This presentation is from 13th chapter of Grainger and Allison--Diagnostic Radiology A TEXTBOOK OF MEDICAL IMAGING. My aim behind all these presentation is to provide authentic images. As our all radiology revolve around images of diseases. We can put these ppts in our androids for study and references.

1. 13
Airway Disease and Chronic
Airway Obstruction
DR MUHAMMAD BIN ZULFIQAR
PGR III FCPS Services institute of Medical
Sciences/ Services Hospital Lahore
GRAINGER & ALLISON’S DIAGNOSTIC RADIOLOGY

2. • FIGURE 13-1 ■ Post-intubation tracheal stenosis
in a severe COPD patient. (A) Axial CT (lung
window). (B) Coronal oblique MPR image
(mediastinal window) along the long axis of the
trachea. (C) Coronal oblique MPR image (lung
window).

3. • FIGURE 13-1 ■ Post-intubation tracheal stenosis
in a severe COPD patient. (A) Axial CT (lung
window). (B) Coronal oblique MPR image
(mediastinal window) along the long axis of the
trachea. (C) Coronal oblique MPR image (lung
window).

4. • FIGURE 13-1, Continued ■D) Coronal oblique average image (21-mm-thick slab). Note the visibility
of the ring cartilages of the trachea. (E) Endoscopic view. There is a circumferential luminal
narrowing of the trachea extending along 2 cm associated with soft-tissue thickening which
produces the characteristic ‘hourglass’ configuration, well assessed on coronal views (C, D). Note
the roughly triangular shape on axial views (A, E) and the slightly irregular and nodular aspect on
3D image (E).

5. • FIGURE 13-1, Continued ■D) Coronal oblique average image (21-
mm-thick slab). Note the visibility of the ring cartilages of the
trachea. (E) Endoscopic view. There is a circumferential luminal
narrowing of the trachea extending along 2 cm associated with soft-
tissue thickening which produces the characteristic ‘hourglass’
configuration, well assessed on coronal views (C, D). Note the
roughly triangular shape on axial views (A, E) and the slightly
irregular and nodular aspect on 3D image (E).

6. • FIGURE 13-2 ■ Infectious tracheobronchitis.. (A) Axial CT
(mediastinal window) at the level of the distal part of the
trachea showing the irregular thickening with a lucency on
the left side (blue arrow) related to the fistulous tract. (B)
Axial CT (lung window) at the same level.

7. • FIGURE 13-2, (C) 3D
reconstruction of the
tracheobronchial tree
perfectly demonstrating
the whole stenosis and the
fistula. (D, E) Axial CT at the
level of the mainstem
bronchi showing a
significant decrease of the
bronchial thickening after
two weeks of antibiotic
treatment: (D) before and
(E) after treatment
Continued

8. • FIGURE 13-2, (C) 3D
reconstruction of the
tracheobronchial tree
perfectly demonstrating
the whole stenosis and
the fistula. (D, E) Axial CT
at the level of the
mainstem bronchi
showing a significant
decrease of the bronchial
thickening after two
weeks of antibiotic
treatment: (D) before and
(E) after treatment

9. • FIGURE 13-3 ■ Adenoid cystic
carcinoma of the trachea. (A)
Axial CT at the level of the supra-
aortic part of the mediastinum.
Soft-tissue mass arising from the
posterior wall of the trachea and
bulging into the lumen of the
trachea. (B) Sagittal reformation
showing the smooth appearance
of the surface of the tumour, and
the posterior extent of the
extraluminal tumour growth.

10. • FIGURE 13-4 ■ Atypical carcinoid tumour of the
intermediate trunk. Atypical carcinoid tumour revealed by
recent recurrent haemoptysis. (A) Axial slice (lung window)
showing the upper portion of the endobronchial lesion with
a rounded shape. (B) Axial slice (mediastinal window)
showing strong enhancement after intravenous contrast
medium

11. • FIGURE 13-4, Continued Sagittal oblique reformation
(mediastinal window) demonstrating the filled
bronchiectasis distally of the tumour. (D) Coronal
oblique reformation (lung window) showing the upper
limit of the tumour obstructing the intermediate trunk
with distal atelectasis.

12. • FIGURE 13-5 ■ Endobronchial metastasis. Patient suffering from lung and
liver metastasis from colon carcinoma. (A) Axial slice with lung window
showing the firstly appeared peribronchial metastasis. (B) Oblique
reformation along the axis of the upper segmental bronchus of the left
lower lobe. The enlarged and filled bronchus reflects the growth of the
metastasis seen 5 months earlier.

