Middle lobe syndrome

Bronchoscopy for management and identification of etiology of right middle lobe syndrome: Analysis of 66 cases

BACKGROUND

Right middle lobe (RML) syndrome is a recurrent or chronic obstruction of the RML causing atelectasis of the right middle lobe due to mechanical and nonmechanical etiologies. The consequences of untreated RML syndrome range from chronic cough to post-obstructive pneumonia and bronchiectasis. We report here our bronchoscopy experience in patients with RML syndrome.

METHODS

We conducted a retrospective study of adult patients who underwent bronchoscopy for RML syndrome at Rabin Medical Center from 2008 through 2022. Demographic data and medical history, bronchoscopy findings and procedures, and follow-up results were collected.

RESULTS

A total of 66 patients (57.6% male, mean age 63 ± 13 years) underwent bronchoscopy for RML syndrome during the study period. Bronchoscopy revealed a mechanical etiology in 49 (74.2%) cases, including endobronchial mass (21, 31.8%) and external compression (7, 10.6%). Malignancy was identified in 20 (30.3%) cases. In 62 patients (93.9%), the bronchoscopy resulted in partial or complete reopening of the RML bronchus. The therapeutic bronchoscopic procedures were balloon dilatation (19), laser ablation (17), mechanical debridement (12), endobronchial stent insertion (11), and cryoablation (6).

CONCLUSIONS

Malignancy was identified as the etiology of RML syndrome in approximately 25% of cases, suggesting bronchoscopy should be performed in every case of RML atelectasis. To our knowledge, this is the first reported series of endobronchial stenting of the RML bronchus in the context of RML syndrome.

The Saudi Thoracic Society guidelines for diagnosis and management of noncystic fibrosis bronchiectasis

This is the first guideline developed by the Saudi Thoracic Society for the diagnosis and management of noncystic fibrosis bronchiectasis. Local experts including pulmonologists, infectious disease specialists, thoracic surgeons, respiratory therapists, and others from adult and pediatric departments provided the best practice evidence recommendations based on the available international and local literature. The main objective of this guideline is to utilize the current published evidence to develop recommendations about management of bronchiectasis suitable to our local health-care system and available resources. We aim to provide clinicians with tools to standardize the diagnosis and management of bronchiectasis. This guideline targets primary care physicians, family medicine practitioners, practicing internists and respiratory physicians, and all other health-care providers involved in the care of the patients with bronchiectasis.

Middle lobe syndrome: an intriguing presentation of tracheobronchial amyloidosis

Pulmonary involvement in amyloidosis is a distinct rarity. This clinical entity usually presents as tracheobronchial amyloidosis (TBA). A 32-year-old, never-smoker man presented with episodic dyspnoea and wheezing along with cough and mucoid sputum. The chest radiograph was suggestive of a middle lobe syndrome (MLS). High-resolution CT (HRCT) of the chest confirmed the presence of MLS. In addition, HRCT showed circumferential thickening of the trachea and the main bronchi, with thickening of the posterior membranous wall of trachea. Fibrebronchoscopy, done to evaluate MLS, visualised multiple small polypoidal lesions in the lower part of trachea and carina. Endobronchial biopsies showed homogeneous, acellular amorphous deposit in the subepithelial region, which was congophilic in nature. A diagnosis of TBA presenting as MLS was made. To the best of our knowledge, this is the first detailed report of MLS as a presentation of TBA in the English literature.

Infectious Causes of Right Middle Lobe Syndrome

Right middle lobe (RML) syndrome is defined as recurrent or chronic obstruction or infection of the middle lobe of the right lung. Nonobstructive causes of middle lobe syndrome include inflammatory processes and defects in the bronchial anatomy and collateral ventilation. We report on 2 case patients with RML syndrome, one due to infection with Mycobacterium avium complex followed by M asiaticum infection and the other due to allergic bronchopulmonary aspergillosis. A history of atopy, asthma, or chronic obstructive pulmonary disease has been reported in up to one-half of those with RML. The diagnosis can be made by plain radiography, computed tomography, and bronchoscopy. Medical treatment consists of bronchodilators, mucolytics, and antimicrobials. Patients whose disease is unresponsive to treatment and those with obstructive RML syndrome can be offered surgical treatment.

