13Airway Disease and Chronic

Airway Obstruction

DR MUHAMMAD BIN ZULFIQARPGR III FCPS Services institute of Medical

Sciences/ Services Hospital LahoreGRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY

• FIGURE 13-1 Post-intubation tracheal stenosis in ■a severe COPD patient. (A) Axial CT (lung window). (B) Coronal oblique MPR image (mediastinal window) along the long axis of the trachea. (C) Coronal oblique MPR image (lung window).

• FIGURE 13-1 Post-intubation tracheal stenosis in ■a severe COPD patient. (A) Axial CT (lung window). (B) Coronal oblique MPR image (mediastinal window) along the long axis of the trachea. (C) Coronal oblique MPR image (lung window).

• FIGURE 13-1, Continued ■D) Coronal oblique average image (21-mm-thick slab). Note the visibility of the ring cartilages of the trachea. (E) Endoscopic view. There is a circumferential luminal narrowing of the trachea extending along 2 cm associated with soft-tissue thickening which produces the characteristic ‘hourglass’ configuration, well assessed on coronal views (C, D). Note the roughly triangular shape on axial views (A, E) and the slightly irregular and nodular aspect on 3D image (E).

• FIGURE 13-1, Continued ■D) Coronal oblique average image (21-mm-thick slab). Note the visibility of the ring cartilages of the trachea. (E) Endoscopic view. There is a circumferential luminal narrowing of the trachea extending along 2 cm associated with soft-tissue thickening which produces the characteristic ‘hourglass’ configuration, well assessed on coronal views (C, D). Note the roughly triangular shape on axial views (A, E) and the slightly irregular and nodular aspect on 3D image (E).

• FIGURE 13-2 Infectious tracheobronchitis.■ . (A) Axial CT (mediastinal window) at the level of the distal part of the trachea showing the irregular thickening with a lucency on the left side (blue arrow) related to the fistulous tract. (B) Axial CT (lung window) at the same level.

• FIGURE 13-2, (C) 3D reconstruction of the tracheobronchial tree perfectly demonstrating the whole stenosis and the fistula. (D, E) Axial CT at the level of the mainstem bronchi showing a significant decrease of the bronchial thickening after two weeks of antibiotic treatment: (D) before and (E) after treatment

Continued

• FIGURE 13-2, (C) 3D reconstruction of the tracheobronchial tree perfectly demonstrating the whole stenosis and the fistula. (D, E) Axial CT at the level of the mainstem bronchi showing a significant decrease of the bronchial thickening after two weeks of antibiotic treatment: (D) before and (E) after treatment

• FIGURE 13-3 Adenoid cystic ■carcinoma of the trachea. (A) Axial CT at the level of the supra-aortic part of the mediastinum. Soft-tissue mass arising from the posterior wall of the trachea and bulging into the lumen of the trachea. (B) Sagittal reformation showing the smooth appearance of the surface of the tumour, and the posterior extent of the extraluminal tumour growth.

• FIGURE 13-4 Atypical carcinoid tumour of the intermediate ■trunk. Atypical carcinoid tumour revealed by recent recurrent haemoptysis. (A) Axial slice (lung window) showing the upper portion of the endobronchial lesion with a rounded shape. (B) Axial slice (mediastinal window) showing strong enhancement after intravenous contrast medium

• FIGURE 13-4, Continued Sagittal oblique reformation (mediastinal window) demonstrating the filled bronchiectasis distally of the tumour. (D) Coronal oblique reformation (lung window) showing the upper limit of the tumour obstructing the intermediate trunk with distal atelectasis.

• FIGURE 13-5 Endobronchial metastasis. Patient suffering from lung and liver ■metastasis from colon carcinoma. (A) Axial slice with lung window showing the firstly appeared peribronchial metastasis. (B) Oblique reformation along the axis of the upper segmental bronchus of the left lower lobe. The enlarged and filled bronchus reflects the growth of the metastasis seen 5 months earlier.

• FIGURE 13-6 Relapsing polychondritis. (A, B) Axial CT images at the ■levels of the distal part of the trachea and mainstem bronchi. Abnormal thickening of the anterior and lateral walls of the trachea and mainstem bronchi and right upper lobar bronchus associated with calcium deposits. The posterior membranous wall of the trachea is unaffected.

