Radiological Features of Bronchiectasis

Chapter 5
Radiological features
of bronchiectasis
P.L. Perera* and N.J. Screaton#
RADIOLOGICAL FEATURES
Summary
Imaging plays a crucial role in the diagnosis and monitoring of
bronchiectasis and the management of complications. Chest
radiography is useful as an initial screening tool and during
acute exacerbations, but has limited sensitivity and specificity.
High-resolution computed tomography (HRCT) is the reference standard for diagnosis and quantification of bronchiectasis, providing detailed morphological information. Computed
tomography (CT) is also valuable in diagnosing and managing
complications. Routine surveillance using HRCT has been
mooted, particularly in cystic fibrosis (CF), where advances in
treatment have increased life expectancy considerably, but
cumulative radiation dose remains a concern.
Pulmonary magnetic resonance imaging is an evolving
technique that provides both structural and functional information. Its advantage is the lack of ionising radiation. Limitations include cost, availability and its inferior spatial resolution
compared to CT. The technique requires further evaluation, but
has potential benefits where serial follow-up imaging is being
considered, such as in CF. Evaluation of mucociliary clearance
using radionuclide scintigraphy may be of value, particularly in
drug development.
Keywords: Bronchiectasis, cystic fibrosis, diagnostic imaging,
magnetic resonance imaging, mucociliary clearance, spiral
computed tomography
*Dept of Radiology, Norfolk and

Norwich University Hospital,
Norwich, and
#
Diagnostic Imaging Dept, Papworth
Hospital, Papworth Everard, UK.
Correspondence: N.J. Screaton,
Diagnostic Imaging Dept, Papworth
Hospital, Papworth Everard, CB23
3RE, UK, Email
nicholas.screaton@papworth.nhs.uk
Eur Respir Mon 2011. 52, 4467.

Printed in UK all rights reserved.
Copyright ERS 2011.
European Respiratory Monograph;
ISSN: 1025-448x.
DOI: 10.1183/1025448x.10003510
44
ronchiectasis is characterised by irreversible dilation of bronchi, which may be focal or diffuse,

and usually occurs with associated inflammation. Its pathogenesis is complex and often
multifactorial, with bronchial wall inflammation, bronchial wall weakness and infection often
occurring in parallel and with numerous aetiological factors. Since it was first described by
LAENNEC [1] in 1819, there have been considerable advances in the understanding, diagnosis and
treatment of bronchiectasis. Imaging now forms the cornerstone of diagnosis of bronchiectasis and
its complications and plays an increasing role in disease monitoring and therapeutic planning. The
present review focuses on imaging features in bronchiectasis and their role in diagnosis and
monitoring of disease. Several imaging modalities are available, with varying strengths and
limitations, which are outlined below. The choice of diagnostic/monitoring strategy shows some
variation depending on access to each modality and interpretive expertise. Image-guided
intervention, such as percutaneous pleural aspiration/drainage and angiography with embolisation
play important roles in treating complications, but are beyond the scope of the present review.
Chest radiography
Chest radiography (CXR) is usually the initial study performed in both suspected bronchiectasis
and the evaluation of nonspecific respiratory symptoms, such as dyspnoea and haemoptysis, when
bronchiectasis may be identified incidentally. Signs on CXR include the identification of parallel
linear densities, tram-track opacities, or ring shadows reflecting thickened and abnormally dilated
bronchial walls. These bronchial abnormalities form a spectrum from subtle or barely perceptible
5-mm ring shadows to obvious cysts. Tubular branching opacities conforming to the expected
bronchial branching pattern may result from fluid or mucous filling of bronchi. Peribronchial
fibrosis results in a loss of definition of vessel walls (fig. 1) [25].
The radiograph may raise the initial suspicion of bronchiectasis, triggering more definitive imaging.
However, its projectional nature and limited contrast resolution lead to limited sensitivity and
specificity, particularly in mild disease. CXR also plays a role in the follow-up of bronchiectasis and
management of exacerbations, although, again, the relative insensitivity to change is highlighted by
proponents of computed tomography (CT) and magnetic resonance (MR) imaging (MRI) [25].
The reported accuracy of CXR has changed over the years as the management emphasis has shifted
from being reactive to complications to one of early detection and proactive management, and as the
diagnostic reference standard has shifted from bronchography to CT. In 1955, GUDJBERG [6]
reported only 7.1% of 114 bronchiectatic patients having a normal CXR, perhaps reflecting the more
florid nature of the condition during this period. In 1987, CURRIE et al. [7] reported an overall
sensitivity of 47%, and only 13% on a lobar basis, in 19 patients with bronchographically proven
bronchiectasis. The same study confirmed significant interobserver variation in CXR interpretation,
with two experienced readers disagreeing on the diagnosis of bronchiectasis in 22% of cases [7].
In comparison to CXR, CT is both more sensitive and provides more specific information. BHALLA
et al. [8] showed that, out of a total of 162 bronchopulmonary segments reviewed, bronchiectasis
was detected in 124 on high-resolution CT (HRCT) and only 71 on CXR.
P.L. PERERA AND N.J. SCREATON
Signs of complications/exacerbations, such as patchy densities due to mucoid impaction and

consolidation, volume loss secondary to bronchial mucoid obstruction or chronic cicatrisation,
are also seen. In the more diffuse forms of bronchiectasis, such as cystic fibrosis (CF), generalised
hyperinflation and oligaemia are often present, consistent with severe small airways obstruction.
Radiographic scoring systems, such as those of CHRISPIN and NORMAN [9] and BRASFIELD et al. [10],
have been developed and subsequently modified for patients with CF. These can be useful clinically,
but are more commonly used for comparison in research. CLEVELAND et al. [11] showed that a score
based on the scoring system of BRASFIELD et al. [10] could be used to assess the longitudinal
progression of lung disease in CF, and was at least as effective as spirometry in this regard.
Although CXR has limitations in specificity in diagnosing bronchiectasis and in detecting early or
subtle changes, it is useful for assessing more florid cases of bronchiectasis, in CF and in follow-up
of bronchiectatic patients.
Computed tomography
45
The CT signs of bronchiectasis were first described by NAIDICH et al. [12] in 1982. Although initial
studies using 810-mm slice thickness showed low sensitivity [1315], the advent of HRCT led to
markedly improved sensitivity, resulting in HRCT replacing bronchography as the diagnostic
reference standard. GRENIER et al. [16] showed that HRCT with 1.5-mm collimation at 10-mm
a)
b)
intervals was accurate in the recognition of bronchiectasis using bronchography as the gold standard in 36
patients.
Multidetector CT (MDCT) with volumetric acquisition further increases
the sensitivity in detection of subtle
nontapering airways. DODD et al. [17]
compared contiguous 1-mm MDCT
with 1-mm incremental HRCT with
10-mm interspaces in 61 bronchiectatic patients and 19 normal controls.
Using MDCT as the gold standard,
the sensitivity, specificity and positive
and negative predictive values of incremental HRCT in detecting bronchiectasis were 71, 93, 88 and 81%,
respectively. Interobserver agreement
for the presence, extent and severity
of bronchiectasis was also better for
MDCT (kappa 0.64, 0.5 and 0.48,
respectively) than for incremental
HRCT (kappa 0.65, 046 and 0.25,
respectively).
Optimal HRCT technique is important for maximising diagnostic accuracy. Importantly, thin slices of
12 mm and a high-resolution lung
reconstruction algorithm are used
to optimise spatial resolution. Incremental imaging with 10-mm slice
interspace reduces radiation dose,
but helical MDCT permits volumetric acquisition in a single breathhold, which is often the preferred
technique. Electronic images should
be viewed in stack/cine mode using the appropriate window settings (centred -400 -950 HU; width
1,0001,600 HU). Difficulties in diagnosing bronchiectasis can arise from
cardiorespiratory motion artefact, use
Figure 1. Chest radiography showing a) cystic bronchiectasis with
multiple cystic airspaces and b) cylindrical bronchiectasis and tramof inappropriate window widths and
track opacities in a cystic fibrosis patient.
levels, and the relatively thick-walled
appearance of bronchial walls on
expiratory scans. Tractional airway dilation associated with pulmonary fibrosis has a characteristic
corkscrew appearance and should be differentiated from pathological bronchiectasis.
CT signs of bronchiectasis
46
Bronchial dilation, the cardinal sign of bronchiectasis, is characterised on HRCT by a

bronchoarterial ratio (BAR) of .1, lack of bronchial tapering, and visibility of airways within
1 cm of the pleural surface or abutting the mediastinal pleural surface [2, 12, 16, 18, 19].
The different morphological types of bronchiectasis

corresponding to the bronchographic classification of
REID [20] show differing radiological features [16, 21],
but this is of little relevance in terms of aetiology and
rather reflects varying severity of the disease. Although,
in cylindrical bronchiectasis, there is uniform dilation
of airways with nontapering walls, in varicose bronchiectasis, dilated bronchi have a beaded appearance and,
in cystic bronchiectasis, grosser bronchial dilation gives
the appearance of cysts (fig. 2).
The BAR refers to the ratio of the internal bronchial
diameter to the diameter of the accompanying pulmonary artery at an equivalent branching level. A BAR
of .1 is considered abnormal [14, 15, 19] and is otherwise known as the signet-ring sign (fig. 3).
Figure 2. High-resolution computed tomography image showing cystic bronchiectasis