A Comparative Study of Video-Assisted Thoracic Surgery with Thoracotomy for Middle Lobe Syndrome

OBJECTIVES

The aim of this study is to evaluate the feasibility and safety of video-assisted thoracic surgery (VATS) for the treatment of middle lobe syndrome (MLS) through comparison with thoracotomy during the same period.

METHODS

We retrospectively reviewed all consecutive patients with MLS who underwent lobectomy or lingular segmentectomy between December 2005 and November 2015 in a single institute. Thirty patients were enrolled and divided into two groups: VATS group (n = 19) and thoracotomy group (n = 11). Data regarding the patients' demographics, medical history were collected and statistically compared.

RESULTS

All patients received successful middle lobe resection or lingular segmentectomy. In terms of operation time, blood transfusion, chest drainage amount, duration of chest drainage and postoperative complications, no significant differences were found between the two groups (p > 0.05). The mean intraoperative blood loss of VATS group was less than thoracotomy group (79.0 ± 63.9 vs. 165 ± 94.9 ml, p = 0.04). In VATS group, the mean length of postoperative hospital stay was 6.0 ± 2.4 days, shorter than that in group thoracotomy (9.0 ± 3.5 days, p = 0.01).

CONCLUSIONS

VATS was a feasible and safe method for the surgical treatment of MLS in selected patients when no severe calcified lymph nodes surrounding hilus pulmonis was observed by preoperative chest CT scan.

Middle lobe syndrome: a singularly rare presentation of complicated pulmonary hydatid disease

Imaging is crucial to the diagnosis of pulmonary hydatid disease, as it is often the first modality that raises suspicion of the disease. Middle lobe syndrome (MLS) as a presentation of this disease is a distinct rarity. A 45-year-old woman, a never-smoker, presented with cough and streaky haemoptysis. Imaging demonstrated a trapezoidal opacity with its base towards the hilum and contiguous with the right cardiac border. The reformatted sagittal view confirmed the diagnosis of MLS. Fibreoptic bronchoscopy (FOB) revealed an avascular white membranous structure wholly occluding the medial segment of the middle lobe. This was completely removed through gentle suction. Bronchial aspirate revealed hooklets of hydatid and echinococcal serology was positive. Subsequently, three cycles of albendazole were administered with remarkable clinical and radiological improvement. To the best of our knowledge, this is the first detailed description of MLS caused by pulmonary hydatidosis that was completely removed through FOB.

Ten years' experience in surgical treatment of right middle lobe syndrome

PURPOSE

In this study we present the clinical, radiological, pathological, bronchoscopic and surgical results of 40 patients with diagnosis of middle lobe syndrome who were referred to our thoracic surgery unit for surgical intervention in a 10 years period.

METHODS

Forty patients with obstructive and non-obstructive causes of middle lobe syndrome referred to our thoracic surgery unit. Clinical data were collected from the patients' records in a ten years period. This study evaluates diagnostic approaches and surgical treatments in right middle lobe syndrome.

RESULTS

We studied 23 females (57.5%) and 17 males (42.5%) with a mean age of 31.7. Clinical findings were cough 95%, sputum 80% and intermittent hemoptysis in 50% of patients. Middle lobe collapse was seen in CT scan of all patients. Bronchiectasis was the most common pathologic finding (55%). Tuberculosis was not rare and was final pathology in 20% of patients. In three patients ruptured hydatid cyst was final finding. Surgery was done without mortality and with only minor complications.

CONCLUSION

Lobectomy of right middle lobe is a good therapeutic option in these patients. Due to high prevalence of tuberculosis and hydatid cyst in Middle Eastern countries these two must be considered as causes of middle lobe syndrome.

