Congenital lobar emphysema

A Four-Week-Old Infant With Respiratory Distress: An Emergency Department Case Presentation of Congenital Lobar Emphysema

Congenital lobar emphysema (CLE) and congenital pulmonary lymphangiectasis (CPL) are rare conditions that are most often identified with prenatal ultrasonography. Occasionally, this disease process is first identified in the emergency department (ED), where the physician should avoid common pitfalls in order to prevent acute decompensation. To the best of our knowledge, there are no prior reports in the emergency medicine literature of CLE or CPL presenting to the ED as undifferentiated respiratory distress in an infant. Here, we describe one such case and then discuss the importance of differentiating these congenital anomalies from more commonly encountered emergency diagnoses, such as pneumothorax and pneumonia. Management differs radically, and the use of chest tubes and positive pressure ventilation in CLE may precipitate acute cardiovascular decompensation.

Congenital lobar emphysema: diagnosis and treatment options

Although congenital lobar emphysema is a rare lung disease, it can cause severe respiratory distress in the newborn. Lobectomy can be difficult because of the hyperinflated lobe and limited space to carry out surgery. During the past two decades, conservative treatment options have increased for patients with mild and moderate disease.

Prenatal diagnosis of congenital lobar fluid overload

Prenatal congenital lobar fluid overload (CLFO), which was first described by Ramsay and Byron, is identical to postnatal congenital lobar overinflation. It is characterized by progressive lobar overexpansion that compresses the other adjacent lung lobes. The underlying cause can be an intrinsic cartilaginous abnormality or an extrinsic airway compression. It may be associated with cardiovascular anomalies in 12%-14% of cases and affects males more frequently than females. Most cases are diagnosed postnatally, but early antenatal diagnosis and sequential follow-up are attempted for early treatment, if clinically indicated. This article provided a thorough review of CLFO, including prenatal diagnosis and differential diagnoses, as well as comprehensive illustrations of the perinatal imaging findings of CLFO. Prenatal diagnosis of fetal lung lesions should include CLFO in the differential diagnosis and prompt investigation for associated anomalies.

Congenital Lobar Emphysema and Tension Pneumothorax in a Dog

Congenital lobar emphysema (CLE) and tension pneumothorax (TPT) are rarely reported in dogs. A case of CLE of the right middle lung lobe predisposing to air trapping, alveolar hyperinflation, and pleural rupture resulting in fatal spontaneous TPT in a 6-month-old mixed breed dog is described. The unique alteration of “bloat line” was observed in this case in addition to compressive atelectasis of all other lung lobes and lack of negative pressure within the thoracic cavity, signifying markedly elevated intrathoracic pressure. Bronchial cartilage hypoplasia and bronchiectasis were confirmed microscopically, which likely led to abnormal dynamic collapse of bronchi during expiration, consequentially leading to increased intrapulmonary pressure, bullous emphysema, and pleural rupture resulting in TPT. TPT consequent to CLE may therefore be considered one of the potential causes of sudden death in young dogs without overt clinical illness.

Congenital lobar emphysema: Challenges in diagnosis and ventilation

Congenital lobar emphysema (CLE) is a rare congenital anomaly of lung causing over aeration of one or more lobes of a histologically normal lung. It presents in infancy with respiratory distress due to compression atelectasis and often associated with mediastinal shift and hypotension. CLE poses a challenge in diagnosis and positive pressure ventilation due to air trapping. We report a case of 8-week-old infant with CLE posted for right lobectomy. Strategies to prevent misdiagnosis, over aeration and use of IPPV have been reviewed.

Congenital emphysema in children: segmental lung resection as an alternative to lobectomy

BACKGROUND

Congenital emphysema is a rare lung malformation characterized by overinflation of lung segments or lobe, together with ventilation and lung perfusion disorders. The lesion frequently causes respiratory distress in infants and may require urgent surgery. The pathogenesis is still controversial, and the usual treatment recommended is a lobectomy.

