ID:156 FC-D01-9 A case of type II plastic bronchitis treated with V-V ECMO

We experienced a case of type II plastic bronchitis (PB) with severe hypoxemia in which V–V ECMO was introduced and thoracic duct reconstruction was performed. Clinical Course: A 20-year-old man, height 170cm, weight 62kg. He had been followed for chylo-pericarditis since 15 years old. Over the past 6 months he had repeated episodes of pneumonia and he was admitted to a previous hospital due to hypoxemia on day X-7. Bronchoscopy (BF) revealed mucus plugs in the trachea and PB was suspected. Despite endotracheal intubation and frequent suctioning of the mucus plugs via BF, persistent hypoxemia continued. A 27 Fr Avalon Elite® (Getinge, Tokyo) catheter was inserted via the right IJV, and V–V ECMO using UNIMO® (Senko Medical, Tokyo) was initiated. As conservative treatment was insufficient, the patient was transferred to our hospital on day X for lymphangiography and possible embolization. On day X + 1, lymphangiography revealed suspected obstruction of the thoracic duct. The findings suggested that impaired lymphatic return to the left venous angle and elevated venous pressure due to pericardial effusion contributed to worsening lymphatic leakage. On day X + 3, reconstruction of thoracic duct and pericardial drainage were performed. Then, daily suctioning of mucus plugs with BF and body fluid removal with continuous hemodiafiltration improved the patient’s pulmonary oxygenation. On day X + 8, V–V ECMO was successfully weaned. Tracheostomy was performed on day X + 9, accumulated left pleural effusion was drained on day X + 13 and the patient was successfully weaned from mechanical ventilation on day X + 14. Finally, he was discharged from ICU to a general ward on day X + 16. Conclusion: During the acute phase of type II PB, V–V ECMO was useful to support oxygenation enabled safe transfer, suctioning of mucus plugs, lymphangiography, and surgical intervention.