Bronchoscopic interventions for chronic bronchitis.

PURPOSE OF REVIEW: Chronic bronchitis is a phenotype of chronic obstructive pulmonary disease (COPD), characterized by chronic cough and sputum production, associated with an increased rate of COPD exacerbations and hospital admissions, a more rapid decline in lung function and reduced life expectancy. Despite optimal medical therapy, chronic bronchitis remains difficult to treat. Interventional bronchoscopic procedures offer novel therapeutic approaches to this highly symptomatic condition. RECENT FINDINGS: A characteristic feature of chronic bronchitis is the presence of an abnormal epithelium with excessive mucus producing cells, parasympathetic overactivity, and airway inflammation. Metered cryospray and bronchial rheoplasty are designed to target this abnormal epithelium to reduce mucus production and inflammation. Targeted lung denervation aims to reduce parasympathetic overactivity, which may drive mucus hypersecretion. Here, we review the available evidence to determine the safety and efficacy across the bronchoscopic interventions. SUMMARY: Interventional bronchoscopy is a rapidly expanding field and its application in the treatment of chronic bronchitis has been recognized by the Global initiative for chronic Obstructive Lung Disease (GOLD). The outcomes from the latest clinical trials will guide future treatment approaches in patients with difficult to treat chronic bronchitis.

Transvenous retrograde thoracic duct embolization for effective treatment of recurrent plastic bronchitis after fontan palliation.

We report the case of a 5.5-year-old patient (16 kg/105 cm) who presented with plastic bronchitis (PB) refractory to conservative treatment 3 months after completion of Fontan palliation. Bi-inguinal transnodal fluoroscopy-guided lymphangiogram confirmed the chylous leak originating from the thoracic duct (TD) into the chest and did not opacify any central lymphatic vessel for direct transabdominal puncture. Retrograde transfemoral approach was adopted to catheterize the TD and selectively embolize its caudal portion using microcoils and liquid embolic adhesive. Recurrence of symptoms after 2 months indicated a redo catheterization to occlude the TD entirely using the same technique. The procedure was successful and the patient was discharged after 2 days with sustained clinical improvement at 24 months postoperative. In the context of refractory PB, end-to-end transvenous retrograde embolization of the TD appears to be an interesting alternative to more complex interventions such as transabdominal puncture, decompression, or surgical ligation of the TD.

Acute plastic bronchitis after Ross procedure treated with veno-venous extracorporeal membrane oxygenation.

PURPOSE: Plastic bronchitis is a rare condition characterized by the formation of airway casts occluding the lower respiratory tract. It is described more commonly in children, especially following correction of congenital heart disease. It involves lymphatic abnormalities leading to endobronchial lymph precipitating airway cast formation. When it presents acutely, it can lead to acute airway obstruction, which can be life-threatening. Plastic bronchitis has been rarely described in adults and is potentially underdiagnosed. The purpose of this case report is to emphasize, for the adult anesthesiologist and adult critical care physician, the importance of prompt diagnosis and respiratory support in a case of plastic bronchitis. CLINICAL FEATURES: A 40-yr-old female with severe aortic stenosis underwent a Ross procedure. The surgery was uneventful, but within two hours of arrival in the intensive care unit, the patient developed severe hypoxemia. Despite attempts to optimize her respiratory status, the patient remained severely hypoxemic, and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated using a percutaneous femoro-femoral cannulation. A bronchoscopy showed bronchial secretions casting the proximal bronchus, suggestive of plastic bronchitis. After numerous bronchoscopies, we were able to clean the airways and wean the ECMO support on postoperative day 3. CONCLUSION: Plastic bronchitis can present in adult patients and be life-threatening when associated with acute respiratory failure. We report an unusual case of an adult patient treated with veno-venous ECMO for plastic bronchitis following cardiac surgery. Use of ECMO support while providing airway cleaning can be lifesaving in patients with respiratory failure secondary to plastic bronchitis.

