Suspected bronchiectasis

BTS bronchiectasis in adults (2019); ERS adult bronchiectasis guideline

A morphological diagnosis made by comparing the calibre of a bronchus with the artery running beside it. Thin-section CT is definitive; the chest radiograph is not, and a normal radiograph in a patient with a productive cough for months does not close the question.

Persistent productive cough beyond about eight weeks, recurrent lower respiratory infections, or infection recurring in the same lobe.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

CT Chest — High Resolution (Interstitial Protocol)

CT Chest

What we'd amend, and why

The diagnosis rests on the bronchoarterial ratio — a bronchus wider than its accompanying artery — plus failure of the airway to taper towards the periphery and airways visible within a centimetre or two of the pleura. All three are sub-millimetre judgements, so section thickness is the diagnosis: on thick sections the airway wall is averaged with adjacent lung and the ratio becomes unmeasurable. The expiratory series is worth keeping even when the diagnosis is obvious, because bronchiectasis is accompanied by small airways disease, and the extent of air trapping tracks functional impairment better than the extent of the dilated airways.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner
rulerule-pregnancy-ionising — Pregnancy status before an ionising exposure; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(2)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.
Pregnancy status before an ionising exposure
Make the pregnancy enquiry immediately before the exposure and record the answer. In the UK this is a statutory operator duty discharged at the time of exposure under the employer’s written procedures required by IR(ME)R 2017 — it is not something the vetting radiologist can perform or pre-empt, and a request is complete without it.
Radiographer at the scannerAt the scanner
Flags back if: The patient states that she is, or may be, pregnant AND the uterus is in or near the primary beam. The exposure is then paused for re-justification by the IR(ME)R practitioner before it proceeds.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Adults

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	CT Chest CT Chest — High Resolution (Interstitial Protocol) usually appropriate	The diagnosis rests on the bronchoarterial ratio — a bronchus wider than its accompanying artery — plus failure of the airway to taper towards the periphery and airways visible within a centimetre or two of the pleura. All three are sub-millimetre judgements, so section thickness is the diagnosis: on thick sections the airway wall is averaged with adjacent lung and the ratio becomes unmeasurable. The expiratory series is worth keeping even when the diagnosis is obvious, because bronchiectasis is accompanied by small airways disease, and the extent of air trapping tracks functional impairment better than the extent of the dilated airways.
Problem solving	CT Chest CT Chest — Unenhanced	For established disease being reassessed — a change in symptom burden, a new organism, or planning before surgery for localised disease — a single volumetric unenhanced acquisition is usually sufficient and keeps cumulative dose down in a group who will be scanned repeatedly across decades.

Pitfalls

Scanning during an exacerbation and reporting reversible dilatation as established bronchiectasis.
Using a thick-section or standard-dose body reconstruction, on which the bronchoarterial ratio cannot be assessed.
Adding intravenous contrast, which contributes nothing to an airway morphology question.
Attributing the whole symptom burden to the visible dilated airways and ignoring the extent of air trapping, which usually correlates better with how breathless the patient is.
Treating a normal chest radiograph as reassuring — radiographic sensitivity for bronchiectasis is poor, particularly for mild and early disease.

Priors — what to pull first

Look for childhood or young-adult imaging — a lobe damaged by a severe infection decades ago explains focal bronchiectasis and needs no further aetiological work-up.
Compare the distribution across studies rather than the absolute extent; a change from focal to diffuse disease points at a systemic cause.

What makes a good request

A good request states the duration of cough, sputum volume and microbiology, the number of exacerbations, and any relevant background — previous severe childhood infection, immunodeficiency, rheumatoid disease, inflammatory bowel disease or aspergillosis.
The scan should be acquired when the patient is clinically stable. Acute infection produces reversible bronchial dilatation and mucus plugging, and scanning during an exacerbation over-diagnoses the disease and spoils the baseline for future comparison.
Identifying bronchiectasis is only half the vetting value; the distribution and associated findings steer the aetiological work-up, so it is worth asking the referrer what they are looking for.

Scoring this once it is done

The classification and risk tools this question ends in.

Bhalla / Brasfield Score (CF)

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

CT Chest — High Resolution (Interstitial Protocol)CT Chest — Unenhanced

Confirm locally

CT Chest — High Resolution (Interstitial Protocol): timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.