Right Middle Lobe Syndrome Follow-up

Updated: May 16, 2018
  • Author: Nemr S Eid, MD, FAAP, FCCP; Chief Editor: Denise Serebrisky, MD  more...
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Follow-up

Further Outpatient Care

Periodic office follow-up with repeat chest radiographs, and pulmonary function testing when applicable 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. This should be done at least 6 to 8 weeks after the initial occurrence.

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. [7] 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

Historically, right middle lobe syndrome has been reported to resolve 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. While recent published data is lacking, with aggressive modern therapy as outlined above, it is more likely that the number of patients requiring lobectomy is far lower. In our own experience spanning thirty years, lobectomy was performed only once due to frequent recurrent pulmonary infections and failure to gain weight. 

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. [8]

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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