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Download Bronchioles - Society of Thoracic Radiology
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Imaging Small Airway Disease Small Airway Disease Small Airway Disease SUNDAY Santiago E. Rossi, MD Learning objectives: Santiago E Rossi MD STR March 2014 Centro de Diagnóstico Dr Enrique Rossi Buenos Aires, Argentina Bronchioles Membranous and respiratory bronchiole Define terminology and classification of small airway disease / bronchiolitis Review common disease entities manifesting as bronchiolar disease Describe clinical and imaging clues helpful in narrowing the differential diagnosis Functional zones T Terminal i l bronchiole b hi l - Conducting C d ti zone Respiratory bronchiole - Transitional zone No cartilage or submucosal glands Smaller than 1-2 mm Bronchi / Bronchioles HRCT Bronchi < 2 mm Not normally visible Alveolar duct - Respiratory zone Alveolar sacs - Respiratory zone Small airway disease Inflammation or fibrosis of bronchiole usually centered in and around membranous and respiratory bronchiole Bronchioles Rarely visible within 1 cm of pleural surface Bronchiolitis Direct signs Bronchiolar wall thickening g Bronchiolectasis Luminal bronchiolar impaction Tree-in-bud pattern Centrilobular nodules I di Indirect t signs i Mosaic - attenuation pattern Air trapping on Expiratory CT 117 SUNDAY Bronchiolitis Direct Signs Bronchiolar Bronchiolitis Direct Signs Bronchiolectasis wall thickening Centrilobular Defined Pathology: Beyond terminal bronchiole Center on respiratory p y bronchiole or alveolar ducts HRCT: In HRCT I center t off SPL 5-10 mm from pleural surface Not related to interlobular septa 118 Bronchiolitis Direct Signs Bronchiolectasis Bronchiolitis Direct Signs Bronchiolitis Direct Di ect Signs Centrilobular nodules ((GG)) Centrilobular nodules Bronchiolitis Direct Signs Tree-inbud pattern Tree-in-bud Small Airways y Disease Tuft: Bronchioles, alveolar ducts Classification SUNDAY Bronchiolitis Direct Signs Stalk:: Last order bronchus Stalk Cellular bronchiolitis Obliterative bronchiolitis Im et al. Pulmonary TB. Radiology 1993 Cellular bronchiolitis Infectious bronchiolitis Aspiration bronchiolitis Respiratory bronchiolitis (RB; RB-ILD) Hypersensitivity pneumonitis Cellular bronchiolitis HRCT Direct signs: Bronchiolar wall thickening Bronchiolectasis Centrilobular nodules Diffuse panbronchiolitis Bronchiectasis (cystic fibrosis, ciliary dyskinesia) Centrilobular nodules and branching lines (tree ( tree--in in--bud) 119 SUNDAY Infectious bronchiolitis Infectious bronchiolitis Endobronchial spread Endobronchial spread Tuberculosis Tuberculosis Nontuberculous mycobacteria Non-TB Viruses, fungi, mycoplasma Viruses, fungi, mycoplasma HRCT: HRCT: Centrilobular nodules Centrilobular nodules Tree-in-bud opacities Tree-in-bud opacities Middle lobe and lingula g bronchiectasis Infectious bronchiolitis Aspirative bronchiolitis p Endobronchial spread Chronic inflammatory reaction Tuberculosis Esophageal disorders Non-TB Neurologic defects Viruses, fungi, mycoplasma Chronic illness HRCT: Centrilobular nodules Tree-in-bud opacities HRCT: Centrilobular nodules U i or bilateral Uni bil t l tree-in-bud t i b d opacities Dependent portions of the lung Diffuse panbronchiolitis 120 Diffuse panbronchiolitis Asian - Idiopathic Sinu-bronchial syndrome Chronic inflammation and accumulation of foamy macrophages at the RB Asian - Idiopathic Sinu-bronchial syndrome Chronic inflammation and accumulation of foamy macrophages at the RB HRCT: Centrilobular nodules Tree-in-bud opacities Progressive bronchiectasisbronchiolectasis Decreased lung attenuation HRCT: Centrilobular nodules Tree-in-bud opacities Progressive bronchiectasisbronchiolectasis Decreased lung attenuation Bronchiectasis (ciliary dyskinesia Most common cause of pulmonary