Severe narrowing of large bronchi may occur in chronic bronchitis, asthma (https://onlineasthmainhalers.com/category/asthma), tuberculosis, sarcoidosis, and amyloidosis. In chronic bronchitis, these changes are said to occur “distal to the third or fourth generation of bronchi.” We have observed a patient with chronic bronchitis who had irreversible bronchial narrowing in her proximal third and fourth order bronchi.
A 38-year-old white woman developed constant shortness of breath without episodic remissions in early 1975. She had smoked 40 cigarettes a day since age 14 and had a chronic daily cough productive of white sputum for more than two years. In January 1976, she was noted to have diffuse wheezes and a right upper lobe infiltrate. Pulmonary function tests showed severe obstructive lung disease (Table 1).
Fiberoptic bronchoscopic examination on three occasions revealed that two left lower lobe segmental bronchi had orifices that were about 1 mm in diameter (Fig 1). These orifices were covered with bubbles that varied with respiration. The right upper lobe bronchus was about 2 mm in diameter; segmental bronchi could not be visualized. The right bronchus intermedius was narrowed to a diameter of approximately 4 mm by a weblike stricture (Fig 2). This stricture prevented visualization of the right middle lobe bronchus and of segmental orifices of the right lower lobe. The remainder of die examination was normal. Biopsy of the left lower lobe and right upper lobe mucosa and submucosa revealed acute and chronic inflammation without evidence of amyloidosis.
Ventilation/perfusion lung scan demonstrated that in die left lower lobe, isotope washout was delayed although perfusion was normal. In the right upper and right middle lobes, both ventilation and perfusion were markedly decreased. A skin test with a 5 TU of purified protein derivative (PPD) was negative as were sputum cultures for acid fast bacilli.
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The patient was treated for two weeks with ampicillin, 2 gm a day, for eight weeks with prednisone, 40 mg a day, and aminophyllme, 800 mg a day. Her symptoms and chest roentgenograms did not show change. Pulmonary function studies continued to demonstrate severe obstruction, although there was a slight improvement (Table 1). Her prednisone regimen was reduced to 20 mg a day. In June 1976, pulmonary function studies showed a further decrease in vital capacity without change in flow rates (Table 1). Elastic recoil and static compliance were normal.
Bronchograms performed in October 1976 revealed discrete coarctations at the orifices of the left lower lobe anterior segment, and the lateral and posterior subsegment (Fig 1). Mucous gland depressions were present in the left upper lobe bronchus. On the right, die upper lobe bronchus was 2 mm in diameter, and die bronchus intermedius was narrowed to 4 mm (Fig 2).
Table 1—Pulmonary Function Test
|FVC (L)||2.24 (71)||2.37 (75)||1.40 (44)|
|FEF25-75% (L/sec)||0.93 (29)||1.22 (38)||1.05 (33)|
|Static compliance L/cmH*0||0.22|
|Coefficient of retraction, cmHjO/L||5.7|
Figure 1. Left . Bronchoscopy photograph demonstrates: 1, left upper lobe orifice; 2, anterior segment left lower lobe orifice; 3, lateral and posterior segment left lower lobe orifice; and 4, superior segment left lower lobe orifice.
Figure 2. Right bronchial tree. Bronchoscopy photograph demonstrates die coarctation in the bronchus intermedius.