Search

Chest CT imaging holds a major role in the diagnosis of lung diseases, many of which affect the peribronchovascular region. Identification and categorization of peribronchovascular abnormalities on CT imaging can assist in formulating a differential diagnosis and directing further diagnostic evaluation. The peribronchovascular region of the lung encompasses the pulmonary arteries, airways, and lung interstitium. Understanding disease processes associated with structures of the peribronchovascular region and their appearances on CT imaging aids in prompt diagnosis. This article reviews current knowledge in anatomic and pathologic features of the lung interstitium composed of intercommunicating prelymphatic spaces, lymphatics, collagen bundles, lymph nodes, and bronchial arteries; diffuse lung diseases that present in a peribronchovascular distribution; and an approach to classifying diseases according to patterns of imaging presentations. Lung peribronchovascular diseases can appear on CT imaging as diffuse thickening, fibrosis, masses or masslike consolidation, ground-glass or air space consolidation, and cysts, acknowledging that some diseases may have multiple presentations. A category approach to peribronchovascular diseases on CT imaging can be integrated with clinical features as part of a multidisciplinary approach for disease diagnosis. [ABSTRACT FROM AUTHOR]

Data are scarce regarding epidemiology and management of critically ill patients with lung abscesses. What are the clinical and microbiological characteristics of critically ill patients with lung abscesses, how are they managed in the ICU, and what are the risk factors of in-ICU mortality? This was a retrospective observational multicenter study, based on International Classification of Diseases, 10th Revision, codes, between 2015 and 2022 in France. In-ICU mortality-associated factors were determined by multivariate logistic regression. We analyzed 171 ICU patients with pulmonary abscesses. Seventy-eight percent were male, with a mean age of 56.5 ± 16.4 years; 20.4% misused alcohol, 25.2% had a chronic lung disease (14% COPD), and 20.5% had a history of cancer. Overall, 40.9% were immunocompromised and 38% qualified for nosocomial infection. Presenting symptoms included fatigue or weight loss in 62%, fever (50.3%), and dyspnea (47.4%). Hemoptysis was reported in 21.7%. A polymicrobial infection was present in 35.6%. The most frequent pathogens were Enterobacteriaceae in 31%, Staphylococcus aureus in 22%, and Pseudomonas aeruginosa in 19.3%. Fungal infections were found in 10.5%. Several clusters of clinicoradiologic patterns were associated with specific microbiological documentation and could guide empiric antibiotic regimen. Percutaneous abscess drainage was performed in 11.7%; surgery was performed in 12.7%, and 12% required bronchial artery embolization for hemoptysis. In-ICU mortality was 21.5%, and age (OR: 1.05 [1.02-1.91], P =.007], renal replacement therapy during ICU stay (OR, 3.56 [1.24-10.57], P =.019), and fungal infection (OR, 9.12 [2.69-34.5], P =.0006) were independent predictors of mortality after multivariate logistic regression, and drainage or surgery were not. Pulmonary abscesses in the ICU are a rare but severe disease often resulting from a polymicrobial infection, with a high proportion of Enterobacteriaceae, S aureus , and P aeruginosa. Percutaneous drainage, surgery, or arterial embolization was required in more than one-third of cases. Further prospective studies focusing on first-line antimicrobial therapy and source control procedure are warranted to improve and standardize patient management. [Display omitted] [ABSTRACT FROM AUTHOR]

Heritable pulmonary arterial hypertension (PAH) is an uncommon cause of PAH and is associated most frequently with pathogenic variants of BMPR2. Prior studies have described abnormalities in pulmonary arterial, venous, and bronchial artery vessels associated with these pathogenic variants. In this series, we describe two patients who demonstrated pulmonary arteriovenous malformations (AVMs) and incidentally were identified by a next generation sequencing gene panel to carry variants of BMPR2 in the absence of PAH. Although pulmonary AVMs commonly are associated with hereditary hemorrhagic telangiectasia and rarely are seen in heritable PAH, evidence is increasing that abnormalities in the BMP9 pathway are found in both of these conditions. Through these cases and the current understanding of the BMP9 pathway, we propose that BMPR2 variants place patients at increased risk of pulmonary AVMs and may warrant screening. [ABSTRACT FROM AUTHOR]

