:22

Is it in the back of the upper lobe?

30:24

Is it in the anterior lower lobes, the lingula

30:27

and right middle lobe or the upper lobes in the

30:30

front anterior.

30:46

Excellent. That's a hard thing. Um, to keep in mind

30:49

that the back of the upper lobe,

30:50

whenever you see an infection, think about tuberculosis

30:58

For a female with bronchiectasis and frequent exacerbations

31:03

and growing pseudomonas and mac, but her IgE is normal.

31:07

What should be the treatment alternative

31:09

to reduce exacerbations?

31:12

Chronic macrolides, inhaled tobramycin,

31:16

prednisone or albuterol?

31:30

This one is a hard one.

31:31

Um, tobramycin is the best answer for this question.

31:39

Okay. Can you please, um, scan this QR code

31:42

and complete the post-test

31:44

and evaluation to claim your credit?

31:47

I really appreciate your time being here

31:49

and I'd love to answer any questions

31:50

that you might have about, um, the lung

31:53

or bronchiectasis, um, or radiology.

31:58

Thank you very much.

32:01

Thank you so much for sharing your lecture with us, Dr.

32:03

Salvato. At this time we will open the floor

32:06

for any questions so you can submit your questions through

32:09

that q and A feature.

32:11

And we have a few in there already,

32:13

so I will throw out the first one is NTM infectious,

32:18

should they get an antibiotic?

32:21

It's a complicated course.

32:22

A lot of patients that have um, uh,

32:25

MAI infections are not treated unless they are symptomatic

32:28

or progressing on radiology.

32:32

It's ubiquitous in in the environment, so, um,

32:34

we don't always, um, treat it.

32:41

Thank you for your question.

32:45

What is the difference between NTM and MAI?

32:49

They are synonymous. They are, uh, alternative terms used.

32:54

Great.

32:56

How much air trapping is normal on expiratory CT scan?

33:01

Hmm. I, um, I divide along into four quadrants

33:05

and I accept that if it's in one, um, one quadrant,

33:10

I call it um, normal.

33:12

And when I see it in two quadrants, I call it mild.

33:15

If I see three quadrants, I call it moderate

33:18

and four severe just so that I say the same thing.

33:21

Um, when I see this, uh, when I see a CT scan so

33:25

that I can be, um, consistent.

33:27

Thank you.

33:32

What is the definition of traction bronchiectasis?

33:35

Okay, so traction bronchiectasis is when we see,

33:38

usually in the periphery

33:39

of the lung we don't see the bronchi.

33:41

So the, when the bronchi become visible in the periphery

33:44

of the lung, um, we call it traction bronchiectasis.

33:48

It's really quite interesting why that would uh, occur.

33:51

Um, when the alveoli collapsed in the periphery of the lung,

33:56

it pulls open the bronchis giving traction bronchiectasis

33:59

and it's associated with, um, fibrotic lung diseases.

34:06

I often see reports with bronchiectasis called when you

34:09

look the dilation is only mild relative

34:12

to the pulmonary vessel

34:13

and often on follow-up the dilation is no longer there.

34:17

Any recommendations on how to tell

34:18

that the dilation is bronchiectasis or a transient?

34:22

Hmm, that's a very good point.

34:24

Otherwise we're gonna be over calling bronchiectasis the

34:27

pulmonologist wait till it's 1.5 times the size

34:31

of the pulmonary artery,

34:32

but in radiology we say bigger than the pulmonary artery.

34:35

For our definition, I guess we would have

34:37

to retract the diagnosis if it became normal

34:39

on the follow-up imaging.

34:41

But by our criteria, if it's bigger on the CT scan,

34:44

I would call it bronchiectasis even if it's,

34:46

um, mildly larger.

34:48

I think an interesting thing too is sometimes it's not

34:50

that the bronchi is bigger, but the bronchis

34:52

wall is thickened,

34:54

which may make the patient have obstructive lung physiology.

34:58

I think both things are interesting to

35:00

or important to report on the CT scan,

35:02

but I differentiate bronchial wall thickening from a

35:05

bronchus that has normal wall thickness

35:07

and is bigger than it's accompanying artery.

35:14

The definition of a bronchiectasis is permanent

35:16

dilation of bronchi.

35:17

Why is there then a reversal of dilation on treatment?

