Right Middle Lobe Syndrome Treatment & Management

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

Medical Care

Long-term follow-up of children with right middle lobe syndrome (RMLS) shows that most patients do not experience recurrent or persisting symptoms. This indicates that the first line of treatment in all cases is conservative medical management, except in cases involving neoplastic origin and those with bronchiectasis.

Chest physical therapy and postural drainage are the hallmarks of therapy.

Treat the asthmatic child with aggressive anti-inflammatory therapy such as inhaled steroids. Consider systemic steroids. Guidelines for the diagnosis and management of asthma have been established.[2]

Provide the patient with chest physical therapy and postural drainage. In unresponsive patients or patients who have a predisposition to airway colonization, an appropriate antibiotic, as determined by a bronchoalveolar lavage (BAL) culture, should be added to their regimen.

Patients with fungal infections (eg, histoplasmosis) or tuberculous infections who have hilar adenopathy and complete blockage of their right middle lobe should be treated aggressively. The addition of systemic corticosteroids may be necessary.

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Surgical Care

Lobectomy

Lobectomy is indicated in cases of malignancy and bronchiectasis that are unresponsive to medical therapy.

Only perform lobectomy when right middle lobe syndrome is associated with systemic symptoms such as failure to thrive, persistent cough, and recurrent fever or when chronic infection threatens the remainder of the lung.

Bronchography

Avoid bronchography because of potential risks to the patient unless surgery is seriously considered; therefore, always explore high-resolution CT imaging as an alternative.

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Consultations

  • Pediatric pulmonologist
  • Pediatric infectious disease specialist
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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.

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  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].

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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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