[Manifestations of lobar atelectasis on chest x-rays and correlation with computed tomography findings]

Atelectasis is an important indicator of potentially severe underlying disease that must be diagnosed as early as possible. One of the most common mechanisms is the reabsorption of air distal to respiratory tract obstruction. The chest x-ray is an excellent tool to diagnose atelectasis, and it is especially useful for ruling out central bronchial obstructions (e.g., from endobronchial tumors). If the signs of volume loss are not recognized correctly, the diagnosis and treatment can be delayed. This article describes the main findings of lobar atelectasis on chest x-rays and their correlations with CT findings, including the classic signs described in the literature and other, less known and sometimes subtle signs.

Middle lobe syndrome associated with major haemoptysis

A 60-year-old Indian woman who was suffering from recurrent pneumonia presented with major haemoptysis and a right-sided pleuritic chest pain. Initially the patient required resuscitation to optimise her haemodynamic parameters while oxygenation remained satisfactory. An urgent computed tomography pulmonary angiogram revealed right middle lobe syndrome which constitutes chronic collapse of the middle lobe accompanied by bronchiectatic changes. Angiography identified an abnormal bronchial artery and venous shunting which was embolised satisfactorily. Subsequently she underwent bronchoscopy which was unremarkable. Her post-operative course was uneventful and patient was discharged home. During the post-operative follow-up patient remained stable and was discharged from out-patient clinic after two years.

Surgical treatment of right middle lobe syndrome in children

OBJECTIVE:

Right middle lobe syndrome is a rare entity in children, causing high morbidity. Our experience of these patients including their clinical and laboratory characteristics, indications forsurgical management, postoperative courses, and follow-up results was evaluated.

METHODS:

A retrospective analysis was performed involving 20 children with right middle lobe syndrome who were hospitalized and treated with surgical resection of the right middle lobe in Van Training and Research Hospital and Yüzüncüyil university hospital, Turkey, between January 2002 and January 2011.

RESULTS:

The mean age of the patients was 10.5 years (range, 5 to 15 years). Twelve patients were boys and eight were girls. The most frequent symptom was chronic cough (75%). Hemoptysis was present in two (10%) patients. One patient was being treated for asthma. 25% positive cultures were identified among the patients. Streptococcus pneumoniae was the most frequently identified agent in sputum. All patients underwent chest computed tomography. There were bronchiectasis in 11 (55%) patients, atelectasis and bronchiectasis in five (25%) patients, and destroyed lung in four (20%) patients. A narrowed middle lobe bronchus was shown in 15 (75%) patients. Bronchoscopy was performed in 18 (90%) patients. Stenosis due to external compression was seen in 12 (60%) patients, hyperemia and bronchitis in two (10%) patients, granulation tissue in two (10%) patients, and dense secretions in two (10%) patients. A history of doctor-diagnosed tuberculosis was present in two (10%) patients. These patients had completed antituberculous treatment. The patients had been symptomatic for the last 1 to 10 years (mean, 4 years) and had received several medical treatments. All patients (totally 20 patients) underwent right middle lobe resection. In one patient, a bronchial abnormality was found intraoperatively. One patient died on postoperative day 10 due to a brain abscess. Three other patients had postoperative complications (15%). Mean duration of follow-up of the patients was 4.5 years (range, 2 months to 12 years). Seventeen patients were asymptomatic, and two patients had improved.

CONCLUSIONS:

Children with right middle lobe syndrome unresponsive to medical treatment should undergo early lobe resection to avoid serious complications and the progression of the disease to other segments or lobes.

Chronic atelectasis of the left lower lobe: a clinicopathological condition equivalent to middle lobe syndrome

OBJECTIVES

Middle lobe syndrome is a well-known clinical condition. In this retrospective study, we report our experience with a similar clinicopathological condition affecting the left lower lobe.

METHODS

The data of 17 patients with atelectasis or bronchiectasis of the left lower lobe who underwent lobectomy during the period from January 2000 to December 2011 were reviewed. Demographic, clinical, radiological and surgical data were collected.