35:22

Um, only with, um, the treatment now that they're,

35:25

it's new to us to be treating cystic fibrosis

35:28

and seeing improvement of the size of the bronchus.

35:30

This is relatively rare.

35:32

Maybe the definition needs to be, um, changed in the future

35:36

to include reversible dilatation, which would help

35:39

with the other problem that we had on one CT scan

35:41

where the bronchus was bigger than the artery

35:43

and on the second one it was not bigger.

35:45

So we could say bronchiectasis on one study versus another,

35:48

but for now it's considered irreversible by definition.

35:52

Hmm. Are the stages

35:54

of circuit doses established based on x-rays or CT scans?

35:59

Thank you for all these questions on x-ray.

36:02

They were initially established but

36:04

because, um, I think that we can apply those to CT scan

36:08

because we can see the same things even more on CT scan

36:13

when we see, um,

36:16

fibrosis in the upper lobes on a chest x-ray

36:20

and instead of, um,

36:21

and it pulls out from the hilum, that's very characteristic

36:25

of sarcoid, especially if there's tenting

36:26

of the hemi diaphragm, which indicates volume loss

36:29

of the upper lobes in contrast to tuberculosis,

36:32

pulls the hilum, superior sarcoid pulls the hilum out.

36:36

So although they are based on chest x-ray initially, now

36:39

that CT is available, we can apply those, um, the grading

36:44

to the CT scan.

36:46

Great. We have

36:50

a couple more questions.

36:51

Are you okay on time to answer them?

36:55

I am awesome. So happy to be able to talk with you all.

36:57

Great. Is there any benefit of low dose CT

37:01

to characterize bronchiectasis?

37:03

Yes, I think we should be moving to low dose CT scan.

37:07

Um, and, and

37:08

and to MRI, you know, we used to use, uh,

37:10

when you've been doing this for long enough, we used

37:12

to use the highest possible dose

37:14

to make the most beautiful picture

37:16

and the pendulum is absolutely swung

37:17

to using the lowest possible dose to see

37:20

what we need to see.

37:22

And I think, um, the followup for that will then be going

37:25

to MRI and if we can see the, the airway dilated,

37:28

there's no reason not to use the lowest dose possible.

37:30

Which, um, I think that lung cancer screening has shown us

37:35

that we can see dilated bronchi with a dose

37:37

of less than three milli gray.

37:41

What is the normal thickness of the bronchial wall?

37:45

It's barely perceptible.

37:46

I, I tell my residents that, um, if you can measure it,

37:50

it's probably thickened.

37:51

I don't think the cursor allows you

37:53

to measure it when it is normal,

37:55

but if you can measure it, I find that it, it is thickened

37:58

to my eye, which has been looking at it for a long time.

38:01

So I would just say that.

38:03

So if you can measure it, it is probably thickened,

38:10

Right?

38:12

In a case where we have middle super

38:14

and lower low bronchiectasis, what may be the origin?

38:19

So I guess common things happen commonly when I see

38:22

bronchiectasis in all the lobes.

38:23

It's oftentimes a very bad case of MAI.

38:26

Um, as diseases advance the early, the, the best way

38:29

to make a diagnosis is the earliest CT scan

38:32

where the disease where it starts.

38:34

Um, by the end, all types of bronchiectasis, all types

38:37

of fibrosis can look, have a lot of overlap

38:39

because there's so much extensive disease.

38:41

Um, so because common things happen, like commonly

38:45

it's usually MAI,

38:47

but any disease in its end stages can have bronchiectasis

38:50

more extensively in all lobes.

38:54

Great. I'm gonna do my best with this one.

38:56

How do you differentiate cystic bronchiectasis from cavitary

39:00

lesions of lung perma on ct?

39:03

Hmm. That would be very difficult, right?

39:05

You're gonna have to rely on, um, coronal images

39:09

and sagittal images to try to reconstruct the, um, the,

39:12

the path to the central trachea.

39:14

And sometimes that path is just, is um,

39:18

is lost, is truncated.

39:20

I think, um, cystic bronchiectasis is clustered

39:24

and usually cavitary lesions are, are seeing may,

39:28

they may be multiple, but they're not

39:29

necessarily touching each other.

39:31

And I think that that might be, um, helpful way of doing it.

