1. Etienne Leroy Terquem – Pierre L’Her
Bronchial syndrome
Atelectasis
Draining bronchus
Bronchiectasis
Etienne Leroy Terquem – Pierre L’Her
SPI / ISP
Soutien Pneumologique International / International Support for Pulmonology

2. Atelectasis Consequence of the obstruction of a bronchus
intrinsic (tumor, foreign body, inflammatory stenosis)
or extrinsic (compression by adenopathy or tumor)
The alveolar air gradually disappears and the lung tissue is retracted.
The retraction can involve one segment, one lobe or the whole lung

3. Main etiologies of atelectasis
Bronchial cancer
Tuberculosis
Extrinsic compression by adenopathy TB (++ children) or malignant
Foreign body (+ + + young children, not always Radio opaque)
Less common causes:
Asthma
Chronic bronchitis
Viral or bacterial pneumonia
Atelectasis after thoracic or abdominal surgery, after trauma
Many other rare etiologies: benign tumor, endobronchial metastasis, lymphoma, granulomatous inflammation regardless of etiology, bronchiolitis, cystic fibrosis, ...

4. ATELECTASIS
The radiographic appearance is an opacity, like a consolidation but:
Systematized (in contact with a fissure)
Retractile (decrease volume)
Homogeneous
Without air bronchogram
With a variable size: a segment, a lobe, the lung

5. M 59 y. Hemoptysis
Smoking = 40 pack-years
AFB sputum negative

6. Cancer Atelectasis of the right upper lobe Endoscopy: neoplastic bud
Ascension of the small fissure = Retraction of RUL
Small fissure in the normal position, horizontal, in pneumonia
Atelectasis of the right upper lobe
M 59 y. Hemoptysis
Smoking = 40 pack-years
AFB sputum negative
Endoscopy: neoplastic bud
in the RUL bronchus
Cancer

7. Male,75 years old, smoker, chronic cough and one episode of hemoptisis

8. Right lower lobe atelectasis by bronchial cancer
Male,75 years old, smoker, chronic cough
and one episode of hemoptisis
Retractile opacity who does not
erase the edge of the heart
Right lower lobe atelectasis by bronchial cancer

9. Middle lobe atelectasis

10. Partial atelectasis of the right superior lobe by cancer

11. Man, 56 years old. High fever, right abdominal and thoracic pain, Muscular defense of the right hypochondrium, X-ray: Middle lobe atelectasis

12. Liver abcess: the reduction of right hemidiaphragm mobility leads to atelectasis above the diaphragm «passive atelectasis»

13. Left upper lobe atelectasis by cancer
Smoker 60 pack-years. Hemoptysis, thoracic pain and dyspnea AFB sputum negative
Left upper lobe atelectasis by cancer

15. RUL consolidation by cancer Atelectasis in the process of constitution
Notice the association with a big hilar round mass
A.Khallil and coll. EMC 386 C

16. Smoker 40 pack-years Hemoptisis Left anterior thoracic pain and cough.
Recent weight loss & asthenia - AFB sputum negative

17. Left upper lobe atelectasis by cancer
Smoker 40 pack-years Hemoptisis
Left anterior thoracic pain and cough.
Recent weight loss & asthenia - AFB sputum negative
Fissure
Retraction
of LUL
Left upper lobe atelectasis by cancer
Notice the round mass on the left hilus

18. Atelectasis + round hilar mass:
In adults = most often cancer
In children = most often TB

19. 1 year old child
TB primary

20. 1 year old child TB primary
Bilateral adenopathies, Left lower lobe atelectasis : compression
of the left inferior bronchus by mediastinal adenopathies

21. But not always…
Look for AFB in sputum
systematiquely
Cancer

22. AFB + ..
W 37 years old, cough and dyspnea. 22

23. Classic retractile evolution with TB treatment
Previous case: evolution under TB treatment. Notice the retractile evolution with ascension of the small fissura (3  and 6 monthes treatment)
Classic retractile evolution with TB treatment 23

24. Opacity of the whole left lung field
Do you think this is an atelectasis of the left lung?

25. No Opacity of the whole left lung field
Do you think this is an atelectasis of the left lung? No
The mediastinum is
pushed by the opacity =
Great abundance
pleurisy

