Lingular division of the left lung: Only superior and inferior bronchi?

The lingular segment bronchi usually bifurcate into superior lingular (B4 ) and inferior lingular (B5 ) segmental bronchi. We report 32 horizontally bifurcated lingular segment bronchi cases, analyzing the bronchovascular variations and the perioperative outcomes. All patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography between January 2019 and January 2022. The bronchovascular patterns were analyzed for each patient. A consecutive 5280 patients were included, and 32 cases of this malformation were identified. The incidence of the lateral (B4 ) and medial (B5 ) lingular segmental bronchi is 0.6%. The A4 and A5 arise separately in 21 (65.6%) patients. In 9 (28.1%) patients, the A4 a arises from the common trunk of A4 + 5 . In 2 (6.3%) patients, the A4 arises from the interlobe artery, while A5 is a mediastinal lingular artery. The common trunk of V4 a + b is found in 19 (59.4%) patients. The V5 is the least changeable of the segmental bronchi veins. Among the 32 patients, five patients had an LS4 segmentectomy. The surgical details of the five patients are summarized. The laterally and medially bifurcated lingular bronchus pattern is a rare anomaly. It implies that the lingular bronchus is not only superiorly and inferiorly bifurcated.

Boyden's triad in the left lung: an interesting phenomenon.

OBJECTIVES: Boyden's triad of the right lung was first proposed in 2021. Here, we report 5 cases of this malformation found in the left lung. METHODS: A total of 5280 patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography between January 2019 and January 2021, prior to surgery; 5 cases of this malformation were identified in the left lung. Bronchovascular patterns were analysed in each patient. RESULTS: The incidence rate of Boyden's triad in the left lung was 0.1%. This malformation was further divided into B3 on B4+5 type and B3 on B4 type. In B3 on B4+5 type, B3 was shifted downwards on the common trunk of B4+5, and A3 arose from the common trunk of A4+5 running alongside B3. In B3 on B4 type, B3 was shifted downwards on B4. A4 and A5 appeared separately. A3 arose from A4, running alongside B3; A5 arose from the common trunk of A8 - 10, and there was also an extraordinary 'posterior vein' (V. post): V1+2c. The incidence of V. post was 0.17%. An additional 'fissure' lies longitudinally between S1+2 and S3+4+5, nearly perpendicular to the oblique fissure, dividing the upper lobe into 'two lobes'. CONCLUSIONS: The B3 downwards-shifting malformation can be found on both lungs, and this is the first description of Boyden's triad in the left lung; it appears to be much rarer than that in the right lung, with some accompanying unique variations.

Thoracoscopic Anatomic Left Lower Lobe S6b Subsegmentectomy.

Although thoracoscopic lung segmentectomy has made significant achievements, there is little known about how to perform subsegmentectomy, which can also acquire a safe margin for curability but with more pulmonary volume reserved. This report presents the surgical procedure for subsegmental anatomic resection of left lower lobe subsegment 6b guided by the simulation of bronchovascular branching through the use of 3-dimensional computed tomographic bronchography and angiography.

Boyden's triad: the past, present and future.

OBJECTIVES: The B3 downwards-shifting malformation was first proposed by Boyden in 1950. Here, we report 14 cases of this malformation in the right lung and the first case of segmentectomy for this malformation. METHODS: All patients with pulmonary lesions underwent three-dimensional computed tomography bronchography and angiography (3D-CTBA) between January 2019 and January 2020, prior to surgery. A consecutive 2356 patients were included, and 14 cases of this malformation were identified; bronchovascular patterns were analysed in each patient. RESULTS: The incidence of this malformation was 0.6%. It was further divided into 3 types: over downwards-shift, partial downwards-shift and normal downwards-shift. The normal downwards-shift type was the most common (8/14), where B3 shifted downwards completely to merge with B4 + 5. In the partial downwards-shift (5/14), only part of the B3 shifted. In the over downwards-shift type (1/14), both B3 and B1b shifted downwards. A bifurcated right upper lobe （RUL) bronchus (B1 defective) was observed in 3 cases. The incidence of V1a, V1b, V2a, V2b, V2c, V3a, V3b and V3c was 100% (14/14). The incidence rates of A1, A3a and A3b were 100% (14/14). The incidence of A2 rec and A2 asc was 92.9% (13/14) and 71.4% (10/14), respectively. CONCLUSIONS: The B3 downwards-shifting malformation or 'Boyden's triad' is a rare anomaly. Anatomical exploration of this malformation is important for surgery.

