Bridging the Gap to Improved Outcomes in Non-Cystic Fibrosis Bronchiectasis: Ensuring Prompt Diagnosis Through Accurate Interpretation of CT Imaging
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May 29, 2024
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About This Presentation
Co-Chairs, Brett Elicker, MD, and David E. Griffith, MD, ATSF, ACCP, OFRSM, discuss non-cystic fibrosis bronchiectasis in this CME/MOC activity titled “Bridging the Gap to Improved Outcomes in Non-Cystic Fibrosis Bronchiectasis: Ensuring Prompt Diagnosis Through Accurate Interpretation of CT Imagi...
Slide Content
Bridging the Gap to Improved
Outcomes in Non-Cystic Fibrosis
Bronchiectasis
Ensuring Prompt Diagnosis Through Accurate
Interpretation of CT Imaging
Brett Elicker, MD Tx David E. Griffith, MD, ATSF, F
Professor of Clinical Radiology 0 ACCP, OFRSM [RF
Chief of Cardiac and Pulmonary á Professor of Medicine |
Imaging Division Ñ National Jewish Health g
University of California, San Francisco PM Denver, Colorado
San Francisco, California A
Go online to access full CME/MOC information, including faculty disclosures.
Outcomes in Non-Cystic Fibrosis
Bronchiectasis
Ensuring Prompt Diagnosis Through Accurate
Interpretation of CT Imaging
Brett Elicker, MD Tx David E. Griffith, MD, ATSF, F
Professor of Clinical Radiology 0 ACCP, OFRSM [RF
Chief of Cardiac and Pulmonary á Professor of Medicine |
Imaging Division Ñ National Jewish Health g
University of California, San Francisco PM Denver, Colorado
San Francisco, California A
Go online to access full CME/MOC information, including faculty disclosures.
Our Goals for Today
Discuss with you the disease burden of NCFBE,
particularly as diagnosis is often delayed due to
unrecognition or misdiagnosis
Show you how to recognize and interpret CT features of
NCFBE to facilitate and ensure accurate diagnosis and
allow for treatment
— + Summarize unmet treatment needs for patients and how
novel and emerging therapies may address these gaps
Copyright © 2000-2024, PeerView
Discuss with you the disease burden of NCFBE,
particularly as diagnosis is often delayed due to
unrecognition or misdiagnosis
Show you how to recognize and interpret CT features of
NCFBE to facilitate and ensure accurate diagnosis and
allow for treatment
— + Summarize unmet treatment needs for patients and how
novel and emerging therapies may address these gaps
Copyright © 2000-2024, PeerView
Unmet Needs of Patients With
Non-Cystic Fibrosis Bronchiectasis
An Overview of Disease Burden and
Emerging Treatment Options
David E. Griffith, MD, ATSF, ACCP, OFRSM gp |
Professor of Medicine | it À
National Jewish Health Mes
Denver, Colorado Y
Ñ
Copyright © 2000-2024, PeerView
Non-Cystic Fibrosis Bronchiectasis
An Overview of Disease Burden and
Emerging Treatment Options
David E. Griffith, MD, ATSF, ACCP, OFRSM gp |
Professor of Medicine | it À
National Jewish Health Mes
Denver, Colorado Y
Ñ
Copyright © 2000-2024, PeerView
What Is Bronchiectasis?
+ Achronic disease characterized
by permanently dilated, inflamed
airways
» Usually associated with a chronic,
daily, and productive cough
« Etymology: Greek,
bronchus + ektasis, stretching
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+ Achronic disease characterized
by permanently dilated, inflamed
airways
» Usually associated with a chronic,
daily, and productive cough
« Etymology: Greek,
bronchus + ektasis, stretching
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Challenges and Unmet Needs in NCFBE
Lack of recognition + No FDA-approved therapies
Increasing prevalence + Suboptimal treatment of
P. aeruginosa
— No routine monitoring for
P. aeruginosa until patients
have frequent exacerbations
Absence of standardized
definitions/diagnosis
— Misdiagnosis due to similar
presentation as other Need for evidence-based
respiratory disorders
— Delayed diagnosis
interventions that reduce
exacerbation frequency
Lack of standardized referral path
— Underdiagnosis/treatment
— Lack of communication between
primary and specialty care
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Lack of recognition + No FDA-approved therapies
Increasing prevalence + Suboptimal treatment of
P. aeruginosa
— No routine monitoring for
P. aeruginosa until patients
have frequent exacerbations
Absence of standardized
definitions/diagnosis
— Misdiagnosis due to similar
presentation as other Need for evidence-based
respiratory disorders
— Delayed diagnosis
interventions that reduce
exacerbation frequency
Lack of standardized referral path
— Underdiagnosis/treatment
— Lack of communication between
primary and specialty care
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Underdiagnosis/Delayed Diagnosis of NCFBE
| Mean Time From Symptom Onset to Diagnosis/Referral |
19 years!
