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Right Middle Lobe Syndrome Follow-up

  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD  more...
 
Updated: Apr 17, 2015
 

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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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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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.

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.[4] 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.[5]

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: Kentucky Chapter of The American Academy of Pediatrics, Kentucky Pediatric Society, American College of Chest Physicians, American Thoracic Society, Kentucky Medical Association

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

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.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

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

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

Acknowledgements

Heidi Connolly, MD Associate Professor of Pediatrics and Psychiatry, University of Rochester School of Medicine and Dentistry; 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.

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

  2. Liu J, Chen SW, Liu F, Li QP, Kong XY, Feng ZC. The diagnosis of neonatal pulmonary atelectasis using lung ultrasonography. Chest. 2015 Apr 1. 147(4):1013-9. [Medline].

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

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

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

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

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

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

  9. 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. 2003 Sep 8. 3(1):2. [Medline]. [Full Text].

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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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