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971

Role of Computed
Tomography in the
Recognition of
Bronchiectasis

N. L. MUller1 To assess the accuracy of computed tomography (CT) in the recognition of bronchiec-
C. J. Bergin2 tasis, CT was performed in 1 1 patients with clinical findings strongly suggestive of this
D. N. Ostrow2 diagnosis. In two patients, CT showed extensive bilateral cystic and varicose bronchiec-
tasis, and bronchography was considered unwarranted. In four patients, bilateral, and
D. M. Nichol&
in five, unilateral bronchograms were obtained. Correlation was made between the CT
and bronchographic findings in these 13 lungs. In only six bronchograms did CT give an
accurate assessment of the presence and extent of disease. In five, the diagnosis of
cylindrical and varicose bronchiectasis was missed on CT. In two, CT suggested the
diagnosis of cylindrical bronchiectasis but the bronchogram was normal. It was con-
cluded that CT may be useful in the diagnosis of cystic bronchiectasis, but is unreliable
in detecting cylindrical and varicose changes. Bronchography, therefore, remains the
definitive method for establishing the diagnosis, extent, and seventy of bronchiectasis.

Bronchiectasis is defined as irreversible, abnormal dilatation of one or more


bronchi [1]. The most widely accepted classification of severity is that proposed
by Reid [2]. She classified the disease into three groups: cylindrical bronchiectasis,
in which the bronchi are dilated but maintain a regular outline; varicose, in which
the bronchi have irregular contours similar to varicose veins; and cystic or saccular,
in which bronchial dilatation increases progressively toward the lung periphery and
the bronchi have a ballooned outline.
The plain chest film often shows findings suggestive of bronchiectasis but is
considered unreliable in determining the anatomic distribution of the disease [1 3]. ,

Bronchography has been classically used as the definitive procedure to establish


the presence, severity, and distribution of bronchiectasis [1 ]. This procedure,
however, has several potential risks, including allergic reactions to the local anes-
thetic, allergic or foreign-body reaction to the bronchographic medium, and tern-
porary impairment of ventilation and diffusion [4]. Recently, Naidich et al. [5]
suggested that computed tomography (CT) may be useful in assessing the pres-
ence and anatomic extent of bronchiectasis [5]. They described six patients, and
in all CT showed abnormalities indicative of the diagnosis. In two of these patients,
the diagnosis of severe cystic bronchiectasis had been made from the plain chest
film. This was further evaluated with linear tomography. In four patients, they
Received January 31 . 1 984; accepted after re- obtained bronchograms and found an excellent correlation between CT and bron-
vision July 9. 1984.
chographic findings. However, all but one of these patients had cystic bronchiec-
Department of Radiology. Vancouver General
tasis.
Hospital, 855 W. 12th Ave., Vancouver, British
Columbia, Canada V5Z 1 M9. Address reprint re- To further assess the reliability of CT as compared with bronchography in
quests to N. L. MUller. detecting the presence, severity, and distribution of disease, we studied 1 1 patients
2 of Medicine, Vancouver General
with clinical findings strongly suggestive of bronchiectasis.
Hospital, Vancouver, British Columbia, Canada V5Z
1M9.
AJR 143:971-976, November 1984 Subjects and Methods
0361 -803Xf84/1 435-0971
© American Roentgen Ray Society CT was performed in 11 patients with a clinical history suggestive of bronchiectasis. The
972 MULLER ET AL. AJR:143, November 1984

-A
i; - B
Fig. 1 -Extensive bilateral vancose and cystic bronchiectasis demonstrated by CT. A, CT scan through upper lobes. B, Just below carina. Involvement of right
middle lobe. lingula, and superior segments of lower lobes.

