BRONCHIOLITIS :

A PRACTICAL
APPROACH FOR THE
GENERAL RADIOLOGIST
Penyaji :
dr. Monika Aprilia Swastika
Pembimbing :
dr.Bambang Satoto, Sp.Rad(K),M.Kes
 Introduction
Bronchiolitis generically refers to inflammation and/or fibrosis involving
airways
Although the term bronchiolitis is commonly used by radiologists,
pathologists, and other clinicians, its meaning may be somewhat different
for each specialty.
In addition, various types of bronchiolitis often share the same
constellation of imaging findings, which include ill-defined opacities on
radiographs and centrilobular nodules with or without air trapping on
computed tomographic (CT) images.
Nevertheless, radiologists who understand bronchiolitis and its various
causes and manifestations are in a unique position to guide diagnosis,
suggest possible causes, and affect management.
INTRODUCTION
Definition, classification & pathology

Inflammation and/or fibrosis involving airways

BROCHIOLITIS
smaller than 2 mm in diameter, which often lack
a cartilaginous wall, and/or the alveolar ducts

CLINICAL Cough
MANIFESTATION Shortness of breath

TYPE
Cellular bronchiolitis inflamantory cell
Constrictive (fibrotic) bronchiolitis
bronchiolar narrowing from adventitial
and submucosal fibrosis
Definition, classification & pathology
 Technique consideration
Tree in bud
Direct Centrilobular nodules

Mosaic attenuation
Indirect Air trapping

High Resolution CT perform on thin-section images with a section

thickness of 3 mm or less, the standard today is 1.001.25 mm and
performed without administration of intravenous contrast material.
 Imaging finding

Micronodules opacities that measure < 3 mm in diameter.

Air trapping mosaic attenuation during inspiration that persist on expiration
Characteristically, areas of normal lung increase in attenuation during
expiration, whereas areas of air trapping maintain low attenuation
However, this finding is seen in mosaic attenuation of vascular origin.
Some authors have postulated that identifying differences in vessel caliber in
areas of higher and lower attenuation may help differentiate airway from
vascular mosaic attenuation on inspiration.
Finally, it is important to recognize that small areas of mosaic attenuation and
air trapping may be seen in healthy subjects ( 20%)
 Imaging finding