13. • FIGURE 13-6 ■ Relapsing polychondritis. (A, B) Axial CT images at
the levels of the distal part of the trachea and mainstem bronchi.
Abnormal thickening of the anterior and lateral walls of the trachea
and mainstem bronchi and right upper lobar bronchus associated
with calcium deposits. The posterior membranous wall of the
trachea is unaffected.

14. • FIGURE 13-7 ■ Late-stage relapsing polychondritis. (A) Axial CT at the
level of aortic arch in mediastinal (A) and lung windowing (B). Thickening
of the anterior and lateral walls associated with narrowing of the tracheal
lumen, which presents a circular shape. (C) Coronal oblique reformation
with minimum intensity projection: thickening of the tracheolateral walls
with tracheal luminal narrowing extending from the cervical part of the
trachea to the carina.

15. • FIGURE 13-7 ■ Late-stage relapsing polychondritis. (A) Axial CT at the level of aortic
arch in mediastinal (A) and lung windowing (B). Thickening of the anterior and lateral
walls associated with narrowing of the tracheal lumen, which presents a circular shape.
(C) Coronal oblique reformation with minimum intensity projection: thickening of the
tracheolateral walls with tracheal luminal narrowing extending from the cervical part of
the trachea to the carina.

16. • FIGURE 13-8 ■ Tracheal involvement in Crohn’s disease.
Axial CT images at the levels of subglottic and upper
thoracic parts of the trachea. Circumferential thickening of
the trachea walls associated with irregularities of the inner
surface of the posterolateral trachea wall, and slight
deformity of the tracheal lumen. Note the right aberrant
retro-oesophageal subclavian artery.

17. • FIGURE 13-8 ■ Tracheal involvement in Crohn’s
disease. Axial CT images at the levels of subglottic
and upper thoracic parts of the trachea.
Circumferential thickening of the trachea walls
associated with irregularities of the inner surface of the
posterolateral trachea wall, and slight deformity of the
tracheal lumen. Note the right aberrant retro-
oesophageal subclavian artery.

18. • FIGURE 13-9 ■ Tracheopathia
osteochondroplastica. Axial CT at the level of
the upper part of the intrathoracic trachea.
Calcified or partly calcified nodules arising from
the inner surface of the trachea which protrude
into the lumen.

19. • FIGURE 13-10 ■ Saber-sheath trachea in a COPD patient. (A) Axial
CT at the level of the upper lobes shows a significant reduction of
the coronal diameter of the trachea. Bilateral centrilobular and
paraseptal emphysematous areas are also present in the upper
lobes. (B) Coronal oblique reformation along the long axis of the
trachea. Reduction of the coronal diameter of the trachea lumen
(arrows). Note the upper part of the trachea above the thoracic
inlet has a normal appearance. (C) Endoscopic view.

20. • FIGURE 13-10 ■ Saber-sheath trachea in a COPD patient. (A) Axial
CT at the level of the upper lobes shows a significant reduction of
the coronal diameter of the trachea. Bilateral centrilobular and
paraseptal emphysematous areas are also present in the upper
lobes. (B) Coronal oblique reformation along the long axis of the
trachea. Reduction of the coronal diameter of the trachea lumen
(arrows). Note the upper part of the trachea above the thoracic
inlet has a normal appearance. (C) Endoscopic view.

21. • FIGURE 13-11 ■
Tracheobronchomegaly. (A) Axial
CT at the upper part of the chest.
Dilatation of the trachea lumen.
(B) Coronal oblique reformatted
slab with application of minimum
intensity projection. The dilatation
of the tracheal lumen is extended
to the mainstem bronchi lumen.

22. • FIGURE 13-12 ■ Tracheobronchomalacia. Axial CT and
sagittal reformation acquired during dynamic
expiratory manoeuvre. Almost complete collapse of
the trachea, (left) mainstem and (right) intermediate
bronchi lumen. The airway lumen is crescent-shaped
because of the anterior bowing of the posterior
membranous trachea.

23. • FIGURE 13-13 ■ Bronchiectasis and obliterative bronchiolitis. (A)
PA chest radiograph shows oligaemia in the lung bases with
pulmonary blood flow redistribution in the upper parts of the lungs,
and slight overinflation of the lungs predominant on the right side.
(B) Targeted image on the right lung basis in the same patient
shows tramlines and ring opacities reflecting the presence of
dilated and wall-thickened bronchi.

24. • FIGURE 13-14 ■ Cystic fibrosis. The PA
radiograph shows a slight overinflation, and the
presence of multiple thin wall ring shadows in the
right lung and the left upper lung, reflecting cystic
bronchiectasis. Some ring shadows contain air–
fluid levels.

