The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Cast of the Right Bronchial Tree

Gavitt A. Woodard, M.D.

Georg M. Wieselthaler, M.D.
University of California, San Francisco
San Francisco, CA
gavitt​.­woodard@​­ucsf​.­edu

A 
36-year-old man was admitted to the intensive care unit with an acute exacerbation of
chronic heart failure. His medical history included heart failure with an ejection fraction of 20%, bioprosthetic
aortic-valve replacement for bicuspid aortic stenosis, endovascular stenting of an aortic aneurysm, and place-
ment of a permanent pacemaker for complete heart block. An Impella ventricular assist device was placed for man-
agement of acute heart failure, and a continuous heparin infusion was initiated for systemic anticoagulation. During
the next week, the patient had episodes of small-volume hemoptysis, increasing respiratory distress, and increasing
use of supplemental oxygen (up to 20 liters delivered through a high-flow nasal cannula). During an extreme bout of
coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree. The right bronchial tree
consists of three segmental branches in the upper lobe (blue arrows), two segmental branches in the middle lobe
(white arrows), and five segmental branches in the lower lobe (black arrows). The patient’s trachea was subsequently
intubated, and flexible bronchoscopy revealed a small amount of blood in the basilar branches of the right lower
lobe. The patient was extubated 2 days later and had no further episodes of hemoptysis. One week after extubation,
he died from complications of heart failure (volume overload and poor cardiac output) despite placement of the
ventricular assist device.
DOI: 10.1056/NEJMicm1806493
Copyright © 2018 Massachusetts Medical Society.

n engl j med 379;22 nejm.org  November 29, 2018 2151

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