Bronchiolitis and Bronchiolar Disorders.

Bronchioles are noncartilaginous small airways with internal diameter of 2 mm or less, located from approximately the eighth generation of purely air conducting airways (membranous bronchioles) down to the terminal bronchioles (the smallest airways without alveoli) and respiratory bronchioles (which communicate directly with alveolar ducts and are in the range of 0.5 mm or less in diameter). Bronchiolar injury, inflammation, and fibrosis may occur in myriad disorders including connective tissue diseases, inflammatory bowel diseases, lung transplant allograft rejection, graft versus host disease in allogeneic stem cell recipients, neuroendocrine cell hyperplasia, infections, drug toxicity (e.g., penicillamine, busulfan), inhalation injury (e.g., cigarette smoke, nylon flock, mineral dusts, hard metals, Sauropus androgynous); idiopathic, common variable immunodeficiency disorder, and a host of other disorders or insults. The spectrum of bronchiolar disorders is wide, ranging from asymptomatic to fatal obliterative bronchiolitis. In this review, we discuss the salient clinical, radiographic, and histological features of these diverse bronchiolar disorders, and discuss a management approach.

Classification of broncholiths and clinical outcomes.

BACKGROUND AND OBJECTIVE: We evaluated effective treatments of broncholithiasis based on its radiographical and bronchoscopic features. METHODS: This retrospective study conducted at Samsung Medical Center, Korea enrolled patients who were suspected of having broncholithiasis based on chest computed tomography (CT). The broncholiths were classified as intraluminal, mixed (both intraluminal and extraluminal) and extraluminal based on chest CT and bronchoscopic findings. RESULTS: The study enrolled 46 patients between 1995 and 2009. Symptoms included cough (n = 21, 45.7%), hemoptysis (n = 19, 41.3%) and purulent sputum (n = 11, 23.9%). Cough was more common in intraluminal boncholiths than in other type of broncholiths (P = 0.03). Based on chest CT, there were 15 (32.6%) intraluminal, 15 (32.6%) mixed and 16 (34.8%) extraluminal broncholiths. All 15 intraluminal broncholiths were removed completely via flexible (n = 2) or rigid (n = 13) bronchoscopy. For the 15 mixed broncholiths, seven (46.7%) bronchoscopic interventions were performed, but complete removal of the broncholiths was not accomplished. Six (40%) mixed and four (25%) extraluminal broncholiths were treated by surgical resection for symptom control. None of the patients who underwent surgical resection suffered morbidity or postoperative mortality. CONCLUSIONS: The treatment of broncholithiasis should be based on chest CT and bronchoscopic findings. Intraluminal broncholiths can be removed via bronchoscopy, while surgery should be considered for symptomatic mixed or extraluminal broncholiths.

[Classification of occupational bronchial diseases: matters of controversy, open problems].

Current national classification of occupational bronchitis lacks to consider drastic changes in understanding pathogenesis of bronchial diseases over the recent decade, that leads to misunderstanding between occupational therapists and general practitioners in using this classification. The authors suggested a variant to classify occupational bronchial diseases: chronic occupational nonobstructive (simple) bronchitis and occupational COPD, that correspond to approaches accepted by international medical community. Tracheobronchial dyskinesia, asthmatic bronchitis and chronic pneumonia should be excluded from the classification.

[Clinical classification of 288 cases of bronchial tuberculosis based on an expert consensus].

OBJECTIVE: To study the clinical application and significance of the recently published expert consensus on endobronchial tuberculosis (EBTB). METHODS: A retrospective analysis of 288 cases of EBTB hospitalized in Tianjin Haihe Hospital from May 2005 to April 2010 was carried out. The classification and typing of the disease were based on a consensus report recently published by Chinese Journal of Tuberculosis and Respiratory Diseases. Chi-square test was performed to analyze the differences between groups. RESULTS: Of the 288 cases of EBTB, 47.9% (138/288) was classified as Type I (Inflammatory infiltrative), 33.3% (96/288) as Type II (ulcerous necrotic), 5.2% (15/288) as Type III (granulomatous hyperplastic), 7.3% (21/288) as Type IV (scar stricture) and 0.4% (1/288) as Type V (Bronchomalacia), respectively. There were 17 cases (5.9%) classified as a mixed type with a combination of Type IV or Type V disease with 1 or more of the other types. 37.5% (108/288) of the patients were young females, while young and middle-aged patients with type I and type II diseases accounted for 74.7% (215/288) of the cases, much more than old aged patients (6.6%, 19/288). 97.2% (n=280) of the cases suffered from secondary pulmonary tuberculosis. In 107 cases, the disease was located in the left, 162 cases in the right, while in 109 cases the right upper lobe bronchus was involved, and right main bronchus in 36 cases, 3 cases and 58 cases in left upper lobe with and without lingular segment, 10 cases in lingular segment only. Chest CT showed that local mucosal thickening of the trachea or bronchus was evident in 40.3% (116/288); toothed or spike protuberance in 30.9% (89/288), bronchial obstruction in 11.1% (32/288), and bronchial stenosis in 87.9% (253/288). The negative rate of sputum in the first month after interventional therapy was 60.2% (56/93), significantly higher than that in non-interventional therapy group (23.1%, 18/78). CONCLUSION: The new consensus report on EBTB was clinically useful for classification and typing of the disease, and for the selection of treatment modalities.

