Case Scenario and

X-Rays / CT Chest

Dr Pranav Ish
MBBS (MAMC), MD (Medicine), DNB (Medicine),
MNAMS, FSM (ISDA), EDARM (ERS)
DM (pulmonary & critical care medicine)
Faculty of Pulmonary, Critical care & Sleep Medicine,
VMMC & Safdarjung Hospital, New Delhi
 Case

• 37 years/female, resident of Bihar

• non smoker, no h/o Biomass Fuel smoke exposure

• homemaker

• Presenting Complaints-

– Dyspnoea since 27 years Increased since last 7 days

– Cough with expectoration since 27 years increased since 7 days

– H/O fever for 1 day 7 days ago

DISCUSSION
 Differentials -

• Chronic Pathology • Acute worsening

Bronchiectasis – exacerbation of
– Post infective underlying disease
– Foreign body/Aspiration – Community acquired
– CF/Immunodeficiencies pneumonia
Asthma – Pulm. Embolism
Congenital Pulmonary – Pneumothorax
Malformations

OTHERS?
 History of presenting illness
• Apparently well till 10 years of age

• developed Fever, dyspnoea, Cough with expectoration –

for which patient was admitted and treated.(DETAILS
NOT AVAILABLE)

• Patient is symptomatic since 10 years of age

• Shortness of breath – 27 years

– Insidious onset,

– progressive

• Progressed from mMRC 1 to mMRC 2 - At the age of 15 years she had to stop to
take breath while walking from school

• further progressed to mMRC 3 – 5 years back (stop for rest after walking for few
minutes)

• Progresses to mMRC 4 during exacerbations- need to take leave from school

during exacerbation

– Associated with wheeze

– Increased during morning hours and on exposure to cold

– No orthopnea, paroxysmal nocturnal dyspnea

– Not a/w palpitations, chest pain, syncope, leg swelling

– Partial Relief by taking inhalers

mMRC
 HOPI
• Cough – 27 years
– insidious onset, progressive in nature, initially resolved with treatment, however, became
persistent since last 5 years
– Sputum production- Baseline- 2 tsp per day, non foul smelling and mucoid
– Increased quantity and purulence during exacerbations-
– Expectoration increased to 1 cup/day
• greenish.
• purulent.
– Seasonal variation present- more in winters and during morning hours with increased OPD
visits
– Increased in right lateral decubitus position
– Partially relieved with course of antibiotics
• H/O haemoptysis since last 5 years, on and off in nature,

– 2 to 3 TSP per day (never massive)

– Last episode 1 year back.

No History of recurrent paroxysmal shortness of breath associated with
wheezing, expectoration of thick tenacious sputum, brown mucus plugs

No history of recurrent nasal blockage, discharge, facial heaviness, post nasal

drip

No History of joint pains, swellings, morning stiffness

No H/o of recurrent dryness of eyes, mouth, dysphagia for > 3 months

No H/o loss of weight, appetite

• No H/O repeated bloody diarrhoea, abdominal pain, altered
bowel

• No H/O any malabsorption, steatorrhea, gall stones

• No h/o frothy urine and pedal edema

• No h/o repeated skin and soft tissue infection, oral thrush

DISCUSSION
 Differentials -

• Chronic Pathology
– Bronchiectasis
– Fibrocavitary disease
– Congenital Pulmonary Malformations
 Current admission
• Fever – 1 episode, 7 days back.

• Not associated with

– chills and rigor,

– skin rash,

– burning micturition,

– altered sensorium,

– Relieved by taking medication

• SOB – mMRC 4

– Associated with wheeze

– No orthopnea, paroxysmal nocturnal dyspnoea

– Not a/w palpitations, chest pain, syncope, leg swelling

 ▪ Cough with purulent expectoration - Expectoration increased to 1
cup/day
greenish.
purulent.
Increased in right lateral decubitus position

• Course in Hospital – She was admitted in the ward 5 days ago was
treated with broad spectrum antibiotics, nebulisation and iv steroids.
• Her symptoms of dyspnoea partially responded to therapy
DISCUSSION
 Differentials -

• Acute worsening
– exacerbation of underlying disease
– Community acquired pneumonia
 Treatment History
Patient has been taking inhalers for her dyspnoea as prescribed
by her physician.

