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The Middle Lobe Syndrome and Its Quasi Variants
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prevention of injury due to cuffed tracheal tubes. Surg Gynecol Obstet 129:1235, 1969 Shelly WM, Dawson RB, May lA: Cuffed tubes as a cause of tracheal stenosis, I. J Thorac Cardiovasc Surg 57:623, 1969 . Bryant LR, Trinkle JK, Dubilier L: Reappraisal of tracheal injury from cuffed tracheostomy tubes. JAMA 215: 625, 1!171 Geffin B, Pontoppidan H: Reduction of tracheal damage by the prestretching of inflatable cuffs. Anesthesiology 31:462, 1969 Grillo HC, Cooper JD, Geffin B, et al: A low-pressure cuH
17 18 19 20
for tracheostomy tubes to mmmuze tracheal injury. J Thorac Cardiovasc Surg 62:898-907, 1!171 Adriani J, Philips M: Use of the endotracheal cuH: Some data pro and con. Anesthesiology 18:1, 1957 Nealon TF, Ching N: Pressure of tracheostomy cuffs in ventilated patients. NY State J Med 71:1923, 1971 Knowlson GTG, Bassett HFM: The pressures exerted on the trachea by endotracheal inflatable cuffs. Br J Anaesth 42:834, 1!170 Stiles PJ: Tracheal reaction following the use of cuffed tracheostomy tubes. Ann Otol Rhino! Laryngol 73:1124, 1964
The Middle Lobe Syndrome and Its Quasi Variants In 1948, Graham et al (Postgrad Med 4:29, 1948) first used the term "middle lobe syndrome." Its essential pathologic features were recorded as small atelectatic right middle lobe, with its bronchus by adjacent enlarged lymph nodes, together with fibrosis and bronchiectasis in the lobe involved. Subsequently, divergent opinions were offered in reference to the clinical picture resulting from a variety of pathologic conditions localized in this structure. Rosenman (Dis Chest 27:80, 1955) suggested that distinction be made between atelectasis of the middle lobe secondary to intraluminal or extraluminal obstruction of the middle lobe bronchus and middle lobe disease characterized by chronic pneumonitis associated with infected and enlarged lymph nodes which occlude the bronchus. Brock (The Anatomy of the Bronchial Tree, London, Oxford U Press, 1947; Thorax 5:5, 1950) called attention to the easy compressibility of the right middle lobe bronchus by adjacent conglomeration of lymph nodes. The latter receive drainage from the entire right lung. Other pertinent contributory factors may be the rather great length and small caliber of this bronchus, and the pronounced sharp angle at its take-off. Enlargement of the respective lymph nodes may be brought about by several causes, including carcinoma, mycoses, sarcoidosis, tuberculosis etc. In addition, occlusion of the middle lobe bronchus may be caused by neoplasms of this bronchus. Kronschnabel (Arch Otolar 76:233, 1962) reported a case in which primary nodular amyloid tumor was responsible for the middle lobe syndrome. Caplin et al (Asthma Res 8:57, 1970) observed severe allergy in two-thirds of their patients with middle lobe syndrome. The latter was attributed by them to edema of the bronchial mucosa, with hypertrophy of the bronchial glands and muscles, bronchospasm and/or bronchial occlusion by secretions and exudate. Concerning the subject of this writing, a persuasive concept was expressed by Culiner (Dis Chest 50:57, 1966). His observations did not reveal evidence of bronchial occlusion in patients with middle lobe syndrome. He stated "that the basic pathogenetic factor for atelectasis (of the middle lobe) lies in the isolation of this small lobe from the right upper and lower lobes, and thus from the aeration effects of collateral ventilation." Furthermore, he emphasized that "there is undoubtedly a selectively increased incidence of middle lobe atelectasis complicating even minor inflammatory processes here." On the
CHEST, 65: 2, FEBRUARY, 1974