(same patient as in fig. 1a).
Physiological influence on BAR was highlighted by LYNCH et al. [23], who showed that 59% of 27
normal volunteers living in Colorado, USA (1,600 m above sea level) had at least one bronchus
that had an internal diameter larger than its accompanying artery. KIM et al. [18] confirmed this
environmental influence on BAR by demonstrating that residents living at 1,600 m exhibited
significantly higher BARs than those living at sea level (0.76 and 0.62, respectively; p,0.001).
Physiological variation can also occur due to regional hypoxia, and so secondary vasoconstriction
causing apparent bronchial dilation must be recognised in order to prevent a spurious diagnosis
of bronchiectasis. Conversely, if there is arterial dilation (e.g. due to pulmonary arterial
hypertension), bronchiectasis could be missed. A practical problem in assessing BAR is the need to
identify the accompanying artery, which may be difficult in the presence of other lung pathology,
such as consolidation. In the setting of consolidation, the presence of bronchial dilation may be a
reversible phenomenon and so caution should be observed when interpreting CT data during an
acute illness.
Although objective measurement may be performed, visual inspection is the usual method of assessing
bronchial dilation. DIEDERICH et al. [24] showed this to
have good interobserver agreement for detection (kappa
0.78) and severity assessment (kappa 0.68).
Figure 3. High-resolution computed tomography image demonstrating signs of

bronchiectasis, the signet-ring sign (short
arrow) and peripheral airway visible within
1 cm of the pleural surface (long arrow).
47
Lack of bronchial tapering or tram-track appearance of

the parallel bronchial walls is a sensitive feature of
bronchiectasis often identified in more horizontally
orientated airways in the mid-zones. KANG et al. [25]
showed that lack of tapering on HRCT was more
sensitive than bronchial dilation in bronchiectasis (79
and 60%, respectively) using pathology as the reference
standard. However, the sign can be difficult to
interpret in nonvolumetric CT studies. KIM et al. [18]
demonstrated lack of tapering on HRCT in 95% of
patients with bronchiectasis, but also in 10% of normal
subjects. It has been suggested that bronchial diameter
should remain unchanged for at least 2 cm distal to a
branching point for this sign to be robust (fig. 4) [26].
The accuracy of the BAR can be limited by a number of factors, including physiological
variation and orientation of the bronchovascular bundle with respect to the imaging plane
[16, 22, 23]. Comparison is best performed on perpendicularly orientated airways. When
oblique to the acquisition plane, airways and vessels appear ovoid and their short axis should
be compared.
Visibility of peripheral airways is another important

direct sign of bronchiectasis [17]. Current HRCT
techniques permit visualisation of airways of up to
2 mm in diameter and walls of around 0.2 mm in
thickness. KIM et al. [18] showed that normal bronchi are
not visualised within 1 cm of the costal pleura, but may
be seen within 1 cm of the mediastinal pleura. Visible
bronchi within 1 cm of the costal pleura or abutting the
mediastinal surface were seen in 81 and 53% of HRCT
images of known bronchiectatic patients (fig. 4).
Ancillary signs commonly identified in bronchiectatic
patients include bronchial wall thickening, mucoid
tomography image showing nontapering
impaction and air-trapping. Minor volume loss can be
bronchi, in keeping with bronchiectasis.
seen in the early stages of bronchiectasis. Larger areas of
collapse secondary to mucous plugging may be seen in more advanced disease. Patchy
consolidation is sometimes seen reflecting superimposed infection.
Figure 4. High-resolution computed
Bronchial wall thickening is often seen in the presence of bronchiectasis [25], but is a variable
nondiagnostic feature. It may result from reversible airway wall inflammation [27] or smooth
muscle hypertrophy and fibroblastic proliferation. Minor bronchial wall thickening has, however,
also been described in normal individuals, asthmatics, asymptomatic smokers and during lower
respiratory tract infections [23, 28].
Identification of bronchial wall thickening on HRCT is often made subjectively and is associated
with significant interobserver variation, with no universally agreed definition. REMY-JARDIN and
REMY [28] defined a thickened bronchus as being twice as thick as a normal bronchus; however,
this definition is difficult in diffuse disease DIEDERICH et al. [24] defined a thick-walled bronchus
by an internal diameter of ,80% of its external diameter and showed good interobserver
agreement (kappa 0.66). However, this can lead to overdiagnosis of thickening in the presence of
bronchoconstriction and underestimation with marked bronchodilation. An alternative approach,
used by BHALLA et al. [8] in CF and subsequently modified by REIFF et al. [29], is to compare
bronchial wall thickness to the diameter of the adjacent artery. As with assessment of BAR,
peribronchial fibrosis and consolidation pose practical difficulties in identifying accompanying
vessels (fig. 5).
Mucous plugging of dilated bronchi is readily identified, causing either complete or partial
luminal filling (fig. 5). Plugging of the smaller peripheral airways and peribronchiolar inflammation are characterised by a tree-in-bud appearance, with V- and Y-shaped branching
nodular opacities [30]. Mucous plugging was scored in
terms of number and generation of involved bronchopulonary segments using the scoring system of BHALLA
et al. [8], and may be reversible.
Figure 5. High-resolution computed tomo-
48
graphy image demonstrating bronchiectasis

with bronchial wall thickening (asterisk) and
mucous plugging (arrow) in the right lower
lobe.
Air-trapping results either from mucous plugging and

abnormal bronchial compliance [31] or inflammation/
fibrosis of the small airways [2]. On HRCT, airtrapping is characterised by patchy lobular areas of
low attenuation with regional vasoconstriction, which
causes a mosaic attenuation pattern, accentuated on
expiratory images, although inspiratory images are
usually characteristic (fig. 6). Air-trapping and bronchiectasis coexist in the same lobe in approximately
half of cases [25]. Whether it is the bronchiectasis and
recurrent infections driving obliterative bronchiolitis
(OB) or primary small airways disease that precedes the
onset of bronchiectasis is debated, and may vary [31].

The latter is supported both by the observation that, in
patients with CT-proven bronchiectasis, expiratory
HRCT identifies air-trapping in 17% of lobes with no
bronchiectatic features and that, in patients with
rheumatoid arthritis (RA)-associated OB, the onset of
symptoms and obstructive function may predate the
onset of bronchiectasis by several years [32].
Imaging and aetiology of bronchiectasis
However, in a large study comparing HRCT features in bronchiectasis of defined aetiology with
idiopathic bronchiectasis, REIFF et al. [29] concluded that, although some HRCT features were
more common in some aetiological groups, the differences were not sufficient to be diagnostic. LEE
et al. [40] reinforced this observation in a study of 108 bronchiectatic patients in whom the correct
cause was identified on CT in only 45% of cases. A confident diagnosis was asserted in a minority
(9%) and was correct in only 35%. Interobserver agreement in likely aetiology was also poor
(kappa 0.2) [40]. However, more recently, CARTIER et al. [41] obtained accurate diagnoses on the
basis of HRCT in 61% of 82 patients with bronchiectasis of known cause, with moderately good
agreement (kappa 0.53). Confident and accurate diagnosis was made in 44% of patients (kappa
0.53). Accuracy was highest in CF (68%), previous tuberculosis (67%) and ABPA (56%). Part of
the reason for the higher number of accurate diagnoses was attributed to the exclusion of patients
in whom the aetiology of bronchiectasis was not known. They concluded that the combination of
radiological pattern and clinical scenario would have improved the accuracy of the evaluation.
HRCT is important in the assessment of mycobacterial infection. This is particularly true of
nontuberculous mycobacteria (NTM), where the diagnosis is often first suggested on HRCT. CT
signs of NTM include bronchiectasis, nodules, tree-in-bud opacity, patchy consolidation and
cavities, often affecting the upper lobes and superior segments of lower lobes in the classic subtype
and middle lobe/lingula in the nonclassic subtype [42]. The presence of this combination of
features with a middle lobe and lingual predominance, especially in the setting of elderly females
with no underlying malignancy or immunocompromise, is particularly suggestive of nonclassic
NTM [43, 44]. Bronchiectasis is more common in NTM infection, being seen in up to 94% of
patients with Mycobacterium avium complex and 27% of patients with M. tuberculosis [45].
There are many aetiologies associated with bronchFigure 6. Inspiratory high-resolution computed tomography image showing bronchiectasis, but a specific underlying cause is found in
iectasis and widespread areas of low
,40% of patients [33]. In some cases, the distribution
attenuation, representing air-trapping.
and pattern of bronchiectasis on HRCT may suggest
the aetiology. Allergic bronchopulmonary aspergillosis
(ABPA) typically demonstrates an upper zone and central predominance [3437], hypogammaglobulinaemia may be associated with bronchiectasis with disproportionate bronchial wall
thickening, middle lobe predominance is common in immotile cilia syndrome [38] and idiopathic
bronchiectasis often has a lower lobe distribution [39].
Bronchiectasis in CF usually has a bilateral, proximal, parahilar and upper lobe predominance.
Other findings include bronchial wall thickening, peribronchial interstitial thickening, mucous
plugging, tree-in-bud opacification, superadded consolidation and mosaic attenuation. SHAH et al.
[27] assessed the CT changes in 19 symptomatic adult CF patients before and after 2 weeks of
therapy and identified airfluid levels in bronchiectatic airways, mucous plugging, centrilobular
nodules and peribronchial thickening as potentially reversible signs.
49
Bronchiectasis with a central or proximal predominance is the characteristic finding in ABPA

(fig. 7a). REIFF et al. [29] showed that the prevalence of central bronchiectasis was higher in ABPA
(11 out of 30) than in idiopathic bronchiectasis (26 out of 179) (p,0.005). However, the sensitivity of the observation of central bronchiectasis in diagnosing ABPA was only 37%. PANCHAL et al. [46]
a)
b)
Figure 7. High-resolution computed tomo-
demonstrated central bronchiectasis in 85% of lobes

and 52% of lung segments in a series of 23 patients
with ABPA. Other common findings in ABPA include
mucous plugging, high-attenuation mucus, tree-inbud opacities, atelectasis, peripheral consolidation or
ground-glass opacification, mosaic perfusion and airtrapping. The bronchiectasis is often cystic or varicose.
WARD et al. [47] assessed CT images from 44
asthmatic patients with ABPA and 38 without and
found much higher levels of bronchiectasis, centrilobular nodules and mucous impaction in ABPA.
They concluded that randomly distributed predominantly central moderate-to-severe bronchiectasis
affecting three or more lobes, bronchial wall thickening and centrilobular nodules in asthmatics is highly
suggestive of ABPA (fig. 7b).
High-attenuation mucous plugs are reported to occur
in 1828% of patients with ABPA, and, if observed, are
thought to be characteristic [4850]. In a study of 155
patients with ABPA, AGARWAL et al. [48] found this
sign in 29 patients, and that it correlated with greater
severity and greater likelihood of relapse.
graphy showing a) proximal bronchiectasis

affecting segmental airways and b) highattenuation mucous plugs in patients with
allergic bronchopulmonary aspergillosis. No
intravenous contrast medium was used in (b).
In summary, there are some recognised clinical

conditions in which assessment of bronchiectasis forms
an important part of management. CT images in
bronchiectatic patients should be examined for features
suggesting ABPA, CF, immotile cilia, opportunist
mycobacteria and tracheobronchomegaly, but these observation need to be correlated with
clinical and laboratory findings.
CT scoring of bronchiectasis
Although the extent, severity and distribution of bronchiectasis may be evaluated subjectively,
more-robust objective scoring systems have been developed particularly for use in the research
arena. With the development of novel software tools, it is now possible to objectively quantify
parameters, such as airway wall area and volume, in a semi-automatic manner. Both subjective
and objective quantification permit correlations between structure and function to be evaluated.
CT scoring systems are based on collective scores for the extent and distribution of a range
of morphological abnormalities, including bronchial dilation, bronchial thickening, abscesses,
mucous plugging, emphysema, collapse and consolidation.
The HRCT score of BHALLA et al. [8] was devised to evaluate the severity of CF in an objective
manner. Severity of bronchial dilation and thickening were defined relative to the adjacent
pulmonary artery, and other parameters were scored according to the number of bronchopulmonary segments involved, as shown in table 1.
50
This scoring system has been modified many times, and has also been adapted for use in MRI
assessment of CF. Modifications have included incorporation of additional findings, such as airtrapping/mosaic attenuation, ground-glass opacification, acinar nodules and septal thickening,
with some scores being per segment and others based on lobar scoring. Each scoring system
attempts to produce both a total score, by combining features, and specific morphological scores.
These have been demonstrated to be more sensitive to disease and show better correlation with
both clinical features and lung function than the CXR-based scoring systems. OIKONOMOU et al. [51]
Table 1. Summary of computed tomography scoring system