• FIGURE 13-7 Late-stage relapsing polychondritis. ■ (A) Axial CT at the level of aortic arch in mediastinal (A) and lung windowing (B). Thickening of the anterior and lateral walls associated with narrowing of the tracheal lumen, which presents a circular shape. (C) Coronal oblique reformation with minimum intensity projection: thickening of the tracheolateral walls with tracheal luminal narrowing extending from the cervical part of the trachea to the carina.

• FIGURE 13-7 Late-stage relapsing polychondritis. ■ (A) Axial CT at the level of aortic arch in mediastinal (A) and lung windowing (B). Thickening of the anterior and lateral walls associated with narrowing of the tracheal lumen, which presents a circular shape. (C) Coronal oblique reformation with minimum intensity projection: thickening of the tracheolateral walls with tracheal luminal narrowing extending from the cervical part of the trachea to the carina.

• FIGURE 13-8 Tracheal involvement in Crohn’s disease. Axial CT ■images at the levels of subglottic and upper thoracic parts of the trachea. Circumferential thickening of the trachea walls associated with irregularities of the inner surface of the posterolateral trachea wall, and slight deformity of the tracheal lumen. Note the right aberrant retro-oesophageal subclavian artery.

• FIGURE 13-8 Tracheal involvement in Crohn’s disease. ■Axial CT images at the levels of subglottic and upper thoracic parts of the trachea. Circumferential thickening of the trachea walls associated with irregularities of the inner surface of the posterolateral trachea wall, and slight deformity of the tracheal lumen. Note the right aberrant retro-oesophageal subclavian artery.

• FIGURE 13-9 Tracheopathia osteochondroplastica. ■Axial CT at the level of the upper part of the intrathoracic trachea. Calcified or partly calcified nodules arising from the inner surface of the trachea which protrude into the lumen.

• FIGURE 13-10 Saber-sheath trachea in a COPD patient. (A) Axial ■CT at the level of the upper lobes shows a significant reduction of the coronal diameter of the trachea. Bilateral centrilobular and paraseptal emphysematous areas are also present in the upper lobes. (B) Coronal oblique reformation along the long axis of the trachea. Reduction of the coronal diameter of the trachea lumen (arrows). Note the upper part of the trachea above the thoracic inlet has a normal appearance. (C) Endoscopic view.

• FIGURE 13-10 Saber-sheath trachea in a COPD patient. (A) Axial CT at the ■level of the upper lobes shows a significant reduction of the coronal diameter of the trachea. Bilateral centrilobular and paraseptal emphysematous areas are also present in the upper lobes. (B) Coronal oblique reformation along the long axis of the trachea. Reduction of the coronal diameter of the trachea lumen (arrows). Note the upper part of the trachea above the thoracic inlet has a normal appearance. (C) Endoscopic view.

• FIGURE 13-11 ■Tracheobronchomegaly. (A) Axial CT at the upper part of the chest. Dilatation of the trachea lumen. (B) Coronal oblique reformatted slab with application of minimum intensity projection. The dilatation of the tracheal lumen is extended to the mainstem bronchi lumen.

• FIGURE 13-12 Tracheobronchomalacia. Axial CT and ■sagittal reformation acquired during dynamic expiratory manoeuvre. Almost complete collapse of the trachea, (left) mainstem and (right) intermediate bronchi lumen. The airway lumen is crescent-shaped because of the anterior bowing of the posterior membranous trachea.

• FIGURE 13-13 Bronchiectasis and obliterative bronchiolitis. ■ (A) PA chest radiograph shows oligaemia in the lung bases with pulmonary blood flow redistribution in the upper parts of the lungs, and slight overinflation of the lungs predominant on the right side. (B) Targeted image on the right lung basis in the same patient shows tramlines and ring opacities reflecting the presence of dilated and wall-thickened bronchi.

• FIGURE 13-14 Cystic fibrosis. The PA radiograph ■shows a slight overinflation, and the presence of multiple thin wall ring shadows in the right lung and the left upper lung, reflecting cystic bronchiectasis. Some ring shadows contain air–fluid levels.

• FIGURE 13-15 Post-■infectious bronchiectasis. Axial CT (left) and coronal multiplanar reformation (right). Bilateral cylindrical bronchiectasis involving the right upper and the lower lobes. Note the presence of bronchial wall thickening and mucoid impactions with slight volume loss of the right lower lobe. Note lung cyst in the posterior part of the right upper lobe.