The pathologist's approach to small airways disease.

The small airways constitute a significant compartment of the lung, and diseases therein are not uncommon, occurring in a wide variety of diseases, either as a primary bronchiolar disorder or as a component of local or systemic disease affecting multiple anatomical compartments. Unlike the idiopathic interstitial pneumonias, there is as yet no consensus classification system for bronchiolar disorders, and a multidisciplinary approach to their classification is discussed. Whereas some conditions show relatively characteristic histological features, others show non-specific or subtle changes that rely on a combination of clinical, radiological and pathological information for accurate final diagnosis. Furthermore, certain diseases of the small airways have been better characterized recently, and several provisional new entities have also been described, some of these being reviewed here.

Endoscopic observation of peripheral airway lesions.

Peripheral airways of 2 mm or less in diameter were observed in 142 patients by means of an ultrathin bronchofiberscope measuring 1.8 mm in outside diameter. On the basis of the observed and photographed endoscopic findings, an endoscopic classification of peripheral airway lesions was proposed. The endoscopic findings showed changes in the bronchial wall consisting of reddening, pallor, absence of mucosal luster, edema, engorgement of blood vessels, irregular mucosal surface, and elevated mucosa. In the lumen, stenosis, obstruction, ectasis, and deformation due to pressure were recognized, in addition to excessive secretion and pigmentation as morphologic abnormalities or abnormal findings at bifurcation.

Endoscopic classification of tracheobronchial tuberculosis with healing processes.

We established an endoscopic classification of tracheobronchial tuberculosis with healing processes. According to this classification, the period of time needed for healing was found to be shorter in patients who were treated by aerosolized streptomycin than in those treated with the conventional triple-drug oral regimen.

Bronchoscopic assessment of the evolution of endobronchial tuberculosis.

BACKGROUND: We previously classified forms of endobronchial tuberculosis (EBTB) into seven subtypes by bronchoscopic finding: actively caseating, edematous-hyperemic, fibrostenotic, tumorous, granular, ulcerative, and nonspecific bronchitic. STUDY OBJECTIVE: To evaluate the value of this classification in predicting the therapeutic outcome of EBTB. DESIGN: A prospective study with serial bronchoscopy performed from the diagnosis of EBTB to the completion of antituberculosis chemotherapy. PARTICIPANTS: Eighty-one patients with biopsy-proven EBTB. INTERVENTIONS: Fiberoptic bronchoscopy was done every month until there was no subsequent change in the endobronchial lesions, every 3 months thereafter, and at the end of treatment. RESULTS: Twenty-two of the 34 cases of actively caseating EBTB changed into the fibrostenotic type, and the other 12 healed without sequelae. Seven of the 11 cases of edematous-hyperemic EBTB changed into the fibrostenotic type, and the other 4 healed. Nine of the 11 cases of granular EBTB, 6 cases of nonspecific bronchitic EBTB, and 2 cases of ulcerative EBTB resolved completely. However, the other two cases of granular EBTB changed into the fibrostenotic type. Seven cases of fibrostenotic EBTB did not improve despite antituberculosis chemotherapy. These various changes in bronchoscopic findings occurred within 3 months of treatment. In 10 cases of tumorous EBTB, 7 progressed to the fibrostenotic type. In addition, new lesions appeared in two cases, and the size of the initial lesions increased in another two cases, even at 6 months after treatment. CONCLUSIONS: The therapeutic outcome of each subtype of EBTB can be predicted by follow-up bronchoscopy during the initial 3 months of treatment, with the exception of the tumorous type. In tumorous EBTB, close and long-term follow-up is advisable because the evolution of the lesions during treatment is very complicated and bronchial stenosis may develop at a later time.

