SESSION TITLE: Bronchology/Interventional Procedures Student/Resident Cases
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 28, 2014 at 07:30 AM - 08:30 AM
INTRODUCTION: Plastic bronchitis is a rare respiratory condition seen in children with an underlying bronchial disease with mucus hypersecretion or a cardiac defect. The disease is characterized by marked airway obstruction due to formation of large gelatinous or rigid bronchial casts. Type I casts, which are composed of inflammatory cells and fibrin, are associated with pulmonary diseases with bronchial inflammation. Type II casts, which are acellular and composed mainly of mucin, are associated with congenital heart disease especially following surgical repair.
CASE PRESENTATION: A 54 year-old man without prior lung disease presented with angina, severe multi-vessel coronary artery disease, mitral regurgitation, and decompensated heart failure. Within hours of cardiopulmonary bypass surgery, he developed hypoxemic and hypercapnic respiratory failure with drastically elevated peak inspiratory pressures on mechanical ventilation. Chest x-ray revealed bilateral infiltrates. Airway inspection showed thick, rubbery, glue-like casts in the trachea and throughout the entire endobronchial tree, which could not be readily cleared by flexible bronchoscopy. Therefore, the patient underwent emergent extracorporeal membrane oxygenation and rigid bronchoscopy to remove the extensive plugs. Histology revealed proteinaceous and mucoid material with few inflammatory cells, consistent with type II plastic bronchitis. The patient subsequently required daily flexible bronchoscopy for a week to remove segmental and subsegmental plugs using forceps, brushes, and suctioning. He also received treatments with bronchodilators, N-acetylcysteine, Dornase Alfa, Budesonide, antibiotics, and intrapulmonary percussive ventilation. With these measures, the burden and viscosity of secretions declined, and the patient was successfully extubated.
DISCUSSION: Various treatments for plastic bronchitis have been described, but the mainstay of therapy is extraction of the thick mucus plugs. Commonly, the bronchial casts are too soft and friable to remove with forceps but too thick to suction. We describe a novel technique of twirling the casts around a cytology brush allowing for more effective, intact removal. Mucolytic agents also likely enhanced extraction of the casts.
CONCLUSIONS: Type II plastic bronchitis is rare and described mostly in children with congenital cardiac defects mainly following surgical repair. Plastic bronchitis is quite rare in adults, and this case likely has a similar underlying mechanism which resulted in life-threatening respiratory failure requiring significant bronchoscopic interventions.
Reference #1: Madsen P et al. Plastic bronchitis: new insights and a classification scheme. Paediatr Respir Rev. 2005 Dec;6(4):292-300
Reference #2: Eberlein MH et al. Plastic bronchitis: a management challenge. Am J Med Sci. 2008 Feb;335(2):163-9
Reference #3: Kunder R et al. Pediatric plastic bronchitis: case report and retrospective comparative analysis of epidemiology and pathology.Case Rep Pulmonol. 2013;2013:649365
DISCLOSURE: The following authors have nothing to disclose: Jason Lee, Gaurav Singh, Vibha Mohindra, Weichia Chen, Allison Friedenberg
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