Plastic bronchitis mimicking foreign body aspiration that needs a specific diagnostic procedure

Plastic bronchitis caused by Haemophilus influenzae

Plastic bronchitis is characterized by sputum obstructing the bronchus and causing atelectasis. Bronchoscopic removal of the clogged bronchial cast is typically performed, but small-diameter bronchoscopes with narrow suction ports cannot achieve adequate suction. Suction using a bronchoscope as a guide sheath may be effective for treating plastic bronchitis in children.

Prediction of risk factors of bronchial mucus plugs in children with Mycoplasma pneumoniae pneumonia

Background

Recently, many cases of pneumonia in children with Mycoplasma pneumoniae infection have been shown to have varying degrees of intrabronchial mucus plug formation. The clinical, laboratory, radiological characteristics, and treatment of patients with Mycoplasma infection are analyzed in this study. The risk factors for M. pneumoniae pneumonia (MPP) mucus plug formation in children are explored, and a risk factor scoring system is established.

Methods

MPP patients treated with bronchoscopy were retrospectively enrolled in the study from February 2015 to December 2019. The children were divided into a mucus plug group and a control group according to the presence or absence of mucus plug formation. The clinical, laboratory, radiological characteristics, and treatment of the two groups of children were compared. Univariate and multivariate logistic regression models were used to identify the risk factors for MPP mucus plug formation. The receiver operating characteristic (ROC) curve was drawn to evaluate the regression model and establish the MPP mucous plug risk factor scoring system.

Results

A univariate analysis showed that the children in the mucous group were older and had a longer fever duration, longer hospital stay, higher fever peak, more cases of wheezing symptoms and allergies, and azithromycin or corticosteroids were administered later. In addition, neutrophil, C-reactive protein (CRP), lactate dehydrogenase (LDH), D-dimer (DD), sputum MP-DNA copy number, and total immunoglobulin A (IgA) levels were higher, while prealbumin (PA) levels were lower. The ROC curve analysis showed that children with MPP had PA ≤144.5 mg/L, had used corticosteroids during the course of the illness of ≥4.5 days, CRP ≥12.27 mg/L, an LDH ≥ 462.65 U/L, and there was a possibility of intra-airway mucus formation. The independent risk factors were scored according to their odds ratio (OR) value. Among the 255 children with MPP, the high-risk group had 44 (83.02%) mucus plugs out of 53; the middle-risk group had 35 (34.3%) mucus plugs out of 102; and the low-risk group had 11 (11%) mucus plugs out of 100.

Conclusions

PA levels, timing of corticosteroid use (use in the first few days), CRP levels, and LDH levels were independent risk factors for MPP mucus plug formation. This provides a basis for the early identification of MPP in children combined with mucus plug formation.

Current evaluation and management of plastic bronchitis in the pediatric population

OBJECTIVE

To describe a multidisciplinary approach for the treatment of plastic bronchitis (PB) in children.

METHODS

Retrospective chart review of children with PB between 1997 and 2017. Data regarding clinical presentation, diagnosis, management, and outcomes were analyzed.

RESULTS

Of 34 patients presenting with PB, 24 had single ventricle (SV) heart disease, 9 had pulmonary disease, and one had no underlying disease. Median (IQR: interquartile range) age at the time of PB diagnosis was 5.5 years (IQR: 9.0). Presenting symptoms included cough productive of casts (n = 27, 79%), wheezing (n = 5, 15%), dyspnea (n = 18, 53%), hypoxia (n = 31, 91%), and respiratory failure (n = 9, 26%). Diagnosis was made based on clinical evaluation, bronchoscopy findings, and/or pathology of casts. Treatment methods included bronchoscopy for cast removal (25% of SV patients, 91% of non-SV patients), chest physiotherapy (SV: 92%, non-SV: 45%), albuterol (SV: 79%, non-SV: 73%), inhaled steroids (SV: 75%, non-SV: 18%), nebulized hypertonic saline (SV: 29%, non-SV: 9%), nebulized heparin (SV: 8%, non-SV: 55%), nebulized tissue plasminogen activator (tPA; SV: 33%, non-SV: 9%), inhaled Dornase Alfa (SV: 54%, non-SV: 9%), antibiotics (SV: 46%, non-SV: 45%), systemic steroids (SV: 13%, non-SV: 45%), and lymphatic embolization (SV: 8%, non-SV: 45%). Of SV patients, 11 had no recurrence, 5 underwent heart transplantation, one awaits transplant, and 3 died due to cardiac disease. Three patients with respiratory disease had recurrent PB and one died from MRSA pneumonia.