Patient was treated with multiple short courses of antibiotics

over the last 27 years

H/O multiple ER visits

H/o short admissions (2-3times/year) since the last 5 years.

 Personal history
• Non smoker
• Denies addiction
• Mixed diet
• Bowel and Bladder – normal
• Modified Kuppusamy’s classification- upper lower
• married with 2 children(12yr boy and 8yr daughter)

• Menstrual History- normal

Family History
 Case summary
• 37 yrs old female

• non smoker

• h/o repeated childhood infections,

• presented with
– C/O SOB since 20 years increased since 7 days,

– Cough with expectoration since 20 years increased since 7 days

– 1 episode of fever 7 days back

• h/o haemoptysis on and off

DISCUSSION
 Provisional diagnosis
• Anatomy • Pathology
– Airway – Bronchiectasis
– Airway with parenchyma – Fibrocavitary disease
• Etiology
ACUTE WORSENING CHRONIC PATHOLOGY
• Exacerbation of underlying Bronchiectasis secondary to
disease • Post infection
• Community acquired • Foreign body
pneumonia • Congenital Pulmonary
Malformations
• ABPA
• Idiopathic
Fibrocavitary disease
secondary to infection
 Examination- general
• Patient conscious/ oriented

• Vitals
– Temp- 98.6 F
– Pulse- 87/ minute, regular, normal
volume, no spl character, no
radio-radio femoral delay, felt in
all accessible peripheral sites
– BP- 138/ 76 mm Hg in RUL in
sitting position
– RR- 28/ min, Thoracoabdominal
– SpO2- 91% at room air

• BMI- 16.5 Kg/m2

• Clubbing – pandigital- Grade -3
• Pallor +
• No icterus/ cyanosis/ pedal oedema/
LAP
• JVP- not raised
Head to toe examination
• Cannula on the right forearm.
• No apparent abnormality seen in hair and scalp
• No evidence of eyelid discharge/oedema, watery eyes
• No evidence of nasal crusting, polyps, sinus tenderness, nasal discharge,
deviated nasal septum, nasal crease.
• Oral hygiene poor, no mouth ulcers, no evidence of cracking at corners of
mouth.
• No obvious bruising or other abnormalities in skin, upper and lower limbs.
Examination- systemic- Respiratory system

• Inspection
– Asymmetrical
– Movements reduced in the left
– Left hemithorax size decreased
– Left Shoulder droop
– Angle of scapula lower- left
– No spine deviation
– Trachea deviated to the left
– Apical impulse not visible
– No scars, sinuses, dilated veins, visible pulsations
– Use of accessory muscle present.
Examination- systemic- Respiratory system

• Palpation

– Findings of inspection- confirmed

– Trachea- to left

– Rib crowding in the left hemithorax

– Apex beat- 5th ICS- 2 cm lateral to mid cl line

– Movements- reduced- left side all areas

– TVF reduced in all areas on the left side except left

supraclavicular, infraclavicular and suprascapular area
 MEASUREMENTS
Chest circumference Exp 60cm Insp 65cm
Right Hemithorax Exp 33.5cm Insp 37cm
Left Hemithorax Exp 26.5cm Insp 28cm

Chest Expansion Total 5cm

Chest Expansion R 3.5cm
Chest Expansion L 1.5cm

Spino Scapular distance R 4cm

Spino Scapular distance L 2.5cm

RATIO .58
AP 17
Transverse 29
 TVF
ANTERIOR Right Left
Supraclavicular Normal Normal
Infra Clavicular Normal Normal
Mammary Normal Reduced
LATERAL Right Left
Axillary Normal Normal
Infra Axillary Normal reduced
POSTERIOR Right Left
Suprascapular Normal Normal
Interscapular Normal Reduced
Infrascapular Normal Reduced
DISCUSSION
 • SIZE OF HEMITHORAX MOVING LESS
• Large –
- Massive pleural effusion
- Large mass lesion
- Giant bullae
- Hydropneumo/ pneumothorax