Chest Radiography CT Images

ill-defined small or hazy clustered
nodules or areas of air trapping
characterized by hyperlucency
and/or oligemia
Centrilobular micronodules
Bronchial wall thickening, bronchial
dilatation,mozaic attenuation
Imaging finding
Make sure Micronodules are centrilobular
Base on anatomy distribution :
Centrilobular micronodules not extending to or involving the pleura
(including the fissures)
Perilymphatic micronodules tend to involve the pleural surfaces and
fissures (seen in sarcoidosis and other entities) , nodularity along the fissures,
which is well depicted on sagittal reformatted images
Anatomically the center of the secondary pulmonary lobule relatively
distant from the subpleural or interlobular interstitium located at the periphery
of the secondary pulmonary lobule
Miliary micronodules are hematogenous lesions that involve the lungs and
exhibit a random distribution
Figure 3
Axial CT image of a 68-year-old
woman with chronic obstructive
pulmonary disease and acute
infectious bronchiolitis shows tree-in-
bud opacities, bronchiectasis, and
marked bronchial wall thickening
Figure 4
Axial inspiratory (left) and expiratory
(right) CT images of a 59-year-old
man with hypersensitivity
pneumonitis show lobular and
subsegmental areas of mosaic
attenuation in the expiratory image
that are due to air trapping.
Do Centrilobular Micronodules Always
Represent Bronchiolitis?
Important to determine that centrilobular micronodule
related to small airways disease not due to vascular cause (
cellulose granulomatosis / tumor emboli )
So centrilobular nodules do not always reflected bronchiolitis
, the clinical context and history is important to formulating
an appropriate differential diagnosis.
Patient with cellulose granulomatosis may have history
abusing pain medication may represent pulmonary
hipertention , arhytmia or sudden death. Another common
risk is patient with inject crushed medication
Figures 6, 7 (6) Drawing shows diffuse and evenly distributed centrilobular nodular opacities. This
pattern of involvement should raise high suspicion for vascular causes, rather than airway causes,
and, in particular, cellulose granulomatosis (injection of crushed tablets intended for oral
consumption). Note the subpleural sparing (between arrows) characteristic of centrilobular
distribution of disease. (7) Cellulose granulomatosis in a 37-year-old man presenting with severe
newonset pulmonary hypertension. (a) Coronal MIP CT image shows extensive, diffuse, and
evenly distributed tree-in-bud nodules bilaterally. (b) Axial CT image shows a dilated pulmonary
trunk consistent with pulmonary hypertension.
 Does Mosaic Attenuation Always
Represent Bronchiolitis?
Mosaic attenuation is defined as a patchwork of regions of differing
attenuation that may represent
(a) patchy interstitial disease
(b) obliterative small airways disease
(c) occlusive vascular disease
Small percents of patient with mosaic attenuation manifest with
chronic occlusive vascular disease
Airway mosaic attenuation is often associated with bronchiectasis
and bronchial wall thickening whereas vascular mosaic attenuation is
typical of pulmonary hypertension and in cases of chronic
thromboembolic disease, the presence of nonocclusive eccentric
pulmonary artery filling defects, a dilated pulmonary trunk from
pulmonary hypertension, and right ventricular hypertrophy.
 Infectious Bronchiolitis
The most common type of bronchiolitis classified acute or chronic
Acute infectious bronchiolitis is typically viral (eg, respiratory syncytial virus and
parainfluenza viruses) or bacterial (eg, Staphylococcus aureus and
Mycoplasma pneumoniae)
Chronic infectious bronchiolitis is frequently mycobacterial (including both
tuberculosis and non tuberculous mycobacterial infection) or bacterial, such
as Pseudomonas aeruginosa pulmonary infection
Acute infectious bronchiolitis has nonspecific CT findings and often manifests
with scattered foci of clustered tree-in-bud opacities and bronchial wall
thickening, which can involve one or several pulmonary lobes
In addition to centrilobular nodules and bronchial wall thickening, chronic
infectious bronchiolitis may demonstrate other imaging findings that indicate
chronicity, such as bronchiectasis mosaic attenuation
In tuberculosis infection upper lobe cavity disease, centrilobular nodule and
tree in bud opacities
Figure 9. Severe community-acquired M pneumoniae pneumonia in a 48-year-old man presenting with
acute dyspnea and fever. (a) Anteroposterior chest radiograph shows ill-defined left upper lobe
heterogeneous opacities (arrow). (b) Axial CT image collimated to the left lung shows clustered ground-
glass and tree-in-bud opacities (arrows). (c) Axial CT image collimated to the right lung at a more inferior
level shows centrilobular
Figures 10, 11. (10) Postprimary pattern of tuberculosis in a 38-year-old man
