1996, The British Journal of Radiology, 69, 589-593

Review article: Imaging in bronchiectasis

1

I E SMITH and 2 C D R FLOWER

department of Respiratory Medicine, Papworth Hospital, Cambridge, and department of Radiology,

Addenbrooke's Hospital, Cambridge, UK
Abstract
Bronchiectasis remains an important and relatively common cause of pulmonary disability. High resolution
computed tomography has revolutionized imaging of the bronchi and has superseded the chest radiograph
and bronchogram in the diagnosis of bronchiectasis. It has enabled a better understanding of the association
between clinical features of the disease and structural abnormalities in the airways and has an important role
to play in understanding the pathogenesis and natural history of bronchiectasis.

Bronchiectasis is defined as irreversible dilatation of

the bronchial tree. It is not a disease in itself but represents the common end stage of a variety of pathological
processes [1]. The condition was first described in 1819
by Laennec who associated the production of fetid
sputum with bronchial dilatation [ 2 ] . In the early part
of the twentieth century bronchiectasis was common due
to the high prevalence of childhood pulmonary infections, in particular pertussis, influenza and tuberculosis.
Vaccination against viral illnesses and the effective treatment of bacterial pneumonia with antibiotics has meant
that the classical form of bronchiectasis, typified by copious purulent sputum and associated with finger clubbing,
is now infrequently encountered in the UK. However,
there is a resurgence of interest in the condition for a
number of reasons.
Advances in medical treatment have led to increased
survival to adulthood of patients with cystic fibrosis,
hypogammaglobulinaemia and immotile cilia syndromes, all of which predispose to bronchiectasis. The
incidence of tuberculosis is increasing, especially in
patients with the acquired immunodeficiency syndrome
(AIDS). An aggressive form of bronchiectasis has been
described in patients with AIDS, even in the absence of
tuberculosis [3]. In immunocompetent patients, atypical
mycobacterial infection with Mycobacterium avion complex is an even more potent cause of bronchiectasis than
tuberculosis [ 4 ] . Bronchiectasis commonly develops
after lung and heart lung transplantation, probably as a
result of chronic rejection [ 5 ] , and in around 10% of
patients after bone marrow transplantation probably due
to chronic graft versus host disease [ 6 ] . With the increasing use of high resolution computed tomography
(HRCT) of the chest during the past decade, less severe
forms of bronchiectasis have become more frequently
Received 12 March 1996 and accepted 20 March 1996.
Address correspondence to C D R Flower, Department
of Radiology, Addenbrooke's Hospital, Hills Road,
Cambridge CB2 2QQ, UK.

Vol. 69, No. 823

recognized [ 7 ] . In this article we review the development

of diagnostic imaging for bronchiectasis and discuss
some of the recent insights revealed by HRCT in
particular.
The chest radiograph
The chest radiograph (CXR) is the initial investigation
in the assessment of most patients in whom bronchiectasis is suspected. Findings related to the abnormal bronchi include tram line opacities and ring shadows,
occasionally with air-fluid levels and a loss of definition
of vessel markings due to peribronchial fibrosis. Retained
mucus may be manifested as tubular opacities, which are
sometimes branched, and there may be volume loss of a
lobe or lung. In 1955 Gudjberg reported 114 bronchiectatic patients of whom only 7.1% had a normal CXR
[ 8 ] . Due to changes in the severity of the disorder, the
CXR is nowadays seldom diagnostic of bronchiectasis
and often normal. In one recent series, abnormalities
were seen on the CXR in only nine of 19 cases where
bronchiectasis was seen on bronchography and on a
lobar basis the CXR had a sensitivity of only 13% for
the diagnosis of bronchiectasis [ 9 ] . In another series of
14 patients with CT evidence of bronchiectasis, the CXR
was diagnostic in none [10].
Scoring systems of the severity of abnormalities on
CXR have been developed for patients with cystic fibrosis
[11, 12] but not all of the radiographic abnormalities
are due to bronchiectasis. Bhalla et al have shown that
CT gives more specific information [13]. While the CXR
appearances are neither sensitive nor specific in bronchiectasis, it still has a role in the planned follow-up of
patients with confirmed bronchiectasis. In a study of 84
patients, 32 of whom had conventional CT performed
on more than one occasion, progression of bronchiectasis
was apparent on the CXR in 14 [14]. In no case was
progression apparent on CT alone, although a true comparison is difficult as the time interval between the first
and latest CXRs was considerably longer than the interval between the CT scans.
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/ E Smith and C D R Flower

