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Teaching File COPD

Chronic Bronchitis


Usual patterns
Mucous Impaction
Cystic Fibrosis


Usual patterns

Index (in German)

Chronic Bronchitis


From the textbook (in German)

Dirty lung. Chest film. Irregular bronchovascular markings as sign of chronic inflammation of the walls of the bronchi.

Hippocratic or "watch glass" nails are signs of impaired pulmonary function in some patients. This patient suffered from bronchial carcinoma.




From the textbook (in German)

Bronchiectasis, gross view of pathologic specimen. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Bronchiectasis, gross view of pathologic specimen. Fibrous adhesions in the fissure. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Bronchiectasis. Chest film a.p. and lateral. Dense bands in both lower parts of the lungs, following the directions of bronchovascular structures. The lateral projection shows them to be in the lower lobes.

Bronchiectasis. Chest film, same film as above. The markings in the lower fields have been electronically sharpened to enhance their visibility. There is a tramline sign on the right side.

Patterns of Bronchiectasis in CT (adapted from Hansell):
(1): Axial cuts of dilated bronchi with adjacent vessel. The normal bronchus should not be wider than its accompanying vessel. If it is dilated, both structures form a signet ring (the term signet ring is also used with Lymphangioleiomyomatosis).
(2): Longitudinal cuts of dilated bronchi. This shows the deformed bronchial walls best. Visualization in lingual or middle lobe can be improved by tilting the gentry 25 degrees caudally (parallel to the bronchial direction).
(3): Mixture of dilated bronchi and nodular densities (caused by dilated bronchi, which are filled with mucous).
(4): Thick and short fingerlike structures are also caused by mucous filled bronchi. They would not be visualized with bronchoscopy, unless they had been cleared.
(5): Micronodules, also caused by filled bronchi. They can easily be overlooked.

Bronchography on both (!) sides with deformed, dilated bronchi in the lingula. This study is only of historical interest (and perhaps of esthetic value, ce qui concerne les images)

Bronchiectasis and CT - thin or thick slices? CT scan, magnified view. Thin slices of 1-2mm and a wide window setting are appropriate (left image). Aside from the dilated and deformed bronchi, their crowding is well demonstrated. This is caused by fibrous shrinking of the inflicted parts of the lung. The 8mm slices show the crowding in the middle lobe only as soft-contoured dense stripes. The neighboring bronchiectasis are not well depicted. The bronchiectasis on the left, dorsally, show up only as vague consolidation. For visualization of bronchiectasis thin slices with a high-resolution filter (HRCT) are indispensable.

Bronchiectasis in the right upper lobe (RUL) and in both lower lobes. Chest film and CT scan, magnified view. Magnified view in CT shows the stretched and dilated upper lobe bronchus up to the periphery. At this point the pleura is thickened by inflammation. The findings are also seen on the chest film. There are linear markings and flecks of density in both lower fields. In this area, CT shows marked bronchiectasis, partly filled with mucous.

Cystic bronchiectasis on both sides. They are partly filled with mucous which forms a fluid-air level. Some bronchi are completely obstructed (dorsal, on the right). Ventral on the left one can see small bronchiectasis free of mucous.

Basal bronchiectasis on the left. CT scan, magnified view. The diameter of the bronchi exceeds that of the accompanying vessel.

Basal bronchiectasis on the right. CT scan, magnified view. The diameter of the bronchi exceeds that of the accompanying vessel.

Bilateral bronchiectasis, more pronounced on the right side. CT scan. Dorsal on the right the dilated bronchi are visualized along their axis.

Cylindrical bronchiectasis. Plain chest film and CT scan, magnified view. CT shows the bronchiectasis longitudinally. The dilatation is tube-like. In the lower part (6th segment, s6) bronchiectasis are seen only as soft-contoured nodules because of mucous filling.

Cylindrical bronchiectasis in the apical segment of the right upper lobe (RUL). CT scan, magnified view.

Bronchiectasis. CT scans. There are multiple dilated bronchi in the middle lobe, lingual and in the LLL (left lower lobe). The lower image shows, on the left and dorsally, very clearly branching bronchi with thickened walls. In the periphery bronchi show up dense because they are obliterated by mucous. The upper image shows bronchi in the middle lobe with irregular contours. There are also some small spotty densities, relating to occluded bronchi. They should not be misinterpreted as nodules of other causes.

