Plastic bronchitis: A management challenge

Plastic bronchitis is an uncommon and underdiagnosed entity, characterized by recurrent expectoration of large, branching bronchial casts. We describe a 39-year-woman with no prior lung disease who had episodic wheezing, severe dyspnea with expectoration of large and thick secretions, branching in appearance, which she described as resembling squid. A comprehensive evaluation revealed no specific cause and a diagnosis of idiopathic plastic bronchitis was made. In plastic bronchitis the bronchial casts may vary in size from small segmental casts of a bronchus to casts filling the airways of an entire lung. Plastic bronchitis can therefore present as an acute life-threatening emergency if mechanical obstruction of major airways occurs. The casts are differentiated into type 1, inflammatory casts, or type II, acellular casts. The type I inflammatory casts are often associated with bronchial disease and often have an acute presentation. The acellular type of cast production is often chronic or recurrent. Numerous systemic illnesses are associated with plastic bronchitis, but often, as in our patient, no underlying cause can be identified. The treatment of plastic bronchitis includes acute therapy to aid the removal and expectoration of casts, and specific short- or long-term treatments attempting to address the underlying hypersecretory process. The therapeutic options are supported only by anecdotal evidence based on case reports as the rarity and heterogeneity of plastic bronchitis confounds systematic investigations of its treatment. Improved understanding of the regulation of mucus production may allow for new treatment options in plastic bronchitis and other chronic lung diseases characterized by hypersecretion of mucus.