Right Middle Lobe Syndrome Follow-up

  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD   more...
 
Updated: Aug 3, 2011
 

Further Inpatient Care

  • Most patients with right middle lobe syndrome (RMLS) are managed as outpatients; however, acute exacerbations may require inpatient care and intravenous antibiotics.
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Further Outpatient Care

  • Periodic office follow-up with repeat chest radiographs is warranted to assess response to medical therapy. Periodic assessment of caregivers' chest physical therapy techniques can be monitored during the visits as well.
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Deterrence/Prevention

  • Prevention of right middle lobe syndrome has not been studied, but, because of the long-term morbidity associated with this condition, perform a repeat chest radiograph in children with asthma who have atelectasis of the right middle lobe during an acute asthma exacerbation and in children with acute pneumonia of the right middle lobe to document resolution.
  • Recently, a more aggressive approach in a cohort of 55 symptomatic children with right middle lobe syndrome followed for a median duration of 2 years yielded good outcome.[3] All these children underwent flexible bronchoscopy at presentation, and specific antibiotic therapy was given based on bronchial alveolar lavage fluid. Bronchiectasis was documented in 27% of patients, and the duration of symptoms correlated with the development of this unfavorable complication.
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Complications

  • Long-term complications range from none to minimal pulmonary scarring of no discernible physiological consequence to severe bronchiectasis requiring surgical intervention.
  • In children with asthma, right middle lobe syndrome may produce a vicious cycle of infection, inflammation, and asthma exacerbation.
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Prognosis

  • Right middle lobe syndrome resolves in approximately 33% of children after bronchoscopy. Approximately 33% recover eventually with medical management, 22% require lobectomy, and 11% have decreased severity of symptoms but should be monitored for the possibility of requiring lobectomy later.
  • About one third of patients with right middle lobe syndrome in early childhood continue to have symptoms in later childhood. These patients usually experience asthma symptoms or another chronic lung condition such as cystic fibrosis. A recent study examined the efficacy of early postnatal corticosteroids for preventing chronic lung disease in preterm infants.[4]
  • The remaining two thirds of children with right middle lobe syndrome do not have persistent symptoms later in adulthood.
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Patient Education

  • Because chest physical therapy and postural drainage are of paramount importance in the management of RMLS, instruct the caretaker with appropriate techniques and position for right middle lobe physiotherapy. This is often performed by a registered respiratory or physical therapist. Regardless, the therapist should be somebody who frequently deals with children.
  • Flutter valve and high-frequency oscillation (known as the vest) have not been studied in this setting, but they may be alternative modalities of delivering chest physical therapy.
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Contributor Information and Disclosures
Author

Nemr S Eid, MD, FAAP, FCCP  Professor of Pediatrics, University of Louisville School of Medicine; Director of Pediatric Pulmonary Medicine, Director of The Childhood Asthma Care and Education Center and the Cystic Fibrosis Center, Medical Director of Pediatric Respiratory Therapy, Kosair Children's Hospital

Nemr S Eid, MD, FAAP, FCCP is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Kentucky Medical Association, and Kentucky Pediatric Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle Eckerle  University of Louisville School of Medicine

Michelle Eckerle is a member of the following medical societies: Kentucky Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas Scanlin, MD  Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Heidi Connolly, MD  Associate Professor of Pediatrics and Psychiatry, University of Rochester; Director, Pediatric Sleep Medicine Services, Strong Sleep Disorders Center

Heidi Connolly, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

References

  1. Springer C, Avital A, Noviski N, et al. Role of infection in the middle lobe syndrome in asthma. Arch Dis Child. May 1992;67(5):592-4. [Medline].

  2. [Guideline] Institute for Clinical Systems Improvement (ICSI). Diagnosis and management of asthma. Jan 2008;[Full Text].

  3. Priftis KN, Mermiri D, Papadopoulou A, et al. The role of timely intervention in middle lobe syndrome in children. Chest. Oct 2005;128(4):2504-10. [Medline].

  4. [Best Evidence] Halliday HL, Ehrenkranz RA, Doyle LW. Early (< 8 days) postnatal corticosteroids for preventing chronic lung disease in preterm infants. Cochrane Database Syst Rev. Jan 21 2009;CD001146. [Medline].