8 years?
17 years
12 years!
1. Nicotra Meta. Chest, 1995:104:955-961. 2. Shoemark A et al. Respir Med, 2007:101:1169-1170. Dass}
3. Anwar GA etal, Respir Med, 2013;107:1001-1007. 4. Giron RM eta. Chronic Respir Dis. 2017:14:360-369. PeerView.com
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| Mean Time From Symptom Onset to Diagnosis/Referral |
19 years!
8 years?
17 years
12 years!
1. Nicotra Meta. Chest, 1995:104:955-961. 2. Shoemark A et al. Respir Med, 2007:101:1169-1170. Dass}
3. Anwar GA etal, Respir Med, 2013;107:1001-1007. 4. Giron RM eta. Chronic Respir Dis. 2017:14:360-369. PeerView.com
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How Does Bronchiectasis Manifest Clinically?
Associated wit!
Sputum production,
sometimes mucopurulent or purulent
Other: hemoptysis, pleuritic chest pain, weight loss
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Associated wit!
Sputum production,
sometimes mucopurulent or purulent
Other: hemoptysis, pleuritic chest pain, weight loss
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Bronchiectasis Prevalence Is on the Rise‘
+ Estimated total patient population in US = 350,000 to 500,000 adults!
+ Prevalence increases with age with an 8- to 10-fold difference in
prevalence after the age of 60 (300 to 500 per 100,000) as compared
with ages <40 to 50 years (40 to 50 per 100,000)24
+ More common A Ann Pete 002007
in women
+ Prevalence
has been
increasing at
8%-10% per year
in some areas?*
1. eycker D et al Chron Respir Dis. 2017:14:377. 2. Quint JK et al. Eur Respir J. 2016:47:186-193 3. Ringahausen FC et al. Eur Respir 2019:54:1900499. 7
4, Henke E et al. Chest, 2018:154:1311. 5. Seitz AE etal. Chest. 2012:142:432-439, PeerView.com
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+ Estimated total patient population in US = 350,000 to 500,000 adults!
+ Prevalence increases with age with an 8- to 10-fold difference in
prevalence after the age of 60 (300 to 500 per 100,000) as compared
with ages <40 to 50 years (40 to 50 per 100,000)24
+ More common A Ann Pete 002007
in women
+ Prevalence
has been
increasing at
8%-10% per year
in some areas?*
1. eycker D et al Chron Respir Dis. 2017:14:377. 2. Quint JK et al. Eur Respir J. 2016:47:186-193 3. Ringahausen FC et al. Eur Respir 2019:54:1900499. 7
4, Henke E et al. Chest, 2018:154:1311. 5. Seitz AE etal. Chest. 2012:142:432-439, PeerView.com
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Bronchiectasis Pathogenesis:
From the Vicious Cycle to the Vicious Vortex!
Cole’s Vicious Cycle Vicious Vortex
; Airway
Heutroptl destruction and
inflammation en
(proteases) (bronchiectasis)
ion
Bacterial pes
colonization de
1. Cole PJ. Eur J Respir Dis. 1988;147:8-15. 2. MeShane PJ etal. Am J Respir Crit Care Med, 2013:188:647-858. 3. Flume PA etal. Lancet. 2018:302:880-890. PeerView.com
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From the Vicious Cycle to the Vicious Vortex!
Cole’s Vicious Cycle Vicious Vortex
; Airway
Heutroptl destruction and
inflammation en
(proteases) (bronchiectasis)
ion
Bacterial pes
colonization de
1. Cole PJ. Eur J Respir Dis. 1988;147:8-15. 2. MeShane PJ etal. Am J Respir Crit Care Med, 2013:188:647-858. 3. Flume PA etal. Lancet. 2018:302:880-890. PeerView.com
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Multiple Etiologies of NCFBE!
Idiopathic
1obe
Postinfectious
1. Lonni $ et al Ann Am Thorae Soe. 2015;12:1764-1770,
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Hereditary
Immune
abnormalities
~40% of cases will
remain idiopathic
despite extensive
evaluation
Focal due to
airway
obstruction
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Idiopathic
1obe
Postinfectious
1. Lonni $ et al Ann Am Thorae Soe. 2015;12:1764-1770,
PeerView.com/VGY827
Hereditary
Immune
abnormalities
~40% of cases will
remain idiopathic
despite extensive
evaluation
Focal due to
airway
obstruction
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Diagnosis of Bronchiectasis'*
Diagnostic Suspicion of Bronchiectasis
Assessment of functional status and
infection in all patients
52553
Firstiine diagnostic investigations to be Bronchoscopy if sputum cannot be
‘considered in al patients ‘obtained or if there is focal abnormality
+ Routine suggest basal emphysema.
