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

Congenital lobar emphysema: A diagnostic dilemma with coexistent congenital heart defects

Key Clinical Message

Clinicians should think beyond pneumonia and left-to-right shunts when young children have persistent respiratory distress. Congenital lung anomalies, including congenital lobar emphysema, should be considered differential diagnoses. Chest X-ray and CT imaging should be conducted to gain insight regarding and establish diagnosis, respectively.

Abstract

Congenital lobar emphysema (CLE) is a rare and life-threatening congenital lung anomaly that often poses a diagnostic dilemma. The issue can be further confused with coexistent congenital heart defects (CHDs) with left-to-right shunts. The clinical presentation of CLE during infancy is similar to that of CHD, with CHD being more common entity, gets detected early. The presence of underlying CLE may only be suspected after CHD repair. In our case, a 2-month-old infant presented with respiratory distress. On evaluation, a large ventricular septal defect and patent ductus arteriosus were detected. After successful cardiac defect repair, the infant continued to experience cough, respiratory distress, and failure to thrive. Furthermore, on radiological reanalysis, CLE was suspected on X-ray and confirmed via computed tomography. CLE can be detected on chest X-rays; however, at an early stage, it is often confusing and misleading.

Surgical management of congenital lobar emphysema associated with CHD

Congenital lobar emphysema is often associated with CHD in early infancy; however, the surgical strategy for this condition is still controversial. We report three successful cases of emphysematous lung lobectomy before the surgical repair of associated CHD. Aggressive lobectomy preceding cardiac interventions is advised when the management of congenital lobar emphysema is difficult.

Early neonatal lobectomy for ILE; is it feasible?

Introduction

Congenital lobar emphysema (CLE) also called congenital lobar overinflation and infantile lobar emphysema is a rare congenital anomaly of lung often presents in the neonatal period, with hyperinflation of one or more pulmonary lobes.

Importance

Author is reporting here an uneventfully done earliest ever neonatal lobectomy for ILE.

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CLE congenital lobar emphysema is often detected in neonates or young infants but, some even present late at childhood.

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Though conservative management has supported by some studies, but however, surgery is the most definitive and curative; either by segmentectomy or lobectomy.

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Having adequate facilities along with normal haematological parameters, early neonatal lobectomy is feasible option in a tertiary care centre after clinical stabilisation.

Managing Congenital Lobar Overinflation Associated with Congenital Heart Disease

The incidence of congenital lobar overinflation (CLO) is reported at 1 in 20,000–30,000 live births and represents 10% of all congenital lung malformations. The occurrence of concomitant congenital heart disease (CHD) and CLO ranges from 12% to 20%. There are diverging views in the management as to whether early lobectomy or repair of the cardiac defect, with the assumption that respiratory symptomatology would gradually resolve, or a combined lung and cardiac repair would be the ideal first step in the management. In concomitant CLO and CHD, the surgical decision has to be individualized. Prior to surgical intervention a thorough evaluation may be needed with contrast computed tomography (CT) or magnetic resonance imaging (MRI), bronchoscopy, and if needed cardiac catheterization. CLO improves with management of many left to right shunts and in those with anomalous vessels, but early lobectomy or combined approach may be considered in those symptomatic patients with more complex CHD.

Current operative management of congenital lobar emphysema in children: A report from the Midwest Pediatric Surgery Consortium

PURPOSE

The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium.

METHODS

After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015).

RESULTS

Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0).

CONCLUSIONS

Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion.

LEVEL OF EVIDENCE

Level III.

A case of congenital lobar emphysema in the middle lobe

Congenital lobar emphysema (CLE) is a rare cause of respiratory distress during the neonate period. It is characterized by overinflation of pulmonary lobe, most commonly the left upper lobe or the right middle lobe. We report a case of a 21-day-old baby with the severe respiratory distress. Diagnosis of CLE was made by computed tomography scan and chest X-ray and confirmed by histopathological studies. We would like to draw attention to this rare condition, and discussing their clinical features and management.

Ventricular septal defect complicated by infantile lobar emphysema

An infant with ventricular septal defect, atrial septal defect, and Down syndrome (trisomy 21) was referred to our institution. The patient gradually developed infantile lobar emphysema of the right upper lobe and became dependent on mechanical ventilator support. When the patient was five months of age, we successfully performed a total correction of cardiac anomalies combined with a right upper lobectomy. The resection of the right upper lobe was performed under cardiopulmonary bypass through a median sternotomy. There was no major airway bleeding or mediastinitis. The patient was extubated on postoperative day 12 and discharged on postoperative day 29.

Congenital lobar emphysema: a case report

Congenital lobar emphysema is a rare variety of congenital malformation of lung characterized by over distension of a lobe of a lung due to partial obstruction of the bronchus. We are reporting a neonate admitted in the pediatric emergency ward with the respiratory distress since 16^th day of life.

Investigation revealed the overexpansion of the left upper lobe with mediastinal herniation, shifting of the mediastinum to the opposite side and collapse of the ipsilateral lower lobe. The baby was treated with conservative treatment and the condition of the baby was improved.

Peripheral Gangrene Associated with Kawasaki Disease and Successful Management Using Prostacycline Analogue: A Case Report

We report a case of child-onset Kawasaki disease that presented as a prolonged fever and manifested with coronary aneurysms and peripheral gangrene of the lower limbs. Therapy with intravenous immunoglobulins, corticosteroids, aspirin, anticoagulants, and ilomedine, a prostacyclin analogue, resulted in rapid improvement in the patient's condition without extremity loss. Those treating patients with Kawasaki disease must be aware of possible vascular ischemia in the disease process that is reversible by early intervention treatments, including the use of a prostacycline analogue, that improve quality of life.