Score
0
Severity of bronchiectasis
Absent
Moderate (luminal
diameter 23 times
that of adjacent
blood vessel)
Severe (luminal
diameter .3 times
that of adjacent
blood vessel)
Peribronchial thickening
Absent
Mild (luminal
diameter slightly
greater than that
of adjacent
blood vessel)
Mild (wall
thickness equal
to diameter of
adjacent vessel)
Severe (wall
thickness .2 times
the diameter of
adjacent vessel)
Extent of bronchiectasis
BP segments n
Extent of mucous plugging
BP segments n
Sacculations or abscesses
BP segments n
Bronchial divisions
involved (bronchiectasis/
plugging) generations
Bullae
Bullae n
Emphysema
BP segments n
Collapse/consolidation
Absent
Present
15
Present
15
Present
15
Up to 4th
Moderate (wall
thickness greater
than and up to
twice the diameter
of adjacent vessel)
Present
69
Present
69
Present
69
Up to 5th
Unilateral
not .4
Present
15
Subsegmental
Bilateral
not .4
Present
.5
Segmental/lobar
Absent
Absent
Absent
Absent
Absent
Absent
Present
.9
Present
.9
Present
.9
Up to 6th and distal
Present
.4
BP: bronchopulmonary. Reproduced from [8] with permission from the publisher.
suggested a simplified scoring system evaluating severity of bronchiectasis, bronchial wall thickening
and atelectasis consolidation. They found strong correlation between the simplified scores and the
complete scores.
SHAH et al. [27] used a modified Bhalla score in bronchiectatic patients undergoing HRCT at
baseline and 2 weeks after exacerbation in order to identify reversible findings, and showed that
airfluid levels, centrilobular nodules, mucous plugging and peribronchial thickening improved
following treatment in 100, 36, 33 and 11% of cases, respectively.
DE JONG et al. [52] compared the original scoring system of BHALLA et al. [8] and four modified
Bhalla systems [5356]. Three observers reviewed thin-slice CT images of 25 children with CF
using the various scoring systems. Interobserver variability was analysed using kappa coefficients
and found to be generally good (kappa .0.76; p,0.05). However, inter- and intra-observer
agreement was less for mild disease, as well as for parameters such as mosaic perfusion, acinar
nodules and airspace disease. All five scoring systems correlated strongly with forced expiratory
volume in 1 second (FEV1), forced vital capacity (FVC), forced expiratory flow between 25 and
75% of vital capacity (FEF2575), FEV1/FVC ratio and each other.
Category
Quantitative computerised evaluation of the airways presents a number of challenges, including

obtaining a plane perpendicular to the airway, exclusion of the adjacent artery, determining the
borders of the bronchus, artefacts and partial volume averaging. Three different methods have
been used to obtain airway measurements, full width at half maximum, model fitting approaches
and boundary fitting approaches [19]. A detailed description of these techniques is beyond the
scope of the present chapter.
51
GORIS et al. [57] looked at automated evaluation of the extent of air-trapping in 25 patients with
mild CF compared to 10 controls; six anatomically matched CT slices were obtained during
inspiration and expiration. Computerised lung segmentation was performed and automated
software used to quantify air-trapping, using analysis of a histogram of the distribution of densities
in the lung, and assessing contiguous low-attenuation voxel regions. In mild CF, air-trapping did
not correlate with global pulmonary function test (PFT) results, except for the ratio of residual
volume (RV) to total lung capacity (TLC); however, the size of the air-trapping defects was the
best discriminator between patients and control subjects (p,0.005).
KIRALY et al. [58] looked at fully automated methods of obtaining three-dimensional (3D) images
and quantification of airway abnormalities. Working from thin-slice image acquisition and using
computerised segmentation techniques, they obtained 3D images of the airways with colour-coded
maps showing BAR, wall thickness and mucous plugging. These have, however, not been fully
clinically validated.
Although these objective tools are interesting, further studies are required to evaluate the
various computerised imaging parameters and their relation to functional and clinical findings
in bronchiectasis. A note of caution was raised by MATSUOKA et al. [59], who used semiautomatic image processing to assess the airways of 52 asymptomatic patients with no
cardiopulmonary disease. They found that luminal area and wall area increased in 10 and 29%
of subjects, respectively, suggesting caution in over-reliance on changes in airway calibre in
disease monitoring.
Structurefunction relationships
Relationships between HRCT data and functional and clinical characteristics have been widely
explored. WONG-YOU-CHEONG et al. [60] showed a clear negative correlation between FEV1 and
extent of bronchiectasis on HRCT (p,0.002; r5 -0.43). SMITH et al. [61] showed correlation
between extent of bronchiectasis on HRCT and both dyspnoea (p,0.01; r50.38) and FEV1
(p,0.01; r5 -0.43). More recently, DE JONG et al. [52] showed strong correlations between five
scoring systems [8, 5356] and FEV1 (r5 -0.69 -0.73), FEF2575 (r5 -0.76 -0.82) and FEV1/
FVC ratio (r5-0.72 -0.78). Correlation with FVC was moderate (r5 -0.54 -0.58).
Authors have investigated which morphological abnormalities are most strongly associated with a
functional deficit. LYNCH et al. [62], in a study of 261 bronchiectatic patients, found significant
correlation between severity of bronchiectasis, FEV1 (r5 -0.362) and FVC (r5 -0.362), and
between bronchial wall thickening and FEV1 (r5 -0.367) and FVC (r5 -0.239). Cystic bronchiectasis was found to show worse PFT results than cylindrical or varicose disease.
In a study of 100 patients with bronchiectasis, ROBERTS et al. [63] found good correlation between
FEV1 and bronchial wall thickening (r5 -0.51; p50.00005) and extent of decreased attenuation on
expiratory HRCT (r5 -0.55, p50.00005) on univariate analysis. These were the only factors that
independently correlated with degree of airflow limitation on multivariate analysis. In this study,
obstructive lung function was not strongly associated with severity of bronchiectasis,
bronchodilation, or retained sections in bronchiectasis (r5 -0.42, -0.35 and -0.19, respectively,
on univariate analysis). Bronchial dilation as an independent factor was positively associated with
airflow obstruction on regression analysis (r250.42). The authors concluded that airflow
limitation in bronchiectasis occurred mainly due to inflammatory or obstructive/constrictive
bronchiolitis. They also suggested that areas of low attenuation attributed to emphysema in
bronchiectatic patients in previous studies (e.g. [64]) should be interpreted with caution,
suggesting that the emphysema demonstrated was often due to air-trapping related to intrinsic
small airways disease rather than emphysema, as evidenced by preserved gas transfer in the both of
these studies.
52
HRCT scoring can also be correlated with clinical parameters. In a study of 61 CF children,
baseline and follow-up PFT and HRCT scores were compared to the number of respiratory
exacerbations over 2 years. Only the HRCT score (r50.91; p50.001) and bronchiectatic score
(r50.083; p50.01) correlated significantly with exacerbation frequency. All HRCT parameters
progressed over this time period except for bronchial wall thickening and mucous plugging,
suggesting that these are reversible features [65]. OOI et al. [66] studied 60 patients with stable
bronchiectasis with HRCT. They showed good correlation between the extents of bronchiectasis, bronchial wall thickening and mosaic attenuation and FEV1 (r5 -0.43 -0.60), FVC
(r5 -0.36 -0.46), FEF2550 (r5 -0.38 -0.57) and FEV1/FVC (r5 -0.31 -0.49). Regression
analysis showed that extent of bronchiectasis and wall thickening were the most significant
determinants of airflow obstruction, correlating with all PFT parameters This study also
demonstrated associations between bronchial wall thickening and clinical factors, such as
exacerbation frequency and 24-hour sputum production (r5 -0.32 and -0.30). ALZEER [67] found
that the HRCT score correlated well with FEV1 (r5 -0.51), as well as with systolic pulmonary
artery pressure (Ppa,sys) (r50.23), in a study of 94 bronchiectatic patients.
The validity of the use of PFTs as the gold standard in evaluating HRCT has been questioned by
several authors. BRODY et al. [69] and HELBICH et al. [53] have shown that early HRCT changes,
including mosaic attenuation and bronchial dilation, can be seen early in disease in the presence
of normal PFT results. LONG et al. [70] showed HRCT changes, including wall thickening and
bronchial dilation in CF infants with a mean age of 2 years, further emphasising the sensitivity
of HRCT.
Regular low-dose HRCT for the surveillance of CF has been adopted by several centres since
the late 1990s [71]. This was initially in the form of 1-mm slice incremental HRCT (with 10mm interspaces), but, more recently, of full-lung volumetric HRCT. CT is performed as early
as an age of 2 years, when it is performed as controlled-ventilation CT (CVCT), requiring
sedation or general anaesthesia. The rationale for using this imaging-intensive approach is that
PFT results may lag behind structural CT changes, difficulty in reliably performing PFTs in
young children and the ability of imaging to follow relevant objective structural markers, such
as bronchiectasis, bronchial wall thickening, air-trapping and mucous plugging. Furthermore,
in the modern era, improved therapy has slowed the annual decline in PFT results such that
individual variability and changes due to other factors, such as technique, puberty and
infections, have made PFTs even less reliable for disease monitoring. However, the benefit has
to be viewed in the setting of radiation risk. DE JONG et al. [72] used a computational model to
estimate mortality effects of regular CTs. The mean radiation dose for the published CT
protocol was 1 mSv. Survival reduction associated with annual scans from the age of 2 years
until death for CF patients with a median survival of 26 and 50 years, were approximately
1 month and 2 years, respectively. Cumulative cancer mortality was approximately 2 and 13%
at age 40 and 65 years, respectively. Biannual CTs exhibit half the risk. This highlights the
increasing reduction in survival with increasing age, an important point given the increasing
life expectancy of CF patients.
Studies on the utility of HRCT in the follow-up of non-CF bronchiectatic patients have been
limited. In a study of 48 patients, SHEEHAN et al. [68] compared serial CT studies with PFTs,
showing correlation of changes in PFT results with air-trapping due to mucous plugging. Greater
severity of mucous plugging, bronchiectasis and bronchial wall thickening were predictive of
decreased FEV1. In a study evaluating morphological features in bronchiectasis at baseline and
2 weeks after exacerbation, SHAH et al. [27] showed that changes in HRCT score during
exacerbation of bronchiectasis also correlate with improvement in FEV1/FVC (r50.39;
p50.049). Severity of bronchiectasis was the component most strongly associated with PFT
results (r50.4 for FEV1 and r50.5 for FVC), whereas tree in bud and mucous plugging were not
strongly correlated.
53
DE JONG et al. [73] studied 48 young patients with CF using serial low-dose HRCT and PFTs
2 years apart. In all children, there was progressive structural HRCT change with deterioration in
HRCT scores by 2.23.5% overall, but particularly with peripheral extension of bronchiectasis and
mucous plugging, despite stable (or, in some cases, improved) lung function. This may reflect
poor PFT technique in young CF children, the use of predicted FEV1 (with reference to a global
population) and/or the greater sensitivity of HRCT for detection of early and regional changes.
JUDGE et al. [74] assessed serial HRCT performed 18 months apart in 39 consecutive CF patients
and found that the modified HRCT score declined faster (2.7% per year; p,0.001) than did FEV1
(2.3% per year). Six patients demonstrated worsening HRCT score with no change in PFT result.
DE JONG et al. [75], in a study of 119 children and adults with CF, showed that PFT results,
component and CT scores deteriorated over 2 years. The CT score (and its components) and PFT
results showed similar rates of deterioration in adults and children (p.0.09). Peripheral
bronchiectasis worsened by 1.7% per year in children (p,0.0001) and by 1.5% per year in adults
(p,0.0001).
In view of the potential for discordance between morphology and function and the complementary nature of these variables, authors have attempted to create more-robust clinically
useful composite scoring systems combining PFT results and HRCT findings [76].
Studies on assessment following therapy have been limited. ROBINSON et al. [76] used a composite
scoring system using many of the HRCT parameters described above and combining them with
PFT measures of obstructive function (FEV1 and FEF2575). They showed the composite
measurement to be more sensitive for assessing response to treatment in 25 CF children who were
randomised to a treatment arm and a nebulised saline arm; FEF2550 showed 13% improvement,
global HRCT 5% and composite score 30%. Small studies have shown some HRCT features to be
useful in post-treatment evaluation. NASR et al. [77] showed a significant improvement in total
HRCT score following recombinant human (rh) deoxyribonuclease (DNAse) therapy compared to
placebo. GORIS et al. [57] compared 25 CF patients with 10 age-matched controls using PFTs and
automated quantitative assessment of lung density. No significant difference was seen in PFT
results, but significant differences in air-trapping were seen, with the size of defects being the best
discriminator. There was a significant decrease in mean HRCT score from 25 to 22 (p50.014),
with improvement in peribronchial thickening (p50.007), mucous plugging (p50.002) and
overall appearance (p50.025).
There have been some differences in the degree of correlation between PFT results and HRCT
findings of bronchiectasis in the various studies, which could be attributed to several causes,
including the scoring system used, radiological interpretation, parameters assessed, population
studied, reliability of PFTs and data analysis (multivariate versus univariate). However, the link
between measures of obstructive lung function (FEV1 and FEF2550) and bronchial wall thickness/
total HRCT score has been consistently shown.
Role of HRCT in bronchiectasis