RESULTS

Seventeen patients were included in this study, only one adult male patient of 52 years and 16 children. The paediatric patients were 10 boys and 6 girls, their age ranged from 2 to 11 years, mean 6.19 ± 2.6 years. Most patients presented with recurrent respiratory infection 15/17 (88.2%). The lag time before referral to surgery ranged from 3 to 48 months, mean 17.59 ± 13.1 months. Radiological signs of bronchiectasis were found in 11 (64.7%) patients. Bronchoscopy showed patent lower lobe bronchus in all patients. The criteria for lobectomy were evidence of bronchiectasis [11 (64.71%) patients], persistent atelectasis of the lobe after bronchoscopy and intensive medical therapy for a maximum of 2 months [6 (35.29%) patients]. Histopathological examination showed bronchiectasis in 11 (64.71%) patients, fibrosing pneumonitis in 4 (23.53%) patients and peribronchial inflammation in 2 (11.76%) patients. Most patients were doing well 1 year after surgery.

CONCLUSIONS

Chronic atelectasis of the left lower lobe is a clinicopathological condition equivalent to middle lobe syndrome. Impaired collateral ventilation together with airway plugging with secretion is an accepted explanation. Surgical resection is indicated for bronchiectatic lobe or failure of 2-month intensive medical therapy to resolve lobar atelectasis.

Middle lobe syndrome: a review of clinicopathological features, diagnosis and treatment

Middle lobe syndrome (MLS) is a rare but important clinical entity that has been poorly defined in the literature. It is characterized by recurrent or chronic collapse of the middle lobe of the right lung but can also involve the lingula of the left lung. Pathophysiologically, there are two forms of MLS, namely obstructive and nonobstructive. Obstructive MLS is usually caused by endobronchial lesions or extrinsic compression of the middle lobe bronchus such as from hilar lymphadenopathy or tumors of neoplastic origin, resulting in postobstructive atelectasis and pneumonitis. In the nonobstructive type, no obstruction of the middle lobe bronchus is evident during bronchoscopy or with computerized tomography of the chest. The etiology of the nonobstructive form is not completely understood. Inefficient collateral ventilation, infection and inflammation in the middle lobe or lingula are thought to play a role, and bronchiectasis is the most common histological finding. Patients with proven endobronchial lesions or malignancy are usually offered surgical resection directly. This contrasts with nonobstructive MLS, where most patients respond to medical treatment consisting of bronchodilators, mucolytics and broad-spectrum antibiotics. However, some patients do not respond to conservative treatment and may suffer irreversible damage of the middle lobe or lingula, in addition to having recurrent symptoms of infection or inflammation. These selected patients can be offered surgical resection of the middle lobe or lingula, which is associated with a low mortality rate and favorable outcome.

[A case of a carcinoid tumour presenting as an "upper lobe syndrome"]

A 53-year-old woman presented with progressive cough related to an endobronchial carcinoid tumour. The location of the tumour in the right upper lobe bronchus could be described as an "upper lobe syndrome" by analogy with the "middle lobe syndrome" or Brock's syndrome. Surgical management consisted of lobectomy and lymph node dissection. This established the diagnosis of typical carcinoid tumour. There was no mediastinal nodal invasion. Three months after surgery all symptoms had disappeared.

Middle lobe syndrome: a nationwide study on clinicopathological features and surgical treatment

INTRODUCTION

Middle lobe syndrome (MLS) is a relatively uncommon lung disease that is characterized by damage to the middle lobe and often needs surgical intervention.

OBJECTIVE

To study clinical, radiological and histological features of all patients who underwent surgical resection for MLS in Iceland over a 13-year period, including evaluation of surgical outcome.

METHODS

Information on patients who underwent surgery of the right middle lobe in Iceland from 1984 to 2006 was obtained from a centralized diagnosis and pathology registry. Clinical data were collected retrospectively from clinical records from hospitals and from private offices. All pathology specimens were reviewed.