Modified left subsuperior segmentectomy via 2-cm uniportal video-assisted thoracoscopic surgery.

Independent subsuperior segmentectomy (S*) via uniportal video-assisted thoracoscopic surgery (VATS) has rarely been reported. We describe our modified technique of performing simplified left subsuperior segmentectomy for a lung nodule, via 2-cm uniportal VATS. The uniportal approach was different from the traditional approach made by blunt separation into the thorax without electrocautery. Our modified technique minimizes damage to the intercostal nerves and muscles. We also simplified the subsuperior segmentectomy procedure according to the findings of three-dimensional (3D) computed tomography angiography and bronchography. Combining these two techniques achieves a new more minimally invasive method for subsuperior segmentectomy.

Lung ultrasound vs chest radiography in the diagnosis of children pneumonia: Systematic evidence.

BACKGROUND: The aim of this meta-analysis was to evaluate the diagnostic value of lung ultrasound (LUS) in comparison to chest radiography (CXR) in children with pneumonia. METHODS: Computer-based retrieval was performed on PubMed and EMBASE. Quality was evaluated according to the quality assessment of diagnostic accuracy studies-2, and Meta-Disc was adopted to perform meta-analysis. Heterogeneity was assessed using Q and I statistics. The pooled sensitivity, specificity, and diagnostic odds ratio (DOR) with 95% confidence intervals (CIs) as the primary outcomes were calculated for each index test. RESULTS: Twenty two studies with a total of 2470 patients met the inclusion criteria. Our results showed that the pooled sensitivity, specificity, and DOR for children with pneumonia diagnosed by LUS were 0.95 (95% CI: 0.94 to 0.96), 0.90 (95% CI: 0.87 to 0.92), and 137.49 (95% CI: 60.21 to 313.98), respectively. The pooled sensitivity, specificity, and DOR for pediatric pneumonia diagnosed by CXR was 0.91 (95% CI: 0.90 to 0.93), 1.00 (95% CI: 0.99 to 1.00), and 369.66 (95% CI: 137.14 to 996.47), respectively. Four clinical signs, including pulmonary consolidation, positive air bronchogram, abnormal pleural line, and pleural effusion were most frequently observed using LUS in the screening of children with pneumonia. CONCLUSIONS: The available evidence suggests that LUS is a reliable, valuable, and alternative method to CXR for the diagnosis of pediatric pneumonia.

CT Manifestations and Clinical Characteristics of 1115 Patients with Coronavirus Disease 2019 (COVID-19): A Systematic Review and Meta-analysis.

RATIONALE AND OBJECTIVES: We aimed to assess the prevalence of significant computed tomographic(CT) manifestations and describe some notable features based on chest CT images, as well as the main clinical features of patients with coronavirus disease 2019(COVID-19). MATERIALS AND METHODS: A systematic literature search of PubMed, EMBASE, the Cochrane Library, and Web of Science was performed to identify studies assessing CT features, clinical, and laboratory results of COVID-19 patients. A single-arm meta-analysis was conducted to obtain the pooled prevalence and 95% confidence interval (95% CI). RESULTS: A total of 14 articles (including 1115 patients) based on chest CT images were retrieved. In the lesion patterns on chest CTs, we found that pure ground-glass opacities (GGO) (69%, 95% CI 58-80%), consolidation (47%, 35-60%) and "air bronchogram sign" (46%, 25-66%) were more common than the atypical lesion of "crazy-paving pattern" (15%, 8-22%). With regard to disease extent and involvement, 70% (95% CI 46-95%) of cases showed a location preference for the right lower lobe, 65% (58-73%) of patients presented with ≥3 lobes involvement, and meanwhile, 42% (32-53%) of patients had involvement of all five lobes, while 67% (55-78%) of patients showed a predominant peripheral distribution. An understanding of some important CT features might be helpful for medical surveillance and management. In terms of clinical features, muscle soreness (21%, 95% CI 15-26%) and diarrhea (7%, 4-10%) were minor symptoms compared to fever (80%, 74-87%) and cough (53%, 33-72%). CONCLUSION: Chest CT manifestations in patients with COVID-19, as well as its main clinical characteristics, might be helpful in disease evolution and management.

The value of the air bronchogram sign on CT image in the identification of different solitary pulmonary consolidation lesions.

