Awesome bronchial cast

Excerpts from the report in the New England Journal of Medicine:

A 36-year-old man was admitted to the intensive care unit with an acute exacerbation of chronic heart failure... An Impella ventricular assist device was placed for management 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... During an extreme bout of coughing, the patient spontaneously expectorated an intact cast of the right bronchial tree.

This report is incorrectly cited elsewhere as a patient "coughing up part of his lung."   This is, as described, a "cast," just as one might make a cast by pouring liquid aluminum into an anthill or a termite mound.  What's amazing is the completeness of the cast, which begins proximally at the carina and extends outward to include (and occlude) the entire right upper lobe (blue arrows), middle lobe (white) and the RLL (black) out to the subsegmental level and beyond.

To me what is interesting is that the cast must have been expectorated shortly after it formed, because with prolonged complete occlusion he would have developed atelectasis of the distal lung and then would not have been able to generate the compressive force to cough it out.

The Atlantic has an informed discussion of the case.