Asthma

 

 

Background: Asthma is a common disorder that primarily involves the airways. Traditionally, asthma has been considered a disorder of airway smooth muscle mediators and anatomic elements of the airway mucosa. In recent years, the roles of immune mediators, such as leukotrienes, prostaglandins, and platelet-activating factor, and the more traditionally considered roles of histamine and other bronchoconstrictors have been increasingly understood. Although the causes of asthma are separated into allergic and nonallergic ones, considerable crossover is observed in the features of both types of asthma, and treatment varies little between them.

While asthma has been considered a disorder of the airways, a number of conditions have a presentation similar to that of bronchial asthma. These conditions originate, often silently, in organ systems other than the lungs, and they either provoke airway responses equivalent to those found in asthma or mimic the clinical findings of asthma.

 

Pathophysiology:

Signs of asthma

Primarily, asthma is manifested by a sudden or prolonged onset of airway narrowing, which accounts for the varying degrees of airway obstruction and accompanying sensation of an inability to breathe in and, more importantly, to breathe out; these symptoms herald hyperinflation. The total lung capacity (TLC), functional residual capacity (FRC), and residual volume (RV) increase.

The hallmark of airway obstruction is a reduction in ratio of the forced expiratory volume in 1 second (FEV1) and the FEV1 to the forced vital capacity (FVC). However, the earliest effects of airway disease are believed to occur in the small airways (<2 mm in diameter), and they are more difficult to measure reliably with standard pulmonary function tests (PFTs), such as tests of the following: forced expiratory flow after 50% of vital capacity has been expelled (FEF50), forced expiratory flow after 25-75% of vital capacity has been expelled (FEF25-FEF75) and maximum midexpiratory flow rate (MMEFR). Less common evaluations include tests of airway resistance (RAW) and single-breath carbon monoxide diffusion capacity (DLCO/VA). With the former, resistance is markedly increased, although the findings are highly variable; with the latter, results are normal or slightly elevated in uncomplicated asthma (Collard, 1994; Boulet, 1995).

Whether the more severe and permanent features of distal airway obstruction and coexisting emphysema supervene in the later and more complicated stages of asthma is controversial. However, in one study, patients with partially reversible airway obstruction that persisted after optimal corticosteroid treatment had a normal diffusion capacity that was comparable to that of patients with completely reversible asthma (Hudon, 1997). The functional abnormalities reflect airway narrowing that results from multiple causes, including bronchial smooth muscle contraction; mucous plugging from mucous gland hypersecretion; submucosal, peribronchial, and interstitial edema from loss of capillary and arteriolar cellular interconnections; and cellular infiltrative changes involving plasma cells, lymphocytes, macrophages, and leukocytes.

Chronic or incompletely reversible asthma is characterized by variable obstruction; a more fixed degree of airway narrowing may also be present in some patients. With repeated episodes of clinically important airway narrowing, generalized thickening of the airways occurs as a result of smooth muscle hyperplasia, postinflammatory thickening of the bronchial basement membranes, and mucous gland hypertrophy.

Childhood asthma

Approximately 80-85% of childhood asthma episodes are associated with prior viral exposure. Prior childhood pneumonia due to infection by respiratory syncytial virus, Mycoplasma pneumoniae, and/or Chlamydia species was found in more than 50% of a small sample of children aged 7-9 years who later had asthma (ALA Denver, 2000). Treatment with antibiotics appropriate for these organisms improves the clinical signs and symptoms of asthma.

Genetic mutations

Research on genetic mutations casts further light on the synergistic nature of multiple mutations in the pathophysiology of asthma, particularly as it is related to the role of platelet-activating factor hydrolase, an intrinsic neutralizing agent of platelet-activating factor in most humans (ALA Utah, 2000).

Environmental factors

Agents inhaled in the workplace and the general environment are implicated in reactive airway dysfunction syndrome, an acute asthmalike condition without a definite allergic substrate and with a somewhat nebulous definition (Bardena, 1999). Occupational asthma involves the triggering of an acute and prolonged airway responses to various agents, including the glutaraldehyde used in endoscopy suites and the formaldehyde in darkroom processing chemicals to which radiographers are exposed (Gannon, 1995; Smedley, 1996). A discussion of the extensive array of environmental agents, which are responsible for as many as one third of the cases of occupational asthma, is beyond the scope of this article.

Treatment agents

The list of chemical agents used to treat asthma has grown beyond the usual mediators of histamine, the slow-reacting substance of anaphylaxis (SRS-A), and immunoglobulin E (IgE) that is associated with allergen-mediated mast cell mediator release. The current list includes the prostaglandin E and F subtypes, interleukin 4, interleukin 12, and interleukin 13, among other agents.

 

Frequency:

  • In the US: The accuracy of statistics about asthma is limited by confounding factors in patients older than age 35 years, changes in the International Classification of Diseases, the lower confirmation rates at autopsy, and problems related to the interpretation of death certificates (Busse, 1995).

    The Asthma Research Center of the American Lung Association indicates that 17.7 million patients are affected; of these, more than one third are children younger than 18 years. The percentage of children with asthma has increased in the last 20 years, and asthma is the leading serious chronic illness in children. The permanent remission of childhood bronchial asthma is uncommon; 85% of girls and 72% of boys continue to have chronic asthma in adulthood. Hospitalizations for a primary diagnosis of asthma currently number 423,000 cases per annum, which represents a 25% increase since 1979. Office visits for a principal diagnosis of asthma numbered 12.9 million in 1998 (ALA Facts, 2000).

    In the United States, the regional prevalence of asthma includes 3.3 million cases in the Northeast, 3.6 million cases in the Midwest, 4.7 million cases in the Southeast, and 3 million cases in the West.

  • Internationally: The prevalence of asthma depends on the definition of asthma, which varies worldwide. Rates in industrialized countries vary from 0.7% in Tokyo to a high of 6.3% in Birmingham, United Kingdom, with an average of 5%. In general, prevalence rates are lower in nonindustrialized countries, although a rate as high as 49% is described in the Western Caroline Islands, where asthma is defined as recurrent wheezing and dyspnea.

    When the same criteria based on questionnaires and exercise provocation testing are used, prevalence rates are higher in New Zealand than in South Wales; this finding suggests that differences between cultures, however defined, are likely to be real (Busse, 1995).

Mortality/Morbidity:

  • Mortality statistics from the United States indicate that a total of 5,438 deaths due to asthma occurred in 1998.

    • This number correlates with a mortality incidence of 2 deaths per 100,000 population.

    • This incident is differentiated by age into less than 0.7 deaths per 100,000 patients younger than 45 years, 1-3 deaths per 100,000 patients aged 45-65 years, and 5-10 deaths per 100,000 patients older than 65 years.

    • Of concern is the fact that the total deaths per annum have increased 109% from 2,598 in 1979 to 5,438 in 1998 despite the steady improvements in the pharmaceutical and environmental management of asthma during this time (Busse, 1995).
  • Internationally, asthma-related mortality rates vary widely by country.

    • In 1985-1987, mortality rates were 7-9 deaths per 100,000 persons in West Germany, Norway, and New Zealand; 4-5 deaths per 100,000 persons in Italy, France, and the British Isles; and 2 per 100,000 in the United States, Canada, the Netherlands, and Hong Kong.

    • From 1980-1987, the mortality rate increased 110% in Finland, 90% in Denmark, more than 160% in Israel, and more than 70% in France and Japan (Busse, 1995).

Race: Prevalence by race in the United States in 1996 was as follows:

  • Whites

    • Patients younger than 45 years - 8.3 million

    • Patients aged 45-65 years - 2.2 million

    • Patients older than 65 years - 1.3 million
  • Blacks

    • Patients younger than 45 years - 1.9 million

    • Patients aged 45-65 years - 0.3 million

    • Patients older than 65 years - 0.1 million

Sex: Prevalence by sex in the United States in 1996 was as follows:

  • Female

    • Patients younger than 45 years - 6.1 million

    • Patients aged 45-65 years - 1.8 million

    • Patients older than 65 years - 0.9 million
  • Male

    • Patients younger than 45 years - 4.5 million

    • Patients aged 45-65 years - 1.2 million

    • Patients older than 65 years - 0.5 million

Age: Prevalence by age in the United States in 1996 was as follows:

  • Patients younger than 45 years - 10.6 million
  • Patients aged 45-65 years - 2.6 million
  • Patients older than 65 years - 1.4 million

Anatomy: The airways of the lungs consist of the cartilaginous bronchi, membranous bronchi, and gas-exchanging bronchi termed the respiratory bronchioles and alveolar ducts. While the first 2 types function mostly as anatomic dead space, they also contribute to airway resistance. The smallest non–gas-exchanging airways, the terminal bronchioles, are approximately 0.5 mm in diameter; airways are considered small if they are less than 2 mm in diameter (Murray, 1988).

Airway structure consists of the following: (1) mucosa, which is composed of epithelial cells that are capable of specialized mucous production and a transport apparatus, (2) basement membrane, (3) a smooth-muscle matrix extending to the alveolar entrances, and (4) predominantly fibrocartilaginous or fibroelastic-supporting connective tissue.

Cellular elements include mast cells, which are involved in the complex control of releasing histamine and other mediators. Basophils, eosinophils, neutrophils, and macrophages also are responsible for extensive mediator release in the early and late stages of bronchial asthma. Stretch and irritant receptors reside in the airways, as do cholinergic motor nerves, which innervate the smooth muscle and glandular units. In bronchial asthma, smooth-muscle contraction in an airway is greater than that expected for its size if it were functioning normally, and this contraction varies in its distribution (Murray, 1988).

