Bronchioles - Society of Thoracic Radiology

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Bronchioles - Society of Thoracic Radiology
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
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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
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Folicullar bronchiolitis
Respiratory
p
y bronchiolitis
Hyperplastic lymphoid follicles with
germinal centers
reactive g
Associated with Sjögren’s, 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
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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
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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

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