The aim of the present study is to investigate the value of air bronchogram sign on computed tomography (CT) image in the differential diagnosis of solitary pulmonary consolidation lesions (SPLs).A total of 105 patients (including 39 cases of lung cancer, 43 cases of tuberculosis, and 23 cases of pneumonia) with SPLs were evaluated for the CT features of air bronchogram sign in this retrospective study. The shape and lumen of the bronchi with air bronchogram sign, the length of the involved bronchus with air bronchogram sign, the length of lesion on the same plane and direction, and the ratio between the length of the involved bronchus and that of the lesion were evaluated.In total, there were 172 segmental and subsegmental bronchi involved. There were 62 segmental and subsegmental bronchi involved among 39 lung cancer cases, 77 segmental and subsegmental bronchi involved among 43 tuberculosis cases, and 33 segmental and subsegmental bronchi involved among 23 pneumonia cases. The shape of the bronchi with air bronchogram sign was significantly different among lung cancer, tuberculosis, and pneumonia (P < .05). The lumen of the bronchi with air bronchogram sign was also significantly different among the 3 SPLs (P < .05). The length of the involved bronchus with air bronchogram sign and the ratio between the length of the involved bronchus and that of the lesion were significantly different between lung cancer and tuberculosis (P < .05), or between lung cancer and pneumonia (P < .05), but not between tuberculosis and pneumonia (P > .05). No significant difference was found in the length of lesion among the 3 SPLs (P > .05).The shape and lumen of the bronchi with air bronchogram sign can be used to distinguish lung cancer, tuberculosis, and pneumonia. The length of the involved bronchus with air bronchogram sign and the ratio between the length of the involved bronchus and that of the lesion can be used to distinguish lung cancer from tuberculosis and pneumonia.

Selective Management of Multiple Bronchopleural Fistulae in a Pediatric Patient on Extracorporeal Membrane Oxygenation: A Multidisciplinary Approach.

INTRODUCTION: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral bronchopleural fistulae (BPF) using minimally invasive techniques. In this study, we present a previously healthy 14-year-old male hospitalized with 2009 H1N1 influenza and methicillin-resistant Staphylococcus aureus coinfection complicated by severe acute respiratory distress syndrome and multifocal necrotizing pneumonia, with significant lung tissue damage requiring prolonged extracorporeal membrane oxygenation (ECMO) support. METHODS: The development of multiple BPFs precluded lung recruitment necessary to wean from ECMO. Treatment options were very limited and endobronchial valves were considered. However, localizing single airleaks with a fogarty balloon is normally the technique to determine appropriate location to place the valves. With multiple fistulae, this technique would be ineffective. Therefore, the patient was brought to interventional radiology and bronchography was performed for selective fistula mapping. With this precise localization, the multiple fistulae were ultimately controlled using image-guided embolization and the placement of multiple endobronchial valves. The success of this intervention enabled positive pressure ventilator support and rehabilitation required for weaning from ECMO support. CONCLUSION: This case highlights the successful utilization of a multidisciplinary approach to numerous bilateral BPFs using minimally invasive techniques.

Air bronchogram in pleomorphic carcinoma of the lung is associated with favorable prognosis.

BACKGROUND: Pleomorphic carcinoma (PC) of the lung is a rare histological type of lung carcinoma. The association between computed tomography (CT) findings and histology with outcome remains unclear. We examined the relationships between CT features and histopathologic findings, and evaluated the impact of CT features and other clinicopathologic factors on survival. METHODS: Thirty-five consecutive patients with PC of the lung who underwent surgery between October 2010 and December 2015 were enrolled in this study. The 35 tumors were classified with or without air bronchogram in the tumors, and with or without intratumoral ground glass opacity (GGO) on CT. RESULTS: Air bronchogram and GGO were detected in 12 (34.3%) and 5 (14.3%) tumors, respectively. Multivariate analysis revealed that air bronchogram was significantly associated with the presence of adenocarcinoma components with lepidic growth patterns (P = 0.005), and predominance of adenocarcinomas (P = 0.026). GGO was significantly associated with the presence of adenocarcinoma component with lepidic growth pattern (P = 0.010). Air bronchogram was an independent favorable prognostic factor for overall survival, whereas GGO did not have a significant effect on survival. CONCLUSION: Air bronchogram observed in PCs of the lung is strongly related with histological components of the tumor and favorable outcome.