Mucous gland hyperplasia leads to inspissated secretions and bronchial obstruction, which is one of the primary causes of morbidity and mortality in patients with asthma. Death from asthma is associated with epithelial desquamation, smooth muscle hypertrophy, thickening of the basement membrane, and eosinophilic proliferation.

Clinical Details: Patients with asthma may be asymptomatic most of the time, with periodic exacerbations induced by various factors, including the following:

 

  • Family and personal history of atopy

     

  • Cigarette smoke

     

  • Intercurrent bronchiolitis or pneumonia

     

  • Congestive heart failure

     

  • Pulmonary embolism

     

  • Dusty and windy environments

     

  • Air pollutants such as fine particulates and oxides of nitrogen and sulfur

     

  • Exposure to pets or previously dampened floor coverings that harbor molds

     

  • Other known and probably unknown allergic factors, some of which can be determined with several modalities of allergy testing.

The cardinal symptom with which patients present is breathlessness; one should take into account the difficulty the patient has in breathing out as well as breathing in. Tightness, as patients describe it, also includes the sensation of respiratory confinement.

Symptoms of bronchial asthma include the following:

 

  • Breathlessness

     

  • Anxiety

     

  • Cough

     

  • Chest tightness

     

  • Diaphoresis

     

  • Exacerbation with exercise

Signs of bronchial asthma include the following:

 

  • Barrel chest

     

  • Global or focal wheezes

     

  • Pallor

     

  • Pulsus paradoxus

     

  • Use of accessory muscles

     

  • Exercise limitation

Complications of asthma often are more apparent than the direct airway imaging findings that are the sequelae of asthma.

 

  • Spontaneous pneumothorax is an uncommon but well-recognized phenomenon.

     

    • The chest radiograph (CXR) is an important tool in the examination of patients with an exacerbation of asthma, but patients should not be left waiting in the treatment room for CXR before treatment (Swain, 1984).

       

    • Pneumothorax may be evident radiographically before it is identified clinically (Gay, 1978).

       

    • Pneumothorax often occurs during recurrent episodes of bronchospasm, as well as in other conditions. The presence of an air-fluid level in a hydropneumothorax can be confused with pneumatocele, infected cysts, and cavitary lung disease.

       

    • An unusual condition of diffuse pulmonary ossification associated with pneumothorax is described in a patient with bronchial asthma (Ikeda, 1998).

     

  • Pneumomediastinum can occur, particularly in young adults (see Images 1-2). The pathophysiologic nature of the process, as previously determined from animal studies, is reported (Jamadar, 1996). Using perfluorocarbon liquid ventilation in a hypoxic patient with status asthmaticus and tension pneumothorax, the authors traced the heavily radiopaque substance through ruptured alveoli, the interlobular spaces, and the axial interstitium to the mediastinum. The liquid agent remained in the interstitial space for 30 days without complications. Pneumomediastinum generally is self-limited, and it requires no additional therapeutic measures beyond those for asthma exacerbation (Ba-Ssalamah, 1999).

     

  • Emphysema can occur in the subdural space, especially in children. Air moves posteriorly from a pneumomediastinum into the intervertebral foramina and further into the most nondependent potential spaces adjacent to the brain coverings (Caramella, 1997). Spinal epidural emphysema is also described in asthmatics, tracking along the great vessels bound by the mediastinal pleural layers (Tsuji, 1989). As reported, these events typically have no neurologic sequelae.

     

  • Pneumopericardium is uncommon and more likely to occur in younger persons because their pericardial layers are more loosely apposed than those in adults (van der Klooster, 1998). As with pneumomediastinum, pneumopericardium generally has a benign course.

     

  • Pneumothorax, pneumomediastinum, pneumoretroperitoneum, pneumorrhachis (ie, spinal epidural air), and extensive subcutaneous emphysema are more likely to occur with episodes of coughing or increased intrathoracic pressure that accompany the recruitment of expiratory muscles when normal airflow is substantially reduced (van der Klooster, 1998).

     

  • More serious is subarachnoid hemorrhage, which developed in a patient with status asthmaticus who received ventilation with permissive hypercapnia. This technique minimizes the overall delivered minute ventilation and airway pressures to maintain adequate oxygenation. However, because of elevated CO2 partial pressures, it also led to cerebral vasodilatation and increased intracranial pressure; when combined with coughing spells and other forms of transmitted intrathoracic pressure, the ventilation was believed to promote cerebral edema and limit cerebral venous drainage (Rodrigo, 1999).

     

  • Noisy breathing may mask potential physical findings in pneumothorax, pneumomediastinum, and pneumonia; therefore, CXR should be performed prior to the use of mechanical ventilation.

Preferred Examination: CXR remains the initial imaging evaluation in most individuals with symptoms of asthma. The value of CXR is in revealing complications or alternative causes of wheezing and the minor importance of wheezing in the diagnosis of asthma and its exacerbations. CXR usually is more useful in the initial diagnosis of bronchial asthma than in the detection of exacerbations, although it is valuable in excluding complications such as pneumonia and asthma mimics, even during exacerbations.

High-resolution CT (HRCT) is a second-line examination. It is useful in patients with chronic or recurring symptoms and in those with possible complications such as allergic bronchopulmonary aspergillosis and bronchiectasis.

Limitations of Techniques: CXR is limited by frequent and sometimes subjective findings that are not specific for asthma; these nonspecific findings include airway thickening and hyperinflation. Nevertheless, in the appropriate clinical setting, CXR findings can support the diagnosis of asthma.

HRCT is more costly than CXR and exposes the patient to more radiation. Nevertheless, CT scans can demonstrate a number of findings that support the diagnosis of asthma; examples of such findings include bronchial wall thickening, bronchiectasis, mucoid impaction, and airtrapping, among others.

DIFFERENTIALS

Airway Foreign Body
Aspergillosis, Thoracic
Aspiration Pneumonia
Atelectasis, Lobar
Bronchiectasis
Bronchopulmonary Dysplasia
Congestive Heart Failure
Emphysema
Epiglottitis, Acute
Gastroesophageal Reflux
Hamartoma, Lung
Laryngeal Carcinoma
Lung Cancer, Non-Small Cell
Lung Cancer, Small Cell
Lung, Carcinoid
Lung, Metastases
Pneumonia, Atypical Bacterial
Pneumonia, Typical Bacterial
Pneumonia, Viral
Pneumothorax
Polyarteritis Nodosa
Pulmonary Edema, Noncardiogenic
Pulmonary Hypertension
Sarcoidosis, Thoracic
Sinusitis
Trachea, Stenosis


Other Problems to be Considered:


Asthma mimics


The aphorism attributed to Chevallier Jackson states, "All that wheezes is not asthma." This recognition suggests that imaging has an important role in differentiating asthma from its mimics and that further diagnostic evaluation and treatment of nonasthma conditions may be necessary. With his or her knowledge of the imaging findings in alternative disorders, the consulting radiologist may be valuable during the workup; he or she can recognize clinical signs and symptoms that indicate the use of high-resolution chest CT, sinus CT, CT pulmonary angiography, or MRI as the best modality for further imaging in the diagnosis.

Various tracheal tumors, foreign bodies, and other conditions can contribute to wheezing. These may be misdiagnosed for several years before they are recognized.

Tracheal and bronchial lesions

Tracheal hamartoma may occur (Tastepe, 1998). Reduction of airflow during both inspiration and expiration occurs with this condition, and the increased velocity of airflow with partial obstruction can sound precisely like refractory bronchial asthma (Reittner, 1999).

Tracheal schwannoma appeared as status asthmaticus in a 16-year-old boy (Weiner, 1998).

A central bronchogenic cyst, adjacent to the mediastinal trachea, may produce the same pathophysiologic features as asthma (Janahi, 1998).

Approximately 20 cases of leiomyoma of the trachea that were reported in the Japanese-language and English-language literature were reviewed (Shirakawa, 1991). Male patients typically were aged 50 years, but female patients had no such age pattern. Of the patients in whom a diagnosis ultimately was determined, 50% had received a misdiagnosis of bronchial asthma had been misdiagnosed, and 2 patients died of respiratory failure.

A rare disease called tracheobronchopathia osteoplastica typically occurs in older men, and its symptoms may simulate those of asthma. On CT scans of the trachea and major bronchi, cartilaginous and bony submucosal nodules cover the intact mucosa, causing the upper airways to become narrow and rigid. The process may be evident with initial spirometric findings, which indicate an obstructive pattern with variable flattening of the inspiratory and expiratory limbs of the flow-volume loop (Park, 1995).

A solitary bronchial papilloma, when present at the carina, can be mobile. It may be seen only on CT scans. Images of bronchial papilloma may demonstrate a lack of extraluminal extension (Abdullah, 1991).

Patients with asthma can have endobronchial carcinoid and mucoepidermoid tumors (see Images 5-6) (Wynn, 1986).

In one report, left mainstem bronchial narrowing produced longitudinal airway narrowing, with coarse airway sounds that mimicked asthma; the narrowing was the result of bronchocentric granulomatosis (Khanijo, 1982).

Subglottic stenosis, which can occur after prolonged endotracheal intubation, and subglottic web are additional tracheal entities that can cause wheezing (Spivey, 1973).