39:37

All right. I heard you say you use aor aortic pulmonary

39:41

ratio to assess for pulmonary hypertension.

39:43

What happens when the aorta is e ecstatic? Mm-Hmm. Ecstatic.

39:49

In my institution we use 29 millimeter

39:51

as cutoff remain pulmonary artery.

39:53

The literature says 29 millimeters is the upper limits

39:56

of normal, but, um, if I, I heard I read a paper

40:00

that they used that said

40:01

that 33 millimeters was 95% confidence interval, so I went

40:05

to 33 millimeters.

40:06

But I still think, um, it's very hard to measure

40:09

that exactly depending on the position of the,

40:11

the patient's pulmonary artery.

40:13

And I'm much more confident when the pulmonary artery is

40:16

bigger than the aorta to call it

40:18

pulmonary artery hypertension.

40:19

I might suggest it at 33.

40:20

I don't do it at 29 um, millimeters.

40:23

I wait till 33 to be more confident

40:25

and I I I make that higher.

40:30

All right. We'll do two more and we'll let you go.

40:32

Thank you so much for answering all these questions

40:34

and thanks for everyone for participating

40:36

and giving us all these questions.

40:38

We appreciate it very much.

40:39

Awesome. Yeah. All right, so two more.

40:41

Um, can you have very small focal bronchial dilations, so

40:47

Very small bronchial dilatations.

40:49

What is a delightful question too?

40:51

Um, the secondary pulmonary lobule is the functional unit

40:54

of the long and shaped like a hexagon,

40:55

and the bronchus is in the middle of it in the earliest.

40:59

So the bronchus we normally don't see.

41:00

So it's very, very tiny in size.

41:03

When the patient has, oh, it's so interesting with,

41:06

we'll take for example, um,

41:09

UIP usual interstitial pneumonitis.

41:11

The patient's alveolar epithelial type

41:14

one cells stop working.

41:15

The type two cells take over the

41:17

function of the type one cells.

41:19

The type two cells make surfactant so there's no surfactant

41:21

to keep the alveoli open.

41:22

The alveoli starts to collapse.

41:24

If all the alveolar collapsing, they pull open the bronchus.

41:27

Now the bronchus is three millimeters in size.

41:30

It's not supposed to be three millimeters in size.

41:32

So that's the smallest little bronchi being dilated.

41:35

When I see that, I know the patient must have, um,

41:38

fibrosis occurring when it's three millimeter in size.

41:43

Over time, as it gets more and more dilated from more

41:46

and more atelectasis,

41:47

the bronchus takes up the whole secondary pulmonary lobule

41:49

and becomes 10 millimeters in size.

41:52

A dilated bronch is 10 millimeters in size,

41:54

and the secondary pulmonary lobule here

41:56

and the secondary pulmonary

41:57

lobule here are touching each other.

41:59

These two 10 millimeter size cystic structures,

42:01

which are the airways now are dilated, touching each other.

42:04

We call that honeycombing.

42:07

Got it. Thank you. Last question,

42:10

please explain Williams Campbell.

42:13

Williams Campbell is, um, a, a congenital disease

42:17

with absence of the cartilage that affects the,

42:20

a specific part of the airway from the fifth

42:22

to the eighth branch where there is no, um, no cartilage.

42:27

So we have ballooning out of the bronchus,

42:30

and when the patient expires, they collapse.

42:33

So they're short of breath because they're air trapping.

42:35

So when you see this ant mini type of appearance

42:37

where the central airways, where the trachea

42:40

and the, the proximal airways are normal

42:43

and the peripheral airways are normal,

42:44

but the middle ones are dilated,

42:46

it's likely Williams Campbell

42:47

and they're gonna do genetic testing to prove that.

42:51

Got it.

42:53

Thank you so much for your lecture

42:55

and for answering all those questions.

42:56

Dr. Salvatore, or, uh, this is a fantastic presentation.

42:59

Thank you so much for being here.

43:02

My sincere privilege. Thank you to all of you.

43:04

Have a beautiful day. Thank you. Thank

43:06

You again.

43:07

And thank you for everyone else

43:09

for participating in this noon conference.

43:11

Be sure to join us next week on Wednesday,

43:15

January 17th at 12:00 PM Eastern

43:17

for a live noon conference featuring Dr.

43:20

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43:23

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43:26

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43:29

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43:33

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