RéSUMé: OBJECTIF: La bronchite plastique est une affection rare caractérisée par la formation de bouchons muqueux qui moulent et obstruent les voies aériennes inférieures. Elle est plus fréquemment décrite chez les enfants, en particulier après la correction d'une cardiopathie congénitale. Elle découle d'anomalies lymphatiques conduisant à l'accumulation de lymphe endobronchique, précipitant la formation de bouchons muqueux dans les voies aériennes. Lorsqu'elle se présente de manière aiguë, la bronchite plastique peut entraîner une obstruction aiguë des voies aériennes, une complication potentiellement fatale. La bronchite plastique a rarement été décrite chez l'adulte et est potentiellement sous-diagnostiquée. L'objectif de cette présentation de cas est de souligner, pour l'anesthésiologiste et l'intensiviste s'occupant d'une population adulte, l'importance d'un diagnostic rapide et d'un support respiratoire en cas de bronchite plastique. CARACTéRISTIQUES CLINIQUES: Une femme de 40 ans souffrant d'une sténose aortique sévère a bénéficié d'une procédure de Ross. La chirurgie s'est déroulée sans incident, mais dans les deux heures suivant son arrivée à l'unité de soins intensifs, la patiente a présenté une hypoxémie sévère. Malgré les tentatives d'optimisation de son état respiratoire, la patiente est restée gravement hypoxémique et une oxygénation par membrane extracorporelle (ECMO) veino-veineuse a été amorcée à l'aide d'une canulation fémoro-fémorale percutanée. Une bronchoscopie a montré des sécrétions bronchiques moulant les bronches proximales, évoquant une bronchite plastique. Après de nombreuses bronchoscopies, nous avons pu nettoyer les voies aériennes et sevrer la patiente du soutien ECMO au 3ème jour postopératoire. CONCLUSION: La bronchite plastique peut se présenter chez les patients adultes et être potentiellement fatale lorsqu'elle est associée à une insuffisance respiratoire aiguë. Nous rapportons un cas inhabituel d'une patiente adulte traitée par ECMO veino-veineuse pour une bronchite plastique après une chirurgie cardiaque. L'utilisation du soutien par ECMO simultanément au nettoyage des voies aériennes peut être nécessaire chez les patients atteints d'insuffisance respiratoire secondaire à une bronchite plastique.

Bronchoscopic interventions for plastic bronchitis in children without structural heart disease.

Plastic bronchitis (PB) is a rare and life-threatening complication encountered in several disease states that leads to airway obstruction by branching casts. PB is most often reported in children with cyanotic congenital heart disease where recurrence is common, and mortality is high. There is limited data on optimal management strategies or recurrence of non-structural heart disease-related PB in children. We describe the clinical features, management, and outcomes in our cohort of children with non-structural heart disease-related PB. Among the 12 identified patients, asthma was the most common (67%) diagnosis. Ventilatory requirements ranged from room air to one patient who required extracorporeal membrane oxygenation (ECMO). Most patients (92%) required bronchoscopy, and cryotherapy was successfully utilized in two patients to relieve refractory obstructive airway casts. All patients received chest physiotherapy, and 11 patients were treated with two or more medications. There was one mortality despite ECMO, and one-third had recurrent PB, all of whom had asthma.Conclusion: Asthma is a risk factor for recurrent PB. Bronchoscopic interventions including cryotherapy are safe and effective treatment options in patients with refractory PB. What is Known: • Plastic bronchitis is a rare but life-threatening cause of airway obstruction caused by branching casts that are generally reported in patients with congenital heart disease. What is New: • In children without structural heart disease, asthma is a risk factor for recurrent plastic bronchitis. Cryotherapy via bronchoscopy is a safe and effective intervention in patients with refractory plastic bronchitis.

Plastic Bronchitis in Adult and Pediatric Patients: A Review of its Presentation, Diagnosis, and Treatment.

