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THE BRONCHI

The trachea bifurcates, giving rise to


the left and right main stem bronchi.
In adults, the right main stem
bronchus is more vertical, wider by
about 2 mm, and
approximately half the length of the
left main stem bronchus.

BRONCHIAL ANATOMY
The right main stem bronchus ends
at the lateral origin of the rightupper-lobe bronchus, and the main
stem continues as the bronchus
intermedius, which terminates where
the middle-lobe bronchus originates
anterolaterally and the superior
segmental bronchus to the rightlower-lobe originates.

BRONCHIAL ANATOMY
The main airway continues as the lowerlobe bronchus, which divides into anterior,
lateral, posterior, and medial basal
segmental bronchi.
Divisions on the left are similar except that
there is a short left-upper-lobe bronchus,
which bifurcates into the lingular bronchus
and a short trunk that almost immediately
divides
into
anterior
and
common
apicoposterior segmental airways.

BRONCHIAL ANATOMY
After giving rise to the superior
segmental bronchus to the left lower
lobe, the lower-lobe airway continues
inferiorly, dividing into three or four
basilar segmental bronchi (in some
instances
there
is
a
common
anteromedial bronchus).
The airways, to the subsegmental level,
are visualized with CT scanning when 3to 5-mm thin-section collimation is used.

BRONCHIECTASIS

Bronchiectasis
defined as irreversible dilatation of
the bronchial tree, may cause chronic
sputum production and hemoptysis,
or it may be asymptomatic.
Types:
cylindrical,
varicose,
cystic

1. Dyskinetic Cilia
Syndrome

represents a spectrum of genetically determined defects in


ciliary structure and function that interfere with mucociliary
clearance.
Although the term immotile cilia syndrome has been used, in
many cases the cilia demonstrate some motility (although
dyskinetic).
Conditions including situs inversus, paranasal sinusitis, and
bronchiectasis (a triad representing Kartagener's syndrome);
recurrent upper and lower respiratory tract infections; and
immotile sperm and infertility have been described.
Prognosis is generally good, and the diagnosis is compatible
with a full life span.

2. Cystic Fibrosis

CF
a relatively common genetic disorder
Affects the upper and lower respiratory
tracts, pancreas, liver and gallbladder,
intestines, and genital tract.
Approximately one in 1,600 live births
is affected.
autosomal recessive disease
occurspredominantly in Caucasians.

Chest radiographic findings


in adult CF include peripheral nodular
and nonvascular linear densities,
specific findings of bronchiectasis,
hyperinflation, atelectasis, and cystic
air spaces

3. Swyer-James
Syndrome

Swyer-James syndrome (SJS), also known as Macleod's


syndrome, is a postinfectious form of bronchiolitis
obliterans (BO) that typically follows a viral respiratory
infection in infancy or childhood. 27,118,119 Chest
radiographic findings include a unilateral small lung with
hyperlucency and air trapping ( Fig. 26-10). The air
trapping
results from gas which enters the air spaces by collateral
air drift and cannot exit because of the bronchiolar
obstruction. The hyperlucency is usually confined to one
lobe or lung; the disease can be bilateral but is usually
unilateral. The other diagnostic considerations when
these findings are recognized include an obstructing
tumor or foreign body in the airway. Bronchiectasis is
present in some but not all cases of SJS.

Swyer-James syndrome
(SJS)(also known asSywer-JamesMacLeod syndromeandBret
syndrome) is a rare lung condition
thatmanifests as
unilateral hemithorax lucencyas a
result of post-infectious
obliterative bronchiolitis.

Epidemiology
The condition typically follows a viral
respiratory infection (adenovirus) in
infancy orchildhood

Radiographic Features
Plain film
It is generallycharacterized on radiographs by a
unilateral small lung with hyperlucency and air
trapping2.
CT
CT shows the affected lung as being hyperlucent with
diminished vascularity. The size of the majority of the
affected lobes are smaller although occasionally they
can be normal3. There is usually no anteroposterior
gradient attenuation4.Bronchiectasismay be
present although this is not a universal finding5.
Nuclear medicine
Quantitative ventilation/perfusion lung scan shows a
photopaenic area in the affected aspect.

Broncholithiasis

Broncholithiasisis a term givenfor


thepresence of calcified or ossified
material within the lumen of the bronchus.
A broncholith is usually formed by erosion
by and extrusion of a calcified adjacent
lymph node into the bronchial lumen and
is usually associated with long-standing
foci
of
necrotizing
granulomatous
lymphadenitis.

Bronchiolitis

Bronchiolitisis a broad term that


refers to any form of inflammation of
thebronchioles. It can carry variable
clinical, functional and morphological
expression. Bronchiolar disease may
be a primary or a secondary
condition.

4 classifications (CT)
(1) centrilobular nodular or branching linear areas
of increased attenuation in patients with infectious
bronchiolitis,
diffuse
panbronchiolitis,
or
bronchiolitis complicating diseases of bronchi;
(2) ground-glass attenuation and consolidation in
patients with bronchiolitis obliterans organizing
pneumonia (BOOP) or respiratory bronchiolitis
associated with smoking;
(3) areas of decreased attenuation and perfusion
in BO; and
(4) bronchiolocentric opacities seen with several
forms of chronic infiltrative lung disease, where CT
may show associated findings for each particular
disease.

Emphysema

Pulmonary emphysemais defined as the


"abnormal permanent enlargement of the
airspaces distal to the terminal bronchioles
accompanied by destruction of the alveolar
wall
and
without
obvious
fibrosis".
Emphysemais one of the entities grouped
together
as
chronic obstructive pulmonary disease .
Emphysema is best evaluated on CT, although
indirect signs can be noticed on conventional
radiography in a proportion of cases.This
article focuses on panlobular emphysema,
paraseptal emphysema, and in particular
centrilobular emphysema.