Peripheral bronchiectasis.

Cystic (sakkiforme) bronchiectasis. Chest film and CT scan, magnified views. CT shows the cystic appearance of the dilated bronchi.

Cystic bronchiectasis. Chest film, p.a. and lateral. Multiple cysts, partially with fluid air levels, in the 3rd, 6th, 9th and 10th segment (s3, s6, s9, s10), questionable also in the middle lobe.

Bilateral cystic bronchiectasis, partially with air fluid levels. CT scans.

Cylindrical to cystic bronchiectasis LUL. Chest film, bronchography and CT scans, magnified views.

Cylindrical and cystic bronchiectasis. CT scan, magnified view.

Concealed (masked) bronchiectasis. Follow up of chest films and CT scans, magnified views. Fever of unknown origin with several week's coughing. Unsuspicious chest film. CT (below, left) was reported as normal, despite the small nodules at the base of the left lung. Following antibiotic treatment, CT now reveals bronchiectasis aside of the nodules. Somehow this seems to be a minor form of mucous impaction.

Distorted and dilated bronchi (arrows), as well as crowding. CT scan, magnified view.

Bronchiectasis with peripheral air trapping (dark area). CT scan, magnified view.

Disseminated bronchiectasis. CT scan.

Traction bronchiectasis. CT scan. After radiotherapy, there is fibrous volume reduction of the right paramediastinal lung parenchyma. Ventrally the bronchi are dilated by scar traction.

Traction bronchiectasis. CT scan and coronal reconstruction. Lobar resection and thoracoplasty. The bronchi have been dilated by scar traction (arrows).

Pseudotumor, or vanishing tumor. CT follow up. First scan with mediastinal window setting, the following with "lung window". Mucous-filled bronchiectasis in right s4. At first the localized finding gave the impression of a tumor. After bronchoscopic clearing the bronchiectasis is well visualized.

Mucous retention (impaction) in bronchi. Chest film and CT scan. In the chest film there are band like densities in the right lower field, basal and lateral. CT shows small densities in s9 on the right.

Mucous impaction in s8 on the left. Chest film, magnified view and CT scan, magnified view. Glove-like densities due to mucous retention in peripheral bronchi.

Mucous impaction. Chest film and CT scan, magnified view.

Cystic Fibrosis. Chest film, a.p. and lateral. Band-like densities by mucous impaction in the upper lobe segmental bronchi.

Cystic Fibrosis. Bronchiectasis on the left. CT scans of lower lung fields. Finger-like dilated and mucous-filled bronchi on the right. Where they are cut axially, they look like nodes.




From the Textbook (in German)

Emphysema of the lungs. Gross anatomic specimen. The name defines an anatomic substrate: an irreversible enlargement of airspaces distal to terminal bronchioles with destruction of alveolar walls and local elastic fiber network, but without scar forming.

Centrilobular and panlobular emphysema. Scheme modified from Konietzko and Wandel.

Centrilobular emphysema. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Emphysema: microscopic image The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Centrilobular Emphysema and anthracosis: gross anatomic specimen The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Emphysema in chest film, p.a. and lateral:
- Hypertransparency of lung fields,
- diminished height of phrenic dome in lateral view (less than 1.5cm height),
- enlarged retrosternal space,
- enlarged sternovertebral diameter,
- straightened vascular markings with diminished arborisation but with enhanced contrast.
- The peripheral zone in the p.a. chest film (where one can see no vessels) is wider than 1cm.
- Small, droplet-shaped heart, barrel chest,
- widened intercostal spaces,
- kyphosis of thoracic spine,
- sudden transition of wide central pulmonary arteries to small vessels.

Emphysema. Chest film. The back parts of the ribs run horizontally and are wide spaced.

Hyperinflation of the lungs in status asthmaticus. In tabula the sternum is opened. The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

True emphysema. At sternotomy the lung does not collapses.The owner of this image interdicts the reproduction of his work on other websites. As long as he doesn`t ask for money you may visit his site however:

Reversible hyperinflation with asthma. Therefore NO emphysema! Chest films:
(1): Status asthmaticus. Hypertransparency, vascular rarification and depressed domes of diaphragms.
(2): After recuperation signs of hyperinflation have resolved.