CT is invaluable in the diagnosis of bronchiectasis, but also plays an important role in the
evaluation of complications and assessment and monitoring of disease severity. HRCT provides
good clinical correlation, and the use of scoring systems holds promise for monitoring of
bronchiectasis. The more robust CT scoring systems have been formulated in CF patients. HRCT
is sometimes of value in identifying the aetiology of bronchiectasis. Advantages of HRCT over
PFTs include its ability to identify focal changes as well as provide a global score, in addition to
assessing multiple parameters, some of which are reversible and others irreversible (fig. 8).
Current British Thoracic Society guidelines recommend HRCT at diagnosis and during exacerbations,
but not for routine follow-up. An exception is in bronchiectasis secondary to humoral immunodeficiency, where follow-up HRCT may be beneficial [78].
54
HRCT is now widely regarded as part of the standard clinical evaluation of patients with CF. The
ability to quantify extent and severity of disease and to serve as a useful outcome marker, and the
potential for assessing treatment response, make this a particularly valuable investigation.
However, although HRCT provides valuable information on initial assessment, the role and
periodicity of serial imaging in CF remains controversial in view of increasing life expectancy and
cumulative radiation exposure. Some authors suggest that HRCT should form part of the routine
monitoring of CF, but with due consideration to the excess radiation [71]. With appropriate
scanning technique, it is estimated that a chest CT

every other year from birth to age 30 years would
involve an effective dose of 15 mSv compared to the
mean background radiation dose over this period of
90 mSv [79].
Thus HRCT forms an important part of the investigation and diagnosis of bronchiectasis and exacerbations.
It is particularly useful in CF, where it has been shown
to be a good marker of outcome and has demonstrated
the ability to pick up subtle and early changes with
greater sensitivity than PFTs.
Interest in the use of MRI for lung imaging arose in

Figure 8. Coronal reconstruction from
the mid-1980s. The inherent difficulties in pulmonary
high-resolution computed tomography
MRI are well documented. Lungs have an intrinsically
showing a bronchial collateral vessel.
low proton density, which results in poor signal
generation. This low signal is further degraded by susceptibility artefact resulting from the
innumerable airtissue interfaces and cardiac and respiratory motion. However, the advent of
parallel imaging and new rapid imaging sequences have permitted marked improvement in
temporal and spatial resolution. Although spatial resolution using conventional proton MRI is
less than that using CT, MRI offers significant morphological information and has advantages in
enabling improved tissue characterisation and providing functional imaging, including vascular
flow and respiratory mechanics. The use of novel imaging techniques, such as oxygen-enhanced
MRI and hyperpolarised helium-3 MRI, potentially permits derivation of further functional
parameters, including regional ventilation, regional oxygen concentration and evaluation of lung
microstructure using the apparent diffusion coefficient (ADC).
Although application of this technique currently lies largely in the research arena, a significant
advantage of MRI is the lack of radiation, which is particularly important in patients who require
recurrent imaging and the younger population group. This is pertinent when considering the
potential cumulative lifetime radiation dose from annual/biannual low-dose CT examination in the
CF population that are currently advocated by some groups [71], especially in view of the rapid
improvement in life expectancy in this patient group, which is projected to continue. Thus it is
unsurprising that much of the work on thoracic MRI imaging has been focused on patients with CF.
Conventional proton MRI features
Magnetic resonance imaging
Owing to the limited spatial resolution of MRI, assessment of bronchial wall thickness and
bronchiectasis are dependent upon bronchial level, wall thickness and wall signal. Thirdgeneration bronchi and beyond are poorly visualised on MRI, except in pathological states, when
the wall and luminal signal are raised due to wall thickening, inflammation and mucus [80].
Inflammation and oedema contribute to wall thickening. Gadolinium-enhanced images may be
useful in demonstrating inflammatory change.
55
Mucous plugging on MRI results in homogeneous high T2-signal intensity in proximal airways or an
abnormal branching grape-like pattern more peripherally, equivalent to the tree-in-bud opacities
seen on HRCT. In contrast to CT, the improved tissue characterisation of MRI can also differentiate
between mucus, haemorrhage and bronchial wall thickening [81]. Airfluid levels may be identified
on MRI, particularly in cystic or varicose bronchiectasis. Unlike CT, using contrast-enhanced MRI
sequences, thickened airway walls can be differentiated from mucous plugging. Consolidation may
also be identified as high T2-signal inflammatory fluid contrasts with the low airway signal,
equivalent to the classical air bronchogram. Air-trapping and mosaic perfusion are not readily seen
on conventional proton MRI in the absence of gadolinium (figs 9 and 10).
a)
b)
Figure 9. a) Transverse magnetic resonance (T2-weighted half-Fourier acquisition single-shot turbo spin-
echo (HASTE)) image and b) corresponding computed tomography image in a 14-year-old female with cystic
fibrosis. In both images, bronchial wall thickening, bronchiectasis, peripheral mucous plugging and dorsal
consolidations are demonstrated, as shown by the arrows. Reproduced from [81] with permission from the
publisher.
An early study of 17 CF patients (aged 730 years) in 1995 [82] found MRI to be inferior to CT in
the assessment of bronchiectasis. Correlations between CT and MRI (r for each observer) were
good for bronchial dilation (r50.81 and 0.50), bronchial thickening (r50.82 and 0.60) and
mucous plugging (r50.93 and 0.70). Progress in MRI technique in recent years has led to marked
improvement in its accuracy. In a study of six paediatric patients with CF, HEBESTREIT et al. [83]
found that CXR and MRI provided equal information, and considered MRI suitable for follow-up.
In a more recent study in 2007, PUDERBACH et al. [84] evaluated 31 patients with CF using CXR,
MDCT and MRI. MRI and MDCT were assessed using a modified Helbich score, whereas CXR
was evaluated using a modified ChrispinNorman score. Mosaic perfusion was excluded from the
original scoring system as this cannot be quantified on MRI. They concluded that morphological
a)
b)
56
Figure 10. T1-weighted magnetic resonance imaging showing appearance a) before and b) after contrast
medium in a 43-year-old cystic fibrosis patient. The post-contrast images demonstrate extensive bronchial
wall enhancement and permit differentiation of a thickened wall from intrabronchial secretions, with
intrabronchial fluid having an airfluid level (arrow). Reproduced from [81] with permission from the publisher.
MRI showed comparable results to MDCT and CXR. Median extent scores for MRI, MDCT and
CXR scores were 13, 13.5 and 14, and correlation between modalities ranged 0.630.80 (MRI/CT
0.80, p,0.0001; MRI/CXR 0.63, p,0.0018; CXR/CT 0.75, p,0.0001). The median lobe-related
concordance was 80% for bronchiectasis, 77% for mucous plugging, 93% for sacculation/abscesses
and 100% for collapse/consolidation.
MONTELLA et al. [85] evaluated patients with primary ciliary dyskinesia using HRCT and MRI.
They used a modified Helbich score for both HRCT and morphological MRI assessment, showing
mean scores of 12 for both, good-to-excellent agreement between HRCT and MRI scores (r.0.8),
and good correlation between both CT and MRI scores and FEV1 and FVC.
Functional MRI
A significant advantage of MRI over CT is its superior ability to assess function. Within the lungs
this mainly involves evaluation of haemodynamic function and perfusion and ventilation studies.
Perfusion imaging
EICHINGER et al. [90] performed morphological and contrast-enhanced MRI sequences on 11