Background: Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied.Research Question: Does nebulized route of Tranexamic Acid (TA) administration reduce the amount of hemoptysis compared to intravenous route in patients presenting to emergency department (ED) with hemoptysis?Methods: We conducted a pragmatic, open labelled, cluster randomized, parallel single centered pilot trial of nebulized TA (500mg tid) versus intravenous TA (500mg tid) in adult patients presenting to emergency department with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcome included amount of hemoptysis at 6h, 12h and 24 h; interventional procedures and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study.Results: Of the 55 patients in each arm, hemoptysis cessation at 30 minutes after TA administration was significantly higher in nebulized arm (n=40) compared to intravenous arm (n=28) [X2 (1, n=110)=5.55, p=0.0019]. Also, hemoptysis amount reduced significantly in nebulization arm at all time periods of observation (P value 30min=0.011, at 6h=0.002, 12h=0.0008, 24h=0.005). Fewer patients in nebulized arm required bronchial artery embolization (13 vs 21, P value=0.024) and thereby higher discharge rates from the ED (67.92% vs 39.02%, P value=0.005). Two patients in nebulized arm had asymptomatic bronchoconstriction which resolved after short acting beta agonist nebulization. No patient discharged from ED underwent any interventional procedure or revisited the ED with rebleed during the 72 hours follow up period.Interpretation: Nebulized TA may be more efficacious than intravenous TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared to intravenous TA in patients with mild hemoptysis. [ABSTRACT FROM AUTHOR]

Chronic thromboembolic pulmonary hypertension (CTEPH) is considered a complication of pulmonary embolism (PE). However, signs of CTEPH may exist in patients with a first symptomatic PE. Which radiologic findings on CT pulmonary angiography (CTPA) at the time of acute PE could indicate the presence of preexisting CTEPH? This study included unselected patients with acute PE who were prospectively followed up for 2 years with a structured visit schedule. Two expert radiologists independently assessed patients' baseline CTPAs for preexisting CTEPH; in case of disagreement, a decision was reached by a 2:1 majority with a third expert radiologist. In addition, the radiologists checked for predefined individual parameters suggesting chronic PE and pulmonary hypertension. Signs of chronic PE or CTEPH at baseline were identified in 46 of 303 included patients (15%). Intravascular webs, arterial narrowing or retraction, dilated bronchial arteries, and right ventricular hypertrophy were the main drivers of the assessment. Five (1.7%) patients were diagnosed with CTEPH during follow-up. All four patients diagnosed with CTEPH early (83-108 days following acute PE) were found in enriched subgroups based on the experts' overall assessment or fulfilling a minimum number of the predefined radiologic criteria at baseline. The specificity of preexisting CTEPH diagnosis and the level of radiologists' agreement improved as the number of required criteria increased. Searching for predefined radiologic parameters suggesting preexisting CTEPH at the time of acute PE diagnosis may allow for targeted follow-up strategies and risk-adapted CTEPH screening, thus facilitating earlier CTEPH diagnosis. [ABSTRACT FROM AUTHOR]

Massive hemoptysis is a medical emergency with high mortality presenting several difficult diagnostic and therapeutic challenges. The origin of bleeding and underlying etiology often is not immediately apparent, and techniques for management of this dangerous condition necessitate an expedient response. Unlike hemorrhage in other circumstances, a small amount of blood can rapidly flood the airways, thereby impairing oxygenation and ventilation, leading to asphyxia and consequent cardiovascular collapse. Of paramount importance is early control of the patient's airway and immediate isolation of hemorrhage in an attempt to localize and control bleeding. A coordinated team response is essential to guarantee the best chances of patient survival. Prompt control of the airway and steps to limit the spread of hemorrhage take precedence. Bronchial artery embolization, rigid and flexible bronchoscopy, and surgery all serve as potential treatment options to provide definitive control of hemorrhage. Several adjunctive therapies described in recent years may also assist in the control of bleeding; however, their role is less defined in life-threatening hemoptysis and warrants additional studies. In this concise review, we emphasize the steps necessary for a systematic approach in the management of life-threatening hemoptysis. [ABSTRACT FROM AUTHOR]

