1
|
Mackie AS, Veldtman GR, Thorup L, Hjortdal VE, Dori Y. Plastic Bronchitis and Protein-Losing Enteropathy in the Fontan Patient: Evolving Understanding and Emerging Therapies. Can J Cardiol 2022; 38:988-1001. [DOI: 10.1016/j.cjca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/08/2022] [Accepted: 03/12/2022] [Indexed: 12/17/2022] Open
|
2
|
Driesen BW, Voskuil M, Grotenhuis HB. Current Treatment Options for the Failing Fontan Circulation. Curr Cardiol Rev 2022; 18:e060122200067. [PMID: 34994331 PMCID: PMC9893132 DOI: 10.2174/1573403x18666220106114518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/22/2021] [Accepted: 11/16/2021] [Indexed: 11/22/2022] Open
Abstract
The Fontan operation was introduced in 1968. For congenital malformations, where biventricular repair is unsuitable, the Fontan procedure has provided a long-term palliation strategy with improved outcomes compared to the initially developed procedures. Despite these improvements, several complications merely due to a failing Fontan circulation, including myocardial dysfunction, arrhythmias, increased pulmonary vascular resistance, protein-losing enteropathy, hepatic dysfunction, plastic bronchitis, and thrombo-embolism, may occur, thereby limiting the life-expectancy in this patient cohort. This review provides an overview of the most common complications of Fontan circulation and the currently available treatment options.
Collapse
Affiliation(s)
- Bart W. Driesen
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Cardiology, Laurentius Ziekenhuis, Roermond, The Netherlands
| | - Michiel Voskuil
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Heynric B. Grotenhuis
- Department of Pediatric Cardiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Utrecht, The Netherlands
| |
Collapse
|
3
|
Pałyga-Bysiecka I, Polewczyk AM, Polewczyk M, Kołodziej E, Mazurek H, Pogorzelski A. Plastic Bronchitis—A Serious Rare Complication Affecting Children Only after Fontan Procedure? J Clin Med 2021; 11:jcm11010044. [PMID: 35011785 PMCID: PMC8745351 DOI: 10.3390/jcm11010044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Revised: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 12/30/2022] Open
Abstract
Background: Plastic bronchitis (PB) may occur not only in children following palliative Fontan procedure but also in those without underlying heart disease. We aim to assess the clinical course, therapeutic measures, outcome, and follow-up of PB in children with congenital heart disease (CHD) and children without cardiac problems. Methods: This retrospective case series assessed children with PB admitted to hospital between 2015 and 2019. Parents or guardians of patients were contacted by e-mail or telephone between September 2017 and June 2019 to enquiry about recurrence of PB and strategy of treatment. The diagnosis of PB was based on the expectoration (spontaneous or during bronchoscopy) of endobronchial plugs. Results: This study delineated the clinical, histological, and laboratory features of plastic bronchitis in children following Fontan procedure (Group A) and in those without heart defects (Group B, non-CHD children). The main symptoms were cough accompanied by dyspnea, and hypoxemia with a decrease in oxygen saturation, often leading to acute respiratory failure. In children with CHD, the first episode of PB occurred at a relatively young age. Although chronic, i.e., lasting more than 3 weeks, inhaled therapy was implemented in both groups of patients, the recurrences of PB were observed. The mean time to PB recurrence after the first episode in Group A was longer than that in Group B (1.47 vs. 0.265 years, p = 0.2035). There was no re-episode with recurrence of PB in 3 cases out of 10 in total in Group A (30%) and 1 case out of 4 in total in Group B (25%). While the majority of children in Group A usually developed bronchial casts on the right side, the patients in Group B (without CHD) suffered from bronchial casts located only on the left side. Conclusions: Despite many similarities, clinical, histological, and laboratory studies in the children with plastic bronchitis after Fontan’s surgery and in children without heart defects suggest that there are differences in the course of the disease in patients without CHD, such as a more advanced age of the first episode of PB, the location of plastic casts on the left side, and a stronger role of inflammatory factors and mechanisms. Further research is needed to understand the pathophysiology of PB and choose the most appropriate therapy.
Collapse
Affiliation(s)
- Ilona Pałyga-Bysiecka
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
- Correspondence: ; Tel.: +48-413303326
| | - Aneta Maria Polewczyk
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
| | - Maciej Polewczyk
- Collegium Medicum, Jan Kochanowski University, 25-736 Kielce, Poland;
| | - Elżbieta Kołodziej
- First Department of Pediatrics, Swietokrzyskie Pediatric Center, 25-736 Kielce, Poland; (A.M.P.); (E.K.)
| | - Henryk Mazurek
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, 03-700 Rabka-Zdrój, Poland; (H.M.); (A.P.)
| | - Andrzej Pogorzelski
- Department of Pneumology and Cystic Fibrosis, Institute of Tuberculosis and Lung Diseases, 03-700 Rabka-Zdrój, Poland; (H.M.); (A.P.)
| |
Collapse
|
4
|
Harteveld LM, Blom NA, Hazekamp MG, Ten Harkel ADJ. Treatment and outcome of plastic bronchitis in single ventricle patients: a systematic review. Interact Cardiovasc Thorac Surg 2020; 30:846-853. [DOI: 10.1093/icvts/ivaa032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/14/2020] [Accepted: 01/30/2020] [Indexed: 12/23/2022] Open
Abstract
Abstract
Plastic bronchitis (PB) is a life-threatening complication in single ventricle (SV) patients of which the exact pathophysiology, outcome and optimal treatment are still unclear. This study aims to systematically review the literature to give insight into the characteristics, outcome and management options of SV patients with PB. A systematic review was conducted, using the electronic database PubMed to find records published up to August 2018, describing SV patients and PB in which characteristics, treatment and/or outcome were adequately described per case. A total of 577 records were screened of which 73 had sufficient data describing 133 SV cases with PB. Most cases had completed a Fontan palliation (n = 126) with a median interval between Fontan completion and diagnosis of PB of 18.4 months (Q1–Q3 5.0–36.3). Overall mortality was 15.2% and was associated with the diagnosis of PB within 12 months after Fontan palliation (5-year survival of 56.1% ≤12 months vs 94.8% >12 months, P = 0.002) and a higher age at Fontan completion (47.4 months for non-survivors vs 36.0 months for survivors, P = 0.015). Most patients received a combination therapy from 3 different treatment strategies, i.e. therapy for relief of airway obstruction, anti-inflammatory treatment and treatment to improve haemodynamics of the Fontan physiology (55.1%). In conclusion, SV patients who are diagnosed with PB within 12 months after Fontan palliation have a higher risk of mortality. Moreover, most cases received a combination therapy consisting of all 3 treatment strategies.
