Plastic bronchitis

Fibrin airway cast obstruction: Experience, classification, and treatment guideline from Denver

BACKGROUND AND OBJECTIVES

Plastic bronchitis (PB) is a condition characterized by the formation of thick airway casts leading to acute and often life-threatening airway obstruction. PB occurs mainly in pediatric patients with congenital heart disease (CHO) who have undergone staged surgical palliation (Glenn, Fontan), but can also occur after chemical inhalation, H1N1, severe COVID-19, sickle cell disease, severe asthma, and other diseases. Mortality risk from PB can be up to 40%-60%, and no treatment guideline exist. The objectives herein are to develop a standardized evaluation, classification, and treatment guideline for PB patients presenting with tracheobronchial casts, based on our experience with PB at the Children's Hospital of Colorado in Denver.

METHODS

We describe 11 patients with CHO-associated PB (post-Fontan [n = 9], pre-Fontan [n = 2]) who presented with their initial episodes. We utilized histopathological analysis of tracheobronchial casts to guide treatment in these patients, utilizing our hospital-wide guideline document and classification system.

RESULTS

We found that 100% of post-Fontan PB patients had fibrinous airway casts, while pre-Fontan PB casts were fibrinous only in one of two patients (50%). Utilizing histopathology as a guide to therapy, PB patients with fibrin airway casts were treated with airway-delivered fibrinolytics and anticoagulants, as well as aggressive airway clearance and other supportive care measures. These therapies resulted in successful cast resolution and improved survival in post-Fontan PB patients.

CONCLUSION

We have shown an improved outcome in PB patients whose treatment plan was based on Denver's PB classification schema and standardized treatment guideline based on tracheobronchial cast histopathology.

[A case report of an adult with bronchial mould infection complicated by purulent pleurisy]

INTRODUCTION

Bronchial mould infection or plastic bronchitis is a rare condition, encountered at any age, but with a predilection for childhood. The clinical diagnosis is made easy by the demonstration of solid, branched expectorations. However, the aetiology is not easy to determine and investigation does not often lead to a pathological diagnosis.

CASE REPORT

We report the case of a 24 year-old patient, with a history of pulmonary tuberculosis in January 2016, who had had chronic, persistent, solid and branched expectorations since January 2015. Fibreoptic bronchoscopy revealed thick white secretions plugging the bronchi. Pathological examination of the bronchial plugs showed fibrous tissue infiltrated with predominantly lymphoplasmocytic and histiocytic inflammatory cells. Investigations carried out on the pleura did not establish the aetiological diagnosis. The diagnosis of bronchial mould disease of tuberculous origin complicated by pleurisy was established. Corticosteroid therapy led to a complete regression of the moulds within six weeks.

CONCLUSION

The presence of solid and branched sputum should suggest fungal bronchitis and is an indication for bronchoscopy for diagnostic and therapeutic purposes. Early management is important to avoid complications.

Case Report: Mucus plug in bronchus mimicking a bronchial solid foreign body obstruction

Bronchial foreign body obstruction is common in all clinical settings. Obstruction of the airway due to foreign bodies and foreign body aspiration are major causes of childhood mortality and morbidity, which are a big challenge to manage. Occasionally, bronchial obstruction may be due to mucus plugs or other endogenous factors. Here we describe a case of bronchial obstruction caused by mucus plug formation that was managed conservatively in a one-year old boy. The patient was suffering from a cough and noisy breathing for 2 days prior to coming to our hospital, when he experienced sudden onset of difficulty in breathing and a severe cough. At the time of presentation his vital sign readings were:- HR 186 bpm, RR 46/min, BP 78/40 MmHg, temp 36.9°C and SPO2 68%. He was given oxygen immediately and nebulization was started. Chest CT scan was performed that suggested the presence of a right bronchial foreign body with right sided obstructive emphysema. The patient was stable with oxygenation and nebulization with ipratropium bromide, albuterol, normal saline and budesonide before the CT scan. Therefore, we conclude that symptoms resembling foreign body obstruction are not always aspirated or inhaled, and sometimes secreted sputum forms a plug, which mimics the symptoms of foreign body obstruction.