{bran En Le Er Reap Monograph. 20112:3249.& hip thoracic alado Corella quelo tronchielaeimadus- :
constan a MAY eal En Rage LAS PeerView.com
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Diagnostic Suspicion of Bronchiectasis
Assessment of functional status and
infection in all patients
52553
Firstiine diagnostic investigations to be Bronchoscopy if sputum cannot be
‘considered in al patients ‘obtained or if there is focal abnormality
+ Routine suggest basal emphysema.
{bran En Le Er Reap Monograph. 20112:3249.& hip thoracic alado Corella quelo tronchielaeimadus- :
constan a MAY eal En Rage LAS PeerView.com
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Appropriate Treatment Based on Disease Severity’
+ Heterogenous disease
— Highly variable impact on patients
+ Treatments can place a large burden on patients
— Time
— Side effects
— Antibiotic resistance
Patients require treatment appropriate to stage and severity of
disease
Individualized treatment approach
1. Chalmers JO et a. Am J Respir Ct Care Med. 2014:189:576-586, PeerView.com
PeerView.com/VGY827 Copyright 4
+ Heterogenous disease
— Highly variable impact on patients
+ Treatments can place a large burden on patients
— Time
— Side effects
— Antibiotic resistance
Patients require treatment appropriate to stage and severity of
disease
Individualized treatment approach
1. Chalmers JO et a. Am J Respir Ct Care Med. 2014:189:576-586, PeerView.com
PeerView.com/VGY827 Copyright 4
Managing Bronchiectasis!
+ Objectives — _
— Prevent OscPEP valves ue,
exacerbations “Vests” clearance
— Reduce symptoms ae meee a
— Improve QOL antibiotics
— Stop disease
progression Macrolides RE
— Reduce mortality
1. Flume PA et al. Lancet. 2018:392:880-890. 2, Polverino E et al. Eur Respir J. 2017:50:1700829. PeerView.com
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+ Objectives — _
— Prevent OscPEP valves ue,
exacerbations “Vests” clearance
— Reduce symptoms ae meee a
— Improve QOL antibiotics
— Stop disease
progression Macrolides RE
— Reduce mortality
1. Flume PA et al. Lancet. 2018:392:880-890. 2, Polverino E et al. Eur Respir J. 2017:50:1700829. PeerView.com
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Stepwise Approach to Treatment!
Airway clearance techniques General Management
(applies to all stages of disease) = =
+ Manage comorbidities and underlying causes
+ Pr nt of exe tions
+ Sputum surveillance of P. aeruginosa and Macrolides for patients with frequent exacerbations,
nontuberculous Mycobacteria inhaled antibiotics, particularly with P. aeruginosa
colonizatk
Inhaled corticosteroids in select patients
Regular physiotherapy + adjuncts
les for pat th (devicesyperosmolar agents)
y advance:
moe ‘Severe bronchiectasis or persistent symptoms
despite standard care
Regular physiotherapy + adjuncts
(device molar agents)
Moderate severity or persistent symptoms
despite standard care
‘There are no antbits cuenty approved forthe treatment of NCFB. :
1. Chalmers JO et al. Eur Respir J.2015;45:1446-1462, PeerView.com
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Airway clearance techniques General Management
(applies to all stages of disease) = =
+ Manage comorbidities and underlying causes
+ Pr nt of exe tions
+ Sputum surveillance of P. aeruginosa and Macrolides for patients with frequent exacerbations,
nontuberculous Mycobacteria inhaled antibiotics, particularly with P. aeruginosa
colonizatk
Inhaled corticosteroids in select patients
Regular physiotherapy + adjuncts
les for pat th (devicesyperosmolar agents)
y advance:
moe ‘Severe bronchiectasis or persistent symptoms
despite standard care
Regular physiotherapy + adjuncts
(device molar agents)
Moderate severity or persistent symptoms
despite standard care
‘There are no antbits cuenty approved forthe treatment of NCFB. :
1. Chalmers JO et al. Eur Respir J.2015;45:1446-1462, PeerView.com
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Exacerbations**
Definition of an exacerbation
— Aperson with bronchiectasis with a deterioration in 23 of the following key symptoms for
at least 48 hours
> Cough, sputum volume and/or consistency, sputum purulence, breathlessness
and/or exercise tolerance, fatigue and/or malaise, hemoptysis
— And
> A determination by a clinician that a change in bronchiectasis treatment is needed
Exacerbations are associated with increased airway and systemic inflammation, and