Collapse
Affiliation(s)
- Lisette M Harteveld
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| | - Nico A Blom
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
- Department of Paediatric Cardiology, Amsterdam University Medical Centre, Academic Medical Centre, Amsterdam, Netherlands
| | - Mark G Hazekamp
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Arend D J Ten Harkel
- The Centre for Congenital Heart Disease Amsterdam–Leiden, Leiden, Netherlands
- Department of Paediatric Cardiology, Leiden University Medical Centre, Leiden, Netherlands
| |
Collapse
|
5
|
Sera T, Hamamoto T, Tani H, Ono D, Ueda T, Takeno S. A Case of Plastic Bronchitis that Required Differential Diagnosis from Bronchial Foreign Body. ACTA ACUST UNITED AC 2018. [DOI: 10.2468/jbes.69.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Takehiro Sera
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Takao Hamamoto
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Hiroo Tani
- Department of Pediatrics, Graduate School of Biomedical Sciences, Hiroshima University
| | - Daichi Ono
- Department of Pediatrics, Graduate School of Biomedical Sciences, Hiroshima University
| | - Tsutomu Ueda
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| | - Sachio Takeno
- Department of Otolaryngology, Head and Neck Surgery, Graduate School of Biomedical Sciences, Hiroshima University
| |
Collapse
|
6
|
Pérez Ruiz E, López Castillo MC, Caro Aguilera P, Pérez Frías J. Management and Treatment of Pediatric Plastic Bronchitis. Arch Bronconeumol 2017; 53:467-468. [PMID: 28238517 DOI: 10.1016/j.arbres.2016.12.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/07/2016] [Accepted: 12/15/2016] [Indexed: 11/20/2022]
Affiliation(s)
| | | | | | - Javier Pérez Frías
- Sección de Neumología, Hospital Materno-Infantil, Málaga, España; Universidad de Medicina, Hospital Materno-Infantil, Málaga, España
| |
Collapse
|
7
|
The Long-Term Management of Children and Adults with a Fontan Circulation: A Systematic Review and Survey of Current Practice in Australia and New Zealand. Pediatr Cardiol 2017; 38:56-69. [PMID: 27787594 DOI: 10.1007/s00246-016-1484-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/15/2016] [Indexed: 01/28/2023]
Abstract
Although long-term survival is now the norm, Fontan patients face significant morbidity and premature mortality. Wide variation exists in long-term Fontan management. With an aim of improving their long-term management, we conducted a systematic review to identify best available evidence and gaps in knowledge for future research focus. We also surveyed cardiologists in Australia and New Zealand managing Fontan patients, to determine the alignment of current local practice with best available evidence. A systematic review was conducted using strict search criteria (PRISMA guidelines), pertaining to long-term Fontan management. All adult congenital and paediatric cardiologists registered with The Australia and New Zealand Fontan Registry were invited to respond to an online survey. Reasonable quality evidence exists for non-inferiority of aspirin over warfarin for thromboprophylaxis in standard-risk Fontan patients. No strong evidence is currently available for the routine use of ACE inhibitors, beta blockers or pulmonary vasodilators. Little evidence exists regarding optimal arrhythmia treatment, exercise restriction/prescription, routine fenestration closure, elective Fontan conversion and screening/management of liver abnormalities. Although pregnancy is generally well tolerated, there are high rates of miscarriage and premature delivery. Thirty-nine out of 78 (50 %) cardiologists responded to the survey. Heterogeneity in response was demonstrated with regard to long-term anti-coagulation, other medication use, fenestration closure and pregnancy and contraception counselling. Substantial gaps in our knowledge remain with regard to the long-term management of Fontan patients. This is reflected in the survey of cardiologists managing these patients. We have identified a number of key areas for future research.
Collapse
|
8
|
Lubcke NL, Nussbaum VM, Schroth M. Use of Aerosolized Tissue Plasminogen Activator in the Treatment of Plastic Bronchitis. Ann Pharmacother 2016; 47:e13. [DOI: 10.1345/aph.1r690] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To present a case of nebulized tissue plasminogen activator (t-PA) treatment for symptomatic plastic bronchitis in a pediatric patient years after a Fontan procedure. CASE SUMMARY A 13-year-old boy with a history of corrected congenital heart disease was admitted to the pediatric intensive care unit after 2 weeks of worsening respiratory distress. A chest radiograph and subsequent bronchoscopy revealed extensive mucus plugging due to plastic bronchitis. Casts reaccumulated quickly after manual removal of the mucus and a regimen of aerosolized t-PA was initiated to break down the casts and prevent further cast formation over the 17-day hospital course. The treatment was successful and the patient was discharged home without evidence of bronchial casts. DISCUSSION Plastic bronchitis is a potentially devastating condition in which pulmonary infiltrates line the bronchial tree, forming casts and prohibiting effective oxygen exchange. There are few effective treatment options for this condition. The use of aerosolized t-PA for the treatment of plastic bronchitis has been reported to be safe and effective in 4 cases but no consistent regimen, dose, or duration of treatment has been established. CONCLUSIONS t-PA can be nebulized and inhaled for successful inhibition of bronchial cast formation. More information to determine the most effective dose and duration of therapy is needed to effectively improve the lives of people with plastic bronchitis.
Collapse
Affiliation(s)
- Nicole L Lubcke
- Nicole L Lubcke PharmD, Clinical Pharmacist, Department of Pharmacy, American Family Children's Hospital, University of Wisconsin Hospital and Clinics, Madison
| | - Vicki M Nussbaum
- Vicki M Nussbaum PharmD BCOP, Clinical Pharmacist, Department of Pharmacy, American Family Children's Hospital, University of Wisconsin Hospital and Clinics
| | - Mary Schroth
- Mary Schroth MD, Pediatric Pulmonologist, University of Wisconsin School of Medicine and Public Health
| |
Collapse
|
9
|
Robinson M, Smiley M, Kotha K, Udoji T. Plastic Bronchitis Treated With Topical Tissue-Type Plasminogen Activator and Cryotherapy. Clin Pediatr (Phila) 2016; 55:1171-5. [PMID: 26507250 DOI: 10.1177/0009922815614358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Kavitha Kotha
- Nationwide Children's Hospital, Columbus, OH, USA Ohio State University, Columbus, OH, USA
| | | |
Collapse
|
10
|
Monagle K, Ryan A, Hepponstall M, Mertyn E, Monagle P, Ignjatovic V, Newall F. Inhalational use of antithrombotics in humans: Review of the literature. Thromb Res 2015; 136:1059-66. [PMID: 26475409 DOI: 10.1016/j.thromres.2015.10.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Revised: 09/22/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Off label use of anticoagulants is common. The association between fibrin deposition in the lungs and primary lung disease, injury or prematurity affords a strong theoretical basis for the potential benefit of antithrombotic therapies administered directly to the lung tissue. This review offers a critical appraisal of current evidence related to the inhalational administration of antithrombotic therapy in humans. MATERIALS AND METHODS An interrogation of 2 databases across a 13 year period of time was undertaken using key words selected a priori. Identified publications were categorized according to the following themes: 1. Inhaled antithrombotic therapy in healthy subjects 2. Inhaled antithrombotic therapy for vascular thromboprophylaxis 3. Inhaled antithrombotic therapy in smoke inhalation and lung injury 4. Inhaled antithrombotic therapy in asthma or allergy 5. Inhaled antithrombotic therapy for plastic bronchitis post-Fontan surgery 6. Inhaled antithrombotic therapy for other indications. RESULTS 33 articles were identified consistent with the inclusion criteria developed for this review. Unfractionated heparin, LMWH, activated protein C and thrombolytic agents have been administered via the respiratory track, with asthma and smoke inhalation/lung injury being the most frequently investigated clinical scenarios described. All studies reported had significant methodological limitations. CONCLUSIONS The safety and clinical utility of inhaled antithrombotic therapies have not been adequately investigated to support the generation of any firm evidence. This review highlights where inhaled antithrombotic therapies have shown promise and importantly, the further research required to confirm mechanism of action and a definitive risk: benefit profile.
Collapse
Affiliation(s)
- K Monagle
- Department of Paediatrics, The University of Melbourne, Australia
| | - A Ryan
- Department of Paediatrics, The University of Melbourne, Australia; Clinical Haematology Department, The Royal Children's Hospital, Australia
| | - M Hepponstall
- Department of Paediatrics, The University of Melbourne, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Australia
| | - E Mertyn
- Department of Paediatrics, The University of Melbourne, Australia
| | - P Monagle
- Department of Paediatrics, The University of Melbourne, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Australia; Clinical Haematology Department, The Royal Children's Hospital, Australia
| | - V Ignjatovic
- Department of Paediatrics, The University of Melbourne, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Australia
| | - F Newall
- Department of Paediatrics, The University of Melbourne, Australia; Haematology Research Group, Murdoch Childrens Research Institute, Australia; Clinical Haematology Department, The Royal Children's Hospital, Australia; Department of Nursing, The University of Melbourne, Australia; Nursing Research Department, The Royal Children's Hospital, Australia.
| |
Collapse
|
11
|
Jasinovic T, Kozak FK, Moxham JP, Chilvers M, Wensley D, Seear M, Campbell A, Ludemann JP. Casting a look at pediatric plastic bronchitis. Int J Pediatr Otorhinolaryngol 2015; 79:1658-61. [PMID: 26250441 DOI: 10.1016/j.ijporl.2015.07.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 07/03/2015] [Accepted: 07/04/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To review clinical presentations and management strategies for children with plastic bronchitis. METHODS Retrospective chart review. RESULTS Seven patients required rigid bronchoscopy to remove bronchial casts over a 17-year study period. Mean age at presentation was 60 months. Mean follow-up was 53 months. Co-morbidities included: congenital heart disease (n=3), chronic pulmonary disorders (n=2) and sickle cell disease (n=1). 4 patients required multiple bronchoscopies for recurrent casts. Adjunctive topical therapies were administered in all 7 patients, without complication. Rigid bronchoscopy for cast removal was performed in 2 patients who were on extra-corporal membrane oxygenation (ECMO), using special precautions to safeguard the ECMO catheters. CONCLUSIONS Bronchial casts in children may present acutely or sub-acutely. Recurrent casts are unusual; however, in combination with severe cardiac disease may lead to mortality. Adjunctive topical therapies are still under investigation. Special safeguards for ECMO catheters are imperative. This case series complements and adds to the International Plastic Bronchitis Registry.