AIM

The aims of the study were to clarify the pathogenesis and relationship to vascular abnormalities and to assess the safety and efficacy of lung-sparing segmental resections.

MATERIALS AND METHODS

Retrospective review of hospital records, chest radiograph, digital subtraction angiography, and contrast-enhanced chest CT were used for diagnosis.

RESULTS

Forty-three (median age 4 months, range 10 days to 10 years) children were diagnosed with congenital emphysema. Most were <1 year of age at presentation (n=33; 77%). The predominant side affected was the left (n=24; 56%), and of these all but one had segmental (not lobar) lesions. Most of these then underwent segmental lung resection (S(1)-S(3)) with preservation of the uninvolved lingual (S(4-5)) segments preserved. A standard lobectomy was used in right-sided lesions. There was a high incidence of vascular abnormalities in association with the emphysematous segments, which may be important in its etiology. One child, referred in extremis and died before surgery could be undertaken. Otherwise, early and late results of surgery were rated as good or excellent in all patients. Longer-term follow-up of the preserved left lingual segments did not suggest any recurrence of emphysema.

CONCLUSION

Segmental resection in cases of left-sided congenital emphysema appears effective and merits further use as a lung-sparing operation.

Rudhe syndrome: reversible right middle lobe emphysema in infants with left-to-right shunts--an historical review

In 1971, the Swedish radiologist Ulf Rudhe wrote a provocative paper on right middle lobe emphysema in infants with left-to-right shunts in which he suggested cardiac surgery rather than lung resection. At the time, this was counter to accepted medical practice. Earlier diagnosis and better medical management of ventricular septal defect in infants has proved Rudhe correct. However, two current cases of large left-to-right shunts in infants with emphysema of the right middle lobe prompt this historical review of what seemed a closed-episode in pediatric cardiac surgery.

Surgical Management of Infants with Congenital Lobar Emphysema and Concomitant Congenital Heart Disease

OBJECTIVE

Congenital lobar emphysema (CLE) is an uncommon cause of infantile respiratory distress. It is diagnosed on the basis of evidence of lobar overaeration, mediastinal shift, and compression of the adjacent lobe. Concomitant congenital heart disease (CHD) and CLE is not uncommon. In the literature a 12% to 20% concomitance rate is given. The optimal treatment of respiratory symptoms associated with CLE and CHD is not clear; however, there has been a great deal of progress in the treatment of CLE and CHD. The aim of this study was to evaluate a clinical experience with and long-term follow-up of the surgical treatment of 13 patients with concomitant CLE and CHD.

MATERIAL AND METHODS

We reviewed the cases of 13 patients with concomitant CLE and CHD. The medical records were evaluated with reference to age, type of CHD, pulmonary artery pressure, clinical symptoms, and results of surgical management.

RESULTS

One patient died. This patient had ventricular septal defect (VSD) and left upper lobe emphysema in the postoperative period. The remaining patients undergoing follow-up were clinically well at the final evaluation. Postoperative thoracic computed tomography revealed complete spontaneous regression of emphysema 3 months after division of ductus arteriosus in 1 patient. Pulmonary hypertensive episode was seen in 3 patients after the early postoperative period. Five of the patients were discharged with bronchodilator treatment after surgery. Six patients needed positive inotropic support. Among the patients with pulmonary hypertension and those with VSD who had undergone cardiopulmonary bypass, we found a greater need for inotropic support, a higher risk of postoperative infection, and a longer intubation period. Echocardiography in the late postoperative revealed decreased pulmonary artery diameter and pressure; myocardial performance was normal. Results of blood gas analyses revealed increased oxygen saturation and decreased partial pressure of carbon dioxide. Normal exercise activity was found in all patients.