other hand, protracted atelectasis should be considered a predilectional site for infection of lung structures because of impaired homeostatic function, including inadequate bronchocatharsis. Uehlinger et al (in Schinz, H R et al: Roentgen Diagnosis, Stuttgart, Thieme, 1957) listed under middle lobe syndrome conditions, such as atelectasis, inflammatory processes and neoplasms, with involvement of the entire lobe or some of its segments. Of the 73 adults with typical middle lobe syndrome, Geroulanos, S et al (Deutsche Med Wochenschr 98:1095, 1973) recorded the following causal factors in a recent report: malignant tumors, 38.3, benign tumors, 5.4, bronchiectasis, 19.1, chronic pneumonia, 5.4, severe tuberculosis, 4.1, lymph node tuberculosis, 8.2, foreign body, 2.7, undetermined origin, 16.4 percent. Prompt and effective treatment requires exact diagnosis. Symptoms of middle lobe syndrome are variable. History of pneumonia, bronchial asthma or of episodes of recurrent respiratory infections may be obtained. The patient may have chronic cough with or without expectoration of sputum, also, pain in the anterior lower part of the chest. Fever may be associated with concurrent pneumonitis. Hemoptysis, which may be recurrent, is noted in about 25 percent of the cases. Rarely, the patient may complain of undue fatigue and weight loss. Seemingly refractory bronchial asthma and recurrent pneumonia in children should be scrutinized for possible middle lobe syndrome. X-ray changes in the postero-anterior and lateral ffims reveal great variations, for the reason that the atelectasis may be partial ( segmental or slight deflation) or total. Abnormal findings may be ill-defined. One may observe bizarre cardiac silhouette on the right side. In addition to standard diagnostic work-up, bronchogram and bronchoscopy are essential for correct diagnosis. Albo, R J et al (Dis Chest 50:509, 1966) pointed out that "frequently the two bronchial divisions of the middle lobe can be seen as linear densities lying in close approximation throughout their entire course extending anteriorly and inferiorly to terminate near the cardiophrenic angle." Early specific conservative therapeutic measures may bring about gratifying results in patients without lung tumor. The sooner the atelectatic lobe is reexpanded the better the chances for complete recovery, prevention of recurrence and of permanent lung damage. In other instances, pulmonary resection is the only appropriate treatment. Andrew L. Banyai, M.D.
TRACHEAL INJURY BY CUFFED TRACHEOSTOMY TUBES 135
prevention of injury due to cuffed tracheal tubes. Surg Gynecol Obstet 129:1235, 1969 Shelly WM, Dawson RB, May lA: Cuffed tubes as a cause of tracheal stenosis, I. J Thorac Cardiovasc Surg 57:623, 1969 . Bryant LR, Trinkle JK, Dubilier L: Reappraisal of tracheal injury from cuffed tracheostomy tubes. JAMA 215: 625, 1!171 Geffin B, Pontoppidan H: Reduction of tracheal damage by the prestretching of inflatable cuffs. Anesthesiology 31:462, 1969 Grillo HC, Cooper JD, Geffin B, et al: A low-pressure cuH
17 18 19 20
for tracheostomy tubes to mmmuze tracheal injury. J Thorac Cardiovasc Surg 62:898-907, 1!171 Adriani J, Philips M: Use of the endotracheal cuH: Some data pro and con. Anesthesiology 18:1, 1957 Nealon TF, Ching N: Pressure of tracheostomy cuffs in ventilated patients. NY State J Med 71:1923, 1971 Knowlson GTG, Bassett HFM: The pressures exerted on the trachea by endotracheal inflatable cuffs. Br J Anaesth 42:834, 1!170 Stiles PJ: Tracheal reaction following the use of cuffed tracheostomy tubes. Ann Otol Rhino! Laryngol 73:1124, 1964
The Middle Lobe Syndrome and Its Quasi Variants In 1948, Graham et al (Postgrad Med 4:29, 1948) first used the term "middle lobe syndrome." Its essential pathologic features were recorded as small atelectatic right middle lobe, with its bronchus by adjacent enlarged lymph nodes, together with fibrosis and bronchiectasis in the lobe involved. Subsequently, divergent opinions were offered in reference to the clinical picture resulting from a variety of pathologic conditions localized in this structure. Rosenman (Dis Chest 27:80, 1955) suggested that distinction be made between atelectasis of the middle lobe secondary to intraluminal or extraluminal obstruction of the middle lobe bronchus and middle lobe disease characterized by chronic pneumonitis associated with infected and enlarged lymph nodes which occlude the bronchus. Brock (The Anatomy of the Bronchial Tree, London, Oxford U Press, 1947; Thorax 5:5, 1950) called attention to the easy compressibility