Exercise-induced asthma is another presentation of asthma. In one case, a 14-year-old boy with hyperlucency in the left lung was ultimately found to have a bronchial carcinoid in the left mainstem bronchus (Wynn, 1986).

Foreign bodies

Foreign body aspiration may cause not only localized wheezing but also generalized wheezing. Wheezing occurs in toddlers as well as in adults. As described in one patient, foreign body aspiration may necessitate bronchoscopic retrieval before the patient even recalls the inciting event, and as many as 25% of patients may never recall the event (Rolfe, 1999). Usually, a cause of localized wheezing, a foreign body can nevertheless cause generalized wheezing in some circumstances.

Other contributing conditions

Other extrinsic conditions, such as lymphadenopathy from Hodgkin lymphoma of the upper mediastinum, can contribute to asthma.

Vocal cord dysfunction syndrome usually is misdiagnosed as bronchial asthma and presents with a sudden onset and offset of wheezes and stridor in an anxious young person with a cough, upper respiratory tract infection, or hoarseness. Vocal cord dysfunction may exist alone or with asthma, it is caused by paradoxical adduction of the vocal cords in inspiration, and it often persists during expiration and disappears with panting (Shao, 1995).

A misdiagnosis as refractory bronchial asthma has resulted in inappropriate chronic treatment with corticosteroids. Flattening of the inspiratory flow-volume loop is noted with PFTs. While vocal cord dysfunction syndrome is usually diagnosed with laryngoscopy, fluoroscopy with a soft-tissue technique has been used expeditiously and successfully when airway compromise or patient compliance is a consideration (Nastasi, 1997).

Pulmonary embolism may appear as asthma when wheezing results from the release of vasoactive and bronchoactive mediators. Local alveolar hypocapnia in which blood-borne carbon dioxide is diverted is suggested as a cause of localized bronchoconstriction that can cause wheezing (Perol, 1990). Although pulmonary embolism can occur in previously healthy individuals, pulmonary embolism especially is suggested when it occurs in individuals with recurrent asthma after years of minimal or no exacerbation of the disease (Olazabal, 1968). Wheezing is not common in patients with pulmonary embolism, however. A high index of suspicion for the underlying disease is important, particularly when symptoms are out of proportion to PFT results and/or the response to treatment is poor (Hatch, 1993). Pulmonary embolism is a particular problem in elderly people (Braman, 1986).

Congestive heart failure causes engorged pulmonary vessels and interstitial pulmonary edema, which reduce lung compliance and contribute to the sensation of dyspnea and wheezing. Cardiac asthma is characterized by wheezing secondary to bronchospasm in congestive heart failure, and it is related to paroxysmal nocturnal dyspnea and nocturnal coughing (Isselbacher, 1994).

In the 1960s, Avery initially described a peculiar syndrome called pulmonary migraine, and her protégé, Tucker, amplified the description in 1977. Pulmonary migraine consists of combined recurrent asthma; cough with thick mucoid sputum; lower back pain radiating to the shoulder; subtotal or total atelectasis of a segment or lobe; and, occasionally, nausea with vomiting. The symptoms are often accompanied closely in time by focal headache. Spastic narrowing of the bronchi is postulated, along with retained mucous secretions, smooth muscle hypertrophy, and thickened bronchial walls, to cause expiratory collapse of selected airways. Cerebral and abdominal vascular migraine episodes are believed to accompany pulmonary migraine.

Diffuse panbronchiolitis is prevalent in Japan and the Far East, and it may mimic bronchial asthma with wheezing, coughing, dyspnea on exertion, and sinusitis (Kim, 1992). HRCT findings include centrilobular nodules and linear markings that usually are more profuse compared with the multifocal bronchiolar impaction sometimes observed with asthma.

Aortic arch anomalies may occur later in adulthood. In one case, the anomalies, which simulated exercise-induced asthma, were noticed first in a young woman only after a vigorous exercise program (Bevelaqua, 1989). On testing, the flow-volume display of this patient suggested an intrathoracic obstruction. The patient had a right aortic arch with ligamentum arteriosum that extended anterior to the trachea. This condition caused constriction when increased pulmonary blood flow, oxygen demand, and tracheal airflow and decreased intratracheal pressure from downstream turbulence distal to the tracheal ring occurred with exercise; combined, these factors produced wheezing and dyspnea.

Sinus disease, especially in children, is associated with bronchial asthma and wheezing. Although the association is not strong in patients with CT evidence of mild sinus mucosal thickening, a scoring system developed by Newman et al showed that extensive sinus disease was correlated with a substantially higher extent of wheezing than that in patients with only mild thickening (Newman, 1994). Of 104 adults, 39% had extensive disease, as visualized on CT scans, which was correlated with asthma and peripheral eosinophilia.

In a Finnish study of hospital admissions for acute asthma, admission CXRs showed abnormalities in 50% of the patients and resulted in treatment changes in 5%. The numbers were more remarkable when a paranasal sinus series was obtained in unselected patients presented primarily because of asthma. A sinus abnormality of any kind was found in 85% of patients; maxillary sinus abnormalities occurred alone in 63%. In 29% of patients with a sinus abnormality, treatment was immediately altered. All abnormalities were identified on the Waters view alone, which is 6 times more useful than the CXR in directing the treatment of acute asthma (Rossi, 1994). Although the findings are provocative and require confirmation, the conventional wisdom regarding the sinus radiographic evaluation of chronic coughing and asthma suggests that a workup for chronic coughing should be performed first (Pratter, 1989).

Cough, recurrent bronchitis, pneumonia, wheezing, and asthma are associated with gastroesophageal reflux (GER) (Shapiro, 1983). The incidence of GER in those with asthma ranges from 38% in patients with only asthma symptoms to 48% in patients with recurrent pneumonia. Scintigraphic studies performed after technetium-99m sulfur-colloid ingestion have shown radionuclide activity in the lungs the next day, but no causal relationship between reflux and asthma has been established. Nevertheless, evidence suggests that increased pulmonary resistance occurs with symptoms of reflux during acid provocation testing; as some have suggested, the changes may be sufficiently significant to produce clinically evident bronchospasm (Shapiro, 1983).

Differential diagnosis of bronchial asthma


The differential diagnosis of bronchial asthma, as adapted from that described by Holden and Mehta, includes the following:

Upper airways

Vocal cord dysfunction syndrome
Laryngeal and tracheal neoplasms
Infection - Epiglottitis, Vincent angina, and diphtheria
Subglottic and tracheal stenosis
Laryngeal edema - Angioedema, burns, and systemic lupus erythematosus
Laryngospasm - Infection, tetany, and psychogenic
Tracheomalacia and laryngomalacia
Laryngeal web

Lower airways

Chronic obstructive pulmonary disease
Bronchial neoplasms
Infections - Pyogenic, tuberculosis, fungal, and parasitic
Aspiration of foreign bodies
Allergic bronchopulmonary aspergillosis
Cystic fibrosis
Mediastinal masses and/or lymphadenopathy
Loeffler syndrome
Bronchiolitis syndromes
Bronchiectasis
Chemical bronchitis
Reactive airway dysfunction syndrome
Endobronchial sarcoidosis
Endobronchial amyloidosis
Bronchopulmonary dysplasia

Vascular and other lesions

Cardiac asthma - Congestive heart failure and mitral stenosis
Vasculitis - Polyarteritis nodosa and allergic vasculitis
Primary pulmonary hypertension
Vascular rings
Subglottic hemangioma
Carcinoid syndrome
Factitious lesion

 

X-RAY

Findings:

Chest radiography

In most patients with uncomplicated asthma, radiographic findings are normal. In patients with more advanced asthma, varying stages of hyperinflation are reflected on CXRs by a flattening of the hemidiaphragm, increased retrosternal airspace, and relatively minor differences in diaphragmatic positions between inspiration and expiration. Other CXR features of bronchial asthma include a mild prominence of the hilar vasculature that results from transient pulmonary hypertension and mucous plugging with or without atelectasis (Webb, 1997).

In early studies, lung opacity on CXR was evaluated in 8 regions in patients with asthma; the findings recapitulated the heterogeneous distribution of localized airtrapping seen on radioactive noble gas scintigrams obtained a decade earlier (Sutherland, 1972). Airtrapping increases the TLC and FRC and reduces the vital capacity (VC) and inspiratory capacity (IC), where IC = TLC - FRC.

FRC, which is the lung volume remaining at the end of expiration, also remains high in the patient with symptomatic asthma; this observation reflects the patient's inability to breathe out in the setting of obstructing secretions, airway narrowing, and edema.

Traditionally, the FRC and TLC have been measured in the pulmonary function laboratory, and planimetry was used in the past to assess the radiographic equivalent of the TLC. A planimeter is a mechanical device used with inspiratory posteroanterior (PA) and lateral CXRs. Formulas are used to calculate the lung volume by using a series of virtual sections in which airspace cross-sectional areas are quantified. This procedure was established as a means of diagnosing hyperinflation in bronchial asthma when correlation coefficients of 0.94 were found for helium dilution lung volumes and body plethysmography. A decrease in the TLC after treatment for asthma can be correlated with patient improvement, even when the FEV1 does not improve; this effect likely is related to an improvement in IC (Blackie, 1990).

The reliability of planimetry in the diagnosis of asthma in children also was established (Salam, 1978). Findings from a more recent study casts doubt on the usefulness of planimetry in patients with occupational asthma (Pappas, 1998).