Airway complications in lung transplantation.

This article reviews the literature on airway healing after lung transplantation. From a historical point of view, this has been the Achilles' heel of lung transplantation through two decades, from the first attempt at single-lung transplantation in 1963 to the clinical successes in the early 1980s. The overall incidence of lethal airway complications is estimated to be 2% to 3%, whereas that of late stricture is 7% to 14%. Comparison of experiences has been difficult without a universal classification; a new classification for airway and anastomotic complications and healing is proposed. Ischemia appears to be the most important factor influencing airway healing. Low-pressure collateral bronchial blood flow from the pulmonary artery may be affected by low cardiac output, reperfusion edema, or rejection; mucosal injury may be further increased by prolonged positive-pressure ventilation. Good bronchial healing appears to be possible without a protective wrap and with early use of steroids. The management of bronchial complications is challenging and requires endoscopic skills including knowledge of endobronchial laser photocoagulation and stent insertion techniques.

Pediatric and adult tracheobronchomalacia.

Twelve cases of tracheobronchomalacia (TBM) cases were reviewed: five were pediatric, and seven were adult, two of which were due to relapsing polychondritis (RPC). In pediatric TBM, the malacic segments were short. Resection of the malacic segment in one case and laryngotracheoplasty with autologous costal cartilage in one case were unsuccessful. However, aortopexy gained good results. Two cases managed conservatively experienced gradual improvement of their symptoms. In adult TBM, plication of pars membranacea was not effective in one case. The insertion of a stent was minimally effective in one case, and distinctly in one polychondritic case. The other four cases managed conservatively have deteriorated gradually. From these findings, a new classification system is proposed.

Bronchiolar disease: spectrum and radiological findings.

Two types of bronchiole, the terminal bronchiole and the respiratory bronchiole, have structural and functional differences. The former is characterized as a conducting airway and the latter is closely related to a gas-exchange function as it has numerous alveoli on the wall. Therefore, the diseases occurring at bronchiole demonstrate different pathological, radiological and clinical pictures depending on which bronchiole is mainly involved. The disease that mainly involves the conducting airway is appreciated as a small airway disease. Constrictive bronchiolitis is a well-recognized entity classified in this category. Whereas the disease mainly involves the respiratory bronchiole and distal alveolar space, it is recognized as an interstitial and parenchymal disease. BOOP or RB-ILD is classified in this category. These two types of bronchiolar diseases reveal the contrast clinical pictures, including incidence, causative disease, response to the treatment, prognosis, respiratory function test as well as the radiological findings. This pictorial essay will illustrate the radiological features of the varieties of bronchiolitis.

Pediatric tracheobronchomalacia and major airway collapse.

Based on histopathologic, endoscopic, and clinical findings of the flaccid airway, new descriptive terms--major airway collapse types 1 through 3--are proposed to better define tracheobronchomalacia. A typing and grading system is offered to objectively analyze and compare clinical cases. Endoscopic and anesthetic techniques are presented for use in children with respiratory distress suggestive of tracheobronchomalacia. Spontaneous ventilation with laryngoscopic insufflation of anesthetic gases and the use of small-diameter telescopes without bronchoscopes are key elements for the examination of the dynamic pediatric airway. Pitfalls of classic bronchoscopy techniques are described that can lead to a missed diagnosis. Between 1987 and 1990, over 200 telescopic bronchoscopies were performed at Wilford Hall US Air Force Medical Center on 129 children 3 years old and younger with respiratory distress. By means of the described techniques, 38 children (30%) with major airway collapse were identified. Major airway collapse was associated with a variety of endoscopic and cardiac abnormalities. With the emergence of sophisticated neonatal pediatric respiratory care, a growing number of premature infants with major airway collapse are surviving. Early, precise endoscopic diagnosis allows optimal management.

[New classification of endobronchial tuberculosis and balloon dilatation of bronchial stenosis].