of the right middle lobe bronchus by adjacent conglomeration of lymph nodes. The latter receive drainage from the entire right lung. Other pertinent contributory factors may be the rather great length and small caliber of this bronchus, and the pronounced sharp angle at its take-off. Enlargement of the respective lymph nodes may be brought about by several causes, including carcinoma, mycoses, sarcoidosis, tuberculosis etc. In addition, occlusion of the middle lobe bronchus may be caused by neoplasms of this bronchus. Kronschnabel (Arch Otolar 76:233, 1962) reported a case in which primary nodular amyloid tumor was responsible for the middle lobe syndrome. Caplin et al (Asthma Res 8:57, 1970) observed severe allergy in two-thirds of their patients with middle lobe syndrome. The latter was attributed by them to edema of the bronchial mucosa, with hypertrophy of the bronchial glands and muscles, bronchospasm and/or bronchial occlusion by secretions and exudate. Concerning the subject of this writing, a persuasive concept was expressed by Culiner (Dis Chest 50:57, 1966). His observations did not reveal evidence of bronchial occlusion in patients with middle lobe syndrome. He stated "that the basic pathogenetic factor for atelectasis (of the middle lobe) lies in the isolation of this small lobe from the right upper and lower lobes, and thus from the aeration effects of collateral ventilation." Furthermore, he emphasized that "there is undoubtedly a selectively increased incidence of middle lobe atelectasis complicating even minor inflammatory processes here." On the
CHEST, 65: 2, FEBRUARY, 1974
other hand, protracted atelectasis should be considered a predilectional site for infection of lung structures because of impaired homeostatic function, including inadequate bronchocatharsis. Uehlinger et al (in Schinz, H R et al: Roentgen Diagnosis, Stuttgart, Thieme, 1957) listed under middle lobe syndrome conditions, such as atelectasis, inflammatory processes and neoplasms, with involvement of the entire lobe or some of its segments. Of the 73 adults with typical middle lobe syndrome, Geroulanos, S et al (Deutsche Med Wochenschr 98:1095, 1973) recorded the following causal factors in a recent report: malignant tumors, 38.3, benign tumors, 5.4, bronchiectasis, 19.1, chronic pneumonia, 5.4, severe tuberculosis, 4.1, lymph node tuberculosis, 8.2, foreign body, 2.7, undetermined origin, 16.4 percent. Prompt and effective treatment requires exact diagnosis. Symptoms of middle lobe syndrome are variable. History of pneumonia, bronchial asthma or of episodes of recurrent respiratory infections may be obtained. The patient may have chronic cough with or without expectoration of sputum, also, pain in the anterior lower part of the chest. Fever may be associated with concurrent pneumonitis. Hemoptysis, which may be recurrent, is noted in about 25 percent of the cases. Rarely, the patient may complain of undue fatigue and weight loss. Seemingly refractory bronchial asthma and recurrent pneumonia in children should be scrutinized for possible middle lobe syndrome. X-ray changes in the postero-anterior and lateral ffims reveal great variations, for the reason that the atelectasis may be partial ( segmental or slight deflation) or total. Abnormal findings may be ill-defined. One may observe bizarre cardiac silhouette on the right side. In addition to standard diagnostic work-up, bronchogram and bronchoscopy are essential for correct diagnosis. Albo, R J et al (Dis Chest 50:509, 1966) pointed out that "frequently the two bronchial divisions of the middle lobe can be seen as linear densities lying in close approximation throughout their entire course extending anteriorly and inferiorly to terminate near the cardiophrenic angle." Early specific conservative therapeutic measures may bring about gratifying results in patients without lung tumor. The sooner the atelectatic lobe is reexpanded the better the chances for complete recovery, prevention of recurrence and of permanent lung damage. In other instances, pulmonary resection is the only appropriate treatment. Andrew L. Banyai, M.D.
TRACHEAL INJURY BY CUFFED TRACHEOSTOMY TUBES 135