PURPOSE OF STUDY: Plastic Bronchitis (PB) is a rare pulmonary condition characterized by the presence of casts in the trachea or bronchial tree. While there are many individual cases reported in pediatric and adult populations, no thorough reviews of pediatric and adult cases of PB exist in the literature. The purpose of this article is to conduct a comprehensive review of PB regarding presentation, diagnosis, pathophysiology, and treatments. ETIOLOGY: In the pediatric population, PB can be attributed to pediatric cardiothoracic surgeries such as Fontan procedures, infections, inflammatory processes, acute chest syndrome, or iatrogenic processes. In the adult population, PB can be idiopathic or due to infections, anatomic variations in lymphatic vessels, surgeries, medications, or other comorbidities. PATHOPHYSIOLOGY: The pathophysiology of PB is still widely unknown; however, associations with inflammatory diseases and cardiac surgery have been proposed. There are two types of cast formations found in plastic bronchitis: Type I casts are associated with inflammatory diseases and Type II casts are associated with surgical procedures. TREATMENT: Historically, PB has been treated by a variety of pharmacological methods including the use of corticosteroids and mucolytics. Recently, the treatment paradigm has shifted towards procedures such as lymphatic embolization, duct ligation, and stent grafting. CONCLUSIONS: The information available regarding PB is still sparse, hence future research is necessary for further understanding of the disease. Due to its numerous presentations and disease associations, awareness of plastic bronchitis, and its treatment options is essential for primary care providers and respiratory specialists.

Decompression of the thoracic duct: A novel transcatheter approach.

In patients with total cavopulmonary connections, elevated central venous pressures (CVP) have detrimental effects on the lymphatic system causing an imbalance in fluid production and drainage of the interstitium. This combination may result in life-threatening lymphatic complications including plastic bronchitis (PB), protein losing enteropathy (PLE), chylothorax, and ascites. While embolization of the abnormal lymphatics has greatly improved outcomes from these complications, alternative treatment strategies have been proposed that would result in improved lymphatic drainage while leaving the lymphatic system intact. We report two novel transcatheter approaches for thoracic duct (TD) decompression in two patients who developed PLE after completion of the Fontan procedure as part of staged palliation for congenital heart disease. In addition, one patient had severe concurrent PB. In both patients, a connection was created between a left superior vena cava (LSVC) to the left atrium allowing for a nonsurgical method to decompress the TD. This procedure resulted in significant clinical and laboratory improvement of both patients' PLE and other symptoms of lymphatic dysfunction.

Abnormal pulmonary lymphatic flow in patients with paediatric pulmonary lymphatic disorders: Diagnosis and treatment.

Pulmonary lymphatic disorders are characterized by the presence of the abnormal lymphatic tissues in the thoracic cavity, presenting clinically as chylothorax, chylopericardium, chyloptysis, interstitial lung disease and plastic bronchitis. These conditions include: neonatal chylothorax, cardiac and non-cardiac plastic bronchitis, non-traumatic chylothorax, post congenital cardiac surgery chylothorax and complex lymphatic malformations. Recently developed lymphatic imaging techniques, such as intranodal lymphangiography and dynamic contrast enhanced magnetic resonance lymphangiography demonstrated abnormal pulmonary lymphatic flow from thoracic duct into pulmonary parenchyma as a pathophysiological mechanism of these diseases. Novel minimally invasive lymphatic interventions, such as thoracic duct embolization, interstitial lymphatic embolization and surgical lympho-venous anastomosis, provide an effective treatment of these conditions.

Pediatric pulmonary lymphatic flow Disorders: Diagnosis and management.

Pulmonary lymphatic flow disorders involve the abnormal lymphatic flow via lymphatic channels to the lungs and pleural space. Plastic bronchitis and chylothorax are the main complications of this abnormal lymphatic perfusion, which has been termed pulmonary lymphatic perfusion syndrome (PLPS). Following lymphatic access, dynamic contrast MR lymphangiography is the imaging modality of choice to diagnose these disorders. Management includes medical therapy, percutaneous interventions under fluoroscopy, and surgical interventions.

Percutaneous embolization of lymphatic fistulae as treatment for protein-losing enteropathy and plastic bronchitis in patients with failing Fontan circulation.