progressive disease
More severe exacerbations and those due to P. aeruginosa are associated with daily
symptoms, lung function decline, decreased QOL, and increase in 5-year mortality
50% of European patients with bronchiectasis have 22 exacerbations per year;
one-third require at least one hospitalization per year
1. Hil AT et al. Eur Resp J 2017:49:1700081. 2. Chalmers JO et al. Am J Resp Crit Care Mad. 2017:195:1364-1993. A
3. Polverino E tl. Eur Resp J. 2017.50:1700829. PeerView.com
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Definition of an exacerbation
— Aperson with bronchiectasis with a deterioration in 23 of the following key symptoms for
at least 48 hours
> Cough, sputum volume and/or consistency, sputum purulence, breathlessness
and/or exercise tolerance, fatigue and/or malaise, hemoptysis
— And
> A determination by a clinician that a change in bronchiectasis treatment is needed
Exacerbations are associated with increased airway and systemic inflammation, and
progressive disease
More severe exacerbations and those due to P. aeruginosa are associated with daily
symptoms, lung function decline, decreased QOL, and increase in 5-year mortality
50% of European patients with bronchiectasis have 22 exacerbations per year;
one-third require at least one hospitalization per year
1. Hil AT et al. Eur Resp J 2017:49:1700081. 2. Chalmers JO et al. Am J Resp Crit Care Mad. 2017:195:1364-1993. A
3. Polverino E tl. Eur Resp J. 2017.50:1700829. PeerView.com
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Exacerbation History:
A Strong Predictor of Future Outcomes‘
so
$
E 4
ax
35”
E
22
E 10
o
E à
Exacerbation per Year at Baseline
Not Gr 2 A7 es
1. Chalmers JO et al. Am J Respir Crt Care Med, 2018:197:1410-1420.
PeerView.com/VGY827
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# 9
5
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o
No. at
Risk
o 657
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Number of Exacerbations Per
Year at Baseline
2 3
Time, y
Go 554
402 381
437 or
sw 7m
o
2
=
4 5
m 163
351134
376 196
CRE
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A Strong Predictor of Future Outcomes‘
so
$
E 4
ax
35”
E
22
E 10
o
E à
Exacerbation per Year at Baseline
Not Gr 2 A7 es
1. Chalmers JO et al. Am J Respir Crt Care Med, 2018:197:1410-1420.
PeerView.com/VGY827
100
# 9
5
a»
no
o
No. at
Risk
o 657
1 452
2 47
Er")
Number of Exacerbations Per
Year at Baseline
2 3
Time, y
Go 554
402 381
437 or
sw 7m
o
2
=
4 5
m 163
351134
376 196
CRE
PeerView.com
Copyright © 2000-2024, PeerView
Prevention of Bronchiectasis Exacerbations'?
cerbations/year
Optimize ainway clearance
Treat underlying causes
P aeruginosa infection Non-P. aeruginosa infection
Lack of response or intolerance
Long-term inhaled Long-term macrolide
antibiotic treatment treatment
Inadequate response Lack of response
or intolerance
Combined oral and inhaled -term targetes
reatment oral antibiotic
1. Potveine E et al. Eur Respir J. 2017:50:1700829, 2. Chalmers JD et al. Lancet Respir Med. 2019:7:845-854, PeerView.com
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cerbations/year
Optimize ainway clearance
Treat underlying causes
P aeruginosa infection Non-P. aeruginosa infection
Lack of response or intolerance
Long-term inhaled Long-term macrolide
antibiotic treatment treatment
Inadequate response Lack of response
or intolerance
Combined oral and inhaled -term targetes
reatment oral antibiotic
1. Potveine E et al. Eur Respir J. 2017:50:1700829, 2. Chalmers JD et al. Lancet Respir Med. 2019:7:845-854, PeerView.com
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Rationale for Novel Agents Targeting Inflammation
Urgent need for effective therapies to break the
vicious cycle of inflammation, lung damage, and
infection for patients with bronchiectasis
— Agents such as DPP-1 inhibitors—which
target neutrophil serine proteases—may block
inflammation and break the vicious cycle,
based on phase 2 data
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Urgent need for effective therapies to break the
vicious cycle of inflammation, lung damage, and
infection for patients with bronchiectasis
— Agents such as DPP-1 inhibitors—which
target neutrophil serine proteases—may block
inflammation and break the vicious cycle,
based on phase 2 data
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DPP-1 Inhibition: Results of Phase 2 WILLOW Trial!