CONCLUSION

PB is a highly morbid disease with limited treatment options. Bronchoscopy and chest physiotherapy for airway clearance are among the most-utilized therapies.

Plugs of the Air Passages: A Clinicopathologic Review

Although mucus is a normal product of the tracheobronchial tree, some diseases of the respiratory tract are characterized by unusually thick (inspissated) forms of mucus that accumulate within the airways. These are known as mucus plugs. The pathologic composition of these plugs is surprisingly diverse and, in many cases, correlates with distinctive clinical, radiologic, and bronchoscopic findings. The best-known conditions that involve mucus plugs are allergic bronchopulmonary aspergillosis, plastic bronchitis, and asthma. Other lung diseases occasionally associated with plugs within the airways include Aspergillus tracheobronchitis, hyper-IgE syndrome, exogenous lipoid pneumonia, pulmonary alveolar proteinosis, and chronic eosinophilic pneumonia. In this review, we describe and illustrate the bronchoscopic, pathologic, and imaging findings in respiratory disorders characterized by mucus plugs or plugs composed of other similar materials. Recognition of the characteristic appearance and differential diagnosis of mucus plugs will hopefully facilitate diagnosis and management of these diseases.

A conservative treatment for plastic bronchitis in pediatric age

Plastic bronchitis is a rare disorder in pediatric age. This disease can cause life-threatening episodes. Broncoscopy plus bronchial lavage is considered the gold standard therapeutic technique. Knowledge of this disease is mandatory to perform correct diagnosis and provide prompt treatment. The authors report the history of a 5-year-old girl affected by plastic bronchitis who was successfully treated by a conservative therapy avoiding the traditional more invasive management.

Tracheobronchial manifestations of aspergillosis

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.

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.

Successful management of plastic bronchitis in a child post Fontan: case report and literature review

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.

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.

Thoracic air leakage in the presentation of cast bronchitis

BACKGROUND

Cast bronchitis is a rare but potentially fatal condition caused by the accumulation of mucus in the bronchial tree usually secondary to infection, inflammation, or vascular stasis. Air leakage is an uncommon presentation of cast bronchitis. We report on three children with cast bronchitis who presented with acute air leakage as the main clinical feature.

METHODS

All three patients underwent bronchoscopic evaluation that led to a diagnosis and removal of bronchial casts.

RESULTS

Pathologic examination of casts from all three patients showed a mucoid substance with eosinophilic infiltration. The outcome for all patients was favorable.

CONCLUSIONS

Acute respiratory failure presenting with wheezing and thoracic air leakage refractory to standard asthma therapy should raise suspicion of cast bronchitis, and urgent bronchoscopy should be performed.

The use of high-frequency jet ventilation for removal of obstructing casts in patients with plastic bronchitis

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.

CT findings of plastic bronchitis in children after a Fontan operation

BACKGROUND

Plastic bronchitis is a rare cause of acute obstructive respiratory failure in children. Life-threatening events are much more frequent in patients with repaired cyanotic congenital heart disease, and most frequent following a Fontan operation. Commonly, the diagnosis is not made until bronchial casts are expectorated. Detailed CT findings in plastic bronchitis have not been described.

OBJECTIVE

To describe the CT findings in plastic bronchitis in children after a Fontan operation.

MATERIALS AND METHODS

Three children with plastic bronchitis after a Fontan operation were evaluated by chest CT. Bronchial casts were spontaneously expectorated and/or extracted by bronchoscopy. Airway and lung abnormalities seen on CT were analyzed in the three children.

RESULTS

CT demonstrated bronchial casts in the central airways with associated atelectasis and consolidation in all children. The affected airways were completely or partially obstructed by the bronchial casts without associated bronchiectasis. The airway and lung abnormalities rapidly improved after removal of the bronchial casts.

CONCLUSION

CT can identify airway and lung abnormalities in children with plastic bronchitis after a Fontan operation. In addition, CT can be used to guide bronchoscopy and to monitor treatment responses, and thereby may improve clinical outcomes.

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.

[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.