CXR findings in bronchial asthma

The direct measurement of airway wall thickness with CXRs was undertaken in patients with mild and severe asthma and in individuals without asthma (Hungerford, 1977). The ratio of the internal luminal diameter to the wall thickness was determined by optically measuring the bronchi, as viewed end-on on radiographs, and by reviewing plain radiographic tomograms. The measurements were compared by means of subjective assessment alone. In 11 of 15 patients with severe asthma, subjective assessment results matched the measurements.

The authors stated that the finding of more than 2 measurably thickened bronchial walls was rare in individuals without asthma; however, in patients with more severe asthma, the margins of the bronchial walls were delineated better and distinguishable from the findings in individuals without asthma. Ratios varied with bronchiolar luminal diameter, and the authors believed that the ratio was more an index of chronicity than an index of severity.

Nonsegmental, widespread, streaky opacities likely represent focal linear atelectasis that are the results of viral superinfection (Alford, 1983). Segmental opacities may represent localized poor airway mucociliary clearance with atelectasis or early consolidation.

Radiographic correlates of increased TLC that result from airtrapping and small bronchiolar obstruction include hyperinflation; low diaphragms; and, in children, sternal bowing. Sternal bowing reportedly is present in children when the hemidiaphragms are below the 9th or 10th posterior ribs or when the dome of the diaphragm is below the 6th mid anterior rib interspace (Alford, 1983). However, the value of these findings as an index of severity is disputed (Gillies, 1980). Hemidiaphragms may be flat or inverted, as in tension pneumothorax, and the lateral slips of the diaphragm may be observed, especially on CT scans.

Recently, observers of 65 children hospitalized for asthma noted the inversion of the pulmonary venous distribution that is typically observed in individuals with left heart failure (Joorabchi, 1994). The children tended to be younger (6.75 y vs a group mean of 9.2 y), and they had tachypnea, retractions, nasal flaring, and tachycardia. The proposed mechanism was increased intrathoracic pressure that led to right ventricular overload, paradoxical septal motion with loss of left ventricular compliance, and elevated left atrial and pulmonary venous pressures. To the authors' knowledge, this finding has not been replicated since that study, but it remains an interesting observation.

Usefulness of CXR in the emergency department

A number of studies have been performed to evaluate the clinical usefulness of CXR (Hodson, 1974; Findley, 1981; Brenner, 1983; Gershel, 1983; Alford, 1983; Heckerling, 1986; Buenger, 1988; Aronson, 1989; Sherman, 1989; White, 1991; Dalton, 1991; Rubenstein, 1993; Tsai, 1993; Roback, 1998).

In a study of 117 patients with asthma who were older than 15 years, hyperinflation and bronchovascular changes were seen on CXR in 31% of patients in whom asthma began before they were aged 15 years. However, these changes were not observed in any patients in whom asthma began after they were aged 30 years (Hodson, 1974).

In a study of outpatients with acute asthma who present to an emergency department (ED), a mean of 55% of patients had normal CXR findings, while 37% had CXR findings of hyperinflation, and 7% had minimal and unchanged interstitial abnormalities (Findley, 1981). Pneumonia was present in 16% of adults. Despite the large statistical range of patients with only normal findings (30-81%) and despite the discovery of pneumomediastinum in 5% of children, the authors concluded that CXR was not helpful unless complications of asthma were suggested clinically.

One of the largest studies of ED visits involving CXRs was performed in a large city hospital. In this study, findings in 5,000 patients were reviewed; 2-view radiographs used in two thirds of the patients and only portable radiographs were used in one third. Overall, 35% of the patients with chest symptoms had serious radiographic findings, but only 14% of the patients with symptoms of asthma had serious radiographic abnormalities. However, the applicability of these findings to individual CXR findings of asthma is limited by the small proportion of total radiographs (4.6%) obtained in patients with asthma (Buenger, 1988).

In a British general hospital ED, findings in 695 episodes of acute asthma in adults and children were evaluated. CXRs were obtained in 135 of 695 patients, or 19% of the total instances of asthmatic exacerbation. Of the radiographs, 79% (presumably portable radiographs) demonstrated normal findings. Abnormalities included evidence of infection (13%), hyperinflation (7%), and edema (2%). Increased perihilar markings were observed in only 2 patients (Dalton, 1991).

CXR in assessing the need for hospital admission

In an early study, the value of routine admission CXR in adults with asthma was evaluated in regard to the presence of pneumonia in patients with acute respiratory complaints. Among patients with asthma, only 2% had concurrent pneumonia (Heckerling, 1986).

Sherman et al examined patients with exacerbations of chronic obstructive airway disease (COPD). More than half of the 242 hospitalized patients had a "predominant clinical pattern of asthma." Wheezing was not specifically listed as a clinical finding for any patient, although cough and dyspnea were included. Only 4.5% of the radiographs resulted in clinically significant findings that changed the treatment planned with clinical and laboratory criteria alone, in the asthma group as well as the whole group.

Sherman et al concluded that admission CXR is justified only after the following selection criteria are met: WBC more than 15,000 x 103 per microliter; polymorphonuclear count more than 8,000 x 103 per microliter; or a history of congestive heart failure, coronary artery disease, chest pain, or edema. The findings affirmed the observation that chronic bronchitis and emphysema can have a presentation similar to that of bronchial asthma. This result is notable because it came in one of the earlier studies that did not find value with routine CXR in the ED for patients with asthma.

In a blinded retrospective review, the effect of CXR on clinical decision making, including those related to hospital admission, was evaluated in a busy large-city ED (Aronson, 1989; Tsai, 1993). Criteria for complicated airway disease included COPD, fever, heart disease, intravenous drug abuse, immunodeficiency, and/or prior thoracic surgery but not diabetes or steroid use. Of the 27 patients in whom treatment was altered, 96% had clinically and radiographically complicated cases. Abnormal CXR features that were influential in the clinical input included infiltrate in 63%, congestive heart failure in 26%, and lobar collapse in 4%. Features of uncomplicated CXRs were peribronchial thickening in 18% and atelectasis and other findings in fewer than 10%. Had the stated criteria for complicated asthma versus uncomplicated asthma been applied, CXR examinations for hospital admission would have decreased by an estimated 34%.

In another study, more than 85% of patients underwent 2-view CXRs; in earlier studies, a lower proportion of PA and lateral examinations were performed relative to portable anteroposterior (AP) studies (Sherman, 1989).

White et al prospectively studied admission CXRs in a large-city ED. PA and lateral radiographs were obtained in more than 95% of the patients who eventually were admitted after a 12-hour course of treatment. Major findings, present in 34% of the patients, included focal opacity, increased interstitial markings, cardiomegaly, pulmonary venous congestion, pneumothorax, and new pulmonary nodules. Minor findings, present in 41%, included hyperinflation, pleural thickening, and calcified granulomas. Focal opacities or increased interstitial markings were correlated with subsequent antibiotic use, independent of an elevated WBC or body temperature. The authors concluded that CXRs should be obtained in all adult patients with acute asthma who are admitted (White, 1991).

CXR in pediatric asthma

In children, the natural overlap of nonbacterial bronchiolitis with bronchial asthma accounts for their similar findings on CXRs. Findings of an increased retrosternal airspace and flattened hemidiaphragms sometimes are accompanied by peripheral arterial attenuation. These findings are components of the hyperinflation observed with both entities (Rencken, 1998).

A study of 371 children with first-time wheezing led to the establishment of criteria for obtaining CXRs (Gershel, 1983). The criteria include a heart rate higher than 160 bpm or a respiratory rate higher than 60 per minute, localized rales or localized decreased breath sounds before treatment, and/or persistent localized rales and localized wheezing after treatment. Patients are more likely to have significantly positive CXR findings when criteria are met. Of children with abnormal CXR findings of segmental atelectasis, pneumonia, and pneumomediastinum, 95% met the prospective criteria. However, negative CXR findings still included hyperinflation, thickened airways, peribronchial thickening, and subsegmental atelectasis.

Roback et al also evaluated the use of CXR in children with first-time wheezing by using the practice parameters of Gershel et al as a yardstick with which to compare actual clinical practice. The retrospective study revealed that, of the 41% of the patients who underwent CXR, 24% had a clinically significant abnormality such as local consolidation, pneumothorax, pneumomediastinum, asymmetric opacity, hyperinflation, segmental atelectasis, edema, cardiomegaly, or airway compression (Roback, 1998).

In the study of Roback et al, an elevated temperature (mean, 37.9°C), absence of a family history of asthma, localized wheezes, decreased breath sounds, and rales significantly predicted the decision to perform CXR. Patients in whom CXR was performed (67%) were more likely to have positive findings when they had a slightly elevated temperature, a family history of asthma, or localized wheezes or rales. Of patients in whom CXR was not performed, 62% would have undergone CXR with the criteria of Gershel et al. Of patients who underwent CXR, 74% did not meet these criteria; this finding suggests that the criteria and actual clinical practice widely differ.

A more recent study of pediatric asthma examined children with first-time wheezing who presented to the ED in a large-city children’s hospital. On the radiographs obtained in these children, 61% showed findings of uncomplicated bronchiolitis or asthma (hyperinflation in 85%, peribronchial cuffing in 68%, interstitial or perihilar opacities in 31%, and atelectasis), and 18% showed parenchymal opacities (lobar or segmental). Only 21% of patients had completely normal radiographic findings.