patients with CF; 198 lung segments were scored for morphological (3 point score of none,
moderate or severe) and perfusion defects (0 normal; 1 impaired perfusion). In 86% of segments
considered morphologically normal, homogenous perfusion was demonstrated, whereas 97% of
segments with severe morphological changes were associated with perfusion defects. Of segments
with moderate morphological changes, 53%showed normal and 47% impaired perfusion. Thus
contrast-enhanced MRI appears to be a feasible method of assessing regional perfusion defects as a
surrogate for small airways disease, although further work is required in order to improve
sensitivity in moderately affected areas of lung.
In bronchiectasis, increased blood flow though bronchial and nonbronchial systemic collateral
vessels results in a systemic arterial to pulmonary venous shunt. Using conventional proton MRI
and phase-contrast flow-sensitive sequences, aortic and pulmonary arterial flow can be readily
quantified. In a study of 10 patients with CF and 15 healthy volunteers, LEY et al. [91] found a
significantly increased shunt in CF patients (1.3 L?min-1) compared to healthy volunteers
(0.1 L?min-1).
In the presence of small airways obstruction, regional ventilation defects lead to impaired gas
exchange and reflex hypoxic vasoconstriction [86]. Perfusion imaging can thus serve as a marker
of airway obstruction. ITTI et al. [87] used radionuclide imaging to show that the degree of
abnormal lung perfusion correlates well with disease severity in CF, as measured by PFTs and the
Shwachman radiographic score. Contrast-enhanced pulmonary MRI imaging can be used to
acquire a 3D data set in just 1.5 seconds [88, 89]. This also has advantages over scintigraphy in
terms of radiation dose and provides regional information.
Oxygen-enhanced MRI exploits the weak paramagnetic properties of oxygen, which cause a
shortening of T1 at high concentration and can be used as a gaseous contrast agent. The solubility
of oxygen means that images represent a combination of ventilation and perfusion. A limitation is
the low signal-to-noise ratio [81]. JAKOB et al. [92] studied five CF patients and five healthy
volunteers using oxygen-enhanced MRI, showing inhomogeneity of the lung parenchyma in the
CF patients.
Hyperpolarised noble-gas-enhanced MRI
57
Imaging of hyperpolarised noble gases using MRI is a relatively new imaging technique that shows
promise in the research arena in the evaluation of several ventilatory functional parameters.
Hyperpolarised helium-3 and hyperpolarised xenon-129 are gaseous contrast agents that provide a
very high MR signal [35]. Since oxygen promotes depolarisation, the polarised helium-3 is mixed
with nitrogen rather than air before being administered by active inhalation via a device such as a
plastic Tedlar bag or respirator-driven gas delivery system. The bag method uses a mixture of
300 mL helium-3 and 700 mL nitrogen and requires a single anoxic breathhold. The respiratordriven system provides an accurate single dose followed by an air chaser and hence no anoxic
breathhold is required.
Polarisation is not renewable and has to be used carefully during the scan, with use of sequences to
maximise use of finite magnetisation [93]. Dedicated receiver coils for the relevant resonance
frequency of helium-3 and xenon-129 are also required.
The different physical properties of helium-3 and xenon-129 present different opportunities.
Although helium-3 provides a better signal and greater polarisation levels have been obtained, its
larger diffusion coefficient results in signal loss. In addition, although helium-3 is virtually
insoluble in water, xenon-129 is highly soluble and hence has potential for use in assessing
perfusion [93]. On a purely practical basis, the limited supply of helium-3, estimated at 200 kg
globally [94], compared to that of xenon-129 is likely to lead to xenon-129 eventually emerging as
agent of choice [95].
The main techniques used in hyperpolarised noble gas imaging are static ventilation imaging and
dynamic ventilation imaging, as well as assessment of lung microstructure using ADC and regional
oxygen tension imaging.
MCMAHON et al. [96] showed that static helium-3 MRI ventilation in CF correlated strongly
with HRCT assessment of structural abnormalities (R50.89; p,0.001), and that the
correlation was higher between helium-3 MRI and PFT results than helium-3 MRI and HRCT.
In a further observational study of 18 patients aged 517 years with CF undergoing
hyperpolarised helium-2 MRI, VAN BEEK et al. [97] confirmed moderate correlation between a
visual score of ventilation on MRI and global assessment of pulmonary function (FEV1 r5 -0.41
and FVC r5 -0.42).
In a study comparing healthy volunteers and CF patients, MENTORE et al. [98] performed
spirometry and hyperpolarised helium-3 imaging at baseline in all cases, and following various
interventions in the eight CF patients. Treatments in the CF group included bronchodilators,
DNAse and chest physiotherapy. The number of ventilation defects was scored. The helium-3
ventilation score correlated moderately with spirometry, and was higher in CF patients than
controls (mean 8.2 and 1.6, respectively). The helium-3 ventilation score was raised in comparison
to controls even in CF patients with normal spirometric results. Defects in the eight treated
patients decreased in response to bronchodilator therapy (p50.025). WOODHOUSE et al. [99]
demonstrated reproducibility of regional and total lung volume measurements using hyperpolarised helium-3 MR in two examinations performed 30 minutes apart in a group of five young
CF sufferers.
The ADC of helium-3 or xenon-129 in the lung and the paramagnetic effect of oxygen are two
novel methods with the potential for extracting clinically relevant data. The ADC provides a
measure of the diffusion of gas and thus an assessment of the degree to which free diffusion is
restricted. Helium-3 has a very high self-diffusion coefficient, but, in the lung, diffusion becomes
restricted by the boundaries of the airspaces, and thus the ADC can be used to interrogate the
microstructure of the lung [93].
58
The oxygen-induced depolarisation of helium-3 or xenon-129 results in signal decay proportional

to the concentration of oxygen [100], permitting estimation of regional oxygen concentration and
uptake and regional pulmonary perfusion, and providing a regional ventilation/perfusion (V/Q)
map at a much higher resolution than that of radionuclide imaging [101]. PATZ et al. [95]
measured regional oxygen concentrations using xenon-129, and, although this is inherently more
complex than with helium-3 due to diffusion into septal tissue and vasculature, an oxygen tension
(PO2) equivalent can be calculated, which can provide valuable functional information.
A limitation of hyperpolarised noble gas MRI is that the signal is also influenced by factors other
than ventilation, including the sensitivity of the MR coil and local oxygen concentration in the
lung. The need for noble gas isotopes and both polarisation hardware and additional MRI
hardware, together with considerable physical and technical support, mean that hyperpolarised
noble gas imaging remains expensive and limited to the research environment. However, the
potential to perform noninvasive evaluation of regional ventilation, diffusion, regional oxygen
concentration, lung microstructure and perfusion without the use of ionising radiation has
potential, especially in the research setting.
Summary
MRI has potential in the imaging of bronchiectasis, particularly in conditions such as CF, in which
young patients may require serial imaging for disease monitoring and assessment of response to
treatment. Compared to HRCT, the ability of MR to provide functional imaging and lack of
radiation could compensate for its limited spatial resolution. With improvement in MRI
techniques, recent studies have shown good reproducibility and good correlation with PFT results.
Further work is required to improve spatial resolution, develop robust validated scoring systems
and evaluate correlations with clinical outcomes.
Currently cost, limited availability and limited spatial resolution limit the use of MRI in
bronchiectasis largely to the research arena. Although hyperpolarised noble gas imaging has great
potential in terms of provision of functional data, technical issues and set-up and ongoing costs
suggest its role will be limited to research for the foreseeable future.
Prior to the advent of HRCT, ventilation (with or without perfusion) scintigraphy was used to aid
disease evaluation in bronchiectasis. DOLLERY and HUGH-JONES [102] studied the physiological
implications of bronchiectasis and found reduced blood flow and impaired ventilation in bronchiectatic
areas. V/Q scintigraphy typically demonstrates matched ventilation and perfusion defects, reflecting
abnormal ventilation secondary to bronchiectasis and associated small airways obstruction [103].
PIFFERI et al. [104] studied 16 children aged 418 years with clinical and CXR evidence of
bronchiectasis, performing HRCT and V/Q scintigraphy. The extent of bronchiectasis, degree of
air-trapping on expiratory HRCT and ventilation and perfusion scores from V/Q scintigraphy
were assessed. HRCT scores for bronchiectasis and air-trapping showed a strong correlation with
perfusion (r50.82; p,0.001) and ventilation scores (r50.72; p,0.01). There was a moderate
negative correlation between FEV1 and HRCT bronchiectatic scores (r5 -0.53; p50.02), airtrapping (r5 -0.64; p50.007) and atelectatic score (r5 -0.54; p50.03).
Scintigraphy
The authors concluded that HRCT provides a comprehensive assessment of children with
bronchiectasis, and V/Q scintigraphy and lung function are additive tools to aid diagnosis and
guide therapeutic management. The ongoing issue of radiation dose and absence of useful
anatomical information, however, limit the value of V/Q scintigraphy in routine practice.
Mucociliary clearance
59
The interaction between the cilia on respiratory epithelium and the periciliary mucous layer
(periciliary liquid (PCL))/overlying mucous layer, together known as the airway surface liquid
(ASL) layer, has been widely investigated. Coordinated function is responsible for the constant
clearance of foreign material, including microorganisms and other debris, towards the pharynx
and ultimate expectoration or swallowing. Impaired mucociliary function has been implicated in
many disease processes, but particularly bronchiectasis. Techniques to objectively measure
mucociliary clearance (MCC) in vivo have been sought in order to improve understanding of the
disease processes and evaluate therapeutic response.
Techniques for measuring MCC