Time to First Exacerbation
10
08
Brensocat 10 mg (P= 03 vs placebo)
os Brensocatib 25 mg (P = .04 vs placebo)
Proportion of Patients With
No Exacerbation
04
o
TR D 6 @ E 6 09 19 tar im 105 169 189 200
mato
erst Time, d
se
Brensocalb 10mg 0/82 379 476 972 1169 13/68 1682 16/02 1860 10150 21/57 24/54 2553 25:52 28%
Brensocalb 25mg 0/87 483 1077 1671 1670 19164 21160 2258 2387 24/56 26/54 26/52 26152 28:49 20/10
Placebo 0187 878 1273 1580 2063 2261 25/57 27/55 20152 3080 3Al47 3744 40/38 40037 428
1. Chalmers JO et al. N Engl J Med, 2020:383:2127-2137. PeerView.com
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Time to First Exacerbation
10
08
Brensocat 10 mg (P= 03 vs placebo)
os Brensocatib 25 mg (P = .04 vs placebo)
Proportion of Patients With
No Exacerbation
04
o
TR D 6 @ E 6 09 19 tar im 105 169 189 200
mato
erst Time, d
se
Brensocalb 10mg 0/82 379 476 972 1169 13/68 1682 16/02 1860 10150 21/57 24/54 2553 25:52 28%
Brensocalb 25mg 0/87 483 1077 1671 1670 19164 21160 2258 2387 24/56 26/54 26/52 26152 28:49 20/10
Placebo 0187 878 1273 1580 2063 2261 25/57 27/55 20152 3080 3Al47 3744 40/38 40037 428
1. Chalmers JO et al. N Engl J Med, 2020:383:2127-2137. PeerView.com
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DPP-1 Inhibition: Results of Phase 2 WILLOW Trial!
Change in Sputum Neutrophil Elastase Concentrations
Mean Changes in Sputum
Neutrophil Elastase, log, mcg/mL
0.2
-04
-0.6
-08
o
Brensocatib 10 mg
Brensocatib 25 mg
14 Hr
Baseline 2 4
1. Chalmers JD eta. M Engl J Med, 2020:383:2121-2137.
PeerView.com/VGY827
12
Time, wk
è
28
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Change in Sputum Neutrophil Elastase Concentrations
Mean Changes in Sputum
Neutrophil Elastase, log, mcg/mL
0.2
-04
-0.6
-08
o
Brensocatib 10 mg
Brensocatib 25 mg
14 Hr
Baseline 2 4
1. Chalmers JD eta. M Engl J Med, 2020:383:2121-2137.
PeerView.com/VGY827
12
Time, wk
è
28
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Ongoing Study: Phase 3 ASPEN’
+ Brensocatib was granted breakthrough therapy designation by the FDA
and PRIME by European Medicines Agency
+ >1,700 patients were enrolled and randomized to receive brensocatib
10 mg, brensocatib 25 mg, or placebo once daily for 52 weeks followed
by 4 weeks off treatment
+ Primary endpoint: rate of adjudicated pulmonary exacerbations over the
52-week treatment period
+ Estimated completion: March 2024
+ Topline data expected later this year
1. ps initial gostudyiNCTO4504368, PeerView.com
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+ Brensocatib was granted breakthrough therapy designation by the FDA
and PRIME by European Medicines Agency
+ >1,700 patients were enrolled and randomized to receive brensocatib
10 mg, brensocatib 25 mg, or placebo once daily for 52 weeks followed
by 4 weeks off treatment
+ Primary endpoint: rate of adjudicated pulmonary exacerbations over the
52-week treatment period
+ Estimated completion: March 2024
+ Topline data expected later this year
1. ps initial gostudyiNCTO4504368, PeerView.com
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T2-High Endotype (Eosinophilic Inflammation)"
* 20%-30% of patients with No. of Exacerbations
bronchiectasis have blood EOS ®
2300 cells/mcL
« Anti-IL-5 (mepolizumab) or anti-IL-5Ra 25 Patient ID
(benralizumab) drugs are associated ge: 12
with good treatment outcomes in 33 , —
severe eosinophilic asthmatic patients ZÉ —4
with comorbid bronchiectasis Bg? =$
+ 5 patients with severe eosinophilic Zs
asthma who received either of the :
above two agents had a significant o
decrease in exacerbations in the 7 o 12 2
2-year follow-up Follow-Up, m
eg atta oat 2016280218214 2 oe NG a Ml Mo 2043714182079 Otro Met Dom 2021972 PesrViewcom
PeerView.com/VGY827 Copyright © 2000-2024, PeerView
* 20%-30% of patients with No. of Exacerbations
bronchiectasis have blood EOS ®
2300 cells/mcL
« Anti-IL-5 (mepolizumab) or anti-IL-5Ra 25 Patient ID
(benralizumab) drugs are associated ge: 12
with good treatment outcomes in 33 , —
severe eosinophilic asthmatic patients ZÉ —4
with comorbid bronchiectasis Bg? =$
+ 5 patients with severe eosinophilic Zs
asthma who received either of the :
above two agents had a significant o