BACKGROUND: To determine the feasibility and clinical result of selective embolization of hepatoduodenal or paratracheal lymphatics in Fontan patients with protein-losing enteropathy (PLE) or plastic bronchitis (PB). METHODS: Dilated lymph vessels in periportal (PLE) or paratracheal (PB) position were percutaneously punctured with a 22G Chiba needle. Intralymphatic position was confirmed by water soluble contrast injection with drainage to hepatoduodenal or tracheal fistulae. After flushing with 10% glucose solution, occlusion of hepatoduodenal or paratreacheal lymphatics was effected by injection of 1-4 cc mixture 4/1 of Lipiodol/n-butyl cyanoacrylate (n-BCA; Histoacryl). RESULTS: Seven patients with proven PLE were treated with periportal lymphatic embolization 10.7 (range: 6.6-13.5) years after the Fontan operation. The Fontan operation was performed at a median age of 3.7 (range: 2.9-5.7) years and PLE started a median of 3.1 (range: 0.9-4.7) years later. Five patients required a second procedure 2-8 months later. Complications were limited (spillage of glue in portal branch, transient cholangitis, and caustic duodenal bleeding). Six of seven patients reported significant improvement in quality of life and normalization of albumin levels after limited follow-up (p < .01). One patient (Fontan at 2.9 years; age 16.4 years) had PB for 2 years. Selective transthoracic cone-beam-directed puncture of left and right paratracheal lymphatics with n-BCA embolization of distal lymphatic fistulae resulted in lasting absence of tracheal casts (11 months). CONCLUSIONS: Embolization of periportal/peritracheal lymphatics is a promising technique in Fontan patients with PLE/PB. Larger series are required to determine incidence and reasons of success/failure, with long-term results and effects on liver function.

An approach to the child with a wet cough.

When children have a wet cough, it suggests the presence of secretions in their airways. This often has an infectious aetiology which is usually a self-limiting viral infection requiring no investigation or treatment. In those with acute wet cough it is, however, important to identify features suggestive of community acquired pneumonia or an inhaled foreign body as these causes require specific management. When there is chronic wet cough, the most common diagnoses are protracted bacterial bronchitis (PBB) and bronchiectasis. The relationship between these two conditions is complex as the development of bronchiectasis manifests as a clinical continuum in which the early features of which are indistinguishable from PBB. It is therefore important to identify PBB and chronic cough endotypes which are associated with an increased risk of bronchiectasis. This article offers a pragmatic approach to the investigation and treatment of children with wet cough. It is hoped this will limit unnecessary investigations whist aiding the prompt diagnosis of conditions needing treatment to reduce symptom burden and prevent further lung damage.

Spicae aetheroleum in uncomplicated acute bronchitis: a double-blind, randomised clinical trial.

BACKGROUND: The trial aimed to evaluate the efficacy and safety of Spicae aetheroleum (Spicae ae.), a phytomedicine obtained by steam distillation of the flowering tops of Lavandula latifolia, as compared to placebo in adult patients with acute bronchitis. METHODS: Patients with uncomplicated acute bronchitis (bronchitis severity score [BSS] ≥ 5 score points) were randomly assigned to treatment with Spicae ae. or placebo in a double-blind, parallel-group design. No additional treatment was admitted. The primary objective was the mean difference of a defined total BSS of 25% between the Spicae ae. and the placebo group after 7 days of full medication dose. Secondary endpoints included the BSS at day 10, additional signs and symptoms of bronchitis, quality of life (QoL) and safety. RESULTS: The mean decrease in BSS at day 7 and day 10 was significant with 4.79 vs. 3.20 (p < 0.005 for a 25% difference) and 6.47 vs. 4.32 (p < 0.009 for a 25% difference) score points respectively in the Spicae ae. (n = 119) vs. placebo group (n = 110). Accordingly, most additional signs and symptoms of acute bronchitis as well as the patients' QoL improved significantly with Spicae ae. as compared to placebo. In all, 258 patients were eligible for safety analysis. The treatment with Spicae ae. was well tolerated; no serious adverse events occurred. CONCLUSION: The defined objectives both for the primary and secondary endpoints have been met. The results of this study provide evidence that Spicae ae. is well tolerated, effective and superior to placebo in the symptomatic treatment of uncomplicated acute bronchitis in adult patients.

[Acute respiratory and urinary tract infections in medical practice†: a selection of complementary medicines]. / Infections aiguës des voies respiratoires et urinaires au cabinet médical†: quelques traitements en médecine complémentaire.

Respiratory tract infections such as bronchitis or sinusitis and urinary tract infections are common in the family doctor's office. Bronchitis and sinusitis are mostly of viral origin and antibiotics rarely hold a place in their management, while urinary tract infections most often require the prescription of antibiotics. In both situations, patients often seek complementary medicines to relieve symptoms or prevent recurrences. This article aims to synthesize available data on efficacy and safety of some treatments in complementary medicine used in these indications, such as South African geranium, the combination of thyme-primrose or thyme-ivy, Echinacea or cranberry.