A Rare Case of Plastic Bronchitis in an Adult Patient After Cardiopulmonary Bypass

Plastic bronchitis is a rare life-threatening complication observed after cardiopulmonary bypass (CPB). We describe a case of a 54-year-old man in whom a fulminant case of plastic bronchitis developed after coronary artery bypass grafting (CABG) and mitral valve repair. A brief review of the literature is also presented.

Airway foreign bodies: A critical review for a common pediatric emergency

BACKGROUND

Airway foreign bodies (AFBs) is an interdisciplinary area between emergency medicine, pediatrics and otolaryngology. It is a life-threatening condition that is not infrequently seen; however, it is poorly covered in medical literature. Accidental aspiration of an element into airways is a widespread clinical scenario among children under 3 years, predominantly males. Moreover, it is the leading cause of infantile deaths and the fourth one among preschool children.

DATA RESOURCES

A systemic search was conducted in July 2015 using PubMed/PubMed Central Database of The National Center for Biotechnology Information (NCBI) (http://www.ncbi.nlm.nih.gov/). A total of 1 767 articles were identified and most of them were meta-analyses, systematic reviews, and case series. Those thoroughly discussing assessment and management of AFBs were retrieved.

RESULTS

AFBs episodes may be either witnessed or missed. Presence of a witness for the inhalation is diagnostic. The later usually present with persistent active cough. A classical triad of paroxysmal cough, wheezing, and dyspnoea/decreased air entry was reported, though many presentations have inconsistent findings. Hence, diagnosis requires high index of clinical suspicion. Flexible fibro-optic bronchoscopy is the gold standard of diagnosis, whereas inhaled objects are best retrieved by rigid bronchoscopes.

CONCLUSIONS

Close supervision of pediatrics is the hallmark of prevention. Caregivers should ensure a safe surrounding milieu, including the toys their offspring play with. Immediate complications result from direct obstruction or injury by the inhaled object. Alternatively, prolonged lodging traps air and induces inflammatory response causing atelectesis and pneumonia, respectively.

Plastic bronchitis associated with influenza virus infection in children: a report on 14 cases

BACKGROUND

Plastic bronchitis (PB) is a rare disease characterized by formation of bronchial casts. It is usually associated with congenital heart disease, sickle cell disease, lymphoma, and lung diseases such as asthma and pneumonia.

OBJECTIVES

To report 14 cases of PB with influenza A or influenza B infection.

METHODS

We analyzed the clinical manifestations, bronchoscopic and histologic findings, clinical courses, and outcomes.

RESULTS

These cases indicate that PB is a life-threatening complication of severe influenza. Plastic bronchitis should be considered in the diagnosis of children with acute respiratory distress such as lung atelectasis accompanied by influenza.

CONCLUSIONS

Diagnosis should be made by bronchial endoscopy and histopathology, and bronchial casts removed as early as possible.

Intratracheal heparin improves plastic bronchitis due to sulfur mustard analog

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.

Spontaneous resolution of plastic bronchitis in a patient post hemi-Mustard/bidirectional Glenn atrial switch procedure in the double-switch operation for congenitally corrected transposition of great arteries after course of Augmentin

We report the case of a five-year-old girl with plastic bronchitis after repaired complex congenital heart disease, who became asymptomatic after a short course of Augmentin. We report the disease regression as response either to antibiotic or as coincidental with spontaneous resolution.

Plastic bronchitis in an adult with asthma

Plastic bronchitis is a rare disease characterized by marked airway obstruction, via the formation of large gelatinous or rigid airway cast. In Korea, there were a few case reports with plastic bronchitis not in adults, but in children. So we report a case of an adult who was diagnosed as plastic bronchitis with eosinophilic casts, with no history of atopic and cardiac disease.

Prospective, longitudinal study of plastic bronchitis cast pathology and responsiveness to tissue plasminogen activator

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.