Collapse
Affiliation(s)
- Tin Jasinovic
- Division of Pediatric Otolaryngology, British Columbia's Children's Hospital, Vancouver, BC, Canada.
| | - Frederick K Kozak
- Division of Pediatric Otolaryngology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - J Paul Moxham
- Division of Pediatric Otolaryngology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - Mark Chilvers
- Division of Pediatric Respirology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - David Wensley
- Division of Pediatric Respirology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - Michael Seear
- Division of Pediatric Respirology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - Andrew Campbell
- Division of Pediatric Cardiac Surgery, British Columbia's Children's Hospital, Vancouver, BC, Canada
| | - Jeffrey P Ludemann
- Division of Pediatric Otolaryngology, British Columbia's Children's Hospital, Vancouver, BC, Canada
| |
Collapse
|
12
|
Houin PR, Veress LA, Rancourt RC, Hendry-Hofer TB, Loader JE, Rioux JS, Garlick RB, White CW. Intratracheal heparin improves plastic bronchitis due to sulfur mustard analog. Pediatr Pulmonol 2015; 50:118-26. [PMID: 24692161 PMCID: PMC4182164 DOI: 10.1002/ppul.23043] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 02/04/2014] [Accepted: 03/04/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND Inhalation of sulfur mustard (SM) and SM analog, 2-chloroethyl ethyl sulfide (CEES), cause fibrinous cast formation that occludes the conducting airways, similar to children with Fontan physiology-induced plastic bronchitis. These airway casts cause significant mortality and morbidity, including hypoxemia and respiratory distress. Our hypothesis was that intratracheal heparin, a highly cost effective and easily preserved rescue therapy, could reverse morbidity and mortality induced by bronchial cast formation. METHODS Sprague-Dawley rats were exposed to 7.5% CEES via nose-only aerosol inhalation to produce extensive cast formation and mortality. The rats were distributed into three groups: non-treated, phosphate-buffered saline (PBS)-treated, and heparin-treated groups. Morbidity was assessed with oxygen saturations and clinical distress. Blood and bronchoalveolar lavage fluid (BALF) were obtained for analysis, and lungs were fixed for airway microdissection to quantify the extent of airway cast formation. RESULTS Heparin, given intratracheally, improved survival (100%) when compared to non-treated (75%) and PBS-treated (90%) controls. Heparin-treated rats also had improved oxygen saturations, clinical distress and airway cast scores. Heparin-treated rats had increased thrombin clotting times, factor Xa inhibition and activated partial thromboplastin times, indicating systemic absorption of heparin. There were also increased red blood cells (RBCs) in the BALF in 2/6 heparin-treated rats compared to PBS-treated control rats. CONCLUSIONS Intratracheal heparin 1 hr after CEES inhalation improved survival, oxygenation, airway obstruction, and clinical distress. There was systemic absorption of heparin in rats treated intratracheally. Some rats had increased RBCs in BALF, suggesting a potential for intrapulmonary bleeding if used chronically after SM inhalation.
Collapse
Affiliation(s)
- Paul R Houin
- Department of Pediatrics, University of Colorado Health Sciences Center, Aurora, Colorado
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Management of plastic bronchitis with nebulized tissue plasminogen activator: another brick in the wall. Ital J Pediatr 2014; 40:18. [PMID: 24524376 PMCID: PMC3974171 DOI: 10.1186/1824-7288-40-18] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 02/09/2014] [Indexed: 11/18/2022] Open
Abstract
Plastic bronchitis is a rare complication of a variety of respiratory diseases and congenital heart disease surgery, particularly Fontan procedure. Bronchial casts with rubber-like consistency develop acutely and may cause severe life-threatening respiratory distress. The management of plastic bronchitis is yet not well defined. Early intermittent, self-administered nebulization of tissue plasminogen activator was found to be effective in preventing deterioration of acute respiratory symptoms in a patient with primary ciliary dyskinesia and recurrent cast formation. Further investigation into new therapeutic strategies for this devastating disease is advocated.
Collapse
|
14
|
Sobush KT, Thornburg CD, Voynow JA, Davis SD, Peterson-Carmichael SL. A 2-year-old girl with co-inherited cystic fibrosis and sickle cell-β+ thalassemia presenting with recurrent vaso-occlusive events during cystic fibrosis pulmonary exacerbations: a case report. J Med Case Rep 2013; 7:203. [PMID: 23890029 PMCID: PMC3750320 DOI: 10.1186/1752-1947-7-203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 05/31/2013] [Indexed: 12/17/2023] Open
Abstract
Introduction This is the first published report of a young girl with co-inherited sickle cell-β+ thalassemia and cystic fibrosis. Although a small subset of patients with co-inherited cystic fibrosis and other hemoglobinopathies have been reported, this patient developed early hematologic and pulmonary complications that were more severe than the previous cases. To assess pulmonary co-morbidities, we used infant pulmonary function testing through the raised volume rapid thoracoabdominal compression technique as both an established study of early cystic fibrosis and also as a newer study of mechanism for early sickle cell lung disease. This further serves as the first report of the raised volume rapid thoracoabdominal compression technique to determine raised volume forced expiratory flows and fractional lung volumes in a patient with a hemoglobinopathy. Case presentation A 2-year-old African-American girl with co-inherited cystic fibrosis and sickle cell-β+ thalassemia developed severe hematologic complications (recurrent vaso-occlusive events, hepatic sequestration, and acute chest syndrome) during periods of cystic fibrosis pulmonary exacerbations and weight loss. Because cystic fibrosis and sickle cell-β+ thalassemia both confer distinct patterns of pulmonary disease, infant pulmonary function testing with the raised volume rapid thoracoabdominal compression technique was used to define respiratory pathophysiology and guide treatment options. Infant pulmonary function testing data demonstrated moderate-to-severe lower airways obstruction, moderate air trapping, and no evidence of restrictive lung disease. Conclusions Infant pulmonary function testing with the raised volume rapid thoracoabdominal compression technique guided therapy in this patient with cystic fibrosis and sickle cell-β+ thalassemia. Although this is an original case report on a unique patient, this case highlights the need to evaluate early respiratory pathophysiology in a broader population of young patients with hemoglobinopathies and screen those at risk for early pulmonary co-morbidities.
Collapse
Affiliation(s)
- Kurtis T Sobush
- Division of Pediatric Pulmonary and Sleep Medicine, Duke University Medical Center, Durham, North Carolina, USA.
| | | | | | | | | |
Collapse
|
15
|
Brooks K, Caruthers RL, Schumacher KR, Stringer KA. Pharmacotherapy challenges of Fontan-associated plastic bronchitis: a rare pediatric disease. Pharmacotherapy 2013; 33:922-34. [PMID: 23686915 DOI: 10.1002/phar.1290] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pediatric pharmacotherapy is often challenging due to the paucity of available clinical data on the safety and efficacy of drugs that are commonly used in children. This quandary is even more prevalent in children with rare diseases. Although extrapolations for dosing and administration are often made from available adult data with similar disease states, this translation becomes even more problematic in rare pediatric diseases. Understanding of rare disease pathophysiology is typically poor, and few, if any, effective therapies have been studied and identified. One condition that illustrates these issues is plastic bronchitis, a rare, most often pediatric disease that is characterized by the production of obstructive bronchial airway casts. This illness primarily occurs in children with congenital heart disease, often after palliative surgery. Plastic bronchitis is a highly clinically relevant and therapeutically challenging problem with a high mortality rate, and, a generally accepted effective pharmacotherapy regimen has yet to be identified. Furthermore, the disease is ill defined, which makes timely identification and treatment of children with plastic bronchitis difficult. The pharmacotherapies currently used to manage this disease are largely anecdotal and vary between the use of macrolide antibiotics, mucolytics, bronchodilators, and inhaled fibrinolytics in a myriad of combinations. The purpose of this review is 2-fold: first, to highlight the dilemma of treating plastic bronchitis, and second, to bring attention to the continuing need for studies of drug therapies used in children so safe and effective drug regimens can be established, particularly for rare diseases.
