Right Middle Lobe Syndrome Follow-up
- Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD more...
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.
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.
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.
In one report, 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. 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.
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.
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.
The remaining two thirds of children with right middle lobe syndrome do not have persistent symptoms later in adulthood.
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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