What is peribronchial cuffing on a chest x-ray (CXR)?

Peribronchial Cuffing on Chest X-Ray

Peribronchial cuffing is a radiographic sign that appears as thickened, ring-like shadows around bronchi viewed end-on, caused by fluid accumulation in the bronchial wall and peribronchial interstitial space, most commonly indicating interstitial pulmonary edema from acute heart failure. 1

Radiographic Appearance

• Peribronchial cuffing manifests as visible thickening around bronchi when viewed end-on (perpendicular to the X-ray beam), creating a "cuffed" or ring-like appearance around the bronchial lumen. 2
• The most commonly assessed bronchus is the anterior segmental bronchus of either upper lobe, which is visible end-on in approximately 40-50% of normal chest radiographs. 3
• The thickened appearance represents edema involving both the bronchial wall itself and the surrounding peribronchial interstitial tissue. 2

Pathophysiology

• The edema causing peribronchial cuffing originates from transudation through bronchial artery capillaries (not pulmonary artery capillaries), which explains why this finding is a manifestation of interstitial rather than alveolar edema. 2
• This bronchial circulation involvement may explain all radiological manifestations of acute interstitial edema and potentially contributes to progression toward alveolar edema. 2

Clinical Significance and Associated Conditions

Acute Heart Failure (Most Common)

• Peribronchial cuffing is a classic chest X-ray sign of acute heart failure, appearing alongside cardiomegaly, pulmonary venous congestion, and pleural effusion. 1
• This finding indicates significant fluid overload requiring treatment with intravenous loop diuretics to improve symptoms and reduce morbidity. 1

Other Causes

• Peribronchial cuffing can also occur in acute eosinophilic pneumonia, appearing with perihilar airspace shadowing and bilateral reticular markings. 4
• It may be seen in viral infections such as Puumala virus (hantavirus), where it represents noncardiogenic interstitial edema. 5
• In bronchiolitis, particularly in children, peribronchial cuffing may be visible on chest X-ray alongside enlarged hila. 6
• Kawasaki disease can present with peribronchial cuffing or increased interstitial markings, occasionally with pulmonary nodules. 1

Diagnostic Limitations and Pitfalls

• Quantitative assessment of bronchial wall thickness shows only minimal differences between normal individuals (0.7 mm) and acute asthmatics (0.8 mm), making peribronchial cuffing an unreliable sign for distinguishing asthma exacerbations from normal radiographs. 3
• The visibility of bronchi end-on is inconsistent, present in only 43-47% of radiographs, limiting the utility of this sign. 3
• Chest radiography has limited sensitivity for detecting mild interstitial changes; when peribronchial cuffing is suspected but not clearly visible, high-resolution CT provides superior visualization of bronchial wall thickening and peribronchial abnormalities. 4, 5

Clinical Context for Interpretation

• When peribronchial cuffing is identified, correlate with clinical presentation, particularly looking for signs of heart failure (dyspnea, orthopnea, peripheral edema), elevated natriuretic peptides (BNP >1500 pg/mL suggests poor prognosis), and echocardiographic evidence of elevated left ventricular filling pressures. 1
• In the absence of cardiac disease, consider alternative diagnoses including infectious etiologies, eosinophilic pneumonia, or systemic conditions like Kawasaki disease. 1, 4, 5
• Lung ultrasound may be more sensitive than chest X-ray for detecting interstitial edema, with 94% sensitivity and 92% specificity for pulmonary edema, and can guide decongestive therapy. 1