Bilobar congenital lobar emphysema in a child: how to approach it?

A 1-month-old, term