Diagnosing Bronchiectasis: CT Imaging and Workup Essentials

In "Diagnosing Bronchiectasis: CT Imaging and Workup Essentials," our experts turn to the imaging signs and workup that confirm a bronchiectasis diagnosis.

Dr. Khabbaza explains how bronchiectasis is recognized on CT imaging. The clearest sign is an airway that appears wider than its adjacent pulmonary artery, he says, since dilated, poorly tapering airways struggle to clear mucus, bacteria, and inflammatory cells effectively. Additional clues include airways that remain dilated even near the pleura, along with tree-in-bud nodules or small cavities that reflect more advanced disease.

The harder question, Dr. Khabbaza notes, is timing: knowing when to order the CT scan in the first place. He identifies delayed imaging and low clinical suspicion as major contributors to delayed diagnosis. Patients labeled with asthma or COPD who remain uncontrolled despite triple therapy or biologic treatment should prompt a CT scan, he argues, since some of these patients turn out to have underlying bronchiectasis and mucoid impaction instead. He also flags patients with recurrent infections or exacerbations, including those told they have had pneumonia multiple times, as candidates for early imaging. His general rule is that persistent respiratory symptoms unresponsive to initial therapy for less than a year should prompt a CT scan rather than waiting further.

Dr. Basavaraj asks Dr. Metersky about broader diagnostic challenges. Dr. Metersky responds that once a CT scan has established the diagnosis, there is relatively little difficulty determining next steps, though he acknowledges that primary care physicians face a harder task screening the large volume of patients who present with cough. The standard etiology workup, he explains, includes antibody levels to assess immunodeficiency, CBC and IgE testing for eosinophilic disease, evaluation for allergic bronchopulmonary aspergillosis when indicated, alpha-1 antitrypsin testing, and sputum cultures for acid-fast bacilli and bacteria, including surveillance for pseudomonas and non-tuberculous mycobacteria. He notes that payer approval for this workup, including CFTR and primary ciliary dyskinesia testing, has become substantially easier to obtain in recent years.

The next episode in this series, "Referral Pathways in Bronchiectasis: When to Send Patients to a Specialist," features Dr. ElMaraachli explaining who typically identifies bronchiectasis first and when specialty referral becomes necessary.