RESULTS

We studied 18 patients, 3 males and 15 females between the ages 2 and 86 years (mean 55). The most common clinical features were recurrent infection (n = 15), chronic cough with productive sputum (n = 9), chest pain (n = 8) or dyspnea (n = 7). The most common findings on chest radiographs and on computerized tomography of the chest were atelectasis, consolidation and bronchiectasis. One patient had a foreign body. The most common major histological finding was bronchiectasis in nine patients, and two had foreign body reaction. Minor findings included bronchiolitis, organizing pneumonia and peribronchial inflammation. All patients survived surgery with minor peri- and postoperative complications.

CONCLUSION

MLS is more common in females, and recurrent infections, chronic productive cough and dyspnea were the most common symptoms. Bronchiectasis is the most common histological finding. MLS can be treated effectively with lobectomy with low mortality and rate of complications.

The pathophysiology of bronchiectasis

Bronchiectasis is defined by permanent and abnormal widening of the bronchi. This process occurs in the context of chronic airway infection and inflammation. It is usually diagnosed using computed tomography scanning to visualize the larger bronchi. Bronchiectasis is also characterized by mild to moderate airflow obstruction. This review will describe the pathophysiology of noncystic fibrosis bronchiectasis. Studies have demonstrated that the small airways in bronchiectasis are obstructed from an inflammatory infiltrate in the wall. As most of the bronchial tree is composed of small airways, the net effect is obstruction. The bronchial wall is typically thickened by an inflammatory infiltrate of lymphocytes and macrophages which may form lymphoid follicles. It has recently been demonstrated that patients with bronchiectasis have a progressive decline in lung function. There are a large number of etiologic risk factors associated with bronchiectasis. As there is generally a long-term retrospective history, it may be difficult to determine the exact role of such factors in the pathogenesis. Extremes of age and smoking/chronic obstructive pulmonary disease may be important considerations. There are a variety of different pathogens involved in bronchiectasis, but a common finding despite the presence of purulent sputum is failure to identify any pathogenic microorganisms. The bacterial flora appears to change with progression of disease.

The Role of Timely Intervention in Middle Lobe Syndrome in Children

STUDY OBJECTIVES

Middle lobe syndrome (MLS) in children is characterized by a spectrum of clinical and radiographic presentations, from persistent or recurrent atelectasis to pneumonitis and bronchiectasis of the right middle lobe (RML) and/or lingula. This study was undertaken to evaluate the effect of early intervention, including fiberoptic bronchoscopy (FOB), in the development of bronchiectasis in MLS.

DESIGN

Children with atelectasis of the RML and/or lingula persisting for > 1 month or recurring two or more times despite conventional treatment underwent high-resolution CT (HRCT) scanning and FOB. Appropriate treatment and follow-up were provided, and the effect of the duration of symptoms on clinical outcome and the development of bronchiectasis was investigated. The patient cohort was retrospectively reviewed.

PATIENTS

We evaluated 55 children with MLS. The median age at diagnosis, duration of symptoms, and duration of clinical deterioration before diagnosis were 5.5 years (range, 3 months to 12 years), 14.5 months (range, 3 to 48 months), and 8 months (range, 3 to 36 months), respectively.

MEASUREMENTS AND RESULTS

FOB revealed marked obstruction in two children (ie, a foreign body and an endobronchial tumor) and positive findings for a culture of BAL fluid in 49.1% of patients. The remaining 53 patients were followed up for a median duration of 24 months (range, 5 to 96 months). The clinical outcome was "cure" in 60.4% of patients, "improvement" in 32.1% of patients, and "no change" in the remaining patients. Bronchiectasis was documented prior to FOB by HRCT scan in 15 patients (27.3%). The duration of the deterioration of symptoms prior to presentation positively correlated with the development of bronchiectasis (p = 0.03) and an unfavorable clinical outcome (ie, improvement or no change) [p = 0.02]; a positive correlation was also found between the duration of symptoms and the development of bronchiectasis (p = 0.04).

CONCLUSIONS

Timely medical intervention in patients with MLS that includes FOB with BAL prevents bronchiectasis that may be responsible for an ultimately unfavorable outcome.