Collapse
Affiliation(s)
- Kristina Brooks
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | | | | | | |
Collapse
|
16
|
Pediatric plastic bronchitis: case report and retrospective comparative analysis of epidemiology and pathology. Case Rep Pulmonol 2013; 2013:649365. [PMID: 23662235 PMCID: PMC3639666 DOI: 10.1155/2013/649365] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 03/24/2013] [Indexed: 12/30/2022] Open
Abstract
Plastic bronchitis (PB) is a pathologic condition in which airway casts develop in the tracheobronchial tree causing airway obstruction. There is no standard treatment strategy for this uncommon condition. We report an index patient treated using an emerging multimodal strategy of directly instilled and inhaled tissue plasminogen activator (t-PA) as well as 13 other cases of PB at our institution between 2000 and 2012. The majority of cases (n = 8) occurred in patients with congenital heart disease. Clinical presentations, treatments used, histopathology of the casts, and patient outcomes are reviewed. Further discussion is focused on the epidemiology of plastic bronchitis and a systematic approach to the histologic classification of casts. Comorbid conditions identified in this study included congenital heart disease (8), pneumonia (3), and asthma (2). Our institutional prevalence rate was 6.8 per 100,000 patients, and our case fatality rate was 7%.
Collapse
|
17
|
Abstract
OBJECTIVE The purpose of this article is to describe 3 patients each of whom developed a different form of tracheobronchial aspergillosis. METHODS We describe our clinical experience with 3 patients who developed significant respiratory symptoms secondary to Aspergillus infection. All patients were followed closely until there was resolution of pulmonary problems or they succumbed to respiratory insufficiency. RESULTS The first patient had asthma and her clinical and bronchoscopic findings were compatible with the diagnosis of mucoid impaction syndrome caused by Aspergillus. Response to therapy was excellent with complete recovery. The second and third patients had what we believe was tracheobronchial pseudomembranous aspergillosis. The precise reason for this complication in the second patient is unknown. The third patient was immunosuppressed and developed tracheobronchial aspergillosis. Despite aggressive therapy, both of these patients died. Diagnostic bronchoscopy was helpful in detecting the airway abnormalities and for obtaining respiratory specimens for culture. CONCLUSIONS These cases show the diverse tracheobronchial manifestations of Aspergillus species. Diagnostic bronchoscopy was helpful in the diagnosis of airway involvement by aspergillus.
Collapse
|
18
|
Plastic Bronchitis After Extracardiac Fontan Operation. Ann Thorac Surg 2012; 94:860-4. [DOI: 10.1016/j.athoracsur.2012.04.043] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 04/10/2012] [Accepted: 04/12/2012] [Indexed: 11/17/2022]
|
19
|
Gibb E, Blount R, Lewis N, Nielson D, Church G, Jones K, Ly N. Management of plastic bronchitis with topical tissue-type plasminogen activator. Pediatrics 2012; 130:e446-50. [PMID: 22802609 DOI: 10.1542/peds.2011-2883] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Plastic bronchitis or cast bronchitis is a rare disease of unclear etiology characterized by formation of airway casts that can lead to life-threatening airway obstruction. There is currently limited data regarding optimal treatment of plastic bronchitis. Several therapies have been suggested, but recurrences are common and mortality remains high. We report the case of a 6-year-old boy with refractory eosinophilic bronchial casts, unresponsive to low-dose systemic corticosteroids, inhaled corticosteroids, azithromycin, and dornase alfa, who was treated successfully and safely with direct instillation of tissue-type plasminogen activator (tPA) to the obstructing casts during flexible bronchoscopy and inhaled tPA. Our case illustrates that the current therapy for plastic bronchitis remains inadequate. To our knowledge, this case is the first to show that direct instillation of tPA can be used safely for treatment of this disease. The use of tPA via direct administration into the airways during bronchoscopy and via a nebulizer appeared to be a safe and effective therapy for plastic bronchitis and should be considered early in the course of the disease to prevent complications of severe airway obstruction.
Collapse
Affiliation(s)
- Elizabeth Gibb
- Division of Pulmonary Medicine, Department of Pediatrics, Benioff Children’s Hospital, University of California San Francisco, San Francisco, California 94143, USA.
| | | | | | | | | | | | | |
Collapse
|
20
|
LaRue M, Gossett JG, Stewart RD, Backer CL, Mavroudis C, Jacobs ML. Plastic Bronchitis in Patients With Fontan Physiology: Review of the Literature and Preliminary Experience With Fontan Conversion and Cardiac Transplantation. World J Pediatr Congenit Heart Surg 2012; 3:364-72. [DOI: 10.1177/2150135112438107] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Madeleine LaRue
- Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Jeffrey G. Gossett
- Division of Pediatric Cardiology, Children’s Memorial Hospital, Chicago, IL, USA
| | - Robert D. Stewart
- Department of Congenital Heart Surgery, Cleveland Clinic Children’s Hospital, Center for Pediatric and Adult Congenital Heart Disease, Cleveland, OH, USA
| | - Carl L. Backer
- Department of Surgery, Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Hospital, Chicago, IL, USA
| | - Constantine Mavroudis
- Congenital Heart Institute, Walt Disney Pavilion, Florida Hospital for Children, Orlando, FL, USA
| | - Marshall L. Jacobs
- Department of Congenital Heart Surgery, Cleveland Clinic Children’s Hospital, Center for Pediatric and Adult Congenital Heart Disease, Cleveland, OH, USA
| |
Collapse
|
21
|
Plastic bronchitis developing 5 years after Fontan procedure in a girl with Kartagener's syndrome. Pediatr Cardiol 2012; 33:846-9. [PMID: 22331057 DOI: 10.1007/s00246-012-0235-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 01/02/2012] [Indexed: 10/28/2022]
Abstract
Although rare, plastic bronchitis (PB) is an important early complication after Fontan procedure. Kartagener's syndrome is characterized by mucociliary dysfunction of the respiratory tract and has a triad of features, including situs inversus totalis, chronic sinusitis, and bronchiectasia. We experienced PB in a patient with Kartagener's syndrome 5 years after Fontan procedure.
Collapse
|
22
|
Abstract
Cast or plastic bronchitis (PB) is an unusual disorder that is rarely encountered in children. Plastic bronchitis is characterized by widespread formation of casts in the tracheobronchial tree with partial or complete airway obstruction. The pathologist may receive bronchial casts that have been removed by bronchoscopy for gross and histopathologic analysis. We describe two children with PB in the setting of an apparent lower respiratory tract infection, where the bronchoscopic removal of major cast segments was associated with a favorable outcome. Patients' clinical and radiographic features and gross anatomic and histopathologic characteristics of casts are presented.
Collapse
Affiliation(s)
- Rashed A Hasan
- Mercy Children's Hospital, Pediatric Intensive Care Unit, Toledo, Ohio 43608, USA.
| | | | | |
Collapse
|
23
|
Do P, Randhawa I, Chin T, Parsapour K, Nussbaum E. Successful management of plastic bronchitis in a child post Fontan: case report and literature review. Lung 2012; 190:463-8. [PMID: 22430124 DOI: 10.1007/s00408-012-9384-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 03/02/2012] [Indexed: 11/27/2022]
Abstract
PURPOSE Plastic bronchitis is the occlusion of the major bronchial airways by a firm, gelatinous mucoid cast. It is a rare condition, which while classically described in asthma and sickle cell disease has greater mortality in patients with congenital heart disease. The management of this disease is obscure given the lack of clinical data regarding treatment therapies. METHODS We describe a case of an 11-year-old female status after Fontan surgery who presented with respiratory distress secondary to atelectasis of the right lung. RESULTS A bronchoscopy was performed demonstrating an obstructing bronchial cast with successful extraction. The plastic bronchitis continued to recur and she was placed on multiple inhaled mucolytics as well as inhaled tissue plasminogen activator with temporary resolution. Further evaluation of the etiology of her casts revealed that she had elevated pulmonary arterial pressures. Repeated bronchoscopic removal of the casts was utilized as well as continuation of the aggressive airway clearance. Ultimately fenestration of her Fontan was performed along with treatment of pulmonary vasodilators sildenafil and bosentan. Although there was improvement of the cast formation, her airway clearance could only be weaned to four times a day therapy with which she was discharged home after a 3-month hospitalization. She continues to remain on this therapy and has not required hospitalization since the initial incident over 1 year ago. CONCLUSIONS Plastic bronchitis in a patient with Fontan physiology presents a treatment dilemma that may require comprehensive therapy in severe cases such as described.