Background: Hemoptysis can cause a life-threatening condition and often needs to be treated urgently. Nearly 20% of hemoptysis cases are diagnosed as cryptogenic after clinical investigation. The purpose of this study was to clarify the clinical and angiographic characteristics of cryptogenic hemoptysis.Methods: We retrospectively reviewed medical records of 35 patients admitted to our hospital with cryptogenic hemoptysis from October 2010 to September 2014.Results: In the 35 cases, bronchial artery embolization was successfully performed in 33 patients (94.3%), whereas bronchoscopic hemostatic therapy was added in one patient (2.8%), and embolization was not performed in one patient (2.8%) because the bronchial artery was too narrow. In the successful embolization group, the non-rebleeding rate was 97.0% for 20 months. The angiographic findings revealed that the diameter of the bronchial arteries was < 2 mm in 13 patients, 2 to 3 mm in 17 patients, and > 3 mm in five patients. Hypervascularization was detected in 29 patients (82.9%) and small bronchial aneurysms in eight patients (22.9%). The amount of hemoptysis was slight (< 50 mL/d) in 12, mild (50-100 mL/d) in 11, moderate (100-200 mL/d) in eight, and massive (> 200 mL/d) in four patients. No obvious relationship was found between the diameter of bronchial arteries and the amount of hemoptysis.Conclusions: BAE was highly effective for the management of cryptogenic hemoptysis. Most cases of cryptogenic hemoptysis have angiographic abnormalities, including small or microaneurysms, which were suspected as the cause in some cases. [ABSTRACT FROM AUTHOR]

Background: Bronchiectasis is frequent in smokers with COPD; however, there are only limited data on objective assessments of this process. The objective was to assess bronchovascular morphology, calculate the ratio of the diameters of bronchial lumen and adjacent artery (BA ratio), and identify those measurements able to discriminate bronchiectasis.Methods: We collected quantitative CT (QCT) measures of BA ratios, peak wall attenuation, wall thickness (WT), wall area, and wall area percent (WA%) at matched fourth through sixth airway generations in 21 ever smokers with bronchiectasis (cases) and 21 never-smoking control patients (control airways). In cases, measurements were collected at both bronchiectatic and nonbronchiectatic airways. Logistic analysis and the area under receiver operating characteristic curve (AUC) were used to assess the predictive ability of QCT measurements for bronchiectasis.Results: The whole-lung and fourth through sixth airway generation BA ratio, WT, and WA% were significantly greater in bronchiectasis cases than control patients. The AUCs for the BA ratio to predict bronchiectasis ranged from 0.90 (whole lung) to 0.79 (fourth-generation). AUCs for WT and WA% ranged from 0.72 to 0.75 and from 0.71 to 0.75. The artery diameters but not bronchial diameters were smaller in bronchiectatic than both nonbronchiectatic and control airways (P < .01 for both).Conclusions: Smoking-related increases in the BA ratio appear to be driven by reductions in vascular caliber. QCT measures of BA ratio, WT, and WA% may be useful to objectively identify and quantify bronchiectasis in smokers.Trial Registry: ClinicalTrials.gov; No.: NCT00608764; URL: www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Blood supply of the tracheobronchial tree is derived from a dual system involving pulmonary and bronchial circulation. Various primary and secondary abnormalities of central airway vasculature can present with patterns that are distinct during bronchoscopy. These patterns maybe visualized during bronchoscopic evaluation of a patient with hemoptysis or as an incidental finding during an airway examination for other indications. Thorough knowledge of airway vasculature abnormalities and recognition of possible underlying pathophysiology is vital for the bronchoscopist. This review is a comprehensive description of vascular anatomy of the airway and the different vascular abnormalities that can be encountered during bronchoscopy. [ABSTRACT FROM AUTHOR]

