What is the initial management for a patient with peribronchial thickening on chest X-ray (CXR)?

From the Guidelines

The initial management for a patient with peribronchial thickening on chest X-ray (CXR) should focus on treating the underlying cause, with the most recent evidence suggesting that chest radiography is usually appropriate as a first step to exclude other respiratory diseases that can cause symptoms overlapping those of airway stenosis 1.

Key Considerations

• Peribronchial thickening on CXR can be caused by various conditions, including inflammatory airway processes, infections, and chronic diseases such as asthma or COPD.
• The management approach should be tailored to the underlying cause, with supportive care, symptomatic treatment, and possibly antibiotics or inhaled corticosteroids being considered.
• Further diagnostic evaluation, including pulmonary function tests and high-resolution CT scans, may be necessary to better characterize the abnormality and guide treatment decisions.

Diagnostic Evaluation

• Chest radiography is usually appropriate as an initial assessment to exclude other respiratory diseases 1.
• CT chest without IV contrast may be appropriate for evaluating the extent, severity, and distribution of bronchiectasis, as well as associated parenchymal disease 1.
• High-resolution CT scans can provide more detailed information about the lung parenchyma and airways.

Treatment Approach

• For acute bronchitis or bronchiolitis, supportive care with hydration, rest, and symptomatic treatment with bronchodilators such as albuterol may be appropriate.
• If bacterial infection is suspected, antibiotics such as azithromycin or amoxicillin-clavulanate may be prescribed.
• For asthma exacerbations, inhaled corticosteroids like fluticasone plus bronchodilators are indicated.
• In cases of chronic bronchitis or COPD, long-acting bronchodilators and possibly inhaled corticosteroids are recommended.

Important Considerations

• Peribronchial thickening represents inflammation and edema of the bronchial walls, so management focuses on reducing this inflammation while addressing the specific underlying etiology.
• The most recent evidence from the American College of Radiology suggests that chest radiography is usually appropriate as a first step in evaluating patients with suspected tracheobronchial disease 1.

From the Research

Initial Management for Peribronchial Thickening on CXR

The initial management for a patient with peribronchial thickening on chest X-ray (CXR) involves a series of steps to determine the underlying cause and appropriate treatment.

• The first step is to review the patient's symptoms, medical history, and physical examination findings to guide further investigation 2.
• A high-resolution CT (HRCT) scan of the thorax may be recommended if the patient does not improve despite initial treatment, as it can provide more detailed information about the lung parenchyma and help identify potential causes of peribronchial thickening 2, 3.
• The CT appearance of peribronchial thickening can be smooth, nodular, or irregular, depending on the underlying cause, and may be associated with other findings such as ground-glass opacities or pleural effusions 3.
• In some cases, additional imaging modalities such as thoracic ultrasound, magnetic resonance imaging (MRI), or positron emission tomography (PET) may be necessary to further characterize the extent and nature of the disease 4.

Differential Diagnosis and Treatment

The differential diagnosis for peribronchial thickening on CXR is broad and includes various infectious, inflammatory, and neoplastic conditions.

• Idiopathic acute eosinophilic pneumonia (IAEP) is a rare condition that can present with peribronchial thickening on CXR, and is typically treated with steroids 2.
• Other conditions that may cause peribronchial thickening include sarcoidosis, pulmonary lymphangitic carcinomatosis, silicosis, and lymphoproliferative disorders, which require specific treatments based on the underlying cause 3.
• In children, peribronchial thickening on CXR can be a common finding in COVID-19 pneumonia, and the severity of the disease can be assessed using modified radiographic scoring systems 5.

Role of Chest Radiography in Initial Evaluation

Chest radiography (CXR) remains an essential tool in the initial evaluation of patients with suspected respiratory disease, including those with peribronchial thickening.

• However, the yield of routine CXR in certain patient populations, such as febrile neutropenic children with cancer, may be low, and its use should be tailored to individual patient needs 6.