Collapse
Affiliation(s)
- Paul Do
- Miller Children's Hospital, 2801 Atlantic Ave. Ground Floor, Long Beach, CA, USA.
| | | | | | | | | |
Collapse
|
24
|
Heath L, Ling S, Racz J, Mane G, Schmidt L, Myers JL, Tsai WC, Caruthers RL, Hirsch JC, Stringer KA. Prospective, longitudinal study of plastic bronchitis cast pathology and responsiveness to tissue plasminogen activator. Pediatr Cardiol 2011; 32:1182-9. [PMID: 21786171 PMCID: PMC3207025 DOI: 10.1007/s00246-011-0058-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2011] [Accepted: 07/08/2011] [Indexed: 11/30/2022]
Abstract
Plastic bronchitis (PB) is a rare disease that often occurs in patients with congenital heart disease (CHD) who have undergone staged single-ventricle palliation. It is characterized by the formation of rubbery "casts" in the airways. PB treatment frequently includes inhaled tissue plasminogen activator (tPA). However, the efficacy of tPA to reduce cast burden is unknown. This is further complicated by our lack of knowledge of cast composition. We obtained spontaneously expectorated PB casts from children (n = 4) with CHD and one adult patient with idiopathic PB. Pathological assessment was made from paraffin-preserved samples. Casts were treated with phosphate-buffered saline (PBS) or tPA. Cast response to tPA was assessed by changes in cast weight and the production of fibrin D-dimer. Independent of dose, tPA reduced cast weight compared with PBS-treatment (P = 0.001) and increased D-dimer levels. Histological staining showed that PB casts from all patients were composed of fibrin and contained notable numbers of lymphocytes. Cast composition did not change over time. Collectively, these data support that in our PB patients, casts are composed of fibrin and are responsive to tPA treatment. This makes inhaled tPA a potentially viable option for symptomatic relief of PB while we work to unravel the complexity of PB pathogenesis.
Collapse
Affiliation(s)
- Lauren Heath
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109 USA
| | - Shelley Ling
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109 USA
| | - Jennifer Racz
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109 USA
| | - Gerta Mane
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109 USA
| | - Lindsay Schmidt
- Division of Anatomic Pathology, Department of Pathology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI 48109 USA
| | - Jeffrey L. Myers
- Division of Anatomic Pathology, Department of Pathology, University of Michigan Hospitals and Health Centers, Ann Arbor, MI 48109 USA
| | - Wan C. Tsai
- Division of Pediatric Pulmonology, Department of Pediatrics and Communicable Diseases, University of Michigan Hospitals and Health Centers, Ann Arbor, MI 48109 USA
| | - Regine L. Caruthers
- Department of Pharmacy, University of Michigan Hospitals and Health Centers, Ann Arbor, MI 48109 USA
| | - Jennifer C. Hirsch
- Department of Surgery, Division of Pediatric Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI 48109 USA
| | - Kathleen A. Stringer
- Department of Clinical, Social and Administrative Sciences, College of Pharmacy, University of Michigan, Ann Arbor, MI 48109 USA
- Corresponding Author: Kathleen A. Stringer, PharmD, Associate Professor, University of Michigan, College of Pharmacy, 428 Church Street, Ann Arbor, MI 48109, Phone: 734-647-4775,
| |
Collapse
|
25
|
Abstract
OBJECTIVE We report two cases of plastic bronchitis presenting with acute respiratory failure and mimicking foreign body inhalation. METHOD The clinical findings, differential diagnoses and radiological investigation are discussed. RESULTS Plastic bronchitis is an uncommon condition, particularly in children. The condition may present to otolaryngologists with symptoms mimicking foreign body inhalation. It is important to consider plastic bronchitis as a differential diagnosis, based on its clinical and radiological signs. Early intervention, in the form of bronchoscopy, can be both diagnostic and therapeutic. CONCLUSION Plastic bronchitis is uncommon and its clinical and radiological features are non-specific. The recommended management is early bronchoscopy to establish the diagnosis and enable therapeutic intervention.
Collapse
|
26
|
Garcia E, da Silva Junior AF, Schorr F, Hota M, Brizzi RG, da Silva AB. Bronchial casts attributed to the use of pegylated interferon and ribavirin. J Bras Pneumol 2010; 35:713-6. [PMID: 19669011 DOI: 10.1590/s1806-37132009000700014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 01/22/2009] [Indexed: 11/21/2022] Open
Abstract
We report the case of a 50-year-old male patient with a rare profile: bronchial casts associated with the use of pegylated interferon and ribavirin. The patient sought treatment in a pulmonology clinic with a history of progressive dyspnea for four months that had evolved to progressive cough followed by frequent and abundant elimination of bronchial casts. The patient was initially treated with bronchodilators, as well as with oral and inhaled corticosteroids. Fiberoptic bronchoscopy, bronchoalveolar lavage and sputum analysis were carried out but did not contribute to the elucidation of the diagnosis. The symptoms developed while the patient was receiving pegylated interferon and ribavirin for the treatment of hepatitis C. The symptoms resolved 30 days after the discontinuation of the treatment. To our knowledge, this is the first report of bronchial casts caused by the use of pegylated interferon and ribavirin.
Collapse
Affiliation(s)
- Eduardo Garcia
- Complexo Hospitalar Santa Casa de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brasil
| | | | | | | | | | | |
Collapse
|
27
|
Mateos-Corral D, Cutz E, Solomon M, Ratjen F. Plastic bronchitis as an unusual cause of mucus plugging in cystic fibrosis. Pediatr Pulmonol 2009; 44:939-40. [PMID: 19658112 DOI: 10.1002/ppul.21063] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Cystic fibrosis patients are known to produce abundant, purulent sputum consisting mainly of DNA and cellular debris. We present a case of a CF patient with recurrent airway obstruction caused by a rare condition known as plastic bronchitis (PB). PB is characterized by the formation of casts of the airways that cause obstruction. Multiple etiologies have been proposed, but to our knowledge, no CF patient has been reported in any PB classification. Histological analysis and in-vitro testing of the cast were important factors in choosing the adequate therapy in this patient.
Collapse
Affiliation(s)
- Dimas Mateos-Corral
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, Canada.
| | | | | | | |
Collapse
|
28
|
Bongaerts D, Wojciechowski M, Suys B, Luijks M, Van Marck E, Jorens PG. Plastic bronchitis in a 5-year-old boy causing asystoly and fatal outcome. J Asthma 2009; 46:586-90. [PMID: 19657899 DOI: 10.1080/02770900902915854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Here we present the case of a 5-year-old boy who experienced a prehospital cardiac arrest after a period of wheezing, upper respiratory tract infection, and diarrhea. After successful resuscitation, ventilation was initially extremely difficult for no obvious reason. Various bronchodilatatory therapies were started with only limited result. Diagnosis of plastic bronchitis was made after bronchoscopy and at autopsy when therapy was withdrawn in view of the absence of cerebral circulation. A thickened basal membrane, a specific hallmark of asthma, was also present. Cardiac arrest in plastic bronchitis due to inflammatory and allergic disease is very rare. Pathological examination of the cast showed a mucinous cast with neutrophilic granulocytes, which is also seldom seen. This case illustrates that the diagnosis of plastic bronchitis can be extremely difficult if only minor respiratory symptoms occur. This resulted in a delayed diagnosis and fatal outcome.