Endobronchial tuberculosis frequently leaves bronchial stenosis as the complication despite of modern efficacious chemotherapy, and it may be misdiagnosed as bronchial asthma or bronchogenic carcinoma. When bronchial stenosis involves major airway, its treatment needs such special measures as steroid therapy, surgical intervention and/or laser therapy, but the therapeutic result is often disappointing. We have introduced a new classification of endobronchial tuberculosis, analyzing bronchoscopic findings in 166 cases of endobronchial tuberculoses. Namely, endobronchial tuberculosis was classified into seven subtypes as stenotic type with fibrosis, stenotic type without fibrosis, actively caseating type, tumorous type, ulcerative type, granular type, and nonspecific bronchitic type. Actively caseating type (48 cases: 28.9%), stenotic type without fibrosis (44 cases: 26.5%), nonspecific bronchitic type (31 cases: 18.7%) and stenotic type with fibrosis (30 cases: 18.1%) were predominant in the order of frequency, but tumorous type (9 cases: 5.4%), ulcerative type (2 cases: 1.2%) and granular type (2 cases: 1.2%) were relatively uncommon. Stenotic type with or without fibrosis, actively caseating type and tumorous type of endobronchial tuberculosis were closely related to bronchial stenosis. In these cases, it is necessary to apply specific measures for preventing or minimizing bronchial stenosis. To consider the therapeutic effect of steroid on the alleviation of bronchial stenosis in endobronchial tuberculosis, it may be very effective when the interval between symptom-onset and treatment with steroid is less than 6 months. To exploit a new treatment modality for bronchial stenosis, balloon dilatation was also carried out in 12 patients with endobronchial tuberculosis. Under local anesthesia, 4F-Fogarty balloon was inserted via bronchofiberscope in ten cases and 10F-Gruentzig balloon was introduced under fluoroscopic guide in two others.(ABSTRACT TRUNCATED AT 250 WORDS)

A new endoscopic standardized grading system for macroscopic central airway complications following lung transplantation: the MDS classification.

OBJECTIVES: After lung transplant, between 9 and 13% of bronchial anastomoses develop complications severe enough to warrant therapeutic intervention. These complications include stenosis, dehiscence, granulation tissue, bronchomalacia and fistula. Most of these have already been included in a classification or another, but none of these have been universally accepted. Moreover, no grading system has integrated all of these complications. The Groupe Transplantation (GT) (Transplant Group), from the Société de Pneumologie de Langue Française (SPLF) [French Language Pulmonology Society], maintains a prospective national registry of lung transplants performed in France. The GT has mandated the Groupe d'Endoscopie de Langue Française (GELF), also from the SPLF, to develop an endoscopic classification, in order to describe the macroscopic aspect of the bronchial anastomoses, and downhill airways, using a standardized and exhaustive grading system. METHODS: An endoscopic classification that would take into account the three major aspects of the description of bronchial anastomoses was elaborated. The first parameter is the macroscopic aspect (M), the second, the diameter (D) of the anastomosis and the third, the sutures (S) of the anastomosis. This classification was then submitted to expert bronchoscopists from nine centres, responsible for lung transplants in France, for their opinion, using a five-item questionnaire, according to the Delphi methodology. RESULTS: After the first round of consultation, all experts (100%) agreed on Questions 1 and 4. Answers were positive for Questions 2 (59%), 3 (56.25%) and 5 (70%). A modified classification, incorporating propositions from the first round, was then submitted. This second round allowed a consensus to be reached between all experts: the MDS classification. Each parameter (M, D and S) can be classified from 0 to 3. For M and D, it is possible to determine the extent of abnormalities downhill from the anastomosis into four subgroups (a, b, c or d). For S, the localization of abnormalities can be divided between two subgroups (e and f). CONCLUSION: The MDS classification, established by a consensus of French experts in bronchoscopy, could represent a standardized, universally acceptable system to describe central airway complications after lung transplant.

Anthracofibrosis or anthracostenosis.

Anthracofibrosis is a bronchial stenosis due to local mucosal fibrosis that also presents anthracotic pigment in the mucosa. The cause has not been well clarified, although there is a frequent association with tuberculosis and the exposure to smoke from biofuel or biomass combustion. It is an entity that has not been reported in Spain, although the influx of people from rural areas of developing countries or rural areas of our own country should make us contemplate this entity in the differential diagnosis of our patients. We present 3 cases detected in Spain (2 of them natives) diagnosed by bronchoscopy and bronchial biopsy, which are techniques necessary to confirm the diagnosis. There is no specific treatment, except for tuberculostatic treatment in cases with coexisting tuberculosis.