Introduction: Plastic bronchitis is an uncommon and underrecognized condition involving dense bronchial casts due to aberrant lymphatic flow. It typically affects children with congenital heart disease but is rarely reported in adults. Treatment ranges from mucolytics and bronchoscopy to definitive lymphatic interventions. We present a case of adult plastic bronchitis requiring ECMO and thoracic duct ablation.
Description: A 55-year-old woman with presumed pulmonary alveolar proteinosis (PAP) was transferred for worsening respiratory failure and intubation. She reported two weeks of progressive dyspnea and productive cough with thick white sputum. Imaging showed diffuse infiltrates and septal thickening. She was placed on veno-venous ECMO for bilateral whole lung lavage (WLL). Bronchoscopy revealed dense, rubbery casts obstructing the bronchial tree. BAL fluid contained elevated triglycerides, and lymphoscintigraphy confirmed abnormal lymphatic drainage. Diagnosis of plastic bronchitis was made. She underwent rigid bronchoscopy with cryodebulking and celiac plexus alcohol ablation of the thoracic duct. Post-procedural imaging confirmed resolution of retrograde lymphatic flow. She was weaned from ECMO and extubated with clinical improvement.
Discussion: This case highlights the diagnostic challenge and severity of adult plastic bronchitis. In critical presentations, ECMO can support both diagnostics and therapy. Bronchoscopic cast removal and lymphatic intervention were key to resolution. Early recognition and multidisciplinary management are essential to improving outcomes. Clinician awareness is limited, and reporting such cases informs recognition, diagnosis, and evolving treatment strategies.