Les infections respiratoires aiguës telles que la bronchite ou la sinusite et l'infection urinaire basse sont des motifs de consultation fréquents au cabinet du médecin de famille. Bronchites et sinusites sont pour la plupart d'origine virale et les antibiotiques n'ont que rarement leur place dans la prise en charge, alors que les infections urinaires requièrent le plus souvent la prescription d'antibiotiques. Dans les deux situations, les patients sont souvent demandeurs de médecine complémentaire pour soulager les symptômes ou prévenir les récidives. Cet article a pour but d'offrir une synthèse des données disponibles concernant l'efficacité et la sécurité de quelques traitements de médecine complémentaire utilisés dans ces indications, tels que le géranium rose, le mélange thym-primevère ou lierre, l'échinacée ou encore la canneberge.

Successful Treatment of Protein-Losing Enteropathy and Plastic Bronchitis by Biphasic Cuirass Ventilation in a Patient with Failing Fontan Circulation.

We present a 16-year-old male patient with hypoplastic left heart syndrome who developed protein-losing enteropathy (PLE) and plastic bronchitis (PB) after a Fontan operation. He received medical therapies, including albumin infusion, unfractionated heparin, and high-dose anti-aldosterone therapy but could not obtain clinical relief. Biphasic cuirass ventilation (BCV) led to expectoration of bronchial casts and prompt resolution of PB. Notably, clinical symptoms related to PLE were dramatically improved after starting BCV. A brief period of BCV increased stroke volume from 26±1.4 to 39±4.0 mL. This case suggests that BCV could be an effective treatment for PLE in patients with failing Fontan circulation.

THE EFFECT OF VIBRO-ACOUSTIC STIMULATION ON CELL DYNAMICS OF INFLAMMATION IN RATS AND THE POSSIBILITIES FOR VIBROACOUSTIC SOUND THERAPY IN COMPLEX TREATMENT OF BRONCHITIS IN CHILDREN.

One of the methods of physiotherapy used in the complex treatment of various diseases is vibroacoustic exposure (VAE), however, the anti-inflammatory effect of this factor has not been studied insufficiently. The purpose of this research was to study the effect of VAE on the cellular dynamics of the inflammation focus. The experimental study was performed on 72 male Wistar rats weighing 180-200 g. The age of the rats was 1-1.5 months. All painful and stressful procedures were performed under ether drug (according to the European Convention for the Protection of Vertebrate Animals (Strasbourg, 08.03.1986). Acute aseptic inflammation of the soft tissues of the thigh of rats was caused by injection of 5 mg λ-caraginen («Sigma¼. USA) in 1 ml of isotonic sodium chloride solution The animals were sacrificed by decapitation at different periods of inflammation The main and control groups consisted of 36 animals in each group. After the introduction of λ-caraginen in the main group, animals were subjected to VAE at the area of the inflammatory focus from the Vitafon apparatus, daily, for 10 days, in 1 mode, with frequency subranges from 20 to 18000 Hz, and the amplitude of microvibration of the membrane within 2.8-8.4 microns, exposure 10 minutes. Cell-tissue dynamics in the focus of inflammation was studied after 6 hours, as well as on the 1-, 3-, 7-, and 10th days. In the control group the inflammation proceeded naturally. The results of an experimental study carried out on the rats showed that the physiotherapeutic factor VAE has an anti-inflammatory effect due to the active involving of the cellular components of physiological body protection measures. Activation of the mechanisms of sanogenesis under the influence of VAE resulted in its inclusion in the physiotherapeutic complex for the treatment of acute simple bronchitis in children, that helped to shorten the periods of their treatment. The anti-inflammatory effect of VAE consists in limiting alterative and enhancing reparative phenomena, considering that neutrophils play a leading role in the development of the inflammatory process, and monocytes-macrophages and fibroblasts - in its attenuation.

ERS statement on protracted bacterial bronchitis in children.