presenting with chronic cough, fatigue, and low-grade fever. (a) Anteroposterior
chest radiograph shows ill-defined heteroge- neous opacities in the upper lobes
(right worse than left), with associated volume loss. (b) Axial CT image shows
extensive bilateral tree-in-bud opacities and a cavitary masslike consolidation in the
right upper lobe. (11) Nontuberculous mycobacterial infection in a 30-year-old man
presenting with chronic cough and sputum production. (a) Posteroanterior chest
radiograph shows extensive heterogeneous and nodular opacities in the upper lobes,
with intrinsic lucencies suggestive of cavitation. (b) Coronal CT image shows
bilateral upper lobe cavitary disease and extensive centrilobular nodules. (c) Axial
MIP CT image shows extensive tree-in-bud opacities in the right lower lobe.
 Aspiration Bronchiolitis
Aspiration bronchiolitis, often referred to as diffuse aspiration bronchiolitis
second most common type but usually misdiagnosis with infectious
bronchiolithis
Many clinical conditions increase the risk of aspiration, including altered
mental status, neurologic conditions ( cerebrovascular accident, brain
injury, Parkinson disease, multiple sclerosis, amyotrophic lateral sclerosis,
and myotonic dystrophy) head and neck cancer, head and neck
irradiation, esophageal abnormalities ( achalasia, esophagitis,
esophagectomy, dysmotility, and large hiatus hernia), and gastric
abnormalities (gastroparesis and gastric banding) , GERD
This identification is particularly important because, if untreated, this
chronic process eventually progresses to bronchiectasis and fibrosis, with
resultant impaired lung function.
Patients with nonresolving cellular bronchiolitis after appropriate
treatment should be screened for aspiration, particularly if there is lower
lobepredominant involvement
Figure 14. Aspiration bronchiolitis in a 43-year- old woman presenting with heartburn and
frequent emesis who had undergone gastric banding 6 years previously. (a) Anteroposterior
fluoroscopic image shows findings of laparoscopically adjustable gastric banding with gastric band
slippage (arrows). (b) Axial chest CT image (mediastinal window) shows a dilated fluid-filled
esophagus (arrow). (c) Axial chest CT image (lung window) shows patchy lower lobe
centrilobular nodules (right worse than left)
Bronchiolitis Manifesting with ground glass
nodules
Cellular bronchiolitis usually demonstrates distinct centrilobular micronodules (eg, tree-
in bud opacities seen in infectious bronchiolitis and aspiration bronchiolitis)
However, the presence of ill-defined and/or ground-glass centrilobular micronodules
helps narrow the differential diagnosis.
Although all types of bronchiolitis may exhibit ground-glass centrilobular nodules,
respiratory bronchiolitis and hypersensitivity pneumonitis are the most common entities
responsible for this imaging pattern
Centrilobular ground-glass nodules may be difficult to identify on CT images,
particularly in the setting of respiratory bronchiolitis, a smoking-related small airways
disease that is present pathologically in virtually all smokers
Occasionally, these micronodules may be more conspicuous on MIP reformatted
images, particularly in the upper lobes
Hypersensitivity pneumonitis is a complex syndrome that is better understood as an
allergic bronchiolitis elicited by a variety of allergens and haptens.
 There was 2 classifies seperate cluster :
Cluster 1 hypersensitivity pneumonitis include extensive and diffuse
ground-glass centrilobular micronodules with superimposed
mosaic attenuation, often with a lobular distribution, and, if
expiratory images are available, air trapping
The HR CT term headcheese pattern refers to the coexistence of
ground-glass opacities, normal lung, and air trapping
Cluster 2 hypersensitivity pneumonitis is characterized by the
presence of fibrosis manifesting with reticulation and
honeycombing and corresponds to the entity generally known as
chronic hypersensitivity pneumonitis
Figures 1517 (15) Drawing shows centrilobular ground-glass nodules with ill-defined borders, which are often
referred to as centrilobular ground-glass opacities (arrow). This pattern is common in hypersensitivity pneumonitis and
respiratory bronchiolitis. (16) Respiratory bronchiolitis in a 63-year-old male smoker. Axial CT (left) and MIP (right)
images show subtle diffuse centrilobular ground-glass micronodules and tree-in-bud opacities that could be easily
overlooked on conventional CT images but become conspicuous on MIP images (oval). (17) Hypersensitivity
pneumonitis in a 61-year-old woman presenting with worsening dyspnea. Left: Axial collimated chest CT image shows
diffuse centrilobular ground- glass nodules (oval) and scattered lobular areas of lucency (arrow) representing
associated mosaic attenuation. Right: Axial collimated expiratory chest CT image shows frank air trapping (arrows)
 Follicular Bronchiolitis