Bronchial thermoplasty has been found to be a safe and effective therapy for severe asthma. We report the case of a mediastinal hematoma and hemothorax developing in a 66-year-old woman several days after an uneventful bronchial thermoplasty of the right lower lobe. Evaluation revealed a bleeding right bronchial artery pseudoaneurysm. Pseudoaneuryms have been reported in association with other procedures involving the therapeutic application of thermal energy, and a single case of hemoptysis requiring bronchial artery embolization occurred in a clinical trial of bronchial thermoplasty. However, bronchial artery pseudoaneurysm with hemomediastinum and hemothorax has not previously been reported after bronchial thermoplasty. [ABSTRACT FROM AUTHOR]

The article cites a study which seeks to evaluate the pathologic changes of bronchial arteries in patients with asthma. The researchers measured the bronchial arteries, the areas of lumen, intima, as well as the medial area in postmortem lungs from three case groups which include fatal asthma, nonfatal asthma and nonasthmatic control subjects. Accordingly, the researchers found that there were no evidential changes in the bronchial arteries among the three groups.

B INTRODUCTION: b Anticoagulation in Eisenmenger syndrome (ES) associated PAH (ES-PAH) presents a clinical challenge, as there is both an increased prevalence of pulmonary artery thrombosis and hemoptysis. The use of anticoagulation in ES-PAH patients is controversial due to balancing risk between thrombosis and hemoptysis, and survival benefits are unclear(2). [Extracted from the article]

After referral for pulmonary endarterectomy, pulmonary angiogram revealed extrinsic pulmonary artery obstruction due to FM without any evidence of thrombi. Angiography found a tortuous bronchial artery with pseudoaneurysm that was embolized, all of which are likely sequela of pulmonary artery obstruction. CT angiography revealed stenosis of the main right pulmonary artery with calcified mediastinal lymphadenopathy consistent with FM. [Extracted from the article]

B INTRODUCTION: b Various conditions might cause hemoptysis, but hemoptysis due to pulmonary vein stenosis after catheter ablation is rare. We experienced very rare case that recurrent hemoptysis caused by catheter ablation procedure due to severe pulmonary vein stenosis. In this case, hemoptysis was not controlled by the bronchial artery embolization, therefore, left lower lobectomy was performed to resolve left pulmonary vein stenosis. [Extracted from the article]

B TYPE: b Abstract Publication B TOPIC: b Pediatrics B PURPOSE: b Report a case of right pulmonary artery agenesis. In order to provide a better understanding of the condition, the radiology team suggested a computed angiotomography of the chest, which detected agenesis of right pulmonary artery. In contrast to left pulmonary artery agenesis, right pulmonary artery agenesis is isolated and is not related to cardiovascular malformations as in the first. [Extracted from the article]

Upon arrival, the patient was intubated for acute hypoxic respiratory failure and underwent emergent 300-500 m particle embolization of two left lobe branches and one right lobe branch arteries and the bleeding ceased. In these patients, particle embolization of bronchial artery may lead to inadvertent embolization of the feeder artery leading to anterior spinal cord infarction. [Extracted from the article]

BRONCHIAL ARTERY EMBOLIZATION: IS THE THIRD TIME THE CHARM? Bronchial artery embolization has a 70-99% success rate of complete cessation of hemoptysis, especially if bronchial, pulmonary and/or systemic arterial circulations are well defined during the procedure [2]. A retrospective study including 223 patients with massive hemoptysis found that 64% of patients underwent at least a second embolization and that vessel recanalization (71%) was the most common cause of recurrent hemoptysis [3]. [Extracted from the article]

B INTRODUCTION: b Unilateral absence of a proximal branch pulmonary artery (PA) is a rare congenital malformation (1) and is usually associated with congenital heart diseases (CHD). B DISCUSSION: b Isolated unilateral PA agenesis is uncommon and it is usually accompanied by CHD, including tetralogy of Fallot, right-sided aortic arch, atrial or ventricular septal defect. [Extracted from the article]

A response from the authors of the article "Technical aspects of endobronchial ultrasound-guided transbronchial needle aspiration: CHEST Guideline and Expert Panel Report" in the 2016 issue is presented.