This European Respiratory Society statement provides a comprehensive overview on protracted bacterial bronchitis (PBB) in children. A task force of experts, consisting of clinicians from Europe and Australia who manage children with PBB determined the overall scope of this statement through consensus. Systematic reviews addressing key questions were undertaken, diagrams in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement constructed and findings of relevant studies summarised. The final content of this statement was agreed upon by all members.The current knowledge regarding PBB is presented, including the definition, microbiology data, known pathobiology, bronchoalveolar lavage findings and treatment strategies to manage these children. Evidence for the definition of PBB was sought specifically and presented. In addition, the task force identified several major clinical areas in PBB requiring further research, including collecting more prospective data to better identify the disease burden within the community, determining its natural history, a better understanding of the underlying disease mechanisms and how to optimise its treatment, with a particular requirement for randomised controlled trials to be conducted in primary care.

Plastic bronchitis: a rare complication of long-term haemodialysis catheter placement in a child.

BACKGROUND: Despite peritoneal dialysis being the preferred mode of renal replacement therapy in neonates and infants, long-term haemodialysis may be necessary in a minority of patients with its attendant risks. CASE DIAGNOSIS/TREATMENT: This case identifies plastic bronchitis as a rare yet serious complication of long-term large bore vascular access when a vessel-sparing approach is not possible. CONCLUSIONS: An appropriately sized catheter should be used for the dialytic therapy required and to optimize access survival.

Strategies to Prevent Cast Formation in Patients with Plastic Bronchitis Undergoing Heart Transplantation.

Plastic bronchitis, a rare complication after Fontan palliation, carries a high morbidity and mortality risk. Heart transplantation is an effective treatment option, but casts may occur in the early post-operative period. We present a case series detailing peri-operative management strategies to minimize morbidity and mortality related to plastic bronchitis in patients undergoing heart transplantation. Patient 1 received no treatment pre-, intra-, or post-transplant for prevention of bronchial casts and developed severe respiratory acidosis 18 h following transplant. Emergent bronchoscopy was performed and a large obstructive cast was removed. The patient recovered and received inhaled tissue plasminogen activator (tPA) for 5 days. Patient 2 received inhaled tPA before, during, and for 5 days after transplantation and no bronchial casts developed. Patient 3 underwent intraoperative bronchoscopy just prior to implantation revealing no casts. The patient underwent non-urgent, preemptive bronchoscopy on post-transplant days 1, 3, and 4, removing several partially obstructive bronchial blood clots/casts, with no casts thereafter. Heart transplantation results in eventual resolution of plastic bronchitis. Residual bronchial casts can still be problematic in the peri-operative period. Airway clearance with inhaled tPA or bronchoscopy may prevent the need for prolonged mechanical ventilation and reduce post-operative morbidity in this unique population.

Invasive Aspergillus Pseudomembranous and Obstructive Tracheo-bronchitis in an Immuno-competent Patient.

A 19 year female, presented with life threatening haemoptysis and cough with minimum expectoration for 3 months. Bronchoscopy showed multiple nodules in airway. The direct microscopy and culture of sputum revealed fungal elements and Aspergillus flavus respectively. Serum Galactomannan was positive. Thus diagnosis of invasive aspergillus tracheo-bronchitis made. She responded to voriconazole. Aspergillus tracheo-bronchitis is a rare form of invasive pulmonary aspergillosis in immuno-competent host. Aspergillus spp in respiratory samples should not be routinely discarded as colonization.

[Bronchitis Plastica - Acute Dyspnea and Branching Airway Casts]. / Bronchitis plastica ­ Akute Luftnot und bronchiale Ausgusspräparate.

A 65 year old female presented to the emergency department with dyspnea and progressive cough with very viscous elongated secretion plugs. She suffered from multiple cardiac comorbidities and chronic heart failure. The CT scan of the thorax demonstrated extensive pulmonary infiltrates, unspecific mediastinal lymphadenopathy and enlargement of pulmonary lymph vessels. Bronchoscopy was performed and showed extensive occlusive bronchial casts. We diagnosed a case of bronchitis plastica. Therapy with inhalative heparin led to clinical improvement. CONCLUSION: bronchitis plastica is a rare disease with formation of occlusive bronchial casts. They are often found in cardiac disease or lymphatic disease.