In vivo assessment of MCC relies on the inhalation of radiolabelled particulate material that
becomes trapped in the mucous layer and can be imaged scintigraphically. Data acquired from the
gamma camera over time can be presented either as a series of images for visual inspection or,
more commonly, as timeactivity curves (fig. 11).
Technetium-99m-labelled human albumin, iron oxide and technetium-99sulfur colloid are some
of the aerosols used. Sulfur colloid is nondiffusible, remains extravascular and is expelled by MCC/
swallowing. Deposition of particles is affected by many factors. Some, such as particle size and
breathing pattern, can be controlled for, whereas others reflect the underlying lung condition (e.g.
obstruction and lung size). Thus, in order to make comparisons, it is important to standardise the
nature of the aerosolised particles (size and distribution) and provide a consistent nebulised flow
in order to produce a reproducible deposition rate [105].
In order to define the margins of the lung and differentiate central (C) and peripheral (P) lung
regions, an initial ventilation study utilising a xenon-133 or krypton-81 scan [106] can be
performed immediately prior to administration of particulate material. Following this, the patient
b)
c)
C
P
d)
e) 100
90
80
70
60
50
40
30
20
10
0
90
80
70
60 VCs
60
0
20
40
60
Time minutes
80
Retention at 120 minutes %
100
Retention %
a)
100
1.0
1.5
2.0
C/P ratio
2.5
3.0
Figure 11. Measurement of mucociliary clearance (MCC). a) A xenon-133 equilibrium scan was used to identify
60
the left (L) and right (R) lung boundaries in a normal subject, and assign central (C) and peripheral (P) regions of
interest (b). c) Deposition image obtained immediately after inhalation of technetiumsulfur colloid in the same
subject. d) Mean rate of clearance of technetiumsulfur colloid from 12 subjects with cystic fibrosis at baseline
(&)
h and immediately after inhalation of hypertonic saline ($) [16]. The fast phase (approximately 020 minutes;
), reflecting clearance from large airways, and slow phase (from 40 minutes to start of cough clearance
measurement; --------), reflecting smaller airway clearance, are highlighted. e) Effect of ratio of radioactive counts
measured in the C and P regions on rate of MCC, as denoted by particle retention at 120 minutes, in a cohort of
normal study subjects. VC: voluntary cough. Reproduced from [105] with permission from the publisher.
inhales nebulised radiolabelled aerosol. Various adjuncts are used during nebulisation in order to
provide consistent reproducible dosing, including pneumotachographic devices with visual
feedback to control inhalation flow rate and tidal volume within specific ranges, metronomes to
guide the timing of inhalation and exhalation, and aerosol dosimetric equipment to pulse aerosol
delivery during specific portions of the breathing cycle [105].
The rate of clearance from central airways is up to 1001,000 times faster than that from
peripheral airways [108, 109]. A two-phase MCC pattern is typically seen, with an initial rapid
phase lasting approximately 30 minutes and reflecting clearance from the central airways and a
prolonged slower phase. The latter occurs over 12 hours and is thought to represent movement
of particles to compartments that are more difficult to clear (e.g. absorption of PCL) or slow
clearance from peripheral airway/alveolar deposition. 24-hour measurement of clearance has also
been used to assess the pattern of clearance during the slower phase, which could also be of value
in assessing response to treatment. This, however, requires a higher administered radiation dose
due to the 6-hour half-life of technetium. A static measurement at 24 hours can be used as a
marker of deposition in the nonciliate airways or alveoli [110]. The relative contributions to the
24-hour measurement of slow clearance from peripheral airways, alveolar deposition and mixing
in a poorly cleared part of the ASL, are not fully understood [105]. The static 24-hour
measurement is useful in aiding calculation of other parameters, such as the tracheobronchial
retention (TBR) curve, which is derived by subtracting the 24-hour retention from the corrected
lung retention (LR) curve.
A potentially more accurate means of assessing peripheral clearance is inhaling particles of
different sizes, smaller (4 mm) particles being deposited more peripherally than larger (7.5 mm)
ones [111]. YEATES et al. [108] proposed labelling the differently sized aerosolised particles with
different radioisotopes to permit simultaneous measurement of central and peripheral regional
clearance. This method is not widely used due to practical difficulties.
Some authors [106] advocate measurement of activity solely in the lung periphery, where uptake
is more homogenous. This avoids the potential errors caused by differential uptake in central and
peripheral airways and confounding by variability of initial deposition. It is, however, limited by
a low signal-to-noise ratio due to lower deposition peripherally and intrinsically slower clearance
in these regions. It is also not possible to assess response to therapy in the central airways using
this method.
Following inhalation, the patient is positioned in front of the gamma camera and the gamma
radiation emitted is detected and recorded. The results are analysed graphically with reference to
the zones defined on the initial ventilation scan. At this stage of analysis, it is important to account
for decay of radioisotope and background radiation level. Given the variability of deposition of
radiolabelled aerosol in various parts of the airways, it is important to measure the initial
deposition pattern. The deposition pattern is usually presented as a ratio between C and P or as the
penetration index (PI), which is the ratio of radioactive counts per pixel in P to counts per pixel in
C [107]. A high initial C/P deposition ratio or low PI is associated with a higher clearance rate in
the central airways, making this a potential confounding factor in analysing final clearance data.
Additional imaging following various interventions, such as cough clearance (CC) assessed after
a standardised pattern of coughing, can also be performed. This has some limitations, as
performing this late in the study makes it less sensitive as the central airways would have been
largely cleared of radioisotope. A further normalisation measurement of C/P ratio must be
performed prior to CC.
Clinical applications
61
Measurement of MCC has important research applications in both understanding disease