Bronchography
Bronchography, first described by Sicard and
Forrestier in 1922 [15], delineated the three forms of
bronchiectasis subsequently described in Reid's anatomical classification [16]. It was unpleasant for the patient,
lead to a temporary impairment of ventilation [17, 18]
and was occasionally associated with allergic and foreign
body reactions to the contrast media. Combining bronchography with fibre optic bronchoscopy was a major
advance, permitting the clearance of secretions before
the accurate instillation of contrast medium [19].
However, even for those experienced in the technique,
underfilling of bronchial segments with contrast medium
was still a limitation.
The interpretation of bronchographic abnormalities is
also problematic, as shown in a study of 27 patients by
Currie et al [ 9 ] . They found disagreement regarding the
diagnosis of bronchiectasis in 22% of lobes considered
by one or other of two readers to contain bronchiectasis.
Despite these difficulties, bronchography was until
recently the investigation of choice for the diagnosis of
bronchiectasis and the gold standard against which the
current best imaging technique, CT, has been compared
[10, 20-24].
Computed tomography of the chest
The first CT description of bronchiectasis was provided by Naidich et al in 1982 [25]. The study was
performed using 10 mm slices. The authors emphasized
the appearances of dilated bronchi, the visualization of
bronchi in the periphery of the lung and bronchial wall
thickening. They proposed that CT might replace bronchography in selected cases whilst raising possible limitations of the technique, in particular the poor definition
of bronchi which did not lie in the plane of the scan.
Subsequent investigators critically compared CT with
bronchography and found the sensitivity disappointingly
low. Silverman and Goodwin [10] used 10 mm thick
sections at 20 mm intervals and reported a sensitivity of
63% and a specificity of 100%. Cooke et al [20] used
10 mm contiguous sections and found a sensitivity of
66% and a specificity of 92%. Phillips et al [21] used
8 mm sections at 15 mm intervals and reported a sensitivity of 79% and a specificity of 99%, concluding that
CT was too insensitive to be a screening test for bronchiectasis and that bronchography was still the investigation of choice.
With the advent of HRCT, the sensitivity of the investigation improved to 82-97% [22-24]. Focal areas of
bronchiectasis shown on HRCT are sometimes not visible on bronchography [22, 24].
Technique is important in HRCT; the lungs should be
scanned from the apices to the diaphragm using a scan
thickness of 1-2 mm with a scan interval of 10 mm, with
additional slices at 5 mm intervals for areas of particular
concern. A scan time of 1 s or less is required to minimize
artefacts from cardiac or respiratory motion, which are
particularly troublesome at the lung bases and may be
further reduced by scanning the patient prone. Cranial
angulation of the scanning gantry (20-25) may be