➢ Small-
- Pleural fibrosis/thickening
- Collapse
- Fibrosis/ Fibrocavitory
- Destroyed lung

➢ Same size-
- Mild/ Moderate pleural Effusion
- Consolidation
Examination- systemic- Respiratory system

• Percussion
– Boundaries of Lung
• Right- 6th 8th and 10th ICS in MCL, MAL and PSL respectively
• Left – 5th 7th 9th ICS in MCL, MAL and PSL respectively

– Tidal percussion- 1 intercostal space

– Sternal percussion- Resonant in upper and dull in lower sternum

– Right and left cardiac borders normal

– Kronig’s isthmus – Resonant on both sides

– Clavicular percussion – resonant on both sides
– Traube-space- tympanic
 PERCUSSION- LUNG FIELDS

ANTERIOR Right Left

Supraclavicular Resonant Resonant
Infra Clavicular Resonant Resonant
Mammary Resonant Impaired
LATERAL Right Left
Axillary Resonant Impaired
Infra Axillary Resonant Impaired
POSTERIOR Right Left
Suprascapular Resonant Resonant
Interscapular Resonant Impaired
Infrascapular Resonant Impaired
 Auscultation

– Air entry bilateral, reduced on left, Normal breath sounds

– Coarse Crepts in left- mammary, axillary, inter and infrascapular
region.
– MID INSP & EXPIRATORY COARSE CREPTS
– No change with coughing
– VR- reduced in all areas except left supra clavicular, infra
clavicular, supra scapular area
– FET- 8 seconds
DISCUSSION
 Other system examination
• CVS
– S1S2 heard,
– no murmurs
• Abdomen-
– soft non tender,
– no organomegaly,
• CNS-
– higher mental functions – normal,
– Cranial nerve examination- normal
– Upper and lower limb- Tone/power/reflexes- normal
DISCUSSION
 Diagnosis
• Anatomy
– Unilateral disease (Left lower lobe)
– Airway, parenchyma
• Pathology –
– Fibro Bronchiectasis
• Etiology
• – Bronchiectasis secondary to
• infection
• Foreign body
• Congenital Pulmonary Malformations
• ABPA
• Idiopathic
• Complication
• – Patient is anemic, underweight and in Respiratory failure, no pulmonary
hypertension.
• Acute Diagnosis - acute infective exacerbation of Bronchiectasis
• Performance Status
– mMRC- 4
CHEST X RAY
HRCT Chest : Mediastinum
HRCT Chest : Lungs
When To Consider Bronchiectasis ?
Radiological Criteria
Airway Vessel
Bronchial:arterial ratio >1
Lack of tapering
Airway visibility within 1cm Bronchiectasis
of pleural surface

Clinical Criteria
Chronic cough
Sputum production
Recurrent respiratory tract infections
Haemoptysis

Associated conditions
Infectious
Autoimmune
Allergic
Inflammatory
Genetic
obstruction
 How to Proceed in This case
Any Work up Required after the diagnosis of
bronchiectasis ?
 ERS Recommendations For Etiology
Testing
We suggest the minimum bundle of etiological tests in adults with a ‘new
diagnosis of bronchiectasis is:

1) Differential blood count;

2) Serum immunoglobulins (total IgG, IgA and IgM);

3) For allergic bronchopulmonary aspergillosis (ABPA).

Note:
sputum culture is expected for microbiological monitoring
Additional tests may be appropriate in response to specific clinical features
(NTM, CF, immunological disorders, PCD, 1-AT) or in patients with severe or
rapidly progressive disease.

Sputum examination for tuberculosis : required in India

 Etiology of Bronchiectasis ( India)

90%
 How to Treat this case ?
• Sputum :
– Gene Xpert –ve, AFB smear -ve,
– Pyogenic culture negative
• Fungal smear –ve
• ABPA work up negative : ( IgE = 287, IgE
Specific for Aspergillus = 0.15 )

• Idiopathic Bronchiectasis
Bronchiectasis Treatment Scheme

Aetiology Exacerbations Eradication

Long-term Long-term Long-term

Anti-inflammatory antibiotics mucoactive

Long-term Thoracic Respiratory

bronchodilators Surgery physiotherapy
 ERS Guidelines for Airway Clearance

Recommendations
• We suggest that patients with chronic productive cough or difficulty to
expectorate sputum should be taught an airway clearance technique (ACT)
by a trained respiratory physiotherapist to perform once or twice daily (weak
recommendation, low quality of evidence).
• We recommend that adult patients with bronchiectasis and impaired exercise
capacity should participate in a pulmonary rehabilitation programme and
take regular exercise.
– strong recommendation, high quality of evidence.