Collapse
Affiliation(s)
- Dries Bongaerts
- Departments of Anesthesiology, Antwerp University Hospital, University of Antwerp, Belgium
| | | | | | | | | | | |
Collapse
|
29
|
Griffiths ER, Kaza AK, Wyler von Ballmoos MC, Loyola H, Valente AM, Blume ED, del Nido P. Evaluating failing Fontans for heart transplantation: predictors of death. Ann Thorac Surg 2009; 88:558-63; discussion 563-4. [PMID: 19632412 DOI: 10.1016/j.athoracsur.2009.03.085] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2009] [Revised: 03/25/2009] [Accepted: 03/26/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND Late complications of the Fontan operation represent a significant management challenge. Failing Fontan patients have two modes of presentation: impaired ventricular function (IVF) and those with preserved ventricular function (PVF) but with failing Fontan physiology (protein-losing enteropathy [PLE] and plastic bronchitis [PB]). This study evaluated whether failing Fontan patients referred for heart transplantation had a different outcome based on the mode of presentation. METHODS The medical records of all Fontan patients evaluated for heart transplantation at a single institution from 1994 to 2008 were retrospectively reviewed. Demographic, hemodynamic, and laboratory data were collected. Patients were stratified into an IVF or PVF group by echocardiographic criteria. Descriptive statistics and Kaplan-Meier analysis were used for hypothesis testing. RESULTS Thirty-four Fontan patients were evaluated for heart transplantation. According to echo description of systolic function, 18 were categorized as IVF and 16 as PVF. The IVF group had a significantly lower cardiac index and venous oxygen saturation, and significantly higher systemic vascular resistance vs the PVF group (p < 0.05). PLE or PB was present in 13 PVF patients and none in the IVF group. Twenty patients underwent transplantation, with similar rates amongst the IVF and PVF groups. Within 1 year from evaluation, 2 IVG patients and 7 PVF patients had died (p = 0.052). CONCLUSIONS Failing Fontan patients with PVF have decreased overall survival independent of whether they underwent transplantation. This trend indicates a need to improve the management and timing for transplantation amongst this population.
Collapse
Affiliation(s)
- Eric R Griffiths
- Department of Cardiac Surgery Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts 02115, USA
| | | | | | | | | | | | | |
Collapse
|
30
|
The use of high-frequency jet ventilation for removal of obstructing casts in patients with plastic bronchitis. Pediatr Crit Care Med 2009; 10:e34-6. [PMID: 19433939 DOI: 10.1097/pcc.0b013e3181a334ba] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To describe improved cast removal with short periods of high-frequency jet ventilation (HFJV) in patients with single ventricle physiology. DESIGN Case report. SETTING Pediatric cardiac intensive care unit. PATIENTS Two patients with plastic bronchitis during prolonged stay in a intensive care unit after a Fontan-type operation. INTERVENTIONS Short periods of HFJV. MAIN RESULTS Plastic bronchitis with lower airway obstruction developed in two intubated patients during intensive care stay after the Fontan operation. Mucolytics and suctioning were not effective in controlling symptoms. Urgent bronchoscopy was considered a high-risk procedure for the first patient and was not available for the second. Cast removal was achieved with short periods of HFJV and subsequent suctioning. CONCLUSIONS The use of short-term HFJV resulted in resolution of the airway obstruction in intubated patients with plastic bronchitis.
Collapse
|
31
|
Do TB, Chu JM, Berdjis F, Anas NG. Fontan patient with plastic bronchitis treated successfully using aerosolized tissue plasminogen activator: a case report and review of the literature. Pediatr Cardiol 2009; 30:352-5. [PMID: 19005718 DOI: 10.1007/s00246-008-9312-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2008] [Accepted: 09/12/2008] [Indexed: 11/27/2022]
Abstract
Plastic bronchitis is an uncommon condition characterized by the production of large pale bronchial casts that obstruct the tracheobronchial tree. The cellular content, cohesiveness, and often rubber-like consistency distinguish bronchial casts from the usual mucus plugs found with such disease states as asthma. Plastic bronchitis can be found secondary to many conditions, and a simplified classification scheme organizes it into two groups: an inflammatory type consisting of casts with an eosinophilic inflammatory infiltrate and an acellular type with a predominance of fibrin distinguished by its relative lack of cellular infiltrate, its mucin predominance, and its appearance only in children with congenital cyanotic heart disease. This report describes a 5-year-old girl who experienced plastic bronchitis 3 months after a Fontan procedure for hypoplastic left heart syndrome that was treated successfully with aerosolized tissue plasminogen activator.
Collapse
Affiliation(s)
- Thomas B Do
- Children's Hospital of Orange County, Orange, CA 92868, USA.
| | | | | | | |
Collapse
|
32
|
Sharma R, Talwar S, Marwah A, Shah S, Maheshwari S, Suresh P, Garg R, Bali BS, Juneja R, Saxena A, Kothari SS. Anatomic repair for congenitally corrected transposition of the great arteries. J Thorac Cardiovasc Surg 2009; 137:404-412.e4. [PMID: 19185160 DOI: 10.1016/j.jtcvs.2008.09.048] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Revised: 08/02/2008] [Accepted: 09/19/2008] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Anatomic repair is being actively evaluated as the preferred option for congenitally corrected transposition of the great arteries. We present our 13-year experience with this approach. METHODS Between May 1994 and September 2007, 68 patients with congenitally corrected transposition of the great arteries underwent anatomic repair. Thirty-one patients (group 1, mean age of 94.8 +/- 42.3 months) underwent a combined Rastelli and atrial switch operation. Thirty-seven patients (group 2, mean age of 36.1 +/- 46.9 months) underwent an arterial switch operation and atrial rerouting. Eight patients in group 2 had an intact ventricular septum. RESULTS Group 1 had 5 early deaths (17%) but no late deaths. Three patients underwent conduit revision at a mean follow-up of 62 months. Group 2 had 5 early deaths (13.5%). There were 4 late reoperations (2 pulmonary baffle revisions, 1 mitral valve replacement, and 1 permanent pacemaker implantation) and 4 late deaths (1 secondary to progressive left ventricular dysfunction, 2 secondary to uncontrolled atrial tachyarrhythmia, and 1 secondary to pulmonary hypertension and right ventricular failure). In group 2, 4 patients have a left ventricular ejection fraction less than 40%, 5 patients have moderate aortic incompetence, 5 patients have symptomatic tricuspid incompetence, 1 patient has tricuspid stenosis, 1 patient has superior cava obstruction, and 3 patients are receiving antiarrhythmic therapy. CONCLUSION The occurrence of left ventricular dysfunction indicate that anatomic repair in the arterial switch group is still fraught with imperfections. The Rastelli group required conduit revisions but has otherwise performed well.
Collapse
Affiliation(s)
- Rajesh Sharma
- Narayana Hrudayalaya Institute of Cardiac Sciences, Bangalore, India
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Khemiri M, Hammami O, Zouari S, Khaldi F, Barsaoui S. [Plastic bronchitis: report of a pediatric case]. REVUE DE PNEUMOLOGIE CLINIQUE 2008; 64:234-237. [PMID: 18995152 DOI: 10.1016/j.pneumo.2008.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 05/28/2008] [Accepted: 05/31/2008] [Indexed: 05/27/2023]
Abstract
Plastic bronchitis (PB) is a rare disease, characterized by the formation of obstructive branching airways tracheobronchial casts. Commonly, PB often complicates the course of cardiac or respiratory disorders. The occurrence of PB before manifestation of the underlying respiratory disease is unusual. We report on the case of a boy, aged three years and eight months, free from underlying pulmonary disease, who presented with extensive atelectasis of the left lung during an acute respiratory tract infection. Bronchoscopy revealed the obstruction of the left tracheobronchial tree with large purulent casts. After bronchoscopic removal of the casts, the boy became asymptomatic. Initial aetiological investigations were negative. Two years later, the patient developed an asthma.
Collapse
Affiliation(s)
- M Khemiri
- Service de médecine infantile A, hôpital d'enfants, Bab-Saadoun-Jabbary, 1007 Tunis, Tunisie.
| | | | | | | | | |
Collapse
|
34
|
|
35
|
Zaccagni HJ, Kirchner L, Brownlee J, Bloom K. A case of plastic bronchitis presenting 9 years after Fontan. Pediatr Cardiol 2008; 29:157-9. [PMID: 17929079 DOI: 10.1007/s00246-007-9127-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2007] [Accepted: 09/21/2007] [Indexed: 11/26/2022]
Abstract
A 15-year-old boy with hypoplastic left heart syndrome experienced plastic bronchitis 9 years after completion of a nonfenestrated lateral tunnel Fontan. Despite cardiac catheterization with coil embolization of collateral vessels and initiation of a pulmonary toilet regimen, including aerosolized tissue plasminogen activator, he continued to expectorate large acellular-mucinous casts. Finally, after optimization of cardiac function with the addition of carvedilol, the expectorated casts decreased in number. This report reviews pathophysiology of plastic bronchitis cast formation and therapy in the context of this late presentation after Fontan.