Thoracoscopic Medial-Basal Segment Segmentectomy.

The technical details and anatomic features of medial-basal segment (S7) segmentectomy have not been reported. We report here thoracoscopic S7 segmentectomy and S7a subsegmentectomy and explain the anatomic knowledge necessary to perform S7 segmentectomy, especially the importance of recognizing bronchus (B7) branching patterns before surgery.

Thoracoscopic Subsuperior Segment Segmentectomy.

To date, anatomic subsuperior segment (S∗) segmentectomy has not yet been reported. Herein we report the technical details of thoracoscopic anatomic S∗ segmentectomy and the anatomic features of the S∗.

Analysis of variation in bronchovascular pattern of the right middle and lower lobes of the lung using three-dimensional CT angiography and bronchography.

OBJECTIVES: General thoracic surgeons must be familiar with anatomical variation in the pulmonary vessels and bronchi. Here, we analyzed the bronchovascular pattern of the right middle lobe (RML) and right lower lobe (RLL) of the lung using three-dimensional CT angiography and bronchography (3DCTAB). METHODS: We reviewed the anatomical patterns of the pulmonary vessels and bronchi in 270 patients using 3DCTAB images. RESULTS: The branching patterns of vessels and bronchi of RML and S6 were classified according to the number of stems. The single-stem type was the most common, except in the artery of the RML, for which the two-stem type was the most common. The artery and bronchus of S*, which is an independent segment between S6 and S10, were observed in 20.4% of cases. The branching pattern of A7 (B7) was classified into four types. The A7a (B7a) type was observed in 74.8% of cases, and was the most common. The branching pattern of the artery and bronchus of S8-10 was classified into five and three types, respectively. The A8 and A9 + A10 type, and the B8 and B9 + B10 type, were observed in 68.1 and 80.4% of cases, respectively, and were the most common types. The branching pattern of V8-10 was more complex than that of A8-10 and B8-10. CONCLUSION: We explored the bronchovascular patterns of RML and RLL and their frequencies using a large number of 3DCTAB images. Our data can be used by thoracic surgeons to perform safe and precise lung resections.

Tracheobronchomalacia diagnosed by tracheobronchography in ventilator-dependent infants.

BACKGROUND: Tracheobronchomalacia prevalence in premature infants on prolonged mechanical ventilation is high. OBJECTIVE: To examine the prevalence of tracheobronchomalacia diagnosed by tracheobronchography in ventilator-dependent infants, and describe the demographic, clinical and dynamic airway characteristics of those infants with tracheobronchomalacia. MATERIALS AND METHODS: This retrospective review studies 198 tracheobronchograms performed from 1998 to 2011 in a cohort of 158 ventilator-dependent infants <2 years of age. Dynamic airway assessment during tracheobronchography determined the optimal positive end-expiratory pressure to maintain airway patency at expiration in those infants with tracheobronchomalacia. RESULTS: Tracheobronchograms were performed at a median age of 52 weeks post menstrual age. The primary diagnoses in these infants were bronchopulmonary dysplasia (53%), other causes of chronic lung disease of infancy (28%) and upper airway anomaly (13%). Of those with bronchopulmonary dysplasia, 48% had tracheobronchomalacia. Prematurity (P=0.01) and higher baseline - pre-tracheobronchogram positive end-expiratory pressure (P=0.04) were significantly associated with tracheobronchomalacia. Dynamic airway collapse during tracheobronchography showed statistically significant airway opening at optimal positive end-expiratory pressure (P < 0.001). There were no significant complications noted during and immediately following tracheobronchography. CONCLUSION: The overall prevalence of tracheobronchomalacia in this cohort of ventilator-dependent infants is 40% and in those with bronchopulmonary dysplasia is 48%. Infants born prematurely and requiring high pre-tracheobronchogram positive end-expiratory pressure were likely to have tracheobronchomalacia. Tracheobronchography can be used to safely assess the dynamic function of the airway and can provide the clinician the optimal positive end-expiratory pressure to maintain airway patency.

Using air bronchograms on multi-detector CT to predict the invasiveness of small lung adenocarcinoma.