Follicular bronchiolitis is a lymphoproliferative disorder consisting of
lymphoid hyperplasia of the bronchus-associated lymphoid tissue
that is confined to the airway wall and characterized histologically
by nodular lymphoid aggregates in the walls of the bronchioles
The clinical importance of follicular bronchiolitis is that treatment is
directed at the underlying disease when it is recognized.
Follicular bronchiolitis can be seen in the setting of autoimmune
disease (eg, rheumatoid arthritis and Sjgren syndrome) and
chronic immunosuppression (eg, AIDS and other acquired or
congenital immunodeficiency states).
CT demonstrates centrilobular nodules, which may have solid or
ground-glass attenuation. Alternatively, these nodules may be
diffusely distributed and, less commonly, peribronchovascular in
location .
 Diffuse Panbronchiolitis
Diffuse panbronchiolitis is a rare form of cellular bronchiolitis
typically found in Asia, predominantly among Japanese
individuals in the 2nd to 5th decades of life
The cause is unknown, but a genetic predisposition has
been suggested .In addition, there is a distinct association
with chronic sinusitis
CT findings are nonspecific and include centrilobular
nodules, tree-in-bud opacities, bronchiolectasis, and
mosaic attenuation and/or air trapping that
characteristically involve all pulmonary lobes
 Constrictive Bronchiolitis
Constrictive bronchiolitis is the preferred histopathologic term
Constrictive bronchiolitis is a common complication of lung and bone marrow
transplantation as a manifestation of chronic rejection
Constrictive bronchiolitis is part of a syndrome referred to as bronchiolitis obliterans
syndrome
This syndrome classically occurs 618 months after transplantation and typically
manifests as an irreversible decrease in the forced expiratory volume in 1 second
(FEV1)
Classic imaging manifestations include mosaic attenuation and expiratory air
trapping; however, bronchiectasis and bronchial wall thickening can also be present
A different subtype of bronchiolitis obliterans syndrome, neutrophilic reversible
allograft dysfunction, has been described to address the finding of predominant
centrilobular nodules and tree-in-bud opacities seen after lung transplantation. This
subtype is responsive to treatment with azithromycin
Aside from bronchiolitis obliterans syndrome, rheumatoid arthritis and idiopathic
constrictive bronchiolitis are the most commonly encountered types of constrictive
bronchiolitis.
Mosaic attenuation and expiratory air trapping are the primary findings on CT images
and are found in most patients. Hyperlucent areas commonly exhibit poorly defined
margins and irregular shapes and are occasionally peripheral, wedge shaped, and
sharply demarcated.
Figure 23 Post infectious constrictive bronchiolitis in a 63-year-old man with Swyer-James-
MacLeod syndrome (a) Posteroanterior chest radiograph shows unilateral hyperlucency of the right
upper lung. (b, c) Axial CT images obtained through the upper lung zone (b) and lower lung zone
(c) show marked mosaic attenuation bilaterally. The process is not unilateral, as suggested by the
radiographic findings. Note the small size of the pulmonary vessels within the areas of
hypoattenuation, the scattered areas of bronchiectasis (arrow on c), and bronchial wall thickening
(arrowhead
 Figure 24. Diffuse idiopathic
neuroendocrine cell hyperplasia in a 67-
year-old woman presenting with
chronic cough and progressive
shortness of breath. Coronal MIP CT
image shows extensive subsegmental
and lobular areas of mosaic
attenuation with scattered small
pulmonary nodules (arrows) smaller than
5 mm in diameter
 Organizing Bronchiolitis
Bronchiolitis obliterans with Organizing Pneumonia (also known as BOOP) /
when the caused is idiopatic Cryptogenic organizing pneumonia
When the histopathologic pattern is identified as a pulmonary reaction
associated with a known cause (eg, infection, autoimmune disease,
inhalation injury, hypersensitivity pneumonitis, radiation therapy, and
aspiration), rather than an idiopathic condition, it is referred to simply as
organizing pneumonia.
The most common imaging finding of organizing pneumonia is bilateral
multifocal airspace opacities, often with a peripheral or peribronchial
distribution
Additional findings at CT include opacities with a perilobular pattern [ie,
arcadelike and polygonal opacities delineating the secondary pulmonary
lobule
Opacities with the reversed halo sign (or atoll sign), referring to ground-
glass opacities surrounded by consolidation; and peribronchovascular
nodules of various sizes
 Conclusion
Given the high rate of occurrence of bronchiolitis,
radiologists must have a systematic approach to its
diagnosis
Recognition of classic imaging manifestations and a
few key elements, which may be clinical and/or
imaging related, may suffice to enable a reasonable
and focused differential diagnosis.
Terimakasih