Characteristics of atopic children with pandemic H1N1 influenza viral infection: pandemic H1N1 influenza reveals 'occult' asthma of childhood

The number of human cases of pandemic H1N1 influenza viral infection has increased in Japan since April 2009, as it has worldwide. This virus is widespread in the Yamaguchi prefecture in western Japan, where most infected children exhibited respiratory symptoms. Bronchial asthma is thought to be one of the risk factors that exacerbate respiratory symptoms of pandemic H1N1-infected patients, but the pathogenesis remains unclear. We retrospectively investigated the records of 33 children with pandemic H1N1 influenza viral infection who were admitted to our hospital between October and December 2009 and analyzed their clinical features. The percentage of children with asthma attack, with or without abnormal findings on chest radiographs (pneumonia, atelectasis, etc.), caused by pandemic H1N1 influenza infection was significantly higher than that of children with asthma attack and 2008-2009 seasonal influenza infection. Of the 33 children in our study, 22 (66.7%) experienced an asthma attack. Among these children, 20 (90.9%) did not receive long-term management for bronchial asthma, whereas 7 (31.8%) were not diagnosed with bronchial asthma and had experienced their first asthma attack. However, the severity of the attack did not correlate with the severity of the pulmonary complications of pandemic H1N1 influenza viral infection. The pandemic H1N1 influenza virus greatly increases the risk of lower respiratory tract complications such as asthma attack, pneumonia, and atelectasis, when compared to the seasonal influenza virus. Furthermore, our results suggest that pandemic H1N1 influenza viral infection can easily induce a severe asthma attack, pneumonia, and atelectasis in atopic children without any history of either an asthma attack or asthma treatment.

Plastic bronchitis requiring bronchoscopy

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.

[Plastic bronchitis: report of a pediatric case]

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.

Bronchial cast: a case report

We present a case of a child who presented with respiratory distress mimicking foreign body aspiration which was treated by bronchoscopic extraction of bronchial cast. Early interventional bronchoscopy in management of plastic bronchitis, though difficult, provides an immediate benefit and good prognosis especially in patients with no underlying cardiopulmonary morbidity.

Treatment of Plastic Bronchitis

Plastic bronchitis may be seen after palliative surgery for cyanotic heart disease. Although type II (acellular) casts are seen more commonly, we describe a type I cast after palliative surgery for cyanotic heart disease in which ligation of thoracic duct did not result in complete resolution.

Effective use of corticosteroids in treatment of plastic bronchitis with hemoptysis in Chinese adults

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.

[Intermittent asphyxia syndrome caused by a bronchial cast in the subglottic region]

We report the case of an intensive care unit patient with acute respiratory failure caused by severe community-acquired pneumonia with empyema. She required orotracheal intubation and mechanical ventilation. Following extubation the patient s condition improved until the onset of several choking episodes caused by a dislodged laryngotracheal cast in the subglottic region. We discuss the differential diagnosis of upper airway obstructions and of the entities related to bronchial cast formation, in particular the clinical and pathophysiological features of plastic bronchitis and the treatment options available.

[Acute airway obstruction during chemotherapy-induced agranulocytosis with fever]

Acute airway obstruction caused by mucoid impaction can cause sometimes life-threatening respiratory distress. Bronchial plugging is usually observed in subjects with chronic diseases such as asthma, allergic bronchopulmonary aspergillosis, or cystic fibrosis. In children, it can be related to heart failure. Acute airway obstruction in a patient without a chronic respiratory disease is exceptional. We report the case of a patient who developed bronchial plugs obstructing the bronchi during a period of agranulocytosis induced by chemotherapy. The patient experienced acute respiratory distress with asphyxia. The plugs were composed of fibrin and required several fibroscopic procedures for clearance. To our knowledge, this is the first case report of acute airway obstruction by plugging during a period of agranulocytosis.

[Plastic bronchitis. A case report and review of the literature]

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.