Fig. 2.-A, CT scan through right middle lobe and lingula. Mild varicose bronchiectasis (arrows). B, Coned-down view ofright bronchogram confirms CT findings.
Similar changes were present in lingula.

patients were 32-73 years old (mean, 49; SD, 1 4). Seven were men bronchiectasis was considered to be present when the bronchi were
and four were women. In no case was there any evidence of pneu- more dilated than in cylindrical bronchiectasis and had a beaded
monia within 6 months of the study. Thus, it may be assumed that appearance [5].
the observed changes represent true bronchiectasis rather than The CT scans were read independently by two radiologists. As
reversible dilatation of the bronchi [4]. In eight patients, the scans would be the case in a radiologic practice, they were aware of the
were obtained with a GE 8800 scanner, one with a GE 9800 scanner, clinical suspicion of the diagnosis. However, neither previous films
and two with a Picker scanner, using 1 0 mm contiguous slices. nor any localizing clinical findings were available to them.
Normal bronchial anatomy and bronchiectasis were analyzed using Bronchography was performed in nine patients; four had bilateral
the criteria established by Naidich and coworkers [5, 6]. Cystic and five had unilateral studies. In the latter, the side of the broncho-
bronchiectasis was recognized by the presence of markedly dilated gram was determined by the clinical findings, chest film, or CT
bronchi, air-fluid levels, and strings or clusters of cysts [5]. Differen- findings.
tiation from emphysematous bullae was made by the presence of a As with the CT scans, the bronchograms were read independently
definable wall, usually thickened by peribronchial inflammation, linear by the same two radiologists. The diagnosis and classification of
arrangement, and by the close relation to pulmonary vessels [5]. severity of findings was based on the widely accepted classification
Cylindrical bronchiectasis was recognized by the presence of dilated of Reid [2].
bronchi, usually thick-walled, extending toward the lung periphery, or The CT reports of the two radiologists showed only minor discrep-
by the presence of dilated bronchi in the lung periphery [5]. Varicose ancies in two patients. These were reviewed by the radiologists
AJR:143, November1984 CT IN BRONCHIECTASIS 973

Fig. 3.-A, CT scan through lower lobes showed no abnormality. B, Coned-down view of selective left bronchogram. Cylindrical bronchiectasis in all basal
segments.

B
Fig. 4.-A, CT scan in region of superior segment of lower lobes. No abnormality was seen. B, Coned-down posteroanterior view of left bronchogram. Localized
varicose bronchiectasis in superior segment of left lower lobe (arrow).

together, and a final consensus was reached before analyzing the was therefore considered unwarranted. Of a total of 1 3 bron-
bronchograms. The reports of the bronchographic findings were chograms in the other nine patients, CT accurately predicted
identical. the presence of bronchiectasis, its extent, and its severity in
six. Two of these were in one patient in whom CT and
bronchograms showed varicose bronchiectasis involving only
Results the right middle lobe and lingula (fig. 2). One patient had
varicose and one, cylindrical bronchiectasis in the right lower
In two patients, extensive bilateral cystic and varicose lobe. In two other patients, both CT and bronchograms were
bronchiectasis was diagnosed on CT (fig. 1). Bronchography normal.
974 MULLER ET AL. AJR:143, November 1984

Fig. 5.-A, CT scan through lower lobes was interpreted as showing severe interstitial changes. No definite evidence of bronchiectasis was seen by either of
two radiologists analyzing CT. B, Coned-down view of selective right bronchogram shows varicose bronchiectasis involving all basal segments.

Fig. 6.-A. CT scan through lingula suggested bronchiectasis (arrows). B, Coned-down view of left bronchogram demonstrates no abnormality.

False-negative results with CT were obtained in five in- another, and in the third instance, in a patient with severe
stances. In two of these, the bronchograms showed cylindri- interstitial lung disease (fig. 5).
cal bronchiectasis in one of the lower lobes (fig. 3), and in In two instances, CT suggested the presence of cylindrical
three, varicose bronchiectasis. This was of a localized nature bronchiectasis but the bronchogram was normal (figs. 6
in one patient (fig. 4), in an atelectatic left lower lobe in and 7).
AJR:143, November1984 CT IN BRONCHIECTASIS 975

