Right middle lobe syndrome & bronchiectasis in 3 yr old

[Frostedpink]

Hello, my daughter, age 3, had a bronchoscopy and CT scan after repeated bouts of pneumonia in the same spot, right middle lobe. This all started after a severe RSV/pneumonia hospitalization as an infant.

Her CT scan was read as "mild bronchiectasis" in the right middle lobe, same spot as her atelectasis. We know for sure that her last bout of pneumonia in march never fully cleared, b/c we did X-rays every 3 months. So she's had this atelectasis spot for quite awhile now.

We have her on qvar, Singulair, and now The Vest twice a day. We did 10 days of antibiotics following the bronch culture results (streptococcus viridians ).

My question is....at what point do we consider surgery on her right middle lobe? Do we give this management plan a good try, like a year? Should we wait until she is older, like 6 or 7? Her pulmonologist said surgery is an absolute last resort, but most of the studies I've read suggest middle lobe resection as the best treatment.

Thanks for any advice!

[David Tinkelman, M.D.]

There can be honest disagreement among experts about the management of RML atelectasis, bronchiectasis and recurrent pneumonia, despite appropriate, intense medical treatment, in young children with a normal immune system. There is general agreement, however that, when localized bronchiectasis, especially of the RML, becomes refractory, more severe or resistant to medical management, lobar resection may be warranted. If I were to describe surgery as a last resort, it would be because it would be definitive therapy, not because it performed in desperation. There has been significant experience with the less surgically invasive video-assisted thorascopic (VATS) surgical approach at a number of major medical centers.

In this circumstance in which your daughter’s pulmonologist seems to be adamantly opposed to surgical resection of her RML, presumably justifiably based on evidence-based medical literature and his personal experience, I believe it would be wise for you to request a second opinion from a pediatric pulmonologist of fine repute, if for no other reason than to put your mind at ease that you have done your best in your daughter’s behalf.

Good luck.

[Frostedpink]

A couple more details..she's had extensive immune system testing. All normal. Allergy tests all negative. Sweat chloride test normal. She's had 3 hospitalizations, first 2 for rsv/pneumonia, the 3rd for metapneumovirus and pneumonia. We've been doing pulmicort and now qvar for the past two years.

Her CT scan was with contrast. Bronchoscopy showed the middle lobe was inflamed and the lavage fluid was tinted pink, indicating inflamation. She has some " tight takeoffs" in this middle lobe, per the pulmonologist