decrease in exacerbations in the 7 o 12 2
2-year follow-up Follow-Up, m
eg atta oat 2016280218214 2 oe NG a Ml Mo 2043714182079 Otro Met Dom 2021972 PesrViewcom
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Other Emerging Therapies—Clinical Trials’
Drug Desc! Phase Status
Nebulized, plasma derived
CSL787 immunoglobulin 1 Completed
ARINA-1 Inhaled ascorbic acid, glutathione 2a Completed
Roflumilast Phophodiesterase-4 inhibitor 2 Recruiting
Elexacaftor/tezacaftor/ Chloride channel opener/CFTR si
ivacaftor modulators # Récuimg
Benralizumab Anti-IL-5Ra 3 Active
HSK31858 DPP-1 inhibitor 2 Recruiting
BCG TB vaccine 2 Completed
2 A ñ Not yet
Hypertonic saline Mucolytic 4 recruiting
AZD5069 CXCR2 antagonist 2 Completed
1. hntps:/ieinicatias gov. PeerVie
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Drug Desc! Phase Status
Nebulized, plasma derived
CSL787 immunoglobulin 1 Completed
ARINA-1 Inhaled ascorbic acid, glutathione 2a Completed
Roflumilast Phophodiesterase-4 inhibitor 2 Recruiting
Elexacaftor/tezacaftor/ Chloride channel opener/CFTR si
ivacaftor modulators # Récuimg
Benralizumab Anti-IL-5Ra 3 Active
HSK31858 DPP-1 inhibitor 2 Recruiting
BCG TB vaccine 2 Completed
2 A ñ Not yet
Hypertonic saline Mucolytic 4 recruiting
AZD5069 CXCR2 antagonist 2 Completed
1. hntps:/ieinicatias gov. PeerVie
PeerView.com/VGY827 Copyright © 2000-2024, PeerView
Summary
NCFBE is characterized by a vicious cycle of infection,
inflammation, and injury that often results in progressive
symptoms, loss of lung function, decreased activities of daily
living, and decreased QOL
Diagnosis is often missed or delayed
Current management
— Improve airway clearance
— Treat and prevent exacerbations
Novel agents that target the underlying inflammation of
bronchiectasis offer potential new means of treatment and
for patients
PeerView.com
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NCFBE is characterized by a vicious cycle of infection,
inflammation, and injury that often results in progressive
symptoms, loss of lung function, decreased activities of daily
living, and decreased QOL
Diagnosis is often missed or delayed
Current management
— Improve airway clearance
— Treat and prevent exacerbations
Novel agents that target the underlying inflammation of
bronchiectasis offer potential new means of treatment and
for patients
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Clinical Consult
Does This Patient Have NCFBE?
Accurate Interpretation of HRCT
Imaging to Ensure Prompt Diagnosis
Brett Elicker, MD
Professor of Clinical Radiology
Chief of Cardiac and Pulmonary Imaging Division
University of California, San Francisco
San Francisco, California
À
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Does This Patient Have NCFBE?
Accurate Interpretation of HRCT
Imaging to Ensure Prompt Diagnosis
Brett Elicker, MD
Professor of Clinical Radiology
Chief of Cardiac and Pulmonary Imaging Division
University of California, San Francisco
San Francisco, California
À
Copyright © 2000-2024, PeerView
Introduction to Patient Case
60-year-old mai
se chief complaint is a chr
, productive cough
+ Cough began several years ago
+ Sometimes coughs up mucus plugs and frequently has respiratory infections
+ Over the past few years, he has lost about 50 pounds
+ Spirometry findings
+ FVC 2.36 L (77% predicted)
+ FEV, 1.60 L (62% predicted)
+ FEV,/FVC 68%
+ His physician refers him for CT imaging
We will return to the case near the end of the presentation
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60-year-old mai
se chief complaint is a chr
, productive cough
+ Cough began several years ago
+ Sometimes coughs up mucus plugs and frequently has respiratory infections
+ Over the past few years, he has lost about 50 pounds
+ Spirometry findings
+ FVC 2.36 L (77% predicted)
+ FEV, 1.60 L (62% predicted)
+ FEV,/FVC 68%
+ His physician refers him for CT imaging
We will return to the case near the end of the presentation
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CXR Is Insensitive for Bronchiectasis
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What Is the Difference?
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What Is the Difference?