  5. American Journal of Medicine. Right middle lobe syndrome progressing to death in a 77-year-old woman. Am J Med. Mar 1987;82(3):471-80. [Medline].

  6. Ayed AK. Resection of the right middle lobe and lingula in children for middle lobe/lingula syndrome. Chest. Jan 2004;125(1):38-42. [Medline]. [Full Text].

  7. Brown M, Lemen R. Bronchiectasis. In: Kendig's Disorders of the Respiratory Tract in Children. Philadelphia, Pa: WB Saunders Co; 1998:150-2.

  8. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 19-1984. A 57-year-old woman with recurrent pneumonia. N Engl J Med. May 10 1984;310(19):1245-52. [Medline].

  9. De Boeck K, Willems T, Van Gysel D, et al. Outcome after right middle lobe syndrome. Chest. Jul 1995;108(1):150-2. [Medline]. [Full Text].

  10. Dees SC, Spock A. Right middle lobe syndrome in children. JAMA. Jul 4 1966;197(1):8-14. [Medline].

  11. Eggleston PA, Ward BH, Pierson WE, Bierman CW. Radiographic abnormalities in acute asthma in children. Pediatrics. Oct 1974;54(4):442-9. [Medline].

  12. Gudmundsson G, Gross TJ. Middle lobe syndrome. Am Fam Physician. Jun 1996;53(8):2547-50. [Medline].

  13. Kinzy JD, Powers WP, Baddour LM. Case report: Blastomyces dermatitidis as a cause of middle lobe syndrome. Am J Med Sci. Oct 1996;312(4):191-3. [Medline].

  14. Kwon KY, Myers JL, Swensen SJ, Colby TV. Middle lobe syndrome: a clinicopathological study of 21 patients. Hum Pathol. Mar 1995;26(3):302-7. [Medline].

  15. Lambert GW, Baddour LM. Right middle lobe syndrome caused by Mycobacterium fortuitum in a patient with human immunodeficiency virus infection. South Med J. Jul 1992;85(7):767-9. [Medline].

  16. Livingston GL, Holinger LD, Luck SR. Right middle lobe syndrome in children. Int J Pediatr Otorhinolaryngol. Jun 1987;13(1):11-23. [Medline].

  17. Priftis KN, Anthracopoulos MB, Mermiri D, et al. Bronchial hyperresponsiveness, atopy, and bronchoalveolar lavage eosinophils in persistent middle lobe syndrome. Pediatr Pulmonol. Sep 2006;41(9):805-11. [Medline].

  18. Rock MJ. The diagnostic utility of bronchoalveolar lavage in immunocompetent children with unexplained infiltrates on chest radiograph. Pediatrics. Mar 1995;95(3):373-7. [Medline].

  19. Saha SP, Mayo P, Long GA, McElvein RB. Middle lobe syndrome: diagnosis and management. Ann Thorac Surg. Jan 1982;33(1):28-31. [Medline].

  20. Shah A, Bhagat R, Panchal N, et al. Allergic bronchopulmonary aspergillosis with middle lobe syndrome and allergic Aspergillus sinusitis. Eur Respir J. Jun 1993;6(6):917-8. [Medline].

  21. Thacher H, Kaplan A. Middle lobe syndrome in asthmatic children. J Maine Med Assoc. Mar 1972;63(3):46-8 passim. [Medline].

  22. Torkian B, Kanthan R, Burbridge B. Diagnostic pitfalls in fine needle aspiration of solitary pulmonary nodules: two cases with radio-cyto-histological correlation. BMC Pulm Med. Sep 8 2003;3(1):2. [Medline]. [Full Text].

  23. Wagner RB, Johnston MR. Middle lobe syndrome. Ann Thorac Surg. Jun 1983;35(6):679-86. [Medline].

 
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Posteroanterior chest radiograph demonstrating right middle lobe collapse and infiltrate. Note blurred right heart border.
Lateral view chest radiograph showing a wedge-shaped density extending from the hilum anteriorly and inferiorly.
Chest CT scan showing extensive bronchiectasis of both medial and lateral segments of the right middle lobe.
 
 
 
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