Right Middle Lobe Syndrome Workup
- Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Michael R Bye, MD more...
The following studies may be indicated in right middle lobe syndrome (RMLS):
Purified protein derivative (tuberculin) skin test
CBC count and differential
Westergren sedimentation rate
Fungal serology by complement fixation and immune diffusion
Quantitative immunoglobulins panel
Chest radiography with anteroposterior (AP) and lateral views
The classic finding of right middle lobe syndrome is a blurred right heart border and a loss of volume in the right middle lobe (see the image below).
A wedge-shaped density extending from the hilum anteriorly and inferiorly is best visualized on a lateral view (see the image below).
Consolidation and infiltration are less commonly observed.
Acute pneumonia should clear radiologically in 6-8 weeks.
If bronchiectasis is suspected, confirm diagnosis by performing high-resolution chest CT scanning (see the image below), which carries less risk to younger patients or patients with asthma than the seldom-used traditional bronchography.
High-resolution chest CT imaging is also helpful for follow-up medical therapy.
Pulmonary function tests (PFTs) can be used to establish a previously unidentified asthmatic component.
Although findings on a baseline forced expiratory volume in one second (FEV1) may be normal, a prebronchodilator and postbronchodilator study with 10-15% changes in FEV1 is diagnostic for asthma.
A study evaluating the usefulness of lung ultrasonography for the diagnosis of neonatal pulmonary atelectasis (NPA) concluded that lung ultrasonography is an accurate and reliable method for diagnosing NPA. This was a study solely in infants. The authors also concluded that lung ultrasonography can find occult lung atelectasis in neonates that could not be detected on chest X-ray.
The value of bronchoscopy is 2-fold, as follows:
It is immediately therapeutic in removing mucus and clearing the airway and can be curative in some cases.
It allows visualization of the airway and the ability to determine patency of the right middle lobe bronchus and to discern whether endobronchial obstruction is the cause.
Bronchoalveolar lavage can be concurrently performed to determine cellular elements in the right middle lobe. It can also be used to assess the presence of infections by culturing and staining for bacterial, fungal, viral, and mycobacterial pathogens.
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