Epidemiology
At the time of initial writing, approximately 210 million
people are affected worldwide leading to 3 million
deaths annually.1It is predominantly a disease of
middle to late life owing to the cumulative effect of
smoking and other environmental risk factors. It
traditionally affected more men than women but with
increased smoking and environmental risk factor
exposure among women, the incidence is now equal
between the sexes. Patients with genetic risk factors
such asalpha-1-antitrypsin deficiencymay present
earlier according to phenotype.
Risk factors include:
smoking: by far the most common
alpha-1-antitrypsin (AAT) deficiency
intravenous injection of methylphenidate (Ritalin lung)

Emphysema is one of a heterogeneous group of


pathological processes forming
chronic obstructive pulmonary disease, and is itself a
relatively vague term encompassing a number of entities
and morphological patterns including:
morphologic subtypes:

centrilobular emphysema (most common)


panlobular emphysema
paraseptal emphysema
paracicatricial emphysema
localised emphysema

idiopathic giant bullous emphysema(or


vanishing lung syndrome)
congenital lobar emphysema
pulmonary interstitial emphysema

Radiographic features

hyperinflation:

flattened hemidiaphragm(s): most reliable sign


increased and usually irregular radiolucency of the lungs
increased retrosternal airspace
increased antero-posterior diameter of chest
widely spaced ribs
sternal bowing
tenting of the diaphragm
saber-sheath trachea

vascular changes:
paucity of blood vessels, often distorted
pulmonary arterial hypertension

pruning of peripheral vessels


increased calibre of central arteries
right ventricular enlargement

It should be remembered, however, that the most common plain


film appearance of COPD is "normal" and the role of chest
radiography is to eliminate other causes of lung symptoms such
as infection, bronchiectasis or cancer6.

Emphysema is one of a heterogeneous group of


pathological processes forming
chronic obstructive pulmonary disease, and is itself a
relatively vague term encompassing a number of entities
and morphological patterns including:
morphologic subtypes:

centrilobular emphysema (most common)


panlobular emphysema
paraseptal emphysema
paracicatricial emphysema
localised emphysema

idiopathic giant bullous emphysema(orvanishing lung


syndrome)
congenital lobar emphysema
pulmonary interstitial emphysema

CT
CT is currently the modality of choice for
detecting emphysema; HRCT is particularly
effective. It should be noted, however, that
there is relatively poor correlation between
autopsy-proven emphysema, pulmonary
function test abnormalities and CT with 20% of
pathology-proven cases not being evident on CT
and 40% of patients with abnormal CT
havingnormal pulmonary function tests.
CT is able to discriminate between centrilobular,
panlobular, and paraseptal emphysema.

Centrilobular emphysema
Centrilobular is by far the most common type
encountered, and is a common finding in
asymptomatic elderly patients. It is
predominantly located in the upper zones of
each lobe (i.e. apical and posterior segments of
the upper lobes, and superior segment of the
lower lobes) andhas a patchy distribution 4. It
appears as focal lucencies(emphysematous
spaces) which measure up to 1 cm in diameter,
located centrally within thesecondary
pulmonary lobule, often with a central or
peripheral dot representing the central
bronchovascular bundle2-4.

Panlobular emphysema
Panlobular emphysema is
predominantly located in the lower
lobes, has a uniform distribution
across parts of thesecondary
pulmonary lobule, which are
homogeneously reduced in
attenuation2-4.

Paraseptal emphysema
Paraseptal emphysema is located adjacent to
the pleura and septal lines with a peripheral
distribution within thesecondary pulmonary
lobule. The affected lobules are almost always
subpleural, and demonstrate small focal
lucencies up to 10 mm in size.
Any lucencylarger than 10 mmshould be
referred to assubpleural blebsorsubpleural
bullae(synonymous)3.
In all three subtypes, the emphysematous
spaces are not bounded by any visible wall 3.

What are the x-ray findings


of emphysema?
Lungs are large and hyper
inflated.
Signs of hyperinflation are:

Low set diaphragm


Flat diaphragm best
determined by lateral chest
Hyper lucent lung fields
Increased AP diameter
Increased retrosternal air
Vertical heart

Signs of hyperinflation can be


seen in emphysema, chronic
bronchitis and asthma.
We can call it emphysema only
when hyperinflation is
associated with blebs and
paucity of vascular markings in
the outer third of the film.

Lateral chest is best to


evaluate flattening of
diaphragm, AP diameter
and retrosternal air.
This lateral chest shows:
Increased AP diameter
Low set flat diaphragms
Hyper lucent lung fields
Increased retrosternal
air encroaching on heart
density
Multiple blebs:
Avascular zones
surrounded by thin wall

Criteria for chest radiographic


diagnosis of emphysema
include two or more of the
following:
1. Depression and flattening of the diaphragm on the
posteroanterior roentgenogram with blunting of costophrenic
angles. The actual level of the diaphragm is not
as significant as the contour. (This can be determined from a
straight line connecting the costophrenic junction to the
vertebrophrenic junction on each side; if
the highest level of the contour is less than 1.5 cm above
this line, the diaphragm can be recorded as flat.)
2. Irregular radiolucency of the lung, caused by irregularity in
distribution of the emphysematous tissue destruction
3. Abnormal retrosternal radiolucency, as seen on lateral
view, measuring 2.5 cm or more from the sternum to the
most anterior margin of the ascending aorta
4. Flattening or even concavity of the diaphragm contour on
the lateral chest radiograph, as determined by the presence
of a sternodiaphragmatic angle of 90 or larger.