Medical Image of the Week: Plastic Bronchitis

Figure 1. Cast removed from the right main stem.

Figure 2. Casts removed from right lower lobe.

Plastic Bronchitis is a rare syndrome characterized with expectoration of bronchial casts.  Conditions associated with plastic bronchitis in adults include asthma, allergic bronchopulmonary aspergillosis, cystic fibrosis, bronchiectasis, tuberculosis, amyloidosis, sickle cell anemia and rheumatoid arthritis. In children, is its associated with congenital heart diseases (1).

Typical casts are large and branched. These can be expectorated or removed endoscopically as in our case of a 52-year old man with respiratory failure (Figures 1 and 2). The exact etiology of his plastic bronchitis remains obscure. These casts were removed using a bronchoscope with a cryotherapy probe. 

Lauren Estep MD and Bhupinder Natt MD FACP

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center, Tucson, AZ USA

Reference

1. Itkin MG, McCormack FX, Dori Y. Diagnosis and treatment of lymphatic plastic bronchitis in adults using advanced lymphatic imaging and percutaneous embolization. Ann Am Thorac Soc. 2016 Oct;13(10):1689-96. [CrossRef] [PubMed]

Cite as: Estep L, Natt B. Medical image of the week: plastic bronchitis. Southwest J Pulm Crit Care. 2018;16(1):28. doi: https://doi.org/10.13175/swjpcc005-18 PDF 

Medical Image of the Week: Pulmonary Metastases of Rectal Cancer

Figure 1. CT scan of the chest shows bilateral masses (white arrows), left sided pleural effusion and endobronchial mass (black arrow).

Figure 2: Endobronchial mass (A) before and (B) after removal.

A 51-year-old woman with known rectal cancer currently receiving systemic chemotherapy presented with 2 weeks of worsening dyspnea on exertion. The day prior to admission she developed persistent inspiratory and expiratory wheeze. CT scan demonstrated right main stem endobronchial mass and a heterogeneous mass comprising the entire left hemithorax (Figure 1). Flexible bronchoscopy demonstrated a fungating mass at the carina extending down both main stems (Figure 2). The mass was snared and removed with cryotherapy and pathology was consistent with metastatic rectal adenocarcinoma.

Michael Insel MD, Naser Mahmoud MD and Afshin Sam MD

Division of Pulmonary, Allergy, Critical Care and Sleep

Banner-University Medical Center Tucson

Tucson, AZ USA

Cite as: Insel M, Mahmoud N, Sam A. Medical image of the week: pulmonary metastases of rectal cancer. Southwest J Pulm Crit Care. 2017;14(2):43-4. doi: https://doi.org/10.13175/swjpcc008-17 PDF 

Medical Image of the Week: Bronchial Clot Removal via Cryotherapy

Figure 1. Chest x-ray showing complete opacification of the left hemithorax.

Figure 2. Flexible bronchoscopy with cryotherapy was used to remove clot that formed casts of the bronchial tree. Black arrow: depicts segmental branch of the left upper lobe.

A 38-year-old man with a history of non-ischemic dilated cardiomyopathy presented with decompensated heart failure, acute renal failure, and possible sepsis. He underwent right cardiac catheterization but developed hemoptysis with concern for pulmonary artery rupture. Subsequently, the patient suffered a cardiac arrest but was resuscitated. Emergent bronchoscopy revealed copious amounts of blood and clot that could not be cleared at the time. The patient was then taken to the operating room and placed on A-A ECMO (left ventricle to aorta). The following morning chest x-ray (Figure 1) revealed a completely opacified left lung. Flexible bronchoscopy showed blood clot along the entire left bronchial tree. Initial attempts to remove the clot with suction and endobronchial graspers was unsuccessful. Ultimately, cryotherapy was used to remove the majority of the clot in fragments (Figure 2).

The use of cryotherapies and specifically, in this case, a cryoprobe, has been shown to safely and effectively remove thrombus from the bronchial tree. The basis behind this technique is the use of pressurized nitrous oxide or carbon dioxide to cool a metal probe tip. The probe then freezes any substance it comes in direct contact with, such as a blood clot. Thus, cryoadherence of the probe to the clot allows for effective removal via flexible endoscopy.  Sriratanaviriyakul et al. (1) reported success rates for cryoextraction of blood clots to be >90%.

Cathy V. Ho MD, Ryan Matika MD, and Mimi Amberger MD

¹Division of Trauma, Critical Care, Burn and Emergency Surgery. Department of Surgery

²The Department of Anesthesia

University of Arizona

Tucson, AZ USA

Reference

1. Sriratanaviriyakul N, Lam F, Morrissey BM, Stollenwerk N, Schivo M, Yoneda KY.Safety and clinical utility of flexible bronchoscopic cryoextraction in patients with non-neoplasm tracheobronchial obstruction: a retrospective chart review. J Bronchology Interv Pulmonol. 2015 Oct;22(4):288-93. [CrossRef] [PubMed] 

Cite as: Ho CV, Matika R, Amberger M. Medical image of the week: bronchial clot removal via cryotherapy. Southwest J Pulm Crit Care. 2016;13(5):253-4. doi: https://doi.org/10.13175/swjpcc109-16 PDF