Rubenstein et al compared the usefulness of routine spirometry with that of CXR in patients with mild ambulatory asthma in a university student population. Although 36% of the patients had spirometric results consistent with airway obstruction (predicted FEV1 <80%, predicted peak expiratory flow rate [PEFR] <85%, or 20% improvement with bronchodilators), 59% had abnormal CXR findings consisting of hyperinflation, increased perihilar markings, and peribronchial or peribronchiolar cuffing. Both bronchitis and/or bronchiolitis and bronchial asthma caused the radiographic findings. Thus, although CXR lacks optimal specificity, it may be valuable in the diagnosis of bronchial asthma when the clinical features were taken into account (Rubenstein, 1993).

 

Bronchography

Bronchography is a technique, now largely archaic, that is used to visualize the trachea and large airways by instilling a radiopaque, oily emulsion into the airways via an airway catheter or bronchoscope. For many years bronchography, was a criterion standard in the detection of bronchiectasis, but bronchography was known to induce transient bronchospasm and impair ventilation and diffusion capacity, especially in individuals with asthma. Typically, bronchography was considered to be contraindicated in severe reactive airway disease, although it was useful in the examination of individuals with milder asthma with suspected bronchiectasis (Neeld, 1990).

A group from Finland used cinetracheobronchography to visualize the main airways in individuals with asthma. The investigators introduced bronchography contrast enhancement and performed radiography during the patient's quiet breathing, forced expiration, and coughing (Standertskjold-Nordenstam, 1981). The authors described findings in a patient in whom complete closure of the distal trachea during coughing was associated with both cartilaginous and membranous weakening. The patient's condition responded to endobronchial prosthesis with a marked improvement in airflow and symptoms.

In dogs, tantalum bronchography was performed in studies of experimental asthma at the Cardiovascular Research Institute during the 1960s and 1970s. Tantalum fine powder was insufflated into the bronchi, and it allowed detailed study of airways in asthma caused by various pharmacologic agents with and without bronchial provocation by allergens and particulates.

In one study, nematode antigen caused airway narrowing of differing degrees, according to airway size. Airways sized 1- to 8-mm had the greatest diameter decrease (49%) compared with airways with diameters greater than 12 mm, 8-12 mm, or 0.5-1.0 mm. Although it is not entirely inert, the stimulation of increased respiratory system resistance by the antigen is controlled by the dose (Kessler, 1973).

Nematode antigen was used to evaluate airway narrowing in some patients with asthma. The advantage of the metallic powder is its relatively inert character in the airways, although it is known to affect mucociliary clearance to a small degree (Forbes, 1979). The agent was used to study the somewhat twitchy airways of patients with asthma, in contrast to the more noxious, typical, oil-based, iodinated suspensions that are commonly used for bronchography.

 

Summary

In summary, the severity of a particular asthma attack is not necessarily reflected in CXR findings because the findings may be normal. However, over time and with episodic recurrence, the pathophysiologic features of bronchial asthma likely are reflected in findings of airway thickening, hyperinflation, atelectasis, and susceptibility to superinfection due to bacterial and nonbacterial processes.

The incidence of findings such as parenchymal opacities and hyperinflation is higher in children than in adults, and the usefulness of CXR in the pediatric population is arguably greater, particularly when practice parameters are applied. Interestingly, study findings in some populations suggest that CXR findings may be abnormal more often than spirometry findings in exacerbations of bronchial asthma. The value of routine CXR in the examination of patients with exacerbations of asthma can be increased by using clinical screening criteria. CXR is indicated in the evaluation of patients with asthma who are hospitalized.

Degree of Confidence: Although bronchial thickening, hyperinflation, and focal atelectasis suggest asthma when they are present, CXRs obtained during asthma exacerbations can demonstrate normal findings, which reduce its sensitivity as a diagnostic tool. Similarly, identical findings may be observed with chronic bronchitis and viral bronchopneumonia, among other conditions, and these similarities limit the specificity of CXR. Clinical correlation remains beneficial in the interpretation of findings, as it is in so many other areas of radiology.

False Positives/Negatives: See Other Problems to be Considered.


CAT SCAN

Findings: In the last decade, the role of CT in the imaging of airway disease increased after the development of lung HRCT. The technical progress of thin-section acquisition, high-spatial-frequency data reconstruction (ie, bone algorithm technique), and targeted reconstruction has allowed the visualization of finer details on HRCT scans; these details include airtrapping, measurable bronchial wall thickening, atelectasis, centrilobular nodules due to mucous plugging, and acinar nodules due to low-grade inflammatory changes (Teel, 1996).

King et al discuss details of HRCT methods for evaluating the airways in obstructive pulmonary disease (King, 1999). They discuss the technical features of HRCT and review its use in the assessment of obstructive airway disease.

 

Animal studies

In one study, the intact lobes of pressurized canine lungs were evaluated with HRCT before and after the administration of carbachol, a bronchoconstrictor. Intermediate-sized airways had the most prominent decreases in luminal area; 2- to 4-mm airways had a 56% reduction in diameter, and 4- to 6-mm airways had a 59% reduction. Wall thickening was believed to result, in part, from increased bronchial blood flow, edema, and smooth muscle hyperplasia. The lower range of visibility was at the generally accepted maximal diameter of small airways, that is, 2 mm (McNamara, 1992).

Herold et al established the usefulness of HRCT in measuring the bronchial response to bronchoconstrictors in the setting of hyperreactivity. Responses to aerosol isotonic sodium chloride solution and histamine were assessed in anesthetized ventilated dogs and corrected for lung volume. Airway cross-sectional area decreased by 43% after histamine administration and by 26% after saline administration alone, but intersubject and intrasubject variability was significant; the irritant effect of the base aerosol was evident. Although airways as small as 1 mm were evaluated, the discrepancy between the response of large airways (ie, bronchoconstriction) and small airways (ie, change in mean airway pressure) could not be explained (Herold, 1991).

The role of vascular engorgement and edema was evaluated with HRCT. Dogs received 3 successive 50 mL/kg isotonic sodium chloride challenges or 2 successive 25 mL/kg blood infusions. This large sodium chloride load caused more airway wall thickening and luminal narrowing than blood alone. With sodium chloride, the luminal area and wall thickness were 68% and 150% of those at baseline, respectively; with blood, the results were 81% and 108% of those of baseline, respectively. The findings were not reversible within 30 minutes. Also, the findings were attributed to edema in airway walls, but they were considered to have only a minor role in the multiple causes of increased airway resistance in asthma and left ventricular dysfunction (Brown, March 1995).

The investigators then showed that, although the initial histamine challenge narrowed the airways to 71% of their baseline luminal area, the sodium chloride challenge alone (100 mL/kg) reduced the airway lumen to 78% of its baseline size. Potentiation of the effect by combining sodium chloride and histamine reduced the luminal area to 54% of its baseline value. These findings were correlated with the known exaggerated constrictor response to provocation in the setting of airway edema (Brown, October 1995).

Findings from later studies of the role of inflammatory mediators in airway hyperresponsiveness led to the conclusion that methacholine and bradykinin, alone or combined, have only minor effects on bronchoconstriction (Brown, 1997).

 

HRCT findings in bronchial asthma

HRCT findings in bronchial asthma include the following:

 

  • Bronchial wall thickening

     

  • Bronchial dilatation

     

  • Cylindrical and varicose bronchiectasis

     

  • Reduced airway luminal area

     

  • Mucoid impaction of the bronchi

     

  • Centrilobular opacities, or bronchiolar impaction

     

  • Linear opacities

     

  • Airtrapping, as demonstrated or exacerbated with expiration

     

  • Mosaic lung attenuation, or focal and regional areas of decreased perfusions

Emphysema, airtrapping, and terminal airspace enlargement

Some initial human studies involved emphysema scoring in patients with asthma. Royle first described emphysema in severe asthma by using radiographs in current or former smokers.

In the late 1980s, a group evaluated the coexistence of emphysema and asthma findings using HRCT. In comparing 10 nonsmoking patients with asthma with 10 matched cigarette smokers with severe airflow obstruction, an emphysema grade of 0% was observed in the nonsmokers, and 100%, in smokers; the emphysema score reflected vascular disruption, bullae, and low-attenuating areas. Although all smokers with a TLC greater than 120% had at least some emphysema, no nonsmoking patients with asthma had emphysema. The authors concluded that, in patients with asthma, elevated TLC between attacks can be explained by hyperinflation, which is entirely due to asthma and not coexisting emphysema (Kinsella, 1988).

Paganin et al studied airway remodeling in nonsmokers with allergic asthma and in those with nonallergic asthma. On HRCT scans, the authors observed emphysema, cylindrical and varicose bronchiectasis, bronchial wall thickening (ie, bronchial recruitment), and linear opacities ("sequellar line shadows"). The findings were significantly more prevalent in individuals with nonallergic asthma than in individuals with allergic asthma. Scores of the findings were significantly greater in both groups and were associated with the severity and duration of asthma (Paganin and Seneterre, 1996). Centrilobular emphysema was most severe in individuals with severe nonallergic asthma and was not observed in control subjects without asthma.

Whether true emphysema exists in patients with asthma or whether only terminal airspace enlargement is involved in bronchial asthma (Snider, 1985), the severity of the findings appears to be correlated with the clinical measures of severe asthma. Paganin et al suggested that some form of airway remodeling accounted for the findings and that the process likely differed in allergic asthma versus nonallergic asthma. An interesting speculation is that interstitial emphysema and peribronchial fibrosis may be the result of rupture of the dilated bronchial glands that are present in bronchial asthma (Paganin, 1997).