Collapse
Affiliation(s)
- H J Zaccagni
- Medical University of South Carolina, Children's Heart Program of South Carolina, 171 Ashley Ave., Charleston, SC 29425, USA.
| | | | | | | |
Collapse
|
36
|
Wang G, Wang YJ, Luo FM, Wang L, Jiang LL, Wang L, Mao B. Effective use of corticosteroids in treatment of plastic bronchitis with hemoptysis in Chinese adults. Acta Pharmacol Sin 2006; 27:1206-12. [PMID: 16923342 DOI: 10.1111/j.1745-7254.2006.00418.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
AIM To investigate whether corticosteroids are effective in the treatment of plastic bronchitis with hemoptysis. METHODS A retrospective, clinical study was undertaken. Thirty two patients with only first episodes of plastic bronchitis with hemoptysis were divided into a steroid group (n=18) treated with glucocorticoids, and a non-steroid group (n=14). The supportive therapy was uniformly applied to both groups, except for glucocorticoids. Variables such as temperature and white blood cell counts were determined. Furthermore, the volume of hemoptysis and bronchial casts were evaluated in detail daily. RESULTS There was no difference in the demographic data and variables at baseline between both groups (all P>0.05). On days 5, 6, 7 and 8, the volume of hemoptysis was significantly decreased in the steroid group compared with the non-steroid group (43+/-15 mL vs 117+/-33 mL on d 5, 29+/-12 mL vs 97+/-23 mL on d 6, 18+/-10 mL vs 80+/-20 mL on d 7, and 13+/-8 mL vs 66+/-14 mL on d 8; all P<0.05), and on d 10 after fibreoptic bronchoscopy, the cases with bronchial casts was reduced evidently in the steroid group in comparison with the non-steroid group (OR=5.69, 95% CI=1.76-43.6; P=0.005). There was no significance in mechanical ventilation and mortality between both groups. CONCLUSION Despite some limitations of this study, it has been demonstrated that, on the basis of common supportive therapy, corticosteroids would be effective and safe for the treatment of plastic bronchitis with hemoptysis.
Collapse
Affiliation(s)
- Gang Wang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | | | | | | | | | | | | |
Collapse
|
37
|
Shah SSA, Drinkwater DC, Christian KG. Plastic Bronchitis: Is Thoracic Duct Ligation a Real Surgical Option? Ann Thorac Surg 2006; 81:2281-3. [PMID: 16731170 DOI: 10.1016/j.athoracsur.2005.07.004] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2005] [Revised: 06/29/2005] [Accepted: 07/05/2005] [Indexed: 11/15/2022]
Abstract
Plastic bronchitis is an unusual clinical scenario of unknown cause and occurs in multiple clinical settings. The disease is characterized by the development of arborizing, thick, tenacious casts of the tracheobronchial tree that results in airway obstruction. Patients with congenital heart disease who have undergone a Fontan operation are at high risk for having this problem develop. Management of this distressing situation is difficult with only palliative options being available, such as repeated bronchoscopies, inhaled heparin, tissue plasminogen activator, inhaled bronchodilators, or azithromycin. The patients with Fontan circuits have a myriad of unique complications develop, such as atrial arrhythmias, recurrent pleural effusions, chylothoraces, protein-losing enteropathy, and plastic bronchitis. High intrathoracic lymphatic pressures with nondemonstrable lympho-bronchial fistulas were believed to be the cause for the development of these recurrent bronchial casts in plastic bronchitis. Faced with recurrent plastic bronchitis resistant to medical management in 2 Fontan patients with normal Fontan pressures on cardiac catheterization, we decided to explore a surgical solution by performing a thoracic duct ligation. This resulted in complete resolution of the formation of casts in both patients, who were discharged home and remain asymptomatic on continued follow-up. Thoracic duct ligation provides a surgical cure for plastic bronchitis by decreasing intrathoracic lymphatic pressure and flow.
Collapse
Affiliation(s)
- S Salman A Shah
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee, USA.
| | | | | |
Collapse
|
38
|
Apostolopoulou SC, Papagiannis J, Rammos S. Bosentan induces clinical, exercise and hemodynamic improvement in a pre-transplant patient with plastic bronchitis after Fontan operation. J Heart Lung Transplant 2005; 24:1174-6. [PMID: 16102469 DOI: 10.1016/j.healun.2004.11.018] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2004] [Revised: 10/15/2004] [Accepted: 11/15/2004] [Indexed: 11/16/2022] Open
Abstract
We present a 14-year-old pre-transplant boy with elevated pulmonary pressure and plastic bronchitis after Fontan operation despite stent fenestration, who improved with long-term oral administration of the endothelin antagonist, bosentan. Bosentan improved the patient's symptoms and aortic saturation, World Health Organization class, maximal and sub-maximal exercise capacity, Borg dyspnea index, invasively measured mean pulmonary pressure, pulmonary blood flow and pulmonary vascular resistance. This is the first literature report examining the effect of endothelin antagonism in failing Fontan circulation and showing clinical, exercise and hemodynamic improvement with bosentan in a pre-transplant Fontan patient with high pulmonary pressure and plastic bronchitis.
Collapse
|
39
|
Tzifa A, Robards M, Simpson JM. Plastic bronchitis; a serious complication of the Fontan operation. Int J Cardiol 2005; 101:513-4. [PMID: 15907428 DOI: 10.1016/j.ijcard.2004.03.085] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2000] [Accepted: 03/28/2004] [Indexed: 10/26/2022]
Abstract
Plastic bronchitis is characterised by the formation of large bronchial casts, which develop in the tracheobronchial tree and can cause airway obstruction. It has been increasingly encountered in more recent years as a serious complication of the Fontan operation with a reported mortality of up to 50% [Am. J. Respir. Crit. Care Med. 155 (1997) 364]. We report a case of a 4-year-old girl with Fontan circulation who developed plastic bronchitis and was successfully treated.
Collapse
|
40
|
Wilson J, Russell J, Williams W, Benson L. Fenestration of the Fontan circuit as treatment for plastic bronchitis. Pediatr Cardiol 2005; 26:717-9. [PMID: 16132280 DOI: 10.1007/s00246-005-0913-8] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Plastic bronchitis is a rare, potentially life-threatening condition in which protein casts form within and occlude the bronchus, resulting in pulmonary failure, and has been identified as a complication after the Fontan procedure. We present a case of a 5-year-old girl who had undergone an extracardiac fenestrated Fontan repair as a component of staged palliation for tricuspid atresia. Six weeks following surgery, the patient presented with airway obstruction, coughing a bronchial cast. Medical therapies to optimize heart function and attempt to control cast formation were implemented, with little clinical impact. Following cardiac catheterization to stent open the fenestration, the symptoms of plastic bronchitis resolved. Cast expectoration recurred following spontaneous closure of the stented fenestration and again resolved with recreation of the baffle defect. Fenestration of the Fontan circuit alters hemodynamics, thereby providing an additional therapeutic option for this devastating disorder.
Collapse
Affiliation(s)
- J Wilson
- Department of Pediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto School of Medicine, 555 University Avenue, Toronto, Ontario M5G1X8, Canada
| | | | | | | |
Collapse
|
41
|
Mendoza Soto A, Galletti L, Gómez de Quero P, Ramos Casado MV, Velasco Bayón JM. [Plastic bronchitis. A case report and review of the literature]. An Pediatr (Barc) 2005; 62:72-5. [PMID: 15642245 DOI: 10.1157/13070185] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Plastic bronchitis is a rare complication in which bronchial casts of lymphatic origin develop in the tracheobronchial tree and cause airway obstruction. The main feature is expectoration of bronchial casts. This condition usually occurs in the postoperative period after the Fontan operation for congenital heart disease. Treatment modalities include mucolytics and chest physiotherapy, and in the most severe cases bronchoscopy to remove the casts and aerosolized urokinase or r-TPA. We describe a 12-year-old boy with pulmonary atresia with intact ventricular septum and severely hypoplastic right ventricle who underwent a modified Fontan operation at the age of 7 years. At the age of 12 years the patient started to present frequent episodes of coughing, dyspnea, and desaturation followed by difficult emission of white bronchial casts. An extracardiac Fontan conversion was performed to improve hemodynamics and symptoms. During the postoperative period frequent episodes of airway obstruction required bronchoscopy and finally improved with administration of aerosolized urokinase.