DISCUSSION

The presence of CHD, especially in infants with unusual respiratory distress symptoms, should be kept in mind, and echocardiography and/or cardiac catheterization should be considered in the diagnosis. In patients with high pulmonary artery pressure, palliative or corrective surgery for CHD in addition to lobectomy can be considered. We believe that for lesions without high pulmonary artery pressure, such as small atrial septal defect and patent foramen ovale, clinical follow-up is sufficient treatment after lobectomy. If the cause of CLE is compression of large ductus arteriosus, only division of the patent ductus arteriosus may be considered before lobectomy and clinical and radiologic follow-up. The cardiac lesion should be assessed as to severity and ease of management. A corrective procedure can be carried out at lobectomy. Because of the technical ease with which the cardiac operation can be performed at the time of lobectomy, we suggest that in addition to lobectomy, operative treatment of cardiac lesions be performed.

Congenital lobar emphysema: Like father, like son

Congenital lobar emphysema (CLE) is an uncommon cause of progressive respiratory distress that typically presents in the first few days of life. There has been a previous report of CLE in a mother and daughter. The authors describe 2 cases involving the right upper and middle lobes in a father and son secondary to relative deficiency of the bronchial cartilage. This provides additional evidence for inherited factors in the etiology of CLE.

Pediatric thoracic anesthesia

The anesthesiologist caring for infants and children undergoing thoracic surgery faces many challenges. An understanding of the primary underlying lesion as well as associated anomalies that may impact perioperative management is paramount. A working knowledge of respiratory physiology and anatomy in infants and children is required for the planning and execution of appropriate intraoperative care. Familiarity with a variety of techniques for SLV suited to the patient's size will allow maximal surgical exposure while minimizing trauma to the lungs and airways. Finally, use of regional anesthetic techniques, including epidural anesthesia and analgesia, facilitates optimal postoperative pain control and pulmonary function.

Prenatal diagnosis and management of congenital lobar emphysema

BACKGROUND

Congenital lobar emphysema (CLE) is a rare anomaly of lung development that usually presents in the neonatal period with respiratory distress and pulmonary lobar hyperinflation. The routine use of prenatal ultrasonography has resulted in the early identification and serial evaluation of congenital lung lesions. CLE can be distinguished from other congenital lung lesions on ultrasonography by the differences in echogenicity and reflectivity.

METHODS

Two cases of CLE diagnosed at midgestation by ultrasonography and ultrafast fetal magnetic resonance imaging (MRI), along with serial sonographic documentation of their prenatal course were reviewed.

RESULTS

The CLE lesions decreased in size over the course of the pregnancy, similar to that seen with other congenital lung lesions such as cystic adenomatoid malformation and bronchopulmonary sequestration. However, these neonates with CLE showed marked air-trapping and respiratory distress requiring lobectomy in the early neonatal period.

CONCLUSIONS

These cases provide insight into the prenatal course of CLE and underscore the need for continued postnatal evaluation of fetuses even those in whom the lesions appear to have resolved in utero. These patients should have ready access to postnatal surgical intervention.

Bronchoscopic appearances of congenital lobar emphysema

Although decreased bronchial cartilage is found in 50% of cases of congenital lobar emphysema (CLE), it can only be surmised that this defect produces a ball valve effect with consequent overinflation. We describe the flexible bronchoscopic features of CLE in a 3-year-old child. The observed airway patency during inspiration, and dynamic airway collapse on expiration suggests that bronchomalacia contributes to lung overinflation in these cases.

Acquired segmental emphysema: the enlarging spectrum of Swyer-James/Macleod's syndrome

Three cases of Macleod's syndrome are described, all of which required surgical resections for distressing symptoms. This provided a rare opportunity to examine the pathologic features of a condition that is usually diagnosed on its radiologic features, and the etiology of which remains unestablished. Three patients (2 women and 1 man), aged 20, 23, and 24 years, were referred from respiratory physicians because of unilateral hyperlucent lungs and associated symptoms. All 3 patients had unilateral hyperlucent lungs, but only 1 patient had demonstrable mediastinal shift on expiratory and inspiratory chest computed tomographic scan. Segmentectomies were performed (n = 4) in all the patients without perioperative morbidity or mortality. Patients have been followed up between 6 and 18 months, and remain asymptomatic with a return to normal lifestyle. Histologic examination of the specimens found inflammation of the bronchus in all 3 patients, but only two specimens had evidence of bronchiolar inflammation. In only 1 patient was there a reduction in bronchiole number. All 3 patients showed presence of emphysema. These cases are notable for the segmental distribution of the disease. Pathologic examination lends support to the theory that previous respiratory tract infection may play a role in the pathogenesis of this condition.