590

helpful in visualizing bronchi that are oblique to the

plane of the scan, particularly in the middle lobe and
lingula [25]. The window should be centred at between
- 4 0 0 and - 9 5 0 HU, with a width of between 1000 and
1600 HU [24, 26-28]. A high resolution algorithm
should be used for the reconstruction of the images.
Diagnostic criteria on HRCT
The diagnostic criteria for bronchiectasis on HRCT
have been developed from those originally established
by Naidich et al for conventional CT [29]. In cylindrical
bronchiectasis there is uniform dilatation of the bronchi
as they extend towards the periphery. In varicose bronchiectasis the airways have a beaded appearance, best
appreciated when they are imaged in the plane of the
scan. Cystic bronchiectasis is recognized by rings representing the markedly dilated bronchi which may be
clustered together and may contain air-fluid levels.
Differentiation of the three types of bronchiectasis is not
always easy, especially when the bronchus is running
obliquely to the plane of the scan.
Bronchial dilatation
Bronchial dilatation is taken to be present if the bronchus has an internal diameter greater than the diameter
of the accompanying pulmonary artery [24]. In a recent
study of 88 patients with suspected bronchiectasis, three
independent readers reported scans for the presence of
bronchial dilatation using this definition [30]. A kappa
value for interobserver variability of 0.79 was found,
showing that agreement on the presence of the sign is
good. Similar results have been found in a study of
patients with asthma [31].
The measurement of absolute bronchial dimensions,
rather than comparisons with the accompanying artery,
has also been investigated. Seneterre et al have shown
that the measurement of the cross-sectional area of bronchi is highly reproducible as long as full inspiration is
assured [28]. Desai et al have argued that measuring
the circumference of the bronchi may reduce the dependence of measurement on the phase of respiration [32].
They found that the interobserver variability on single
scans was small and that the intraobserver variability on
repeated scans was less than 10%. These data show that
HRCT is probably suitable for the follow-up of patients
with bronchiectasis, looking for evidence of progression
or resolution on different therapies, although a study
comparing its usefulness with CXR is still needed.
Although bronchial dilatation is the key part of the
definition of bronchiectasis and can be reliably demonstrated on HRCT, Lynch et al cautioned over the specificity of the sign [33]. They found that 59% of normals
had at least one bronchus with a diameter greater than
the adjacent pulmonary artery although the dilatation
was usually mild. The authors emphasized the lack of
normal bronchial tapering and the importance of identifying bronchial dilatation on consecutive slices for the
diagnosis of bronchiectasis.
The sensitivity of the sign of bronchial dilatation has
been investigated by Kang et al who compared the pre-

The British Journal of Radiology, July 1996

Review article: Imaging in bronchiectasis

operative HRCT appearances with pathological examination of lung specimens resected for bronchiectasis [26].
They found that lack of bronchial tapering was 79%
sensitive for the diagnosis of bronchiectasis while bronchial dilatation alone was only 60% sensitive. This
difference was explained by the fact that the pulmonary
artery cannot always be identified because of peribronchial fibrosis. Changes in pulmonary artery diameter, such
as are seen in pulmonary hypertension and in hypoxic
vasoconstriction, may also lead to under or over diagnosis of bronchial dilatation. Abnormal bronchial tapering is therefore a more specific and sensitive sign than
bronchial dilatation alone.
Bronchial wall thickening
Bronchial wall thickening is another of the CT signs
originally described by Naidich [29] but it is an inconstant feature and is not a prerequisite for the diagnosis.
This sign is not specific to bronchiectasis as it is also
seen in asthmatics [33] and occasionally in asymptomatic smokers [34]. Kang et al [26] found a sensitivity
of 68% for the subjective appearance of bronchial wall
thickening in the diagnosis of bronchiectasis compared
with pathological examination post-resection. However,
interpreting these findings is confounded by there being
no accepted definition of bronchial wall thickening.
Remy-Jardin defined a bronchus as being thick walled
when the bronchial wall was at least twice as thick as
that of a normal bronchus [34]. Such an assessment is
limited when the abnormality is diffuse. Diederich et al
have defined a bronchus as thick walled if the internal
diameter is less than 80% of the external diameter [30]
and interobserver agreement on the presence of the sign
was good (K = 0.66). Whilst such a measurement is useful
if bronchi are of normal diameter or only slightly dilated,
wall thickness will be undercalled in markedly dilated
bronchi and may be overestimated when there is bronchoconstriction, for example with asthma.
An alternative method of scoring bronchial wall thickness is to compare it with the adjacent pulmonary artery.
This system was first described in cystic fibrosis [13]
with a scoring system of 1 to 3, where 1 represents
bronchial wall thickness equal to the diameter of the
adjacent pulmonary artery. This is too insensitive for use
in most patients with bronchiectasis in whom the degree
of thickening is considerably less. Reiff et al have developed the method and redefined the score of 1 as representing a bronchial wall thickness of half the diameter
of the accompanying artery [35]. This approach seems
promising, but they did not report the interobserver
variability of the sign defined in this way or describe the
frequency with which it was impossible to use the scoring
system when the artery was obscured by peribronchial
fibrosis.
The significance of bronchial wall thickening on
HRCT has not been established. While Kang et al have
described its sensitivity compared with pathological
examination, they did not describe the pathological correlates [26]. It has been suggested that it is evidence of
chronic and recurrent infection [13]. Compared with