Computed tomography angiography (CTA) showed a right lower pulmonary artery PsA (Fig 1). CTA showed a bleeding PsA in a RLL posterior pulmonary artery. A second nonbleeding PsA of a RLL superior pulmonary artery was also noted (Fig 2A). [Extracted from the article]

B INTRODUCTION: b We report a case of an electrocautery knife biopsy of an endobronchial lesion complicated by bronchial artery pseudoaneurysm with massive hemoptysis one month later. Three months later, repeat bronchoscopy with Electrocautery knife and loop biopsy was performed for further sampling on endobronchial lesions in the left lingula, right bronchus intermedius and right upper lobe without immediate complications. Pseudoaneurysm of the bronchial artery following electrocautery knife biopsy has not been well documented. [Extracted from the article]

B INTRODUCTION: b Rasmussen aneurysm (RA) is a rare vascular complication after mycobacterium tuberculosis (MTB). CT angiogram of the chest showed enhanced dilated vessel within the old TB cavity consistent with RA in the setting of history of TB. Embolization of multiple Rasmussen aneurysms as a treatment of hemoptysis. [Extracted from the article]

B INTRODUCTION: b Spontaneous bronchial artery rupture is an uncommon cause of hemomediastinum. Following the procedure, we re-evaluated his imaging with thoracic radiology who identified a bronchial artery pseudoaneurysm (PSA) with extravasation into the lesion. [Extracted from the article]

At the same time, Nucleic Acid Amplification (NAA) tests for both MTB and Mycobacteria avium complex (MAC) returned negative. B DISCUSSION: b This case presents a diagnostic challenge in that the patient's rapidly growing culture and negative NAA test suggested against MAC. B CONCLUSIONS: b Diagnosis of mycobacterial lung disease requires microbiologic confirmation, and culture remains the gold standard test. NAA test serves as a reliable tool for rapid identification to guide early treatment. [Extracted from the article]

B INTRODUCTION: b Pulmonary aspergilloma can cause significant hemoptysis and can be difficult to manage with conventional therapies to include bronchial artery embolization (BAE) or surgical resection1,2. The patient was empirically started on broad spectrum antibiotics and a bronchoscopy with bronchial alveolar lavage (BAL) was performed that revealed an aspergillus galactomannan antigen level of 2.28 (reference range 0.00-0.49). The patient showed significant clinical and radiographic improvement of the aspergilloma with no additional hemoptysis since the initial treatment. [Extracted from the article]

The article presents a case study of a 28-year-old male tourist from Thailand who was admitted due to haemoptysis. It discusses results of his physical examination, computed tomography (CT) angiogram,and the magnetic resonance imaging (MRI) of the brain. The patient was found to have complication of bronchial artery embolization (BAE).

Bronchial artery embolization is an effective treatment for patients with hemoptysis. Serious complications are rare, but may occur if the arterial supply to other structures is compromised. We present a case of unilateral diaphragmatic paralysis following bronchial artery embolization in a patient with cystic fibrosis. We believe that the diaphragmatic paralysis was due to the inadvertent obstruction of the left pericardiacophrenic artery during the embolization procedure, with compromise of the phrenic nerve blood supply. This resulted in a significant loss of lung function in our patient, who did not recover despite the subsequent return of diaphragmatic function. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 80-year-old female who was presented to the hospital with hemoptysis. She was undergone with computed tomography to her chest and showed left lower lobe dense consolidation distal to her bronchial narrowing. Topic discussed about chronic bronchitis with massive hemoptysis associated with pseudosequestration and Pasteurella multocida pneumonia.

An abstract of the article "Prospectively Triggered Multidetector Row CT Angiography in Preprocedural Planning Prior to Bronchial Artery Embolization in Cystic Fibrosis Patients With Hemoptysis" by Don Hayes et al. is presented.