Collapse
Affiliation(s)
- A Mendoza Soto
- Instituto Pediátrico del Corazón, Hospital Universitario 12 de Octubre, Madrid, Spain.
| | | | | | | | | |
Collapse
|
42
|
Wakeham MK, Van Bergen AH, Torero LE, Akhter J. Long-term treatment of plastic bronchitis with aerosolized tissue plasminogen activator in a Fontan patient. Pediatr Crit Care Med 2005; 6:76-8. [PMID: 15636664 DOI: 10.1097/01.pcc.0000149320.06424.1d] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To report the successful treatment of plastic bronchitis with aerosolized tissue plasminogen activator. DESIGN Case report. PATIENTS A 4-yr-old boy with congenital heart disease, who developed plastic bronchitis 33 months after a Fontan operation INTERVENTIONS Long-term treatment with aerosolized tissue plasminogen activator. MEASUREMENTS AND MAIN RESULTS We describe the case of a boy who developed recurrent episodes of life-threatening airway obstruction secondary to plastic bronchitis. Following the failure of multiple therapeutic interventions, his condition improved significantly with aerosolized tissue plasminogen activator. Several attempts to wean him off this treatment resulted in clinical deterioration. He has remained on long-term aerosolized tissue plasminogen activator. CONCLUSION Treatment of plastic bronchitis with aerosolized tissue plasminogen activator may benefit patients in whom other therapies have failed.
Collapse
Affiliation(s)
- Martin K Wakeham
- Pediatric Critical Care, Advocate Hope Children's Hospital, Oak Lawn, IL 60453, USA.
| | | | | | | |
Collapse
|
43
|
|
44
|
Abstract
We report a case of perioperative management of a toddler with plastic bronchitis complicated by tracheal obstruction. We discuss our management of this case as well as the diverse group of patients who may present with this disease. We also reviewed the literature regarding medical management of cast bronchitis.
Collapse
Affiliation(s)
- Sabina DiCindio
- Department of Anesthesia and Critical Care, Nemours Children's Clinic-Wilmington, Alfred I.duPont Hospital for Children, Wilmington, DE 19899, USA.
| | | | | | | | | |
Collapse
|
45
|
Ishman S, Book DT, Conley SF, Kerschner JE. Plastic bronchitis: an unusual bronchoscopic challenge associated with congenital heart disease repair. Int J Pediatr Otorhinolaryngol 2003; 67:543-8. [PMID: 12697358 DOI: 10.1016/s0165-5876(03)00004-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Plastic bronchitis is a rare disorder characterized by the formation of branching mucoid bronchial casts. Several pathophysiologic conditions are associated with development of these intrabronchial casts, including congenital heart defects. The management of plastic bronchitis presents an unusual and interesting bronchoscopic challenge. We describe a patient who underwent a Fontan procedure for correction of a congenital heart defect and subsequently developed respiratory distress secondary to plastic bronchitis on two occasions. In both cases, endoscopic intervention was required to remove these casts. A review of the literature, including the proposed etiologies, diagnosis, and current medical and surgical management, is also undertaken.
Collapse
Affiliation(s)
- Stacey Ishman
- Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee 53226, USA
| | | | | | | |
Collapse
|
46
|
Abstract
Cast or plastic bronchitis is an unusual disorder that is rarely encountered in the pediatric population. It is characterized by the expectoration of large, branching plugs of airway debris. These "casts" conform to the shape of portions of the tracheobronchial tree, and give the disorder its name. Cast bronchitis is typically seen in association with several primary pulmonary disorders and cyanotic congenital heart disease. It can be classified as inflammatory or acellular, based on the histologic characteristics of the casts. The presence of large, obstructive plugs filling the airways of lobes or entire lungs can result in a variety of clinical signs and symptoms, and may ultimately lead to respiratory failure and death. Conventional treatment of cast bronchitis has focused on the clearance of obstructing material from the airways combined with therapy for any underlying cardiopulmonary disease. Unfortunately, this approach has not proven very effective, and patient mortality remains high. We report on a case in which a patient with cast bronchitis was treated with long-term, low-dose oral azithromycin. This therapy resulted in clinical, spirometric, and radiographic improvement of the patient.
Collapse
Affiliation(s)
- Karen D Schultz
- Pulmonology Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA.
| | | |
Collapse
|
47
|
Noizet O, Leclerc F, Leteurtre S, Brichet A, Pouessel G, Dorkenoo A, Fourier C, Cremer R. Plastic bronchitis mimicking foreign body aspiration that needs a specific diagnostic procedure. Intensive Care Med 2003; 29:329-31. [PMID: 12594596 DOI: 10.1007/s00134-002-1610-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2002] [Accepted: 11/13/2002] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To report two children admitted to our emergency department with respiratory failure, one for status asthmaticus with pneumomediastinum and requiring mechanical ventilation and the other for high suspicion of foreign body aspiration. INTERVENTIONS Bronchoscopy revealed obstructive plugs and permitted their extraction and their identification as bronchial casts after the immersion in normal saline. Allergy was suspected in the first one, and Hemophilus influenzae infection was present in the second. The outcome was favorable. CONCLUSIONS Plastic bronchitis is an infrequent cause of acute life-threatening respiratory failure that can mimic foreign body aspiration or status asthmaticus. Bronchoscopic extraction must be performed urgently in the case of severe obstruction. This entity is probably underestimated as the casts with their specific ramifications are difficult to recognize. We recommend the immersion in normal saline of all plugs discovered in children with predisposing diseases mainly represented by infections, allergy, acute chest syndrome, and congenital cardiopathies.
Collapse
Affiliation(s)
- O Noizet
- Pediatric Intensive Care Unit, University Hospital of Lille, 59037 Lille, France
| | | | | | | | | | | | | | | |
Collapse
|
48
|
Onoue Y, Adachi Y, Ichida F, Miyawaki T. Effective use of corticosteroid in a child with life-threatening plastic bronchitis after Fontan operation. Pediatr Int 2003; 45:107-9. [PMID: 12654082 DOI: 10.1046/j.1442-200x.2003.01659.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Yoichi Onoue
- Department of Pediatrics, Toyama Medical and Pharmaceutical University, Toyama, Japan
| | | | | | | |
Collapse
|
49
|
Brogan TV, Finn LS, Pyskaty DJ, Redding GJ, Ricker D, Inglis A, Gibson RL. Plastic bronchitis in children: a case series and review of the medical literature. Pediatr Pulmonol 2002; 34:482-7. [PMID: 12422347 DOI: 10.1002/ppul.10179] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Plastic bronchitis is characterized by marked obstruction of the large airways by bronchial casts. We reviewed our experience and the literature to determine whether mortality rates are determined by underlying disease or cast type. We present 3 children with obstructive bronchial casts. One 3-year-old patient with Noonan's syndrome developed respiratory failure following surgery for tetralogy of Fallot requiring support with extracorporeal membrane oxygenation (ECMO) the first such case. There were 42 cases in the literature of children with plastic bronchitis. Casts may be divided into two types. Type I casts are inflammatory, consisting mainly of fibrin with cellular infiltrates, and occur in inflammatory diseases of the lung. Type II, or acellular casts, consist mainly of mucin with a few cells, and usually occur following surgery for congenital cardiac defects. Patients categorized by underlying disease included 31% with asthma or allergic disease, 40% with underlying cardiac defects, and 29% with other diseases. Mortality was 16%, but increased to 29% in patients with cardiac defects. Deaths occurred as long as 1 year after surgical repair for underlying defects. There were no deaths in patients with asthma. Life-threatening events were statistically higher in patients with cardiac defects (41%) than in those with asthma (0%, P = 0.02). Higher mortality in patients with type II casts compared to type I casts did not reach statistical significance (28% vs. 6%; P = 0.06). In conclusion, patients presenting with plastic bronchitis are at high risk for serious complications, especially with underlying cardiac disease.
Collapse
Affiliation(s)
- Thomas V Brogan
- Children's Hospital and Regional Medical Center, Seattle, Washington 98105, USA
| | | | | | | | | | | | | |
Collapse
|
50
|
|