processes and assessing therapeutic response. To date, the technique has not been broadly adopted
clinically, being cumbersome to establish.
Disorders that impair MCC can seriously affect respiratory function, with build-up of
thick mucus in the airways/lungs and inability to expel harmful material. This can predispose to complications, such as infection and structural lung disease. Other factors may influence
MCC, which is faster in nonsmokers and enhanced by b2-agonists, particularly in nonsmokers [112].
CF is a prominent example of a condition in which measurement of MCC could prove useful.
Scintigraphic evaluation has also been used to demonstrate impaired MCC in primary ciliary
dyskinesia [110] and following lung transplantation [113]. There have been limited studies in
idiopathic bronchiectasis [114].
In CF, disordered ion transport leads to dehydration of the ASL layer [115], impaired ciliary
motion and decreased mucus clearance, ultimately leading to degradation of cilia [105],
exacerbating the cycle of frequent infections. Ongoing research is focused on the earliest stages of
disease pathogenesis and therapeutic interventions to target defective mucus clearance.
Biomarkers objectively measuring MCC have the potential to assess response to treatment at
an early stage in contrast to longer-term end-points, such as clinical or functional parameters,
and thus to expedite drug development.
In a study of 24 patients with CF, DONALDSON et al. [116] showed improved MCC, measured using
technetium-99-labelled iron oxide, at both 1 and 24 hours after inhalation of hypertonic saline,
and that pretreatment with amiloride reduced the magnitude of this improvement. Using
radiolabelled iron oxide BENNETT et al. [106] demonstrated significantly reduced baseline MCC at
40 minutes in CF patients compared to healthy volunteers. In the CF group, treatment with
uridine 5-triphosphate and amiloride in combination improved peripheral MCC to near-normal
levels. Similar studies have used technetiumsulfur colloid to demonstrate improved MCC and CC
following inhaled hypertonic saline and mannitol in CF patients [117].
In summary, MCC can be measured using radiolabelled particulate materials, such as technetium99sulfur colloid. In the research setting, this provides a potential biomarker for evaluation of
mucociliary dysfunction and, in particular, assessment of the impact of targeted therapies. This is
especially true in conditions such as CF, in which impaired MCC plays a significant part in the
pathophysiology of the disease and where treatment is targeted at improving this.
Conclusions
Imaging plays a central role in the diagnosis, characterisation and quantification of disease severity
in bronchiectasis, as well as the evaluation of complications. Currently CXR and CT are the main
modalities. CXR is the initial screening tool, but has well-documented limitations in sensitivity
and specificity, particularly in early disease. Radiography also plays an important role in the
diagnosis of complications. HRCT is the reference standard in identifying airway dilation,
permitting detection of disease and quantification of extent. Routine surveillance CT has potential
for the diagnosis of structural disease at an early stage and impact on patient care, particularly
where these is discordance with functional parameters. Radiation dose, however, remains an
area of concern requiring further elucidation, particularly in the cohort of CF patients given their
ever-increasing life expectancy and the potentially large cumulative radiation dose. Although the
present review concentrates on the monitoring of disease, CT is an excellent problem-solving tool,
permitting the diagnosis of both infective complications, such as abscess, empyema and
aspergilloma, as well as identification of small pneumothoraces or enlarged systemic collateral
vessels (fig. 11) and aiding relevant image-guided intervention.
62
MRI offers opportunities to image the lung structure and its function without the use of ionising
radiation. The spatial resolution is inferior to that of CT but has improved substantially over
recent years. An increasing role for structural (proton) MRI is anticipated, but widespread
adoption will require further evidence to support its effectiveness. Although hyperpolarised noble
gases permit interrogation of a range of physiological parameters, the set-up costs of this technique
are likely to ensure it remains a predominantly research tool for at least the foreseeable future.
Evaluation of MCC using scintigraphy is another area in which there is great potential, particularly
in order to expedite and reduce costs of drug development.
Statement of interest
None declared.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
Laennec RTH. De lAuscultation Mediate ou Traite du Diagnostic des Maladies des Poumons et du Coeur. [On
Mediate Auscultation or Treatise on the Diagnosis of the Diseases of the Lungs and Heart]. Paris, Brosson and
Chaude, 1819.
Hansell DM. Bronchiectasis. Radiol Clin North Am 1998; 36: 107128.
Javidan-Nejad C, Bhalla S. Bronchiectasis. Radiol Clin North Am 2009; 47: 289306.
Smith IE, Flower CDR. Imaging in bronchiectasis. Br J Radiol 1996; 69: 589593.
Collins J, Stern EJ, eds. Chest Radiology. The Essentials. 2nd Edn. Philadelphia, Lippincott Williams & Wilkins,
2007.
Gudjberg CE. Roentologic diagnosis of bronchiectasis. Acta Radiol 1955; 43: 209226.
Currie DC, Cooke JC, Morgan AD, et al. Interpretation of bronchograms and chest radiographs in patients with
chronic sputum production. Thorax 1987; 42: 278284.
Bhalla M, Turcios N, Aponte V, et al. Cystic fibrosis: scoring system with thin-section CT. Radiology 1991; 179:
783788.
Chrispin AR, Norman AP. The systematic evaluation of the chest radiograph in cystic fibrosis. Pediatr Radiol
1974; 2: 101106.
Brasfield D, Hicks G, Soong S, et al. Evaluation of scoring system of the chest radiograph in cystic fibrosis:
a collaborative study. AJR Am J Roentgenol 1980; 134: 11951198.
Cleveland RH, Zurakowski D, Slattery DM, et al. Chest radiographs for outcome assessment in cystic fibrosis.
Proc Am Thorac Soc 2007; 4: 302305.
Naidich DP, McCauley DI, Khouri NF, et al. Computed tomography of bronchiectasis. J Comput Assist Tomogr
1982; 6: 437444.
Phillips MS, Williams MP, Flower CD. How useful is computed tomography in the diagnosis and assessment of
bronchiectasis? Clin Radiol 1986; 37: 321325.
Cooke JC, Currie DC, Morgan AD, et al. Role of computed tomography in diagnosis of bronchiectasis. Thorax
1987; 42: 272277.
Silverman PM, Godwin JD. CT/bronchographic correlations in bronchiectasis. J Comput Assist Tomogr 1987; 11:
5256.
Grenier P, Maurice F, Musset D, et al. Bronchiectasis: assessment by thin-section CT. Radiology 1986; 161: 9599.
Dodd JD, Souza CA, Muller NL. Conventional high-resolution CT versus helical high-resolution MDCT in the
detection of bronchiectasis. AJR Am J Roentgenol 2006; 187: 414420.
Kim JS, Muller NL, Park CS, et al. Cylindrical bronchiectasis: diagnostic findings on thin-section CT. AJR Am J
Roentgenol 1997; 168: 751754.
Webb WR, Muller NL, Naidich DP. High-resolution CT of the lung. 3rd Edn. Philadelphia, Lippincott, Williams
& Wilkins, 2000.
Reid LM. Reduction in bronchial subdivisions in bronchiectasis. Thorax 1950; 5: 233247.
Munro NC, Cooke JC, Currie DC. Comparison of thin section computed tomography with bronchography
for identifying bronchiectatic segments in patients with chronic sputum production. Thorax 1990; 45:
135139.
Kim SJ, Im G, Kim OA, et al. Normal bronchial and pulmonary arterial diameters measured by thin section CT.
J Comput Assist Tomogr 1995; 19: 365369.
Lynch DA, Newell JD, Tschomper BA, et al. Uncomplicated asthma in adults: comparison of CT appearance of
the lungs in asthmatic and healthy subjects. Radiology 1993; 188: 829833.
Diederich S, Jurriaans E, Flower CD. Interobserver variation in the diagnosis of bronchiectasis on high-resolution
computed tomography. Eur Radiol 1996; 6: 801806.
Kang EY, Miller RR, Muller NL. Bronchiectasis: comparison of preoperative thin-section CT and pathologic
findings in resected specimens. Radiology 1995; 195: 649654.
Kim JS, Muller NL, Park CS, et al. Bronchoarterial ratio on thin section CT: comparison between high altitude
and sea level. J Comput Assist Tomogr 1997; 21: 306311.
Shah RM, Sexauer W, Ostrum BJ, et al. High-resolution CT in the acute exacerbation of cystic fibrosis: evaluation
of acute findings, reversibility of those findings, and clinical correlation. AJR Am J Roentgenol 1997; 169:
375380.
63
1.
References
64
28. Remy-Jardin M, Remy J. Comparison of vertical and oblique CT in evaluation of bronchial tree. J Comput Assist
Tomogr 1988; 12: 956962.
29. Reiff DB, Wells AU, Carr DH, et al. CT findings in bronchiectasis: limited value in distinguishing between
idiopathic and specific types. AJR Am J Roentgenol 1995; 165: 261267.
30. Nishimura K, Kitaichi M, Izumi T, et al. Diffuse panbronchiolitis: correlation of high-resolution CT and
pathologic findings. Radiology 1992; 184: 779785.
31. Stern EJ, Frank MS. Small-airway diseases of the lungs: findings at expiratory CT. AJR Am J Roentgenol 1994; 163:
3741.
32. Remy-Jardin M, Remy J, Cortet B, et al. Lung changes in rheumatoid arthritis: CT findings. Radiology 1994; 193:
375382.
33. Cole PJ. Bronchiectasis. In: Brewis RAL, Corrin B, Geddes DM, et al., eds. Respiratory Medicine. 2nd Edn.
London, W.B. Saunders, 1995; pp. 12861317.
34. Currie DC, Goldman JM, Cole PJ. Comparison of narrow section computed tomography and plain
chest radiography in chronic allergic bronchopulmonary aspergillosis. Clin Radiol 1987; 38:
593596.
35. Greenberger PA. Allergic bronchopulmonary aspergillosis and fungoses. Clin Chest Med 1988; 9:
599608.
36. McCarthy D, Simon G, Hargreave F. The radiological appearances in allergic broncho-pulmonary aspergillosis.
Clin Radiol 1970; 21: 366375.
37. Neeld DA, Goodman LR, Gurney IW, et al. Computerized tomography in the evaluation of allergic
bronchopulmonary aspergillosis. Am Rev Respir Dis 1990; 142: 12001206.
38. Nadel HR, Stringer DA, Levison H, et al. The immotile cilia syndrome: radiological manifestations. Radiology
1985; 154: 651655.
39. Westcott JL. Bronchiectasis. Radiol Clin North Am 1991; 29: 10311042.
40. Lee PH, Car DH, Rubens MB, et al. Accuracy of CT in predicting the cause of bronchiectasis. Clin Radiol 1995;
50: 839841.
41. Cartier Y, Kavanagh PV, Johkoh T, et al. Bronchiectasis: accuracy of high-resolution CT in the differentiation of
specific diseases. AJR Am J Roentgenol 1999; 173: 4752.
42. McGuinness G, Naidich DP. CT of airways disease and bronchiectasis. Radiol Clin North Am 2002; 40:
119.
43. Hartman TE, Swenson SJ, Williams DE. Mycobacterium avium-intracellulare complex evaluation with CT.
Radiology 1993; 187: 2326.
44. Moore EH. Atypical mycobacterial infection in the lung: CT appearance. Radiology 1993; 187:
777782.
45. Primack SL, Logan PM, Hartman TE, et al. Pulmonary tuberculosis and Mycobacterium avium-intracellulare:
a comparison of CT findings. Radiology 1995; 194: 413417.
46. Panchal N, Bhagat R, Pant C, et al. Allergic bronchopulmonary aspergillosis: the spectrum of computed
toography appearances. Respir Med 1997; 91: 213219.
47. Ward S, Heyneman L, Lee MJ, et al. Accuracy of CT in the diagnosis of allergic bronchopulmonary aspergillosis
in asthmatic patients. AJR Am J Roentgenol 1999; 173: 937942.
48. Agarwal R, Gupta D, Aggarwal AN, et al. Clinical significance of hyperattenuating mucoid impaction in allergic
bronchopulmonary aspergillosis: an analysis of 155 patients. Chest 2007; 132: 11831190.
49. Logan PM, Muller NL. High attenuation mucus plugging in allergic bronchopulmonary aspergillosis. Can Assoc
Radiol J 1996; 47: 374377.
50. Silva CIS, Colby TV, Muller NL. Asthma and associated conditions: high resolution CT and pathological
findings. AJR Am J Roentgenol 2004; 183: 817824.
51. Oikonomou A, Tsanakas J, Hatziagorou E, et al. High resolution computed tomography of the chest in cystic
fibrosis (CF): is simplification of scoring systems feasible? Eur Radiol 2008; 18: 538547.
52. de Jong PA, Ottink MD, Robben SGF, et al. Pulmonary disease assessment in cystic fibrosis: comparison
of CT scoring systems and value of bronchial and arterial dimension measurements. Radiology 2004; 231:
434439.
53. Helbich TH, Heinz-Peer G, Eichler I, et al. Cystic fibrosis: CT assessment of lung involvement in children and
adults. Radiology 1999; 213: 537544.
54. Santamaria F, Grillo G, Guidi G, et al. Cystic fibrosis: when should high-resolution computed tomography of the
chest be obtained? Pediatrics 1998; 101: 908913.
55. Brody AS, Molina PL, Klein JS, et al. High-resolution computed tomography of the chest in children with cystic
fibrosis: support for use as an outcome surrogate. Pediatr Radiol 1999; 29: 731735.
56. Castile RG, Long FR, Flucke RL, et al. Correlation of structural and functional abnormalities in the lungs of
infants with cystic fibrosis. Pediatr Pulmonol 2000; 20: 2427.
57. Goris ML, Zhu HJ, Blankenberg F, et al. An automated approach to quantitative air trapping measurements in
mild cystic fibrosis. Chest 2003; 123: 16551663.
58. Kiraly AP, Odry BL, Godoy MC, et al. Computer-aided diagnosis of the airways: beyond nodule detection.
J Thorac Imaging 2008; 23: 105113.
65
59. Matsuoka S, Kurihara Y, Nakajima Y, et al. Serial change in airway lumen and wall thickness at thin-section CT in
asymptomatic subjects. Radiology 2005; 234: 595603.
60. Wong-You-Cheong J, Leahy B, Taylor P, et al. Airways obstruction and bronchiectasis: correlation with
duration of symptoms and extent of bronchiectasis on computed tomography. Clin Radiol 1992; 45:
256259.
61. Smith IE, Jurriaans E, Diederich S, et al. Chronic sputum production: correlations between clinical
features and findings on high resolution computed tomographic scanning of the chest. Thorax 1996; 51:
914918.
62. Lynch DA, Newell J, Hale V, et al. Correlation of CT findings with clinical evaluations in 261 patients with
symptomatic bronchiectasis. AJR Am J Roentgenol 1999; 173: 5358.
63. Roberts HR, Wells AU, Milne DG, et al. Airflow obstruction in bronchiectasis: correlation between computed
tomography features and pulmonary function tests. Thorax 2000; 55: 198204.
64. Loubeyre P, Paret M, Revel D, et al. Thin-section CT detection of emphysema associated with bronchiectasis and
correlation with pulmonary function tests. Chest 1996; 109: 360365.
65. Brody AS, Sucharew H, Campbell JD, et al. Computed tomography correlates with pulmonary exacerbations in
children with cystic fibrosis. Am J Respir Crit Care Med 2005; 172: 11281132.
66. Ooi GC, Khong PL, Chan-Yeung M, et al. High-resolution CT quantification of bronchiectasis: clinical and
functional correlation. Radiology 2002; 225: 663672.
67. Alzeer AH. HRCT score in bronchiectasis: correlation with pulmonary function tests and pulmonary artery
pressure. Ann Thorac Med 2008; 3: 8286.
68. Sheehan RE, Wells AU, Copley SJ, et al. A comparison of serial computed tomography and functional change in
bronchiectasis. Eur Respir J 2002; 20: 581587.
69. Brody AS, Klein JS, Molina PL, et al. High resolution computed tomography in young patients with cystic
fibrosis: distribution of abnormalities and correlation with pulmonary function tests. J Pediatr 2004; 14:
3238.
70. Long FR, Williams RS, Castile RG. Structural airway abnormalities in infants and young children with cystic
fibrosis. J Pediatr 2004; 144: 154161.
71. Tiddens HA, de Jong PA. Update on the applications of chest computed tomography scanning to cystic fibrosis.
Curr Opin Pulm Med 2006; 12: 433439.
72. de Jong PA, Mayo JR, Golmohammadi K, et al. Estimation of cancer mortality associated with repetitive
computed tomography scanning. Am J Respir Crit Care 2006; 173: 199203.
73. de Jong PA, Nakano Y, Lequin MH, et al. Progressive damage on high resolution computed tomography despite
stable lung function in cystic fibrosis. Eur Respir J 2004; 23: 9397.
74. Judge EP, Dodd JD, Masterson JB, et al. Pulmonary abnormalities on high-resolution CT demonstrate more
rapid decline than FEV1 in adults with cystic fibrosis. Chest 2006; 130: 14241432.
75. de Jong PA, Lindblad A, Rubin L, et al. Progression of lung disease on computed tomography and pulmonary
function tests in children and adults with cystic fibrosis. Thorax 2006; 61: 8085.
76. Robinson TE, Leung AN, Northway WH, et al. composite spirometriccomputed tomography
outcome measure in early cystic fibrosis lung disease. Am J Respir Crit Care Med 2003; 168:
588593.
77. Nasr SZ, Kuhns LR, Brown RW, et al. Use of computerized tomography and chest X-rays in evaluating efficacy of
aerosolized recombinant human DNase in cystic fibrosis patients younger than age 5 years: a preliminary study.
Pediatr Pulmonol 2001; 31: 377382.
78. Pasteur MC, Bilton D, Hill AT. British Thoracic Society guideline for non-CF bronchiectasis. Thorax 2010; 65:
Suppl. 1, i1i58.
79. Brody AS, Tiddens HA, Castile RG, et al. Computed tomography in the evaluation of cystic fibrosis lung disease.
Am J Respir Crit Care Med 2005; 172: 12461252.
80. Puderbach M, Eichinger M, Gahr J, et al. Proton MRI appearance of cystic fibrosis: comparison to CT. Eur Radiol
2007; 17: 716724.
81. Altes TA, Eichinger M, Puderbach M. Magnetic resonance imaging of the lung in cystic fibrosis. Proc Am Thorac
Soc 2007; 4: 321327.
82. Carr DH, Oades P, Trotman-Dickenson B, et al. Magnetic resonance scanning in cystic fibrosis: comparison with
computed tomography. Clin Radiol 1995; 50: 8489.
83. Hebestreit A, Schultz G, Trusen A, et al. Follow-up of acute pulmonary complications in cystic fibrosis by
magnetic resonance imaging: a pilot study. Acta Paediatr 2004; 93: 414416.
84. Puderbach M, Eichinger M, Haeselbarth J, et al. Assessment of morphological MRI for pulmonary changes
in cystic fibrosis (CF) patients: comparison to thin-section CT and chest X-ray. Invest Radiol 2007; 42:
715725.
85. Montella S, Santamaria F, Salvatore M, et al. Lung disease assessment in primary ciliary dyskinesia: a comparison
between chest high-field magnetic resonance imaging and high-resolution computed tomography findings. Ital J
Pediatr 2009; 35: 24.
86. Euler US, Liljestrand G. Observations on the pulmonary arterial blood pressure in the cat. Acta Phys Scand 1947;
12: 301320.
66
87. Itti E, Fauroux B, Pigeot J, et al. Quantitative lung perfusion scan as a predictor of aerosol distribution
heterogeneity and disease severity in children with cystic fibrosis. Nucl Med Commun 2004; 25:
563569.
88. Fink C, Bock M, Puderbach M, et al. Partially parallel three-dimensional magnetic resonance imaging for the
assessment of lung perfusion initial results. Invest Radiol 2003; 38: 482488.
89. Ley S, Fink C, Puderbach M, et al. Kontrastmittelverstarkte 3D-MR-Perfusion der Lunge: Einsatz paralleler
Bildgebungstechniken bei gesunden Probanden. [Contrast-enhanced 3D MR perfusion of the lung: application of
parallel imaging technique in healthy subjects.] Rofo 2004; 176: 330334.
90. Eichinger M, Puderbach M, Fink C, et al. Contrast-enhanced 3D MRI of lung perfusion in children with cystic
fibrosis initial results. Eur Radiol 2006; 16: 21472152.
91. Ley S, Puderbach M, Fink C, et al. Assessment of hemodynamic changes in the systemic and pulmonary
arterial circulation in patients with cystic fibrosis using phase-contrast MRI. Eur Radiol 2005; 15:
15751580.
92. Jakob PM, Wang T, Schultz G, et al. Assessment of human pulmonary function using oxygen-enhanced T1
imaging in patients with cystic fibrosis. Magn Reson Med 2004; 51: 10091016.
93. van Beek EJ, Wild JM, Kauczor HU, et al. Functional MRI of the lung using hyperpolarized 3-helium gas. J Magn
Reson Imaging 2004; 20: 540554.
94. Kauczor H-U, Surkau R, Roberts T. MRI using hyperpolarized noble gases. Eur Radiol 1998; 8: 820827.
95. Patz S, Hersman W, Muradian I. Hyperpolarized 129Xe MRI: a viable functional lung imaging modality? Eur J
Radiol 2007; 64: 335344.
96. McMahon CJ, Dodd JD, Hill C, et al. Hyperpolarized 3helium magnetic resonance ventilation imaging of
the lung in cystic fibrosis: comparison with high resolution CT and spirometry. Eur Radiol 2006; 16:
24832490.
97. van Beek EJ, Hill C, Woodhouse N, et al. Assessment of lung disease in children with cystic fibrosis using
hyperpolarized 3-helium MRI: comparison with Shwachman score, ChrispinNorman score and spirometry.
Eur Radiol 2007; 17: 10181024.
98. Mentore K, Froh DK, de Lange EE, et al. Hyperpolarized HHe 3 MRI of the lung in cystic fibrosis: assessment at
baseline and after bronchodilator and airway clearance treatment. Acad Radiol 2005; 12: 14231429.
99. Woodhouse N, Wild JM, van Beek EJR, et al. Assessment of hyperpolarized 3He lung MRI for regional
evaluation of interventional therapy: a pilot study in pediatric cystic fibrosis. J Magn Reson Imag 2009; 30:
981988.
100. Eberle B, Weiler N, Markstaller K, et al. Analysis of intrapulmonary O2 concentration by MR imaging of inhaled
hyperpolarized helium-3. J Appl Physiol 1999; 87: 20432052.
101. Kauczor H-U. Hyperpolarized helium-3 gas magnetic resonance imaging of the lung. Top Magn Reson Imaging
2003; 14: 223230.
102. Dollery CT, Hugh-Jones P. Distribution of gas and blood in the lungs in disease. Br Med Bull 1963; 19:
5963.
103. Singh MM, Talwar D, Jena A, et al. Ventilationperfusion studies in bronchiectasis. Ind J Tub 1987; 34:
182186.
104. Pifferi M, Caramella D, Bulleri A, et al. Pediatric bronchiectasis: correlation of HRCT, ventilation and perfusion
scintigraphy, and pulmonary function testing. Pediatr Pulmonol 2004; 38: 298303.
105. Donaldson SH, Corcoran TC, Laube BL, et al. Mucociliary clearance as an outcome measure for cystic fibrosis
clinical research. Proc Am Thorac Soc 2007; 4: 399405.
106. Bennett WD, Olivier KN, Zeman KL, et al. Effect of uridine 5-triphosphate plus amiloride on mucociliary
clearance in adult cystic fibrosis. Am J Respir Crit Care Med 1996; 153: 17961801.
107. Robinson M, Eberl S, Tomlinson C, et al. Regional mucociliary clearance in patients with cystic fibrosis. J Aerosol
Med 2000; 13: 7386.
108. Yeates DB, Gerrity TR, Garrard CS. Characteristics of tracheobronchial deposition and clearance in man. Ann
Occup Hyg 1982; 26: 245257.
109. Wilkey DD, Lee PS, Hass FJ, et al. Mucociliary clearance of deposited particles from the human lung: intra- and
inter-subject reproducibility, total and regional lung clearance, and model comparisons. Arch Environ Health
1980; 35: 294303.
110. Marthin JK, Mortensen J, Pressler T, et al. Pulmonary radioaerosol mucociliary clearance in diagnosis of primary
ciliary dyskinesia. Chest 2007; 132: 966976.
111. Pavia D, Sutton PP, Agnew JE, et al. Measurement of bronchial mucociliary clearance. Eur J Respir Dis 1983; 64:
Suppl. 127, 4156.
112. Mortensen J, Lange P, Nyboe J, et al. Lung mucociliary clearance. Eur J Nucl Med 1994; 21: 953961.
113. Laube BL, Karmazyn YJ, Orens JB, et al. Albuterol improves impaired mucociliary clearance after lung
transplantation. J Heart Lung Transplant 2007; 26: 138144.
114. Isawa T, Teshima T, Hirano T, et al. Mucociliary clearance in pulmonary vascular disease. Ann Nucl Med 1988;
2: 4147.
115. Rowe S, Accurso F, Clancy JP. Detection of CFTR activity in early phase clinical trials. Proc Am Thorac Soc 2007;
4: 387398.
67
116. Donaldson SH, Bennett WD, Zeman KL, et al. Mucus clearance and lung function in cystic fibrosis with
hypertonic saline. N Engl J Med 2006; 354: 241250.
117. Robinson M, Daviskas E, Eberl S, et al. The effect of inhaled mannitol on bronchial mucus clearance in cystic
fibrosis patients: a pilot study. Eur Respir J 1999; 14: 678685.

