Plastic bronchitis is a rare condition characterized by formation of airway casts. The accompanying image demonstrates arborizing bronchial casts that were extracted from the airway of a 12-yr-old patient with a history of surgically corrected transposition of great arteries. Plastic bronchitis in children, especially those with a Fontan circulation, has been attributed to presence of central venous hypertension and lymphatic abnormalities that lead to endobronchial egress of lymph precipitating airway cast formation. This unique complication occurs months to years after surgical correction of cyanotic heart disease. Children present with dyspnea, coughing, wheezing, tachypnea, and cyanosis.1–3 

Anesthetic management for bronchoscopic removal of casts can be challenging because children are often apprehensive, uncooperative, and in respiratory distress from critical airway compromise. Because positive pressure ventilation can potentially displace casts distally, inhalational mask induction and preservation of spontaneous breathing...

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