25. • FIGURE 13-15 ■ Post-
infectious bronchiectasis.
Axial CT (left) and coronal
multiplanar reformation
(right). Bilateral
cylindrical bronchiectasis
involving the right upper
and the lower lobes. Note
the presence of bronchial
wall thickening and
mucoid impactions with
slight volume loss of the
right lower lobe. Note
lung cyst in the posterior
part of the right upper
lobe.

26. • FIGURE 13-15 ■ Post-infectious bronchiectasis. Axial CT (left) and
coronal multiplanar reformation (right). Bilateral cylindrical
bronchiectasis involving the right upper and the lower lobes. Note
the presence of bronchial wall thickening and mucoid impactions
with slight volume loss of the right lower lobe. Note lung cyst in the
posterior part of the right upper lobe.

27. • FIGURE 13-16 ■ Bronchiectasis in a patient with cystic fibrosis suffering from chronic
infectious bronchiolitis. Bilateral cylindrical, varicose and cystic bronchiectasis with
thickened walls predominating at the level of the upper lobes. (A) Axial CT at the level of the
upper lobes. Note a moderate volume loss of these lobes with some degree of alveolar
consolidation on the right side. (B) Coronal oblique reformation targeted on the left side
demonstrates the beaded configuration of varicose bronchiectasis (blue arrows) at the level
of the lingula. Note also the mucoid impaction appearing as lobulated glove-finger (orange
arrow). (C) Axial CT targeted on the left lower lobe—centrilobular nodules predominating at
the level of the lateral segment. (D) Axial maximum intensity projection (MIP) image (5-mm-
thick slab) clearly demonstrating the tree-in-bud appearance related to infectious
bronchiolitis.

28. • FIGURE 13-16 ■ Continued (D) Axial maximum
intensity projection (MIP) image (5-mm-thick
slab) clearly demonstrating the tree-in-bud
appearance related to infectious bronchiolitis.

29. • FIGURE 13-17 ■ Cystic bronchiectasis and obliterative bronchiolitis. Cystic fibrosis
in a young female patient chronically infected with P. aeruginosa, Mycobacterium
abscessus and Aspergillus fumigatus—low-dose CT performed on inspiration and
expiration with a CTDI of, respectively, 0.66 and 0.33 mGy, resulting in a DLP of,
respectively, 24 and 11 mGy/cm. (A) Axial CT at the level of the upper lobes
showing alveolar consolidation with cystic lesions predominating on the right side.
(B) Coronal oblique mIP image (3-mm-thick slab) perfectly assesses the varicose
and cystic bronchiectatic nature of the cystic lesions. (C) Sagittal coronal oblique
minimal intensity projection (mIP) image (3-mm-thick slab) targeted on the right
lung on inspiration. (D) Sagittal mIP image (3-mm-thick slab) at the equivalent level
on expiration. Note the multifocal air trapping on (D) perfectly matched with areas
of low attenuation that reflect hypoperfusion due to hypoventilation secondary to
obliterative bronchiolitis (mosaic perfusion) on (C) well assessed by adapting the
window width and window level.

30. • FIGURE 13-17 ■ Continued. (C) Sagittal coronal oblique minimal intensity
projection (mIP) image (3-mm-thick slab) targeted on the right lung on inspiration.
(D) Sagittal mIP image (3-mm-thick slab) at the equivalent level on expiration. Note
the multifocal air trapping on (D) perfectly matched with areas of low attenuation
that reflect hypoperfusion due to hypoventilation secondary to obliterative
bronchiolitis (mosaic perfusion) on (C) well assessed by adapting the window
width and window level.

31. • FIGURE 13-18 ■ Allergic bronchopulmonary aspergillosis.
Axial CT in the upper lobes. Presence of mucoid impactions
within segmental and subsegmental dilated bronchi of the
upper lobes. Small centrilobular linear branching opacities
are seen in the periphery of the right upper lobe.

32. • FIGURE 13-19 ■ Allergic bronchopulmonary aspergillosis.
Axial CT targeted on the right lung at the level of the right
upper lobar bronchus in lung windowing (A) and
mediastinal windowing (B). The oval mass located in the
posterior segment of the right upper lobe presents a hyper
attenuated component, reflecting the presence of calcium
into a large mucoid impaction within a dilated bronchus.

33. • FIGURE 13-20 ■ Dyskinetic cilia syndrome. Axial CT at
the level of the lower part of the chest. Bilateral
bronchiectasis in the right middle lobe and the left
lower lobe with some mucoid impactions. Note the
presence of bronchial wall thickening and multiple foci
of ‘tree-in-bud’ sign, reflecting infectious bronchiolitis.
This patient also has situs inversus (Kartagener’s
syndrome).