• FIGURE 13-15 Post-infectious bronchiectasis. Axial CT (left) and coronal ■multiplanar reformation (right). Bilateral cylindrical bronchiectasis involving the right upper and the lower lobes. Note the presence of bronchial wall thickening and mucoid impactions with slight volume loss of the right lower lobe. Note lung cyst in the posterior part of the right upper lobe.

• FIGURE 13-16 Bronchiectasis in a patient with cystic fibrosis suffering from chronic infectious ■bronchiolitis. Bilateral cylindrical, varicose and cystic bronchiectasis with thickened walls predominating at the level of the upper lobes. (A) Axial CT at the level of the upper lobes. Note a moderate volume loss of these lobes with some degree of alveolar consolidation on the right side. (B) Coronal oblique reformation targeted on the left side demonstrates the beaded configuration of varicose bronchiectasis (blue arrows) at the level of the lingula. Note also the mucoid impaction appearing as lobulated glove-finger (orange arrow). (C) Axial CT targeted on the left lower lobe—centrilobular nodules predominating at the level of the lateral segment. (D) Axial maximum intensity projection (MIP) image (5-mm-thick slab) clearly demonstrating the tree-in-bud appearance related to infectious bronchiolitis.

• FIGURE 13-16 Continued ■ (D) Axial maximum intensity projection (MIP) image (5-mm-thick slab) clearly demonstrating the tree-in-bud appearance related to infectious bronchiolitis.

• FIGURE 13-17 Cystic bronchiectasis and obliterative bronchiolitis. Cystic fibrosis in a ■young female patient chronically infected with P. aeruginosa, Mycobacterium abscessus and Aspergillus fumigatus—low-dose CT performed on inspiration and expiration with a CTDI of, respectively, 0.66 and 0.33 mGy, resulting in a DLP of, respectively, 24 and 11 mGy/cm. (A) Axial CT at the level of the upper lobes showing alveolar consolidation with cystic lesions predominating on the right side. (B) Coronal oblique mIP image (3-mm-thick slab) perfectly assesses the varicose and cystic bronchiectatic nature of the cystic lesions. (C) Sagittal coronal oblique minimal intensity projection (mIP) image (3-mm-thick slab) targeted on the right lung on inspiration. (D) Sagittal mIP image (3-mm-thick slab) at the equivalent level on expiration. Note the multifocal air trapping on (D) perfectly matched with areas of low attenuation that reflect hypoperfusion due to hypoventilation secondary to obliterative bronchiolitis (mosaic perfusion) on (C) well assessed by adapting the window width and window level.

• FIGURE 13-17 Continued■ . (C) Sagittal coronal oblique minimal intensity projection (mIP) image (3-mm-thick slab) targeted on the right lung on inspiration. (D) Sagittal mIP image (3-mm-thick slab) at the equivalent level on expiration. Note the multifocal air trapping on (D) perfectly matched with areas of low attenuation that reflect hypoperfusion due to hypoventilation secondary to obliterative bronchiolitis (mosaic perfusion) on (C) well assessed by adapting the window width and window level.

• FIGURE 13-18 Allergic bronchopulmonary aspergillosis. ■Axial CT in the upper lobes. Presence of mucoid impactions within segmental and subsegmental dilated bronchi of the upper lobes. Small centrilobular linear branching opacities are seen in the periphery of the right upper lobe.

• FIGURE 13-19 Allergic bronchopulmonary aspergillosis. Axial CT ■targeted on the right lung at the level of the right upper lobar bronchus in lung windowing (A) and mediastinal windowing (B). The oval mass located in the posterior segment of the right upper lobe presents a hyper attenuated component, reflecting the presence of calcium into a large mucoid impaction within a dilated bronchus.

• FIGURE 13-20 Dyskinetic cilia syndrome. Axial CT at the ■level of the lower part of the chest. Bilateral bronchiectasis in the right middle lobe and the left lower lobe with some mucoid impactions. Note the presence of bronchial wall thickening and multiple foci of ‘tree-in-bud’ sign, reflecting infectious bronchiolitis. This patient also has situs inversus (Kartagener’s syndrome).