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Chapter 5

*Dept of Radiology, Norfolk and

Eur Respir Mon 2011. 52, 4467.

ronchiectasis is characterised by irreversible dilation of bronchi, which may be focal or diffuse,

P.L. PERERA AND N.J. SCREATON

Signs of complications/exacerbations, such as patchy densities due to mucoid impaction and

Bronchial dilation, the cardinal sign of bronchiectasis, is characterised on HRCT by a

The different morphological types of bronchiectasis

Figure 2. High-resolution computed tomography image showing cystic bronchiectasis

Figure 3. High-resolution computed tomography image demonstrating signs of

Lack of bronchial tapering or tram-track appearance of

P.L. PERERA AND N.J. SCREATON

Visibility of peripheral airways is another important

Figure 5. High-resolution computed tomo-

graphy image demonstrating bronchiectasis

Air-trapping results either from mucous plugging and

onset of bronchiectasis is debated, and may vary [31].

Imaging and aetiology of bronchiectasis

P.L. PERERA AND N.J. SCREATON

Bronchiectasis with a central or proximal predominance is the characteristic finding in ABPA

Figure 7. High-resolution computed tomo-

demonstrated central bronchiectasis in 85% of lobes

graphy showing a) proximal bronchiectasis

In summary, there are some recognised clinical

Table 1. Summary of computed tomography scoring system

P.L. PERERA AND N.J. SCREATON

Quantitative computerised evaluation of the airways presents a number of challenges, including

P.L. PERERA AND N.J. SCREATON

Role of HRCT in bronchiectasis

scanning technique, it is estimated that a chest CT

Interest in the use of MRI for lung imaging arose in

Conventional proton MRI features

P.L. PERERA AND N.J. SCREATON

Magnetic resonance imaging

EICHINGER et al. [90] performed morphological and contrast-enhanced MRI sequences on 11

P.L. PERERA AND N.J. SCREATON

Hyperpolarised noble-gas-enhanced MRI

The oxygen-induced depolarisation of helium-3 or xenon-129 results in signal decay proportional

P.L. PERERA AND N.J. SCREATON

Techniques for measuring MCC

Retention at 120 minutes %

P.L. PERERA AND N.J. SCREATON

Measurement of MCC has important research applications in both understanding disease

P.L. PERERA AND N.J. SCREATON

P.L. PERERA AND N.J. SCREATON

P.L. PERERA AND N.J. SCREATON

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