insufficiency in the fi t 3 decades first d d off life lif Chronic and recurrent respiratory infections Situs inversus (50%) HRCT: Cylindrical bronchiectasis Bronchial wall thickening Mucous plugging T Tree-in-bud i b d opacities iti Cellular bronchiolitis HRCT Direct signs: Bronchiolar wall thickening SUNDAY Bronchiectasis (cystic fibrosis) Sinusitis Bronchiectasis HRCT: Bronchial wall thickening Bronchiectasis Bronchiolectasis Tree-in-bud opacities Hypersensitivity yp y pneumonitis p Immunologic disorder Inhaled organic - inorganic antigens Dyspnea,, cough, Dyspnea cough, malaise Bronchiolectasis Centrilobular nodules HRCT: Centrilobular GG nodules Centrilobular nodules and branching lines (tree ( tree--in in--bud) Patchy or diffuse GGO Hypersensitivity yp y pneumonitis p Respiratory p y bronchiolitis Immunologic disorder Inhaled organic - inorganic antigens Dyspnea,, cough, Dyspnea cough, malaise Cigarette g smokers HRCT: Centrilobular GG nodules HRCT: Patchy or diffuse GGO Patchy GGO Expiratory air air-trapping trapping Upper lobes predominance Expiratory air air-trapping trapping > 30 pack-years Restrictive function Centrilobular GG nodules 121 SUNDAY Folicullar bronchiolitis Respiratory p y bronchiolitis Hyperplastic lymphoid follicles with germinal centers reactive g Associated with Sjögrens, RA, immunodeficiencyy HRCT: Centrilobular and peribronchiolar nodules Mild bronchial dilatation /bronchial wall thickening Pure inhalation talcosis Accidental inhalation by children Bronchiolitis HRCT Chronic inhalation of talc used Indirect signs: for cosmetic purposes (adults) Mosaic attenuation Air Air--trapping pp g No increase risk of neoplasm Bronchiolitis HRCT Inspiration Obliterative bronchiolitis Inspiration Expiration Infection (viral, bacterial, mycoplasma) Indirect signs: Toxic fume inhalation Mosaic attenuation Air Air--trapping pp g Collagen vascular disorders Chronic lung transplant rejection Ch i graft Chronic ft versus host h t disease di Hypersensitivity pneumonitis 122 Idiopathic Supine Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--smoke inhalation Post SUNDAY Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--smoke inhalation Post Supine Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--smoke inhalation Post Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--infectious Post Inspiration Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--infectious Post Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Swyer y James James--McLeod syndrome y Expiration 123 SUNDAY Air-trapping on Expiratory CT AirOblit Obliterative ti bronchiolitis b hi liti Post--transplant Post p Inspiration Air-trapping on Expiratory CT AirMi i Oblit ti b hi liti Mimics Obliterative bronchiolitis Asthma Expiratiion 46 y, severe asthma Air-trapping on Expiratory CT AirMi i Oblit ti b hi liti Mimics Obliterative bronchiolitis Bronchiolitis HRCT Tree-in-bud T i b d pattern tt Infection Aspiration Centrilobular nodules poorly defined (GGO) H Hypersensitivity iti it pneumonitis iti Respiratory bronchiolitis (RB; RBILD) Mosaic attenuation / Air trapping Obliterative bronchiolitis Hypersensitivity pneumonitis 46 y, severe asthma Bronchiolitis HRCT Bronchiolitis HRCT T Tree-in-bud i b d pattern tt T Tree-in-bud i b d pattern tt Infection Infection A pirati Aspiration A pirati Aspiration Centrilobular nodules poorly defined (GGO) H Hypersensitivity iti it pneumonitis iti Respiratory bronchiolitis (RB; RBILD) Mosaic attenuation / Air trapping 124 Centrilobular nodules poorly defined (GGO) H Hypersensitivity iti it pneumonitis iti Respiratory bronchiolitis (RB; RBILD) Mosaic attenuation / Air trapping Obliterative bronchiolitis Obliterative bronchiolitis Hypersensitivity pneumonitis Hypersensitivity pneumonitis SUNDAY Acknowledgements Lane Bennion Bennion,, Medical Illustrator G. Abbott, MD Amrysis 125