The clinical and imaging spectrum of findings in patients with congenital lobar emphysema

Congenital lobar emphysema (CLE) is an important cause of infantile respiratory distress that may require surgical intervention. We retrospectively reviewed the clinical and imaging findings in eight infants with CLE. In our series, CLE was more common in females, predominantly involved the right lung, often presented with an opaque lobe from retained fetal lung fluid, and frequently involved the lower lobes, multiple segments or lobes, and both lungs. Most patients with CLE were diagnosed and managed on the basis of clinical and plain radiographic findings alone. Computed tomography, and occasionally ventilation/perfusion scintigraphy, were helpful in confirming the diagnosis and in guiding management decisions in several cases; bronchoscopy showed that stenosis of the right mainstem bronchus was the cause of CLE in one case. Three patients experienced progressive worsening of respiratory distress and required surgical resection of the affected lobe for cure; the remaining five patients were managed medically with eventual remission of symptoms.

Surgical management of thoracic anomalies in infants. Respiratory-tract malformations, congenital chylothorax and mediastinal masses

The clinical presentation and surgical treatment of thoracic anomalies--developmental malformations of the respiratory tract, congenital chylothorax or mediastinal masses--in 15 infants are reported. The age range at operation was 2 weeks to 8 months. The diagnoses were lobar emphysema (3 cases), bronchogenic cyst (3), cystic adenomatoid malformation (1), enteric duplication (2), hyperplastic thymus (2), neuroblastoma (1), chylothorax (1), cystic lymphangiectasia (1) and tracheal stenosis (1). The most common symptom was respiratory embarrassment, with acute development in half of the cases. The diagnosis could be established or suspected from chest radiography in 14 of the 15 infants. All were submitted to thoracotomy. None died postoperatively, but three had major complications. At postoperative follow-up 13 of 14 patients were free from respiratory symptoms.

Successful surgical treatment of a newborn with bilateral congenital lobar emphysema

A case report is presented of a newborn boy of 1,600 g who developed symptoms of bilateral congenital lobar emphysema. Successful surgical treatment performed in one operative session consisted of left upper and right middle lobectomy.

The pathobiology and epidemiology of human emphysema

Emphysema is defined in anatomical terms as enlargement of the gas-exchanging part of the lung (the acinus) accompanied by destruction of respiratory tissue. Emphysema is classified by the way that the acinus is dominantly involved. In proximal acinar emphysema, the proximal part of the acinus-respiratory bronchioles-is dominantly involved and two forms of proximal acinar emphysema are usually recognized: centrilobular emphysema and simple pneumoconiosis of coalworkers. The acinus is more or less uniformly involved in panacinar emphysema, and several clinical associations have been described with this lesion. In distal acinar emphysema, alveolar ducts and sacs are particularly involved, and spontaneous pneumothorax of young adults is associated with this form of emphysema. Scarring is usually associated with irregular involvement of the acinus (irregular emphysema) and is usually asymptomatic. No uniform agreement exists as to the application of this classification and there is widespread discrepancy of classification of emphysematous lungs between experts, especially when emphysema is severe. The precise definition of destruction of respiratory tissue in emphysema has not been agreed on, and this had led to wide variations in the assessment of prevalence of emphysema in autopsy series. Tobacco smoking is the most important cause of emphysema and is thought to bring it about by imbalance between the protease-antiproteinase mechanisms in the lung. Increasing severity of emphysema is accompanied by increasing frequency of symptoms, but a substantial proportion of subjects with severe emphysema will be apparently free from symptoms. The major functional characteristics of severe emphysema are reduction in expiratory flow, increase in lung volumes, and diminished diffusing capacity. Diminished expiratory flow in emphysema is determined in part by loss of elastic recoil and in part by associated airway disease. Loss of recoil in emphysematous lungs may be brought about by functional changes in the apparently normal intervening lung between the emphysematous spaces.

