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Right Middle Lobe Syndrome Treatment & Management

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

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.[3]

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

Consultations may include a pediatric pulmonologist and/ or a 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: 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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