C D

Fig. 7.-True- and false-positive CT scan in same patient. A and B, CT tasis in right lower lobe. 0, Left bronchogram is normal. On the basis of CT
scans through lower lobes. Thick-walled, dilated bronchi suggestive of varicose findings, patient would have been a poor surgical candidate because of sup-
bronchiectasis on right side (arrows). Bronchiectasis, albeit less severe, was posedly bilateral involvement. However, because bronchogram showed left
also thought to be present in left lower lobe (arrowheads). c, Coned-down side to be normal, right lower lobectomy was performed.
view from selective right bronchogram demonstrates varicose bronchiec-

Discussion determine the distribution of anatomic involvement [1 ]. This


procedure, however, is not without morbidity [4].
Bronchiectasis was defined by Reid [2] as dilatation of one Recently, the ability of CT to image bronchi was dem-
or more bronchi, but the term is usually reserved for condi- onstrated by Naidich et al. [6]. In other publications, they
tions in which the dilatation is irreversible [1 ]. Changes have reported on the usefulness of CT in diagnosing bronchial
suggestive of the diagnosis are seen on the chest film in most pathology [7] as well as bronchiectasis [5]. They have shown
patients [1 3]. These changes
, are often nonspecific, and the that cystic bronchiectasis can be diagnosed reliably by CT
extent and severity of the disease may be underestimated. when areas of cystic dilatation are seen in a patent bronchus
Bronchography is mandatory to establish the diagnosis and or when air-fluid levels are noted. The cystic dilatation may
976 MULLER ET AL. AJR:143, November 1984

appear as strings of cysts when the bronchus courses hori- ably because secretions within the bronchial lumen prevented
zontally or as clusters when several adjacent bronchi are visualization. Because of the difficulty in differentiating be-
dilated [5]. As on the plain film, air-fluid levels caused by tween extensive fibrotic changes in the interstitium and ab-
retained secretions in dilated bronchi are specific for cystic normally dilated bronchi, bronchiectasis in patients with inter-
bronchiectasis [5]. Varicose bronchiectasis is recognized by stitial lung disease can also be missed easily (fig. 5).
seeing dilated bronchi with a beaded appearance. Cylindric More difficult to explain are the false positives on CT. They
bronchiectasis may be diagnosed when dilated, but otherwise may be from normal variation in bronchial diameter. On CT,
normally shaped bronchi extend toward the lung periphery. the diameter might appear abnormally large, but the broncho-
Bronchiectasis may also be diagnosed when dilated bronchi gram, by showing normal branching pattern of the bronchi,
are seen in the peripheral parts of the lung [5]. The differen- would be unremarkable. Alternatively, patchy fibrosis or pos-
tiation of dilated bronchi from emphysematous bullae or blebs sibly bullae may be misinterpreted as peripheral bronchi, as
is made possible by establishing their continuity with the suggested in two of our patients (figs. 6 and 7).
proximal bronchial tree, by their usually thickened wall, and In summary, in our study CT reliably diagnosed the ana-
by the presence of a branch of the pulmonary artery lying tomic extent of cystic bronchiectasis. However, it was unre-
contiguous to the dilated bronchus [5]. They describe six liable in the diagnosis of cylindric and varicose bronchiectasis.
patients with bronchiectasis, in four of whom bronchographic Therefore bronchography remains the definitive procedure in
confirmation was obtained. CT accurately predicted the se- the assessment of the presence and extent of involvement in
verity and extent of involvement in all cases. However, all patients with bronchiectasis.
except one of these patients had cystic bronchiectasis. This
can often be diagnosed reliably by plain films, although CT
ACKNOWLEDGMENTS
provides a more accurate method for determining the extent
of disease [5]. In two of our patients, CT showed beyond We thank P. Champion, R. Abboud, S. Gryzbowski, R. Donovan,
doubt extensive bilateral cystic changes. Bronchography was and G. Copland for referring patients; M. Young for encouragement;
therefore not performed. In another patient with cystic bron- and B. Fowler for manuscript preparation.
chiectasis limited to the right lower lobe, the CT findings were
confirmed by bronchography. Our results indicate, however, REFERENCES
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