[Middle lobe syndrome]

Broncholithiasis is uncommon and usually a late complication of tuberculosis in France. The most common cause of broncholithiasis is erosion by and extrusion of a calcified lymph node into a bronchial lumen. Clinical symptoms are not specific and diagnosis may be an endoscopic or a radiologic surprise. We report a case of broncholithiasis in a patient with chronic cough. Fibroscopy established the diagnosis by showing the broncholith.

Resection of the Right Middle Lobe and Lingula in Children for Middle Lobe/Lingula Syndrome

STUDY OBJECTIVE

To review our experience with specific characteristics, indications, and results of pulmonary resection in children with middle lobe/lingula syndrome.

DESIGN

Retrospective cohort study.

SETTING

Thoracic Surgery Department, Chest Diseases Hospital, Kuwait.

PATIENTS AND INTERVENTION

Thirteen children with middle lobe, lingula, or both syndromes were treated with pulmonary resection from January 1995 to December 1999.

RESULTS

The mean age was 7.5 years (range, 5 to 10 years). Eight patients were girls, and five were boys. All patients underwent high-resolution CT and bronchoscopy. Bronchiectasis and atelectasis of right middle lobe, lingula, or both was noted in nine patients. Bronchial stenosis and inflammation of the bronchus was found endoscopically in four patients. The indications for surgery were recurrent respiratory tract infection with persistent atelectasis and bronchiectasis in nine patients, and recurrent respiratory tract infection with bronchiectasis in four patients. A right middle lobectomy was done on seven patients and a lingulectomy on four patients. Two patients underwent staged thoracotomies (right middle lobectomy and lingulectomy). There were no operative deaths. Only two patients had postoperative complications: atelectasis (n = 1), and pneumothorax (n = 1). Mean follow-up was 3.5 years (range, 3 to 5 years) for all patients. Nine patients were asymptomatic, and four patients had improved.

CONCLUSION

Right middle lobe or lingula syndrome with the presence of bronchiectasis, bronchial stenosis, or failure of lung to re-expand are indications for early pulmonary resection.

Right middle lobe atelectasis associated with endobronchial silicotic lesions

BACKGROUND

In a period of 18 months, we have encountered 4 cases of right middle lobe atelectasis associated with endobronchial silicotic lesions of right middle lobe bronchi. All patients had occupational exposure to mineral dusts (3 coal miners and 1 sand blaster) for months to decades.

METHODS

The nature of the endobronchial silicotic lesions that caused the bronchial obstruction has been confirmed by endobronchial biopsies and energy-dispersive spectrometry of the lesions. Extrinsic compression has been excluded by careful radiographic and computed tomographic image analysis.

RESULTS

The endobronchial silicosis does not appear to correlate with the degree of pneumoconiosis of the lung parenchyma. The endobronchial silicosis may cause bronchial obstruction in the absence of radiographic evidence of pulmonary silicosis.

CONCLUSION

The endobronchial silicosis and consequent lung atelectasis may be associated with silica exposure.

Case report: Blastomyces dermatitidis as a cause of middle lobe syndrome

Middle lobe syndrome is a clinical term used to describe right middle lobe atelectasis with or without bronchial compression. Fungal disease has been implicated rarely as a cause of middle lobe syndrome. This is a patient with Blastomyces dermatitidis infection who presented with right middle lobe syndrome.