34. • FIGURE 13-21 ■ Post bone
marrow transplantation
obliterative bronchiolitis. (A)
Axial CT at the level of the lower
part of the chest. Diffuse
hypoattenuation of lung
parenchyma. Lung vessels are
reduced in number and in calibre.
Note the slight dilatation of the
bronchi lumens and the presence
of bronchial wall thickening. (B)
Low-dose axial CT performed at
short suspended end-expiration
at the same level as A. The
absence of increase in lung
attenuation and significant
reduction in lung cross-sectional
area reflect the presence of
diffuse air trapping. The complete
collapse of the bronchial lumens
in the lower lobes testifies that CT
was acquired at the end of a
forced expiratory manoeuvre.

35. • FIGURE 13-22 ■ Chronic bronchitis and obstructive lung disease. Postero-
anterior chest radiograph shows mild overinflation. A ring shadow is
visible above the left hilum (arrow), reflecting bronchial wall thickening.
There is also an accentuation of linear markings in the right lung basis.

36. • FIGURE 13-23 ■ Severe diffuse emphysema. Postero-anterior (A) and
lateral (B) chest radiographs. The diaphragm is displaced downwards,
and appears flattened. On the PA radiograph (A), the transverse cardiac
diameter is reduced. The diaphragm appears irregular in contours due to
an abnormal visibility of diaphragmatic insertions on the ribs. Note the
depression of vessels in the periphery of the lungs. On the lateral
radiograph (B), there is a widening of the sternodiaphragm angle and an
increase of dimensions of the retrosternal transradiant area.

37. • FIGURE 13-24 ■ Giant bullous emphysema. The PA chest
radiograph shows large avascular transradiant areas in the
upper and lower parts of the right lung. The bullae are
marginated with thin curvilinear opacities.

38. • FIGURE 13-25 ■ Respiratory bronchiolitis in heavy smoker.
Axial CT at the level of the upper lobes. Centrilobular ill-
defined small nodular opacities distributed in the periphery
of the upper lobes on a background of ground-glass
opacities. Some small centrilobular and paraseptal
emphysematous spaces are also present.

39. • FIGURE 13-26 ■ COPD
patient with airway
disease predominant
phenotype. Axial CT at the
levels of the upper (A) and
lower (B) parts of the chest.
Few small centrilobular and
paraseptal emphysematous
spaces in the upper lobes.
Bronchial wall thickening,
slight bronchial dilatation
and lung parenchyma
hypoattenuation reflecting
obstructive bronchiolitis in
the lower lobes.

40. • FIGURE 13-27 ■ Centrilobular emphysema. HRCT
targeted on the right lung shows multiple small
round areas of low attenuation distributed
through the lungs, mainly around the
centrilobular arteries.

41. • FIGURE 13-28 ■ Advanced centrilobular emphysema in a
smoker. Axial CT at the level of the upper lobes shows large
and coalescent areas of low attenuation with lobular
margins corresponding to advanced centrilobular
emphysematous spaces predominantly distributed on the
right side. The patient had a history of left upper lobectomy
for bronchopulmonary carcinoma. Note the thickened
bronchi related to associated airway remodelling (arrow).

42. • FIGURE 13-29 ■
Panlobular emphysema in
a patient with alpha 1-
antitryspin deficiency.
Axial CT at the levels of
the mid (A) and lower
parts (B) of the lung with
diffuse lung attenuation
and paucity of the
pulmonary vessels. The
presence of multiple thin
lines, particularly
throughout the lung
bases, reflects a distortion
of the anatomical
structure of the lung
parenchyma and
thickening of the
remaining interlobular
septa by lung fibrosis.

43. • FIGURE 13-30 ■ Paraseptal emphysema. Axial CT at
the level of the upper lobes. Predominant paraseptal
emphysema in a COPD patient appearing as areas of
low attenuation mainly distributed along the
peripheral and mediastinal pleura on the left side. Note
associated centrilobular emphysema.

44. • FIGURE 13-31 ■ Bullous
emphysema. (A) Coronal
reformat. (B) Coronal
average image (200-mm-
thick slab) giving a
rendering of chest X-ray
equivalent.

45. • FIGURE 13-32 ■ Mild persistent asthmatic
patient. Axial CT at suspended end-expiration.
Patchy areas of air trapping involving
individual lobules and segments in the lower
and right middle lobes.

46. • FIGURE 13-33 ■ Moderate
persistent asthmatic patient.
Axial CT at the levels of mid- (A)
and lower (B) parts of the lungs.
Diffuse bronchial wall thickening
with mucoid impactions in the
subsegmental and segmental
bronchi in the basilar segments
of the right lower lobe. Patchy
areas of hypoattenuation in the
anterior, lateral and
posterobasal segments of the
right lower lobe and the
posterior segment of the left
lower lobe, reflecting the
presence of small airway
remodelling.