Large airways Small airways
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Large airways Small airways
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Causes of Airways Diseases: The Radiologist’s Perspective
Large airways Small airways
+ Chronic bronchitis + Asthma
* Cystic fibrosis + Infectious bronchiolitis
+ NTM + Aspiration bronchiolitis
+ ABPA + Constrictive bronchiolitis
+ Immunodeficiency + Interstitial lung diseases
* Ciliary dyskinesia (eg, HP, RB, FB)
* Cartilage disorders + Panbronchiolitis
+ Yellow nail syndrome
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Large airways Small airways
+ Chronic bronchitis + Asthma
* Cystic fibrosis + Infectious bronchiolitis
+ NTM + Aspiration bronchiolitis
+ ABPA + Constrictive bronchiolitis
+ Immunodeficiency + Interstitial lung diseases
* Ciliary dyskinesia (eg, HP, RB, FB)
* Cartilage disorders + Panbronchiolitis
+ Yellow nail syndrome
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Correct CT Procedure/Method for Bronchiectasis
+ Noncontrast chest CT
* Slice thickness 1.5 mm or less
« Full inspiratory effort
« Expiratory images on the first CT to evaluate air trapping
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+ Noncontrast chest CT
* Slice thickness 1.5 mm or less
« Full inspiratory effort
« Expiratory images on the first CT to evaluate air trapping
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Bronchiectasis
* Irreversible
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* Irreversible
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Bronchiectasis
+ Irreversible
+ CT findings
— Enlarged broncho-arterial ratio
— Lack of bronchial tapering
— Visible airways <1 cm from pleura
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Copyrigh 4
+ Irreversible
+ CT findings
— Enlarged broncho-arterial ratio
— Lack of bronchial tapering
— Visible airways <1 cm from pleura
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Copyrigh 4
Bronchiectasis
+ Irreversible
+ CT findings
— Enlarged broncho-arterial ratio
— Lack of bronchial tapering
— Visible airways <1 cm from pleura
* Often associated with findings of inflammation
— Airway thickening/plugging
— Centrilobular nodules + tree-in-bud opacities
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+ Irreversible
+ CT findings
— Enlarged broncho-arterial ratio
— Lack of bronchial tapering
— Visible airways <1 cm from pleura
* Often associated with findings of inflammation
— Airway thickening/plugging
— Centrilobular nodules + tree-in-bud opacities
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Bronchiectasis: CT Definition’
1. Images courtesy of Brett Elicker, MD. PeerView.com
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1. Images courtesy of Brett Elicker, MD. PeerView.com
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Bronchiectasis: CT Definition’
1. Images courtesy of Brett Elker, MD. PeerView.com
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1. Images courtesy of Brett Elker, MD. PeerView.com
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Bronchiectasis: CT Definition’
1. Images courtesy of Brett Elickr, MD. PeerView.com
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1. Images courtesy of Brett Elickr, MD. PeerView.com
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Bronchiectasis: CT Definition!
1. Images courtesy of Brett Elicker, MO, PeerView.com
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1. Images courtesy of Brett Elicker, MO, PeerView.com
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Bronchiectasis: CT Definition!
B/A ratio >1 or 1.5 Má
1. Images courtesy of Bret Elker, MO, PeerView.com
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B/A ratio >1 or 1.5 Má
1. Images courtesy of Bret Elker, MO, PeerView.com
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Bronchiectasis: CT Definition’
B/A ratio >1 or 1.5 M4
1. Images courtesy of Bret Elker, MO, PeerView.com
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B/A ratio >1 or 1.5 M4
1. Images courtesy of Bret Elker, MO, PeerView.com
PeerView.com/VGY827 Copyright © 2000-2024, PeerView
Bronchiectasis: CT Definition’
B/A ratio >1 or 1.5 M4
1. Images courtesy of Bret Elickr, MO, PeerView.com
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B/A ratio >1 or 1.5 M4
1. Images courtesy of Bret Elickr, MO, PeerView.com
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Types of Bronchiectasis
Inflammatory
+ Smooth to saccular shape
+ Wall thickening and mucous impaction
+ Centrilobular nodules, tree-in-bud,
mosaic attenuation
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Inflammatory
+ Smooth to saccular shape
+ Wall thickening and mucous impaction
+ Centrilobular nodules, tree-in-bud,
mosaic attenuation
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Types of Bronchiectasis
Inflammatory
+ Smooth to saccular shape
+ Wall thickening and mucous impaction
+ Centrilobular nodules, tree-in-bud,
mosaic attenuation
Traction
+ Irregular, cork-screw shaped
+ Dry
+ Lung findings of fibrosis
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Types of Bronchiectasis
Inflammatory
+ Smooth to saccular shape
+ Wall thickening and mucous impaction
+ Centrilobular nodules, tree-in-bud,
mosaic attenuation
Traction
+ Irregular, cork-screw shaped
+ Dry
+ Lung findings of fibrosis
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Inflammatory Bronchiectasis: Types
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Inflammatory Bronchiectasis: Types
| Varicose ]
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| Varicose ]
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Inflammatory Bronchiectasis: Types
Severe
Chronic
Mild
Acute
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| Varicose ]
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Severe
Chronic
Mild
Acute
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| Varicose ]
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Symmetric Upper Lung
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Symmetric Upper Lung
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Right Middle Lobe/Lingular Predominant
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Symmetric Lower Lung
Recurre
aspiration
Longstanding
constrictive
bronchiolitis
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Recurre
aspiration
Longstanding
constrictive
bronchiolitis
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Central Bronchiectasis
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Central Bronchiectasis
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Central Bronchiectasis
aspergillos
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aspergillos
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Central Bronchiectasis
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Paucity of Inflammation
Cartilage
disorders
a
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Cartilage
disorders
a
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Constrictive Bronchiolitis
More common than
you think
Baseline 7 years 16 years
End result of
various insults
Wide variety
of manifestations
Irreversible
Azithromycin therapy
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More common than
you think
Baseline 7 years 16 years
End result of
various insults
Wide variety
of manifestations
Irreversible
Azithromycin therapy
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Secondary Features: Air Trapping
ES
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ES
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Reasons for Subsequent Imaging
Surveillance
Is there evidence of progression of disease?