• FIGURE 13-21 Post bone marrow ■transplantation obliterative bronchiolitis. (A) Axial CT at the level of the lower part of the chest. Diffuse hypoattenuation of lung parenchyma. Lung vessels are reduced in number and in calibre. Note the slight dilatation of the bronchi lumens and the presence of bronchial wall thickening. (B) Low-dose axial CT performed at short suspended end-expiration at the same level as A. The absence of increase in lung attenuation and significant reduction in lung cross-sectional area reflect the presence of diffuse air trapping. The complete collapse of the bronchial lumens in the lower lobes testifies that CT was acquired at the end of a forced expiratory manoeuvre.

• FIGURE 13-22 Chronic bronchitis and obstructive lung disease. ■ Postero-anterior chest radiograph shows mild overinflation. A ring shadow is visible above the left hilum (arrow), reflecting bronchial wall thickening. There is also an accentuation of linear markings in the right lung basis.

• FIGURE 13-23 Severe diffuse emphysema. Postero-anterior (A) and lateral (B) ■chest radiographs. The diaphragm is displaced downwards, and appears flattened. On the PA radiograph (A), the transverse cardiac diameter is reduced. The diaphragm appears irregular in contours due to an abnormal visibility of diaphragmatic insertions on the ribs. Note the depression of vessels in the periphery of the lungs. On the lateral radiograph (B), there is a widening of the sternodiaphragm angle and an increase of dimensions of the retrosternal transradiant area.

• FIGURE 13-24 Giant bullous emphysema. The PA chest ■radiograph shows large avascular transradiant areas in the upper and lower parts of the right lung. The bullae are marginated with thin curvilinear opacities.

• FIGURE 13-25 Respiratory bronchiolitis in heavy smoker. Axial ■CT at the level of the upper lobes. Centrilobular ill-defined small nodular opacities distributed in the periphery of the upper lobes on a background of ground-glass opacities. Some small centrilobular and paraseptal emphysematous spaces are also present.

• FIGURE 13-26 COPD ■patient with airway disease predominant phenotype. Axial CT at the levels of the upper (A) and lower (B) parts of the chest. Few small centrilobular and paraseptal emphysematous spaces in the upper lobes. Bronchial wall thickening, slight bronchial dilatation and lung parenchyma hypoattenuation reflecting obstructive bronchiolitis in the lower lobes.

• FIGURE 13-27 Centrilobular emphysema. HRCT ■targeted on the right lung shows multiple small round areas of low attenuation distributed through the lungs, mainly around the centrilobular arteries.

• FIGURE 13-28 Advanced centrilobular emphysema in a smoker. ■Axial CT at the level of the upper lobes shows large and coalescent areas of low attenuation with lobular margins corresponding to advanced centrilobular emphysematous spaces predominantly distributed on the right side. The patient had a history of left upper lobectomy for bronchopulmonary carcinoma. Note the thickened bronchi related to associated airway remodelling (arrow).

• FIGURE 13-29 Panlobular ■emphysema in a patient with alpha 1- antitryspin deficiency. Axial CT at the levels of the mid (A) and lower parts (B) of the lung with diffuse lung attenuation and paucity of the pulmonary vessels. The presence of multiple thin lines, particularly throughout the lung bases, reflects a distortion of the anatomical structure of the lung parenchyma and thickening of the remaining interlobular septa by lung fibrosis.

• FIGURE 13-30 Paraseptal emphysema. Axial CT at the level ■of the upper lobes. Predominant paraseptal emphysema in a COPD patient appearing as areas of low attenuation mainly distributed along the peripheral and mediastinal pleura on the left side. Note associated centrilobular emphysema.

• FIGURE 13-31 Bullous ■emphysema. (A) Coronal reformat. (B) Coronal average image (200-mm-thick slab) giving a rendering of chest X-ray equivalent.

• FIGURE 13-32 Mild persistent asthmatic ■patient. Axial CT at suspended end-expiration. Patchy areas of air trapping involving individual lobules and segments in the lower and right middle lobes.

• FIGURE 13-33 Moderate ■persistent asthmatic patient. Axial CT at the levels of mid- (A) and lower (B) parts of the lungs. Diffuse bronchial wall thickening with mucoid impactions in the subsegmental and segmental bronchi in the basilar segments of the right lower lobe. Patchy areas of hypoattenuation in the anterior, lateral and posterobasal segments of the right lower lobe and the posterior segment of the left lower lobe, reflecting the presence of small airway remodelling.