PURPOSE: To investigate the prevalence of multidetector CT (MDCT) air bronchograms and their value in predicting the invasiveness of lung adenocarcinomas. METHODS: MDCT scans of 606 nodules in 582 patients with a lung adenocarcinoma less than 2cm in diameter confirmed by surgery and pathology were reviewed. Air bronchograms were classified into three patterns: type I, bronchus with intact lumen; type II, bronchus with dilated or tortuous lumen; and type III, bronchus with obstructed lumen. RESULTS: Air bronchograms were demonstrated on MDCT in 210 of 606 (34.7%) lung adenocarcinomas with 16.6% (35/211) preinvasive lesions (PL), 30.5% (50/164) minimally invasive adenocarcinoma (MIA), and 54.1% (125/231) invasive adenocarcinoma (IAC) (P=0.000); 18.3% (44/240) pure ground-glass nodules (GGNs), 44.2% (137/310) mixed GGNs, and 51.8% (29/56) solid nodules (P=0.000). Type I was slightly more common in MIA (36/164, 22.0%) than IAC (40/231, 17.3%) and PL (30/211, 14.2%) but without differences among them (P=0.147). Type II (PL: 5/211, 2.4%; MIA: 13/164, 7.9%; IAC: 53/231, 22.9%) and type III (PL: 0/211; MIA: 1/164, 0.6%; IAC: 32/231, 13.9%) were observed more frequently with increasing lung adenocarcinoma invasiveness (both P=0.000). CONCLUSIONS: The prevalence and patterns of air bronchograms on MDCT can predict the invasiveness of small lung adenocarcinomas.

Is bronchial wall imaging affected by temporal resolution? comparative evaluation at 140 and 75 ms in 90 patients.

PURPOSE: To evaluate the influence of temporal resolution (TR) on cardiogenic artefacts at the level of bronchial walls. MATERIAL AND METHODS: Ninety patients underwent a dual-source, single-energy chest CT examination enabling reconstruction of images with a TR of 75 ms (i.e., optimized TR) (Group 1) and 140 ms (i.e., standard TR) (Group 2). Cardiogenic artefacts were analyzed at the level of eight target bronchi, i.e., right (R) and left (L) B1, B5, B7, and B10 (total number of bronchi examined: n = 720). RESULTS: Cardiogenic artefacts were significantly less frequent and less severe in Group 1 than in Group 2 (p < 0.0001) with the highest scores of discordant ratings for bronchi in close contact with cardiac cavities: RB5 (61/90; 68%); LB5 (66/90; 73%); LB7 (63/90; 70%). In Group 1, 78% (560/720) of bronchi showed no cardiac motion artefacts, whereas 22% of bronchi (160/720) showed artefacts rated as mild (152/160; 95%), moderate (7/160; 4%), and severe (1/160; 1%). In Group 2, 70% of bronchi (503/720) showed artefacts rated as mild (410/503; 82%), moderate (82/503; 16%), and severe (11/503; 2%). CONCLUSION: At 75 ms, most bronchi can be depicted without cardiogenic artefacts. KEY POINTS: • Quantitative CT helps analyze morphologic changes in COPD patients • Cardiogenic artefacts may hamper precise analysis of bronchial dimensions • Temporal resolution of CT acquisitions is an important parameter for bronchial imaging.

Mosaic Attenuation: Etiology, Methods of Differentiation, and Pitfalls.

Mosaic attenuation is a commonly encountered pattern on computed tomography that is defined as heterogeneous areas of differing lung attenuation. This heterogeneous pattern of attenuation is the result of diverse causes that include diseases of the small airways, pulmonary vasculature, alveoli, and interstitium, alone or in combination. Small airways disease can be a primary disorder, such as respiratory bronchiolitis or constrictive bronchiolitis, or be part of parenchymal lung disease, such as hypersensitivity pneumonitis, or large airways disease, such as bronchiectasis and asthma. Vascular causes resulting in mosaic attenuation are typically chronic thromboembolic pulmonary hypertension, which is characterized by organizing thrombi in the elastic pulmonary arteries, or pulmonary arterial hypertension, a heterogeneous group of diseases affecting the distal pulmonary arterioles. Diffuse ground-glass opacity can result in a mosaic pattern related to a number of processes in acute (eg, infection, pulmonary edema), subacute (eg, organizing pneumonia), or chronic (eg, fibrotic diseases) settings. Imaging clues that can assist the radiologist in pinpointing a diagnosis include evidence of large airway involvement, cardiovascular abnormalities, septal thickening, signs of fibrosis, and demonstration of airtrapping at expiratory imaging.