Congenital lobar emphysema: problems in diagnosis and management

A retrospective study was made of 9 patients with congenital lobar emphysema who presented over the past 13 years. The ages of the patients at diagnosis ranged from 2 weeks to 10 years. The earlier the presentation, the more severe were the symptoms. Two patients were misdiagnosed initially at the referring hospitals with near disastrous results. Pitfalls in diagnosis are outlined and the various investigative procedures discussed. A flow chart for the diagnostic approach is presented. Treatment was usually by lobectomy but 2 older children presenting late with mild symptoms were managed conservatively with satisfactory results.

Congenital lobar emphysema of left upper lobe. A case report

In a 2 1/2-year-old boy chest X-ray examination because of dyspnoea revealed hyperlucency of the left upper lobe with herniation of the hyperinflated lobe into the right hemithorax. Surgical exploration showed the upper lobe of the trilobed lung to be the site of congenital lobar emphysema, while the lingula and left lower lobe were collapsed. Left upper lobectomy was successfully performed.

The value of cardiac catheterization and cineangiography in infantile lobar emphysema

Lobar emphysema is an uncommon cause of respiratory distress in infancy. Congenital heart disease is seen in about 20% of the patients with infantile (congenital) lobar emphysema. We described six infants with lobar emphysema. In three of them a congenital heart disease was demonstrated by cardiac catheterization and cineangiography; two had a tetralogy of Fallot with right aortic arch and the third infant a ventricular septal defect. The pulmonary angiography showed stretching of the arteries with very poor filling of the peripheral arteries and a characteristic smaller pulmonary vein in the affected lobe. In all the six patients the pulmonary artery pressure was normal. All the patients underwent lobectomy with good results. We feel that a preoperative cardiac catheterization and cineangiography is of value in this very sick group of infants.

Unilateral hyperlucent lung: the case for investigation

Seventeen children with unilateral hyperlucent lungs were referred for investigation. Of the 11 who had a referring diagnosis of possible Macleod's syndrome only two were shown to have post-viral bronchiolitis. Three of the 11 had conditions that required surgical treatment and a further two with brochiectasis were treated medically. To avoid confusion we suggest that Macleod's syndrome is reserved exclusively for children with post-viral bronchiolitis. Radioisotopic regional lung function studies were useful in the investigation of the subjects from three points of view. Firstly, they distinguished children with primary perfusion abnormalities and normal ventilation, secondly, they defined the extent of altered respiratory function, and thirdly, they were able to distinguish compensatory emphysema from congenital lobar emphysema. As bronchography and bronchoscopy may be hazardous in small children with poor respiratory reserve, such regional studies may be useful in indicating which patients do not require further invasive investigation.

Pulmonary scintigraphy in pediatrics

Pulmonary radionuclide studies in children provide reliable information on regional lung perfusion and ventilation. They are easily and safely performed and they do not usually require full patient cooperation. Their clinical indications and applications are not as well defined as and frequently differ from those in pulmonary disorders of the adult patient. Radiation exposures resulting from radionuclide pulmonary examinations are well within acceptable limits set up for a variety of radiologic diagnostic procedures. Our lung scanning experience with a spectrum of congenital and acquired cardiopulmonary diseases is presented and the contribution of the radionuclide methods to the specific problems facing the pediatrician or the surgeon is discussed.