Airway obstruction in sheep with burn and smoke inhalation injuries

The goals of this study were (i) to compare the degree and (ii) temporal changes in airway obstruction in sheep with pulmonary injury induced by smoke inhalation and/or burn; (iii) to qualitatively assess the cellular and mucous content of obstructive material; and (iv) to statistically assess a possible relationship between the degree of airway obstruction and pulmonary dysfunction. Using masked histologic slides, we estimated the degree of luminal obstruction in all cross-sectioned airways. The mean degree of bronchial, bronchiolar, and terminal bronchiolar obstruction was significantly greater in animals with smoke injury alone or combined smoke inhalation and burn (S+B) injury, compared with animals with burn injury alone or uninjured animals (P < 0.05). In S+B animals, the degree of bronchial obstruction was maximal at 24 h, with a progressive decrease over 72 h. In contrast, the degree of bronchiolar obstruction increased over time. Qualitatively, bronchial casts were largely composed of mucus at early times after injury, whereas neutrophils were the principal component of bronchiolar obstructive material. Localization of specific mucin subtypes in S+B tissues suggests that increasing bronchiolar obstruction is derived, in part, from upper airway material. Multiple linear regression analysis of airway obstruction scores compared with PaO2/FIO2 values showed a correlation coefficient of r = 0.76, with bronchial and bronchiolar scores predictive of PaO2/FIO2, (P < 0.05). These results suggest that strategies to remove or decrease formation of upper airway obstructive material may reduce its deposition into small airways and parenchyma and may improve respiratory function in victims of smoke inhalation injury.

Plastic bronchitis: an unusual bronchoscopic challenge associated with congenital heart disease repair

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.

Plastic bronchitis in children: a case series and review of the medical literature

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.

Treatment of plastic bronchitis in a Fontan patient with tissue plasminogen activator: a case report and review of the literature

Plastic bronchitis is a condition in which large, bronchial casts with rubber-like consistency develop in the tracheobronchial tree and cause airway obstruction. We describe a 4-year-old girl who had Fontan physiology and who developed plastic bronchitis and report for the first time the use of aerosolized tissue plasminogen activator for treatment of this condition. The literature is reviewed with emphasis placed on the occurrence of this disorder in patients with single ventricle physiology.

Plastic bronchitis occurring late after the Fontan procedure: treatment with aerosolized urokinase

OBJECTIVE

To describe the use of aerosolized urokinase in a patient with plastic bronchitis after a Fontan procedure.

DESIGN

Case report.

SETTING

Pediatric intensive care unit in a university-affiliated children's hospital.

PATIENTS

Report of one patient with acute respiratory failure secondary to plastic bronchitis.

INTERVENTIONS

Aerosolized urokinase, multiple bronchoscopies, corticosteroids, mucolytics, bronchodilators, and atrial pacing.

MEASUREMENTS AND MAIN RESULTS

Airway obstruction secondary to recurring casts improved with the treatments. Histologic analysis of the casts demonstrated less fibrin after treatments with aerosolized urokinase. No adverse events were noted.

CONCLUSIONS

The addition of aerosolized urokinase to this patient's treatment regimen helped to resolve life-threatening airway obstruction secondary to fibrin casts.

Bronchial casts in children with cardiopathies: the role of pulmonary lymphatic abnormalities

Expectoration of bronchial casts, a condition also called plastic bronchitis, is very rare in children. Bronchial casts may be associated with bronchopulmonary diseases associated with mucus hypersecretion, bronchopulmonary bacterial infections, congenital and acquired cardiopathies, or pulmonary lymphatic abnormalities. A classification based on anatomy and pathology has been proposed which identifies an "acellular" group associated with congenital cardiopathies and palliative surgery. We report on 3 cases with bronchial casts associated with cardiopathy. Observations suggest that the formation of bronchial casts may result from lymphatic leakage into the bronchi. The 3 cases on which we report were immunodeficient and had pulmonary lymphatic abnormalities. The bronchial casts contained lymphocytes and lipids, as determined by histologic examination. In the absence of congenital pulmonary or diffuse lymphatic dysplasia associated with cardiopathy, the principal factors resulting in the formation of bronchial casts appear to be surgical trauma to the lymphatic channels surrounding the bronchi, pleural adhesions, and high systemic venous blood pressure. The prognosis for these patients is poor, and possibilities for treatment are limited.