Centrilobular emphysema. CT scan. Window setting is important for proper visualization. If the density of the lung is heavily diminished, lung structures might no longer be visible in a "wide" lung window setting, i.e. window 1500, center -500 HE. This is demonstrated in the left image. In such cases a lower window setting should be applied, as shown in the right picture.

Centrilobular emphysema.

Centrilobular emphysema.

Centrilobular emphysema.

Centrilobular emphysema.

Centrilobular emphysema. There are small dark empty spaces. In their center central structures (core structures) like a chimney standing up in a ruin can sometimes be discerned.

Centrilobular emphysema.

Centrilobular and paraseptal emphysema. CT scans, magnified view. There are small cyst-like spaces in the lung parenchyma, with core structures now and then. In addition, there are small peripheral (paraseptal) cysts and bullae.

Paraseptal emphysema

Paraseptal emphysema

Paraseptal emphysema (peripheral emphysema) has developed into bullae. In addition, marked centrilobular emphysema.

Paraseptal emphysema with adjacent fibrotic densities.

Bullous emphysema. Chest film. Bilateral bullae in middle and lower lung fields with compression of adjacent lung parenchyma.

Emphysema with bilateral big bullae. Caudally, the bullae are demarcated by compressed lung (see lateral projection). Hyperlucency of right middle and upper lung fields

Bullae. Chest film and CT scan. CT shows bullae to a better advantage. Nonetheless, the chest film shows the compressed lung quite well.

Lung cyst in LLL. Atypical thick wall. ©Dr. Lund, Hamburg

Bullous emphysema. Chest film and CT scans. In CT there is a diffuse hypodensity in the upper lung fields. Only the bronchovascular structures are well marked. There are ventral and dorsal bullae. Minimal parenchymal losses are better visualized in CT than in conventional radiography.

Wall of bulla. CT scans. Bullae are air filled cysts with a diameter of more than 10mm. Thickness of the wall should be less than 1mm. This should distinguish them from post infectious epithelialized cysts or from caverns. In reality, bullae frequently show thicker walls, probably by compressed or retracted lung parenchyma.

Bullae. CT scan, magnified view. Ventrally there are cystic patterns. They are partly irregular. A cyst bigger than 10mm is called bulla. It should not have a thick wall like a cavity from necrosis. But bullaefrequently show up with thick walls due to compression (or probably retraction) of the adjoining lung tissue.

Large bulla in the periphery of the mid lung field. There is a fluid-air level. Pattern of emphysema with flattened dome of diaphragm in the lateral view.

Apical bulla on the left. CT scan. Sometimes huge bullae are misinterpreted as a pneumothorax. A bulla can safely be diagnosed when there are spider-web-like lines crossing the empty space between lung and pleura.

Bulla and pneumothorax. There is a right ventral pneumothorax and a soft tissue emphysema in the right lateral thoracic wall. On the other side, one finds bullae dorsal and lateral. Is there a big bulla dorsal on the right, or is it a pneumothorax? The discrete dorsal septum (arrows) shows that these are bullae.

Emphysema (CT scan) with big spaced destruction of parenchyma (bulla). Examining the chest film someone decided this had to be a pneumothorax and placed a chest tube. CT shows spider webs crossing the empty space, indicating bullae

Emphysema and fibrosis. CT scan. Frequently, fibrotic retraction of lung tissue leads to hyperinflation of the remaining lung.

Unilateral emphysema with Swyer-James-McLeod-Syndrom. Conventional pulmonary angiography, delayed films. There is gross reduction of lung structures on the left. The mediastinum shifts to the right. Because of peripheral hypoplasy of vessels, the contrast medium remains in the central parts of the vessels.

Swyer-James-McLeod-Syndrom. Chest film, CT, Perfusion Scintigraphy, and angiography. In CT there is pronounced rarification of patterns in the left lung. Digital subtraction angiography also shows hypoplastic vessels with diminished arborisation in the left lower lung. Scintigraphy shows reduced counts on the left side.

Swyer-James-McLeod-Syndrom. Chest film in inspiration and expiration. There are marked differences in density between left and right. The left lung shows marked rarification and hypoplasy of vessels.

CT in Swyer-James-McLeod-Syndrom. There are pronounced differences in vessel size and in density of the left lung compared to the right.

Unilateral bright lung on the right due to unilateral giant bullae emphysema. Marked mediastinal shift to the left. The diaphragm is depressed and flattened. This impairs respiratory excursions.


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