Plastic bronchitis
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Formation of thick, branched, highly adherent plugs (known as casts or molds) that partially or completely block the tracheobronchial lumen. The majority of cases are associated with an underlying disease:
- cardiac: constrictive pericarditis, cardiac malformation corrected with a Fontan procedure
- pulmonary disease: cystic fibrosis, asthma, allergic bronchopulmonary aspergillosis, tuberculosis, bronchocentric pneumonia, granulomatosis
- lymphatic drainage disorders, lymphangiomatosis
- others: acute chest syndrome with sickle cell disease, rheumatoid arthritis, membrane colitis, neoplasia (lymphoma), smoke inhalation
Based on the contents of these intrabronchic casts, two types are identified:
- type I: inflammatory: contains fibrin and cells
- type II: acellular: of lymphatic origin, consisting mainly of mucin
The most common form (40 %) of plastic bronchitis in children is a complication of a Fontan procedure. The presence of chronic elevated pressure in the pulmonary venous system is an obstacle to the drainage of the pulmonary lymphatic vessels and causes the leakage of protein- and lipid-rich fluid into the bronchial tree. Relapse is common and mortality is high.
Depending on the size and location of the bronchial casts, the clinical presentation of plastic bronchitis can result in:
- a productive cough, dyspnea, fever and wheezing,
- expectoration of bronchial casts, hemoptysis
- atelectasies
- an almost complete obstruction of the airways with dyspnea and cyanosis.
Treatments:
- rigid bronchoscopy
- instillation or aerosols of thrombolytics (alteplase, urokinase) or mucolytics
- surgery or bronchoscopy under ECMO
In case of recurrence: ligation or embolization of the thoracic duct, embolization of the large pulmonary lymphatic vessels, heart transplantation
Anesthetic implications:
in case of bronchoscopy: maintain spontaneous ventilation, topical anesthesia glottic and tracheal, anticholinergic if possible; risky management of a patient with Fontan patient: venous return to the chest should be facilitated as well as avoiding excessive positive pressure ventilation, hypoxemia and hypercarbia; risk of SIRS during the bronchial lavage; anesthesia under ECMO
References :
- DiCindio S, Theroux M, Costarino AT Jr, Cook S, O’Reilly R.
Plastic bronchitis.
Pediatr Anesth 2004; 14: 520-3
- Verghese S, Jackson M, Vaughns J, Preciado D.
Plastic bronchitis in a child with Fontan’s physiology presenting for urgent rigid bronchoscopy.
Anesth Analg 2008; 107:1446-7
- Gibb E, Blount R, Lewis N, Nielson D, Church G, Jones K et al.
Management of plastic bronchitis with topical tissue-type plasminogen activator.
Pediatrics 2012;130 : e446-50
- Singhal NR, Da Cruz EM, Nicolarsen J, Schwartz LI et al.
Perioperative management of shock in two Fontan patients with plastic bronchitis.
Semin Cardiothorac Vasc Anesth 2013; 17: 55-60
- Jasinovic T, Kozak FK, Moxham JP, Chilvers M et al.
Casting a look at pediatric plastic bronchitis.
Int J Pediatr Otorhinolaryngol 2015; 79: 1658-61
- Nakamoto H, Kayama S, Harada M, Honjo T, Kubota K, Sawamura S.
Airway emergency during general anesthesia in a child with plastic bronchitis following Fontan surgey: a case report.
JA Clin Rep 2020 :6 :6
- Chhabada S, Khanna S.
Plastic bronchitis.
Anesthesiology 2020; 133: 429
Updated: August 2020