Giant lobar emphysema--neonatal diagnosis

Giant emphysema of a lung lobe has distinctive features. Classically there is overdistension of the affected lung lobe, with one lobe only being involved, and, 50% of cases occur in the newborn infant [1, 4, 8]. The authors describe a particularly severe example with marked mediastinal shift and initially the hemithorax on the side of the lesion was opaque. Angiography was carried out and followed by resection when the infant was 4 months old.

Successful treatment with CPAP of two infants with bronchomalacia

Two children with severe bronchial collapse secondary to bronchomalacia improved dramatically after institution of continuous positive airway pressure (CPAP). Treatment was discontinued after 14 weeks without reappearance of symptoms. Repeated bronchoscopy revealed a diminution in the bronchial collapsibility. It is suggested that CPAP should be given if generalised bronchomalacia is present to tide the children over a bad period while the bronchus is becoming more stable.

Clinical spectrum of infantile lobar emphysema

Infantile lobar emphysema in an uncommon disease affecting newborns and infants with varying degrees of respiratory distress, evidence of lobar overaeration, mediastinal shift, and herniation. Congenital malformations of the bronchi and alveoli and extrinsic compression by vessels and cysts account for less than 50% of these cases. All segments of the upper and middle lobe may be involved, but the major overexpansion occurs in the anterior segment. Respiratory distress may be absent, mild, or severe, and the condition may be acutely progressive, acutely reverisble, chronic, or recurrent. This symptom complex is the result of multiple factors requiring investigation prior to definitive operation.

Congenital lobar emphysema

Congenital lobar emphysema is frequently a life-threatening disorder presenting in infancy. The diagnosis should be considered when the patient shows signs of respiratory distress and the x-ray demonstrates the characteristic hyperlucent lobe with compression of the surrounding lung tissue. The morphologic aspects and pathogenesis are not clearly defined, although it is thought that an abnormality of bronchial cartilage is probably associated with the development of lobar emphysema. The results of treatment by lobectomy are excellent, and the mortality with surgery is low. Consideration of nonsurgical management is worthwhile in mildly affected or asymptomatic patients. Long-term follow-up of both groups indicates a very favorable prognosis in this disease entity.

Segmental lung resection in the first year of life

Segmental lung resection was performed in 5 infants with congenital lung disease. The lesions were cystic adenomatoid malformation in 2, congenital cystic disease in 2, and congenital lobar emphysema in 1. A higher than expected incidence of major segmental bronchovascular anomalies was encountered (3 of 5 patients). Other than prolonged air leak in 1 patient, complications were negligible. All patients were well from one to six and one-half years after operation. Segmentectomy is a sensible operation for congenital pulmonary disease and ultimately may have as its greatest virtue the preservation of normal lung tissue.

Generalized pulmonary hyperinflation and Fallot's tetralogy in a neonate investigated by pulmonary physiological and radioisotopic methods

An infant is described who presented a complex cardiopulmonary problem which was evaluated with the help of new physiological techniques. the infant was born at term after an emergency Caesarian section for fetal distress and was found to have meconium aspiration. He remained persistently tachypnoeic and hypoxic despite high ambient oxygen. Chest radiography suggested cystic lesions at the lung bases, and lung function tests confirmed hyperinflation with delayed nitrogen washout. In addition the child had signs of Fallot's tetralogy, and this diagnosis was confirmed by cardiac catheterization. Because of persistent hypoxia and tachypnoea disproportionate to the cardiac condition, the possibility of localized lung disease was considered. Regional lung function tests were carried out in the neonatal period and again at six months of age useing radioisotopic 13N given by both inhalation and injection. These studies showed gross ventilation/perfusion imbalance in the lungs, particularly marked at the bases, but with enough generalized abnormality to preclude the possibility of surgical intervention. The principles of the measurement of lung mechanics in the newborn by whole-body plethysmography, nitrogen washout, and regional radioisotopic spirometry are outlined. The particular value of these techniques in the evaluation of complex disorders is discussed, especially where both cardiac and pulmonary abnormalities are present.