Middle lobe syndrome: a clinicopathological study of 21 patients

Middle lobe syndrome (MLS) is an uncommon lung disorder involving the right middle lobe and/or lingula and is characterized by a spectrum of clinical and pathological lesions ranging from recurrent atelectasis or pneumonias to bronchiectasis. Despite several series reporting the clinical features of MLS, histopathological descriptions are rare. We reviewed the clinical characteristics and pathological findings in 21 patients with MLS who underwent surgical resections. Six male and 15 female patients between the ages of 5 and 80 years (mean, 47 years) were studied. All patients were symptomatic and complained of chronic cough (8), hemoptysis (6), chest pain (4), dyspnea (3), or fever (2). The right middle lobe was involved in 11 patients, the lingula in four patients, and both right middle lobe and lingula in six patients. Chest radiographs, bronchograms, and/or computed tomography scans were available for review in 19 patients and showed consolidation (8), bronchiectasis (9), patchy infiltrates (5), and atelectasis (4) in various combinations. Pathological findings included bronchiectasis in 10 patients, chronic bronchitis/bronchiolitis with lymphoid hyperplasia in seven, patchy organizing pneumonia in six, atelectasis in five, granulomatous inflammation in five, and abscess formation in four. Three patients with granulomatous inflammation had associated atypical mycobacterial infection. Broncholithiasis was confirmed by pathological examination in one patient. No pathological cause for bronchial obstruction was identified in the remaining 20 patients, although one was thought to have had broncholithiasis on the basis of preoperative bronchoscopy. The presence of bronchiectasis, bronchitis or bronchiolitis, organizing pneumonia, or atelectasis in specimens from the right middle lobe or of lingula in the absence of an identifiable cause of bronchial obstruction should suggest a diagnosis of MLS.

Role of infection in the middle lobe syndrome in asthma

Twenty one children with asthma aged 1.0-10.5 years (mean (SD) 3.3 (2.5) years) were admitted to the hospital to evaluate pulmonary right middle lobe or lingular collapse lasting one to 12 months (mean (SD) 4.4 (3.8) months). Seven children had mild asthma and were treated with inhaled beta 2 agonists as needed. Nine had moderate asthma treated with either sodium cromoglycate or slow release theophylline. Five had severe asthma treated with inhaled steroids. Each child underwent fibreoptic bronchoscopy under local anaesthesia and a bronchoalveolar lavage. Differential cell counts of the lavage fluid revealed predominance of neutrophils in 12 patients (57%). In nine of these patients cultures grew pathogenic bacteria, mainly Haemophilus influenzae and Streptococcus pneumoniae. There was no correlation between the severity of asthma and a positive bacterial culture. There was also no correlation between the duration of the right middle lobe collapse and a positive culture. We conclude that longstanding right middle lobe collapse in asthmatic children is often associated with bacterial infection.

Quantitation and pattern of parenchymal lung injury in blunt chest trauma. Diagnostic and therapeutic implications

Sixty-nine patients with nonpenetrating pulmonary trauma were studied by chest computed tomography (CT) within 24 hours of admission. The percentage of air-space filling was quantitated and compared with the requirement for ventilatory support. Pulmonary intraalveolar hemorrhage always is gravity dependent originating at the site of injury. Utilizing CT, the patients' pulmonary status was classified into three separate clinicoradiologic groups: Grade I injury (less than 18% air-space filling, no ventilator support required), Grade II injury (18-28% air-space filling, ventilator support sometimes required), and Grade III injury (greater than 28 air-space filling, ventilator support always required). The CT quantitation correlated with clinical functional studies and was useful in the therapeutic management of nonpenetrating lung injury.

Right middle lobe syndrome in children

Right middle lobe syndrome (RMLS) is characterized by a spectrum of diseases from recurrent atelectasis and pneumonitis to bronchiectasis of the middle lobe. It has been described among all age groups, although the diagnosis in pediatrics may be delayed or missed because of non-specific symptoms or findings. Twenty-one children with RMLS were evaluated during the past 10 years with particular attention to the history, bronchoscopic and pathologic findings. Most of these patients had asthma or a family history of atopic disorders; 3 patients had a family history of RMLS. Only two of the 21 patients had sufficient obstruction on bronchoscopy to account for their disease. Four had evidence of concomitant laryngeal pathology. The various theories of pathogenesis are discussed. In this series, the non-obstructive (impaired collateral ventilation) theory appeared to be most plausible. Bronchoscopy was performed in all instances to rule out obstruction due to foreign body or tumor. It was therapeutic in two-thirds of the cases. Resolution occurred promptly in one-third, and eventually in another third. Of the remaining patients, 4 required lobectomy and were cured; two have decreased but persistent symptoms. An aggressive medical management following bronchoscopy is warranted in all cases, especially when there is a possibility of asthma.