Images in Clinical Medicine: Bronchial Casts From Inhalation of Forest-Fire Smoke

Why It Matters

Bronchial casts from wildfire smoke illustrate a growing, preventable respiratory hazard, underscoring the need for rapid airway intervention and climate‑aware health strategies.

Key Takeaways

• Elderly patient developed bronchial casts after prolonged forest‑fire smoke exposure
• Flexible bronchoscopy revealed black particulate casts obstructing main bronchi
• Cryoprobe removal successfully cleared casts, enabling rapid extubation
• Climate‑driven fire frequency raises risk of smoke‑related airway injuries
• Early bronchoscopy can prevent ventilation complications in smoke inhalation cases

Summary

The video presents a case study of an 87‑year‑old man who developed obstructive bronchial casts after inhaling dense smoke from a multi‑hour forest fire.

Physical exam showed diffuse rales without burns; escalating airway pressures prompted flexible bronchoscopy, which visualized black particulate casts coating the carina and mainstem bronchi. The casts were extracted with a cryoprobe, allowing immediate extubation and full recovery within two weeks.

The report links the event to climate‑change‑driven fire frequency, noting that the image was selected from a global NEJM call highlighting emerging health threats tied to environmental shifts.

Clinicians should consider early bronchoscopic evaluation in severe smoke inhalation to avert ventilation failure, while public‑health planners must account for rising fire‑related respiratory morbidity as climate patterns evolve.

Original Description

After inhaling smoke from a forest fire for several hours, an 87-year-old man presented to the ED with difficulty breathing. He rapidly developed respiratory failure, and a flexible bronchoscopy revealed bronchial casts from inhalation of particulate matter from the smoke.

Read the full case details in the Images in Clinical Medicine article “Bronchial Casts from Inhalation of Forest-Fire Smoke” at NEJM.org.

This video is part of an #earthday2026 spotlight illustrating the effects of the climate crisis on clinical health. View more resources at NEJM.org.

#climatechange #nejm