Vol. 69, No. 823

patients with idiopathic or other specific causes for bronchiectasis, those with hypogammaglobulinaemia have
more pronounced bronchial wall thickening for a given
degree of bronchial dilatation [35]. In a study of patients
with chronic sputum production, we found that two
patients with hypogammaglobulinaemia had no bronchial dilatation but both had bronchial wall thickening
[36]. The balance between bronchial dilatation and wall
thickening may therefore be dependent on the degree of
immunocompetence and this may guide future investigations into the inflammatory processes which lead to
bronchiectasis.
Associations between clinical features and radiological
appearances
The three most important clinical features of bronchiectasis are chronic sputum production, usually with
infective exacerbations, airflow limitation and haemoptysis. Radiological investigation of the possibility of bronchiectasis is justified in patients presenting with these
features without apparent cause.
Chronic sputum production is commonly attributed
to chronic bronchitis due to airway damage caused by
cigarette smoking. However, it seems likely that many
patients with this symptom have bronchiectasis. Using
bronchography, Currie et al [9] studied 27 patients with
chronic sputum production and found bronchiectasis in
19 while accepting that referral for bronchography probably selected patients more likely to have bronchiectasis.
In a study using HRCT, we found that 27 of 40 patients
with chronic sputum production had bronchiectasis
[36]. The only features of the clinical history which
predicted the presence of bronchiectasis were the continual production of purulent sputum and childhood pertussis. Other features of the history which did not
differentiate between those with or without bronchiectasis included: the duration of symptoms, the volume of
sputum per day, haemoptysis and smoking history.
Auscultation of the chest was equally poor at distinguishing the two groups.
The association between airflow limitation and bronchiectasis is a determinant of outcome [37]. Two studies
have shown a highly significant negative correlation
between the forced expiratory volume in one second
(FEV1) and the extent of bronchiectasis on HRCT [36,
38]. The airflow limitation is thought to be produced
by sputum obstructing the airways [39] and by the
bronchiolitis which accompanies the large airways dilatation in the large majority of cases [26]. It is likely that
the narrowing and eventual obliteration of the peripheral
bronchial divisions has a greater impact on pulmonary
function than does bronchial dilatation [40].
When small airways are obliterated, collateral ventilation occurs during inspiration via the pores of Kohn
and maintains inflation in areas where the bronchioles
are obstructed. Airflow is obstructed during expiration
and the air is trapped. Hansell et al have shown air
trapping using expiratory scans performed with ultra fast
CT in subjects with bronchiectasis [41]. The degree of
air trapping was estimated by scoring the area of
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/ E Smith and C D R Flower

increased transradiancy and this was independent of the

smoking history but related to the extent of bronchiectasis and inversely to the FEV1. It is unlikely that the
transradiancy was due to coexistent emphysema as gas
transfer was normal or raised in the patients studied. Of
particular interest was the demonstration of areas of air
trapping in lobes where there was no evidence of bronchiectasis, raising the possibility that small airways disease
may precede bronchiectasis in some cases.
Haemoptysis is a frequent symptom of bronchiectasis.
In patients with otherwise unexplained haemoptysis and
a non-diagnostic CXR, bronchiectasis is the most frequently diagnosed cause on further radiological investigation. In 40 patients with haemoptysis investigated with
combined bronchoscopy and bronchography, bronchiectasis was demonstrated in six (15%) by bronchography [42]. Using conventional CT in 40 patients with
haemoptysis and normal bronchoscopic findings, Millar
et al demonstrated bronchiectasis in seven (17.5%) with
no evidence of bronchiectasis in 93 controls [43]. In two
studies comparing the value of HRCT and bronchoscopy
in patients with haemoptysis, the prevalence of otherwise
cryptic bronchiectasis on HRCT was 15% and 17%
[44, 45].
Conclusion

The radiological investigation of bronchiectasis has

advanced considerably in the last decade with HRCT
emerging as the investigation of choice. Airway diameter
is well demonstrated and its measurement is reproducible
between observers and on sequential films. Thickening
of the bronchial wall still awaits an accepted definition
but may have important clinical and laboratory correlates which warrant further investigation. Air trapping,
demonstrated on expiratory scans, correlates with the
degree of airflow limitation and may offer new insights
into the natural history of bronchiectasis. While there is
little doubt that HRCT can clearly demonstrate detail
of the airways and lung parenchyma, further work is still
required to fully explore the pathological and clinical
correlates of these radiographic appearances.
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