26. Whole left lung atelectasis
Retraction
Whole left lung atelectasis

27. Compressive pleural effusion
Pushing back
Atelectasis
Retraction

28. Draining bronchus -TB cavern +++ - bacterial nonTB abcess +/-

29. Small TB cavern with a draining bronchus
Silhouette sign
Opacity does not erase
the left side of the heart
Small TB cavern with a draining bronchus
associated with a lower lobe TB pneumonia

30. TB cavity Notice the draining bronchus and right axillar infiltrate

31. Bronchiectasis
Bronchial disease characterized by a permanent increase in bronchial caliber
The cartilaginous framework of the bronchial wall
is destroyed or broken up

32. Figure 2. Normal Lung and Airways (Panel A) bronchi steadily declining gauge going towards the periphery
and the Lung of a Patient with Bronchiectasis (Panel B). In Panel B, bronchiectasis is primarily in the lower lobe, which is the most common distribution. And also in lingula The saccular dilatations and grape-like clusters with pools of mucus are signs of severe bronchiectasis.
Barker A. N Engl J Med 2002;346:

33. Bronchiectasis: etiologies
Located
Pulmonary TB
Bacterial / viral infection in children (measles, whooping cough ..)
Foreign body
Bronchial stenosis, extrinsic compression(adenopathy)
Diffuses
Bacterial or viral infection in children (measles, whooping cough ..) TB
Cystic fibrosis
Other congenital diseases: Situs inversus, Imotile cilia Syndrome
Dysglobulinemia, chronic immune deficiency, autoimmune diseases ...

34. Bronchiectasis: clinical features
Bronchopulmonary infections repeated
Hemoptysis
Significant, Chronic and often purulent sputum, with AFB negative
Frequent history of TB or
Severe respiratory infection in early childhood
Bronchiectasis is a frequent and underestimated pathology, especially in countries with high incidence of TB and
childhood lung diseases

35. Bronchiectasis radiological features
Round or cylindric images (clarity with thick or thin wall)
Sometimes with fluid level if active infection
Localized in a lobe or a segment, or diffuse
The lipiodol bronchography
is replaced by the scanner

36. Bronchectasis (opacification with iodin hydrosoluble solution)
“Ampullary
Saccular“
Bronchectasis (opacification with iodin hydrosoluble solution)

37. Bronchiectasis “Cylindrical“
(opacification with iodin hydrosoluble solution)

38. chronic cough with morning
abundant sputum. Repeted
bronchial infections and frequent
antibiotic treatments.
Typical railway picture in middle lobe & RLL with associated round cavities : Bronchiectasis

39. Railway picture : Middle lobe bronchiectasis
Another case
Railway picture : Middle lobe bronchiectasis

40. Railway picture : Middle lobe bronchiectasis
With CT scan the diagnosis is obvious. Bronchography is not available now, you don’t have scanner. You must be able to identify
Bronchiectasis on CXR
Railway picture : Middle lobe bronchiectasis

41. Unilateral bronchiectasis of the left lower lobe
Chronic purulent sputum
Unilateral bronchiectasis of the left lower lobe

42. Bilateral bronchiectasis

43. Digital hippocratism is often associated with bronchiectasis

44. Female, 25 y, chronic cough and purulent sputum
Female, 25 y, chronic cough and purulent sputum * Measles at the age of 6 years
* Bronchorrhea

45. (1 case/ 2000 births in Europa)
Young woman, 20 y, repeated bronchus infections from a very early age, and gradual respiratory insufficiency
MUCOVISIDOSIS
(1 case/ 2000 births in Europa)

46. Right severe bronchiectasis, Retractile sequela of extensive TB
CXR from Lao TB
Prevalence survey
Right severe
bronchiectasis,
Retractile sequela
of extensive TB
of the right lung
Bronchiectasis is very frequent
and underestimated, in countries
with high TB incidence

47. Bronchial syndrome Dilation of bronchus, Bronchiectasis
You must be able to identify
Atelectasis
Draining bronchus
Bronchiectasis
Dilation of bronchus, Bronchiectasis
is a common disease with many etiologies:
Sequelae of TB
Effects of early childhood infections (Measles + + +, pertussis),
Congenital malformations (rare)
Not to be confused with TB cavitations