• All interventions should be tailored to the patient’s symptoms, physical

capability and disease characteristics
 Long term Bronchodilator therapy
• We suggest not routinely offering long-acting bronchodilators for adult
patients with bronchiectasis (conditional recommendation, very low
quality of evidence).

• We suggest offering long acting bronchodilators for patients with

significant breathlessness on an individual basis (weak recommendation,
very low quality of evidence).

• We suggest using bronchodilators before physiotherapy, including inhaled

mucoactive drugs, as well as before inhaled antibiotics. (good practice
point, indirect evidence).

• We suggest that the diagnosis of bronchiectasis should not affect the use
of long acting bronchodilators in patients with comorbid asthma or COPD
(good practice point, indirect evidence)

European Respiratory Society guidelines for the management of adult bronchiectasis

 Long term anti-inflammatory Rx
• suggest not offering treatment with inhaled corticosteroids to
adults with bronchiectasis (conditional recommendation, low
quality of evidence).

• recommend not offering statins for the treatment of

bronchiectasis (strong recommendation, low quality of evidence).

• diagnosis of bronchiectasis should not affect the use of inhaled

corticosteroids in patients with comorbid asthma or chronic
obstructive pulmonary disease (best practice
advice, indirect evidence).

European Respiratory Society guidelines for the management of adult bronchiectasis

No inhaled antibiotics at this stage
 Case FU :
• Patient was apparently well till March 2022 , then he
developed fever, cough with expectoration (greenish
yellowish) and SOB on mild exertion & reported to OPD and
had taken took Ceftum for 5 days but no relief

• How to manage this case ?

Role of microbiology in management of

Bronchiectasis ?
 Case FU :
• Sputum c/s – Pseudomonas (pansensitive)

• How to treat this patient ?

Pseudomonas aeruginosa Eradication Therapy

Polverino et al. Eur Respir J 2017;50:1700629

Radiology discussion for bronchiectasis
• Cxray
• CT
Imaging- CXR
 CT Chest findings

• Ratio of the inner or outer airway diameter to

the artery diameter of 1.0 or more
• lack of tapering of the airways
and
• the presence of radiographically visible
airways in the perimeter
HARRISON
• CT findings include airway dilation (detected as parallel “tram tracks” or as the
• “signet-ring sign”—a cross-sectional area of the airway with a diameter
• at least 1.5 times that of the adjacent vessel), lack of bronchial tapering
• (including the presence of tubular structures within 1 cm from the
• pleural surface), bronchial wall thickening in dilated airways, inspissated
• secretions (e.g., the “tree-in-bud” pattern), or cysts emanating
• from the bronchial wall (especially pronounced in cystic bronchiectasis
DO NOT FOLLOW B/A RATIO STRICTLY

• small-vessel or small-airways diseases →

vasoconstriction resulting in smaller arterial
diameters with an increase in B/A ratio.
• enlarged pulmonary arteries in cases of
pulmonary hypertension result in pseudo-
normalization of the B/A ratio (in cases ofunder- or over-
bronchiectasis) diagnosis of
bronchiectasis
 RADIOLOGY-
Bronchiectasis types
CT chest findings
A. Tubular
B. Signet ring
appearance
C. dilated and thick
walled airway
within 1 cm of the
visceral pleura
• regions of cystic
bronchiectasis
• classic cluster of
grapes
appearance.
• Cystic
bronchiectasi
s
• Bronchi are
dilated and
thick walled.
• air-fluid
levels
 Other CT findings

• mucus plugging
• “tree in bud nodularity”
• Waxing and waning
pattern to nodules
• cystic changes and
cavitation may be seen