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Congenital lobar emphysema
Congenital lobar emphysema (CLE) is a respiratory abnormality characterized by respiratory distress due to hyperinflation of one or more affected lobes of the lung.
It is a rare disease with the incidence being 1/20,000 to 1/30,000 births.
Most cases present in the neonatal period or in early infancy. Patients with less severe manifestations may present in early childhood or rarely in adulthood. Clinical picture can range from asymptomatic or mildly symptomatic to severe respiratory impairment requiring immediate intervention. Symptomatic patients present with respiratory distress, dyspnea, tachycardia, cyanosis, and failure to thrive. The left upper lobe is most commonly affected (41%) followed by the right middle lobe (34%) and the right upper lobe (21%). CLE can occur in association with cardiac malformations in 15 to 20% cases.
About 50% of cases have no identifiable etiology; however an abnormality or absence of cartilaginous rings, intrinsic obstruction caused by redundant mucosa, extrinsic obstruction (vascular or bronchial) or hyperinflation alone might explain the CLE. Polyalveolar lobe has also been reported as a cause of CLE.
Chest X ray and CT scan are the key imaging modalities used for diagnosis. Chest X ray shows hyperlucent affected lobes with mediastinal shift and collapse of ipsilateral unaffected segments. CT scan provides details of affected lobes and vascular involvement. Echocardiography to detect concomitant heart disease can also be performed.
Respiratory distress and radiolucency in chest X rays can lead to a misdiagnosis of tension pneumothorax. Differential diagnoses also include congenital pulmonary airway malformation (see this term), pneumonia, bronchiolitis and foreign body aspiration.
Prenatal diagnosis can be made with ultrasonography by identifying hyperechoic areas in fetal lung.
Management and treatment
Lobectomy of affected lobes is the widely accepted form of management with a satisfactory outcome. Asymptomatic or mildly symptomatic cases can be managed conservatively but follow up is necessary. Thoracoscopic resection has been attempted and seems to have better post operative outcomes.
Asymptomatic cases may regress spontaneously. Prompt diagnosis and surgical intervention usually provide good long term outcome in symptomatic cases. In some cases, CLE can be lethal.