(nodules, ca
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Surveillance
Is there evidence of progression of disease?
(nodules, ca
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Summary
Bronchiectasis is an irreversible dilation of bronchi bigger than
the accompanying artery
The dilated bronchus is described based on its morphology
The pattern of bronchiectasis helps us to limit the
differential diagnosis
Acquiring the proper type of CT scan is an important part of
patient diagnosis
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Bronchiectasis is an irreversible dilation of bronchi bigger than
the accompanying artery
The dilated bronchus is described based on its morphology
The pattern of bronchiectasis helps us to limit the
differential diagnosis
Acquiring the proper type of CT scan is an important part of
patient diagnosis
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Return to Patient Case
60-year-old man whose chief complaint is a chronic, productive
cough who has now been referred for CT imaging
CT imaging showed significant central bronchiectasis
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60-year-old man whose chief complaint is a chronic, productive
cough who has now been referred for CT imaging
CT imaging showed significant central bronchiectasis
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Return to Patient Case
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Return to Patient Case
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Return to Patient Case
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Return to Patient Case
60-year-old man whose chief complaint is a chronic, productive cough
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Initial blood tests showed marked eosinophilia, prompting Aspergillus
serological testing
Total IgE: >2,000 U/mL
Aspergillus IgE: 750 U/mL
Aspergillus IgG: 45 U/mL
Patient was subsequently diagnosed with ABPA
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60-year-old man whose chief complaint is a chronic, productive cough
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Initial blood tests showed marked eosinophilia, prompting Aspergillus
serological testing
Total IgE: >2,000 U/mL
Aspergillus IgE: 750 U/mL
Aspergillus IgG: 45 U/mL
Patient was subsequently diagnosed with ABPA
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Patient Case 2
Id
45-ye with complicated past history
+ Multiple respiratory infections and recurrent pneumonia starting in childhood
+ Sputum culture positive for
— Pseudomonas, Mycobacterium avium complex and Mycobacterium
abscessus
+ CT imaging showed diffuse cystic and varicose bronchiectasis with mid and
upper lobe prominence
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Id
45-ye with complicated past history
+ Multiple respiratory infections and recurrent pneumonia starting in childhood
+ Sputum culture positive for
— Pseudomonas, Mycobacterium avium complex and Mycobacterium
abscessus
+ CT imaging showed diffuse cystic and varicose bronchiectasis with mid and
upper lobe prominence
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Patient Case 2
—
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—
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Patient Case 2
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Patient Case 2
45-year-old m: h complicated past history
+ Initial sputum cultures positive for Pseudomonas aeruginosa
+ Initial sputum AFB cultures positive for Mycobacterium avium complex (MAC)
and Mycobacterium abscessus
+ Pulmonary function testing: FVC 84% of predicted, FEV, 83% of predicted
+ Sweat chloride level > 60 (X2)
+ CFTR mutation analysis showed presence of F508delta mutation plus one other
pathogenic mutation
+ Patient diagnosed with cystic fibrosis
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45-year-old m: h complicated past history
+ Initial sputum cultures positive for Pseudomonas aeruginosa
+ Initial sputum AFB cultures positive for Mycobacterium avium complex (MAC)
and Mycobacterium abscessus
+ Pulmonary function testing: FVC 84% of predicted, FEV, 83% of predicted
+ Sweat chloride level > 60 (X2)
+ CFTR mutation analysis showed presence of F508delta mutation plus one other
pathogenic mutation
+ Patient diagnosed with cystic fibrosis
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Audience Q&A | ©
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