Confirming earlier findings, authors from Japan also showed that smokers with moderately severe asthma have a significantly higher emphysema score (13.7% vs 2.3%) than that of nonsmokers. As expected, the diffusion capacity was correlated with the emphysema score and the pack-years of cigarette smoking. The authors concluded that, in smokers with asthma, emphysema develops independent of the asthmatic condition (Kondoh, 1990). Determining the difference between the 2 conditions may illuminate variations in the decline of lung function and the prognosis.

The 10-year mortality rate in patients with an emphysematous form of COPD (ie, 60%) is substantially worse than that of atopic control subjects or nonsmokers with known asthma (15%) (Burrows, 1987). Therefore, differentiating between the 2 groups is important from an imaging point of view.

Findings of a later study confirmed that a subgroup of individuals with asthma who also had emphysema tended to smoke more than others and that they have poorer lung function (Lynch, 1993). In this study, the patients with asthma were selected from a group with suspected allergic bronchopulmonary aspergillosis (ABPA) who actually did not have ABPA, cystic fibrosis, bronchiectasis, or immune deficiency, as prior laboratory and HRCT findings revealed.

In another study, a group of individuals with reversible asthma were stratified in terms of absent, mild, or severe emphysema. Neither the duration nor the severity of asthma was correlated with the presence of emphysema, whereas smoking history, sex, and age were strongly correlated. Patients with long-standing and partially reversible bronchial asthma did not have emphysema if they were nonsmokers (Mochizuki, 1997). The findings also were consistent with the observation that DLCO typically is preserved in nonsmokers with asthma.

More recently, the correlation of airtrapping with pulmonary function was studied by using HRCT in 74 patients with chronic airway disease, including asthma (Lucidarme, 1998). On expiratory HRCT scans, the airtrapping and expired volume scores were inversely correlated with FEV1, FEV1/FVC, and FEF25. The TLC was not correlated with any of the imaging, age, sex, cigarette smoking history, or visual HRCT scores. Airtrapping was found, even when PFT results were normal; this finding suggests a complementary role for HRCT in the functional evaluation of asthma. HRCT may be more sensitive than PFT or DLCO alone in the evaluation of centrilobular and panlobular emphysema (Paganin, 1997).

By the late 1980s, the HRCT features that were accepted as demonstrating emphysema included low-attenuating regions, pulmonary vascular pruning, distortion, disruption, and bullae. The use of an attenuation mask allowed the semiautomated measurement of hypoattenuation in focal regions of the lungs, with quantification in regions of interest, in which other findings then were correlated (Muller, 1988).

Gevenois et al demonstrated that the distribution of lung attenuation, as visualized on CT scans, depends on the TLC and, to a lesser degree, age (Gevenois, 1996). However, Biernacki et al showed a considerable overlap in lung attenuation, as measured in Hounsfield units, in the evaluation of patients with chronic asthma, patients with chronic bronchitis and emphysema, and control subjects without asthma. The authors confirmed a correlation (r = 0.63) between TLC and the index of lung attenuation, although neither lung attenuation nor TLC changed after PEFR improved with the use of a nebulized adrenergic bronchodilator (Biernacki, 1997).

Ng et al investigated airtrapping as an expression of small airway narrowing, as demonstrated on HRCT scans (see Images 3-4). The authors examined 106 patients with small airway disease and 19 healthy individuals. They found that decreased attenuation was more prominent on expiratory HRCT scans than on inspiratory HRCT scans (Ng, 1999).

Quantitative CT analysis also has promise. Newman et al demonstrated that patients with asthma could be distinguished from individuals without asthma by using machine calculations of the percentage of lung area near the diaphragm with an attenuation less than –900 HU at end expiration (Newman and Lynch, 1994). This finding was true for both standard CT and HRCT, and it was correlated with the degree of airtrapping, as measured with the FRC and RV. A report of expiratory HRCT findings of airtrapping included inspiratory scans that had normal findings and suggested that the most common underlying causes of airtrapping were asthma and bronchiolitis obliterans (Arakawa, 1998).

Additional methods have emerged with the development of dynamic HRCT scanning. With these methods, anatomic variations in bronchial obstruction can be studied after a provocative challenge. For example, the temporal development of airtrapping can be demonstrated with the successive, rapid acquisition of CT images during expiration (Paganin and Chanez, 1996).

Dynamic CT scans demonstrate that the increase in attenuation in the dependent and basilar portions of the lungs in individuals without asthma is greater than that of individuals with asthma (Webb, 1993). Nevertheless, images in 4 of 10 individuals without asthma also showed airtrapping during rapid exhalation. Clinically, the usefulness of this modality is yet to be determined.

Bronchial dilatation, bronchiectasis, mucoid impaction, and allergic bronchopulmonary aspergillosis

Studies of HRCT images in asthma consistently reveal the presence of bronchiectasis in patients with asthma but not ABPA. In ABPA, bronchiectasis often is considered part of the definition of the disease. Dilated airways may take the form of cylindrical, varicose, or cystic bronchiectasis. Park et al observed bronchial dilatation in 31% of patients with asthma versus 7% of control subjects. The authors measured bronchoarterial ratios but did not find a statistically significant difference between the groups (Park, 1997).

Lynch et al showed that dilated bronchi, defined as bronchi that are larger than accompanying arteries in which the tapering pattern is not lost, were observed in 59% of the control subjects compared with 77% of the patients with asthma. Other researchers found no or few such features in control subjects. A decreased arterial diameter with hypoventilation and hypoxic vasoconstriction, a sectioning artifact near the branching arteries and bronchi, a bronchodilator effect on medium-sized airways, and subclinical ABPA are potential explanations for the unexpectedly high percentage of findings in control subjects. The authors discussed CT scanner gantry tilting, as used in HRCT examination of patients with bronchiectasis (Remy-Jardin, 1988). They outlined their ability to follow the natural branching pattern of the bronchi in their plane (Lynch, 1993).

The reported prevalence of dilated, normally tapering bronchi ranged from 18% with skin test results that were positive for Aspergillus species, which are common in patients with mild asthma, to almost 80% in patients with moderately severe asthma. The varicose type, observed in as many as 60% of patients, was considered to be more specific for nonallergic asthma and severe asthma, whereas the cylindrical type occurred in both allergic asthma and nonallergic asthma with varying degrees of severity (Paganin and Seneterre, 1996).

In a study by Grenier et al, subsegmental and distal bronchiectasis was more common in patients with asthma (29%) than in healthy volunteers (7%). The changes were considered permanent, especially if they were varicose or cystic; the prevalence of these changes and the number of involved lobes increased with disease severity. The authors studied interobserver variability and found that interobserver and intraobserver agreement (k = 0.40) were clinically acceptable for bronchial wall thickening, bronchial dilatation, small centrilobular opacities, and decreased lung attenuation. Interobserver and intraobserver agreement was not clinically acceptable with subtypes of bronchiectasis, such as the cylindrical and varicose subtypes (Grenier, 1996).

Investigators in early studies used HRCT findings to prove that bronchial dilatation was prevalent in 41% of the pulmonary lobes in 8 patients with asthma who had clinical and immunologic evidence of ABPA and in 15% of lobes studied in 8 patients with asthma who had positive skin test results for only Aspergillus fumigatus (Neeld, 1990). The authors speculated that the unexpected findings in individuals with asthma alone may have been due to steroidal suppression of immunologic markers in these patients who actually had ABPA, non-Aspergillus fungal disease, or cylindrical bronchiectasis.

Although upper lobe involvement and bronchial wall thickening were considered nonspecific findings, Neeld et al raised the awareness that asthma may be more destructive than previously thought. Also, central bronchiectasis in its various forms primarily may reflect the duration of an inflammatory airway process rather than determine the difference between ABPA and asthma per se (Neeld, 1990).

Compared with the value of the traditional modality of bronchography, the value of thoracic HRCT in demonstrating central bronchiectasis in ABPA was proven in all 21 patients with the disease and in most of the segments (see Image 8). Central and peripheral bronchiectasis, but not peripheral bronchiectasis alone, have been evaluated by using both CXR and HRCT images as a diagnostic criteria for ABPA. Angus et al observed bronchial dilatation in 82% of their 17 patients and in 41% of the affected lobes in patients with ABPA versus 18% and 5%, respectively, in patients with asthma and in those without ABPA. However, peripheral bronchiectasis alone was not found in any of the patients with ABPA (Angus, 1994).

Mucoid impaction is a well-defined finding in patients with ABPA. It may appear as centrilobular bronchiolar plugging or have a tree-in-bud appearance on HRCT scans. Mucoid impaction is believed to be one of the physiologic origins of mosaic lung attenuation (Webb, 1997). Paganin et al attributed the development of varying degrees of cylindrical bronchiectasis to sequela of multifocal mucoid impactions and bronchial hypersecretion in asthma (Paganin and Seneterre, 1996).

Grenier et al found a 21% incidence of centrilobular opacities on HRCT scans obtained in patients with asthma, compared with 5% in individuals without asthma. The authors believed that these opacities and the decreased lung attenuation can be related to the severity of asthma. The authors studied intraobserver and interobserver variability and found that, with bronchial wall thickening, bronchial dilatation, small centrilobular opacities, and decreased lung attenuation, intraobserver (k = 0.60-0.79) and interobserver (k = 0.40-0.64) agreement was clinically acceptable (Grenier, 1996).

Bronchial wall thickening

Carroll et al found that, in cartilaginous airways, the total areas of the inner wall and outer wall, smooth muscle, mucous gland, and cartilage were greater in fatal cases of asthma than in control and nonfatal cases (Carroll, 1993). The internal size of segmental to sixth-generation bronchi was studied in healthy control subjects by using HRCT. Measurements ranged from 0.8-8 mm in diameter, with the use of 2-HU windows, 5X optical magnification, and automated luminal area calculation. The authors used a 2-HU window to clarify the edges of the bronchial walls to enhance the reproducibility of the measurement (Seneterre, 1994).

Hudon et al used HRCT to show that bronchial thickening in patients with asthma and irreversible airflow obstruction was significantly greater (2.4 mm) than that of patients with completely reversible asthma (2.0 mm) despite the similar internal diameters of their airways (Hudon, 1997).

Lynch et al observed bronchial wall thickening on CXRs and HRCT scans in 71% and 92% of individuals with asthma, respectively (vs HRCT in 19% of control subjects) (see Image 7). The authors' patient selection was somewhat biased toward those with asthma complications and smokers (44%) (Lynch, 1993). As discussed before, a decreased arterial diameter with hypoventilation and hypoxic vasoconstriction, a sectioning artifact near branching arteries and bronchi, a bronchodilator effect on medium airways, and subclinical ABPA were considered to be potential explanations for the unexpectedly high percentage of findings in control subjects.

Park et al found bronchial wall thickening proportional to severity in 44% of stable nonsmokers with asthma versus 4% of control subjects. Bronchial wall thickening occurred in 83% of patients with severe airflow obstruction versus 35% in patients with mild obstruction and 38% in control subjects (Park, 1997).

Grenier et al found bronchial wall thickening in 82% of patients with asthma versus 7% of control subjects; this finding established one of the largest differentials between these groups, although the measurements were solely subjective. Nevertheless, the method of measurement appeared to be reliable in terms of intraobserver and interobserver variability (Grenier, 1996). Others had similar findings (Angus, 1994; Paganin, 1992; Paganin and Seneterre, 1996; Webb, 1994).

In an autopsy study of individuals who died with asthma as well as those who died from asthma, large airway and small airway thickening was observed in individuals with lethal asthma, whereas small airway thickening was observed only in nonlethal asthma (Carroll, 1993).

Awadh et al studied airway wall thickening and found no significant difference in the ratio of wall thickness to outer diameter or the percentage of wall area to the total outside cross-section in patients with near-lethal asthmatic attacks versus patients with moderate asthma. Both groups differed from patients with mild asthma and from individuals without asthma. Nevertheless, even the group with mild asthma differed from individuals without asthma; this finding confirming those of others and demonstrating that individuals with mild asthma can have airway thickening if the condition is chronic. The findings were present in both the small airways (<2 mm) and the larger airways (>2 mm). The findings support the concept of chronic airway thickening in asthma and the likelihood of airway remodeling; interstitial peribronchial fibrosis; and, perhaps, parabronchial inflammation, which may cause accompanying centrilobular emphysema.

Bronchial responsiveness and the role of small airways

Okazawa et al evaluated a known feature in patients with asthma, that is, the exaggerated airway response to bronchoconstricting stimuli. Patients with mild-to-moderate asthma and control subjects received a methacholine challenge, and airway lumen narrowing was normalized for FRC. In both groups, the site similar (small, <2 mm; medium, >2 mm) and extent of airway luminal narrowing on HRCT scans were similar, as were the reductions in FEV1 values. Only patients with asthma had extensive small airway wall thickening without an increased airway wall area; this finding did not change much after a bronchoconstrictor was administered. Control subjects did not have wall thickening, and their airway wall area decreased. The authors concluded that nonreversible small airway wall thickening in patients with asthma contributed to an exaggerated response of the small airways to stimuli (Okazawa, 1996).

In the intermediate bronchi of individuals with asthma and fixed or partly reversible obstruction, Boulet et al observed no difference in bronchial wall thickness relative to the diameter compared with that of control subjects. Small airways, in which asthma and COPD cause substantial pathophysiologic changes, were not studied. The authors suggested that mechanical properties of the airway wall were probably more important than wall thickness in determining airway responsiveness (Boulet, 1995).

In another study of bronchoeffector agents, the appearance of the airways on HRCT scans showed that airway internal luminal diameter slightly decreased in individuals with mild asthma and that specific airway resistance increased after methacholine administration; this effect completely reversed after the bronchodilator agent albuterol was administered, and an improvement compared with baseline values was even observed. Airway wall thickness did not change in terms of the diameter, and pulmonary functions did not change with treatment. The investigators were able to quantify the changes in patients with asthma and control subjects by using HRCT scans (Kee, 1996).

In attempting to differentiate COPD from asthma with HRCT scans, Park et al showed that bronchial walls were thicker in bronchial asthma (2.3 mm thicker than normal) than in COPD (0.9 mm thicker than normal). However, the ratio of wall thickness to luminal diameter was not correlated with clinical features such as smoking history, duration of symptoms, physiologic measures (eg, FEV1), specific airway conductance, and a provocative concentration of the bronchoconstrictor methacholine. HRCT findings of tubular bronchiectasis, emphysema, and mosaic lung attenuation were correlated with a long history of asthma symptoms, compromised lung function, and decreased bronchial hyper responsiveness (Park, 1997). The authors concluded that differentiating COPD from asthma is possible from the data, although the usefulness of the data in individual cases remains speculative.

Carr et al studied the role of the small airways in severe asthma by using HRCT. Inspiratory and expiratory scans were obtained with an electron-beam scanner. The mean decrease in the expiratory-to-inspiratory cross-sectional area was measured: Findings were 76% in patients versus 45% in control subjects. The results showed marked initial inspiratory airway narrowing, and further narrowing with expiration in patients with asthma was limited. The authors also found that FEV1 was correlated with this narrowing and with CT features of airtrapping, but not with features of airway wall thickening or airway dilatation. Airtrapping was observed with and without overt bronchiectasis in some lung regions; this finding led to the speculation that small airway disease with airtrapping may precede bronchiectasis. As previously shown, FEV1 and RV are correlated with end-expiratory airtrapping in individuals with asthma (Carr, 1998; Newman and Lynch, 1994).

Guckel et al also evaluated the source of mosaic attenuation on HRCT scans and observed the influence of oxygen administration on this appearance. In 22 patients with asthma who received a methacholine challenge, high-flow oxygen administered by face mask at a rate of 12 L/min produced the greatest increase in volume-corrected attenuation in regions of mosaic attenuation, compared with the nasal administration of oxygen at a rate of 5 L/min or the use of room air. The proposed and plausible explanation is that hypoxic vasoconstriction, another known cause of mosaic attenuation (airtrapping) besides bronchial narrowing, may account for foci of decreased attenuation in patients with asthma (Guckel, 1999).

In addition, airtrapping is observed in some areas of bronchiectasis in individuals with asthma due to weakness of the bronchiolar walls and resultant airway collapse during exhalation (Stern, 1994). Ng et al investigated airtrapping as an expression of small airway narrowing on HRCT scans. The authors examined 106 patients with small airway disease and 19 healthy individuals. They found that decreased attenuation was more prominent on expiratory HRCT scans than on inspiratory HRCT scans (Ng, 1999).

Effect of treatment

Paganin et al found both reversible and irreversible findings on HRCT scans of individuals with asthma. Mucoid impaction, acinar opacities, and lobar collapse resolved within 2 weeks of treatment with oral steroids. Bronchiectasis, bronchial wall thickening, linear opacities, and emphysema were unchanged during that interval and were considered permanent. While CXR alone showed abnormal findings in 38% of patients, CT demonstrated abnormal findings in 72% of patients, and the authors concluded that patients with more severe asthma are more likely to have irreversible abnormalities (Paganin, 1992).

Grenier et al also studied the effect of treatment in patients with asthma without ABPA who had more mucoid impaction or lobar collapse on HRCT scans than on CXRs alone. The features tended to resolve with use of corticosteroids (Grenier, 1996).

Another study of bronchoeffector agents and the appearance of airways on HRCT scans revealed that airway internal luminal diameter slightly decreased and specific airway resistance increased after the administration of methacholine in patients with mild asthma. These effects completely reversed after the bronchodilator agent albuterol was administered, and an improvement compared with baseline values was even observed. Airway wall thickness did not change with treatment in these patients or in the control subjects. In the control subjects, neither airway luminal diameter nor pulmonary function changed. HRCT scans significantly aid in quantifying the changes in patients with asthma and in control subjects (Kee, 1996).

Goldin et al examined 15 patients with asthma and 8 control subjects by using spirometry and HRCT and by using a methacholine challenge and albuterol inhalant reversal (see Images 9-11). The authors showed a shift in the frequency distribution curve of lung attenuation and small airway cross-sectional area after bronchoprovocation; the findings reversed after bronchodilators were administered. The findings were correlated with changes in FEV1 in individuals with asthma and with a lack of changes in control subjects (Goldin, 1998) (see Image 11).

Summary and future directions

Mclean et al have thoughtfully laid out the current limitations of HRCT in the evaluation of asthma, which involve patient selection and study design; CT acquisition methods; the definition and scoring of abnormalities; and data reproducibility, both intrinsic inaccuracy and observer bias. King et al outlined the need for an assessment of the innate variability in the most common measurements and the need for further application of computer-based algorithms for quantitative imaging analysis of airway luminal area and wall thickness with histologic correlation. The correlation of physiologic parameters, such as lung volume and transpulmonary pressure, remains to be explored further in humans (King, 1999).

The relationship between centrilobular emphysema and peribronchial inflammatory change in bronchial asthma is an area that should be explored, despite the observation that DLCO has been used to distinguish smokers with asthma who also have emphysema from smokers with asthma alone. Airtrapping can be detected by using HRCT scans, even when DLCO is preserved; this finding suggests that these 2 methods may have complementary roles in the assessment of obstructive lung disease. HRCT findings of bronchiectasis, emphysema, and mosaic lung attenuation are correlated with a long history of asthma symptoms, compromised lung function, and decreased bronchial hyperresponsiveness (Park, 1997).

Small airway disease with airtrapping may precede the development of bronchiectasis (Carr, 1998). Study findings have established that HRCT is more sensitive in the assessment of various abnormalities in bronchial asthma, and HRCT remains the most applicable clinical and research tool for the study of the airways in asthma and in small airway disease.

Degree of Confidence: HRCT remains the most sensitive study for morphologic changes associated with asthma. HRCT has the potential to aid with the functional assessment of the lungs, such as tests of airtrapping and the bronchodilator response. The specificity of HRCT for bronchial asthma is limited by the similarity of its changes to those of other diseases, such as bronchiectasis, chronic bronchitis, emphysema, and bronchopulmonary aspergillosis.

MRI

Findings: Aside from cardiovascular applications, MRI of the thorax is used primarily as a problem-solving modality in the workup of patients with lung, mediastinal, or pleural lesions. MRI is a useful alternative to CT pulmonary angiography in evaluating possible pulmonary embolic disease in patients in whom iodinated contrast agent cannot be administered and when the avoidance of ionizing radiation is preferred. In bronchial asthma, the most promising work appears to involve the use of special paramagnetic gases, which amplify the low signal-to-noise ratio of conventional spin-echo and gradient-echo techniques by several thousand times. The use of such gases offsets the disadvantages of the large magnetic susceptibility states with consequent shortened T2* signals induced by the air-alveolar interfaces.

Using hyperpolarized helium-3 produced as needed in a local laser laboratory, de Lange and colleagues performed 32 MRI examinations with a 2-dimensional fast low-angle shot (FLASH) sequence and an interleaved echo-planar sequence immediately after the patient inhaled 1-2 L of freshly prepared gas. The imaging required short-to-intermediate breath holds (approximately 5-22 s), a set of Helmholtz coils centered over the anterior and posterior thorax, and a special radiofrequency receiver tuned to the 48-MHz Larmor frequency of 3He gas. The gas is prepared with an optical pumping technique by which energy is transferred by laser to a small quantity of a rubidium agent, which, in turn, conveys it to low-energy-state dipoles of the resident 3He. In healthy individuals, 3He gas is transferred immediately and completely to the most peripheral airways and airspaces because of its high intrinsic diffusibility.

When ventilation defects are observed, healthy areas continue to have a homogeneous distribution. One patient in the de Lange study had a history of asthma and normal findings with initial testing. One week later, when the patient had mild seasonal allergies, repeat examination revealed 2 new, discrete, peripheral ventilation defects when the patient had a new onset of allergic symptoms. The findings subsequently resolved on MRIs obtained 1 week later and after treatment (de Lange, 1999).

A later study demonstrated similar reversibility in patients receiving the bronchodilator albuterol (Altes, 2001) (see Images 12-13). The proposed mechanism of action is mucous plugging or bronchospasm, although peripheral defects alone are not believed to be unique to asthma, and they also reflect small airway processes such as emphysema, bronchiolitis, and cystic fibrosis.

In comparison to the results of nuclear medicine ventilation lung scanning with xenon-133 gas, the resolution of ventilation defects on MRIs is substantially superior. Interobserver variability is yet to be tested on a larger scale, but it appeared to be acceptable in the group studied (de Lange, 1999; Altes, 2001). Problems related to the availability of the fundamental gas are yet to be overcome, but they may be solved by hyperpolarizing the gas and making slight modifications to the MRI unit.

Additional studies have been performed by using hyperpolarized xenon-129 gas. Oxygen has significant paramagnetic properties and, when used in a 100% concentration, it obviates the use of specialized materials and equipment that is required in 3He hyperpolarized gas. The use of oxygen requires specialization of the pulse sequences, but it is highly diffusible, cheap, and available, and oxygen can by used readily without modifications to the basic MRI unit.

In animal and human studies, Chen et al have shown the effectiveness of centrically reordered single-shot rapid acquisition with relaxation enhancement, a short effective echo time, and short interecho spacing (Chen, 1998; Ohno; 2001). Oxygen-enhanced MRI techniques also show great promise in functional imaging of the airways.

Degree of Confidence: MRI of the thorax for assessment of airway function, although promising, remains experimental at this time.

ULTRASOUND

Findings: Generally, the use of ultrasonography in chest imaging is limited to the evaluation of mediastinal masses or pleural disease, with or without procedural localization. In airway diseases, the numerous reflective interfaces of the air spaces severely limit the acquisition of diagnostic information. Sonography does not provide truly reproducible images of specific airways that are useful in diagnosis or in monitoring treatment responses. One study of paranasal A-mode ultrasonography compared with radiography recognized the need to screen patients with asthma for correlative sinus disease. The authors found no reliable relationship between use of A-mode ultrasonography and the standard use of plain radiography (Pfister, 1994).

PICTURES

 

Caption: Picture 1. Posteroanterior chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Mediastinal air is noted adjacent to the anteroposterior window and airtrapping extends to the neck, especially on the right side. (This image was obtained in the same patient as in Image 2.)
Picture Type: X-RAY
Caption: Picture 2. Lateral chest radiograph demonstrates a pneumomediastinum in bronchial asthma. Air is noted anterior to the trachea. (This image was obtained in the same patient as in Image 1.)
Picture Type: X-RAY
Caption: Picture 3. High-resolution CT scan of the thorax obtained during inspiration demonstrates airtrapping in a patient with asthma. Inspiratory findings are normal. (This image was obtained in the same patient as in Image 4.)
Picture Type: CT
Caption: Picture 4. High-resolution CT scan of the thorax obtained during expiration demonstrates a mosaic pattern of lung attenuation in a patient with asthma. Lucent areas (arrows) represent areas of airtrapping. (This image was obtained in the same patient as in Image 3.)
Picture Type: CT
Caption: Picture 5. High-resolution CT scan of the thorax obtained during inspiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (arrow).
Picture Type: CT
Caption: Picture 6. High-resolution CT scan of the thorax obtained during expiration in a patient with recurrent left lower lobe pneumonia shows a bronchial mucoepidermoid carcinoma (same patient as in Image 5). Note the normal increase in right lung attenuation during expiration (right arrow). The left lung remains lucent, especially the upper lobe, secondary to bronchial obstruction with airtrapping (left upper arrow). The vasculature on the left is diminutive, secondary to reflex vasoconstriction. Left pleural thickening and abnormal linear opacities are noted in the left lower lobe; these are the result of prior episodes of postobstructive pneumonia (left lower arrow).
Picture Type: CT
Caption: Picture 7. High-resolution CT scan of the thorax demonstrates mild bronchial thickening and dilatation in a patient with bilateral lung transplants and bronchial asthma.
Picture Type: CT
Caption: Picture 8. High-resolution CT scan of the thorax demonstrates central bronchiectasis, a hallmark of allergic bronchopulmonary aspergillosis (right arrow), and the peripheral tree-in-bud appearance of centrilobular opacities (left arrow), which represent mucoid impaction of the small bronchioles.
Picture Type: CT
Caption: Picture 9. Baseline high-resolution CT scan of the thorax obtained during expiration in a patient with bronchial asthma. (This image was obtained in the same patient as in Image 10.)
Picture Type: CT
Caption: Picture 10. High-resolution CT scan of the thorax obtained during expiration and after a methacholine challenge in the same patient as in Image 9. Note the greater degree of airtrapping in the posterior subpleural aspects of the right upper lobe after methacholine is administered.
Picture Type: CT
Caption: Picture 11. Graph demonstrates results in right-upper-lobe matched pairs before and after a methacholine challenge. The resulting frequency distribution of regional lung density in the mid right upper lobe demonstrates a leftward shift to lower attenuation after methacholine administration. (Image courtesy of Dr Jonathan Goldin, University of California, Los Angeles)
Picture Type: Graph
Caption: Picture 12. Coronal hyperpolarized helium-3 MRI in a patient with moderately persistent asthma who underwent imaging twice: This first image was obtained before treatment with an inhaled bronchodilator (ie, albuterol). Multiple dark areas of wedge-shaped ventilation defects improve or resolve after albuterol treatment. (This image was obtained in the same patient as in Image 13 and is courtesy of Drs T. Altes and E. de Lange, University of Virginia.)
Picture Type: MRI
Caption: Picture 13. Coronal hyperpolarized helium-3 MRI in a patient with moderately persistent asthma who underwent imaging twice: This second image was obtained 40 minutes after treatment with an inhaled bronchodilator (ie, albuterol). Multiple dark areas of wedge-shaped ventilation defects improve or resolve after albuterol treatment. The forced expiratory volume in 1 second improved from 83% of the predicted value to 93% after treatment. (This image was obtained in the same patient as in Image 12 and is courtesy of Drs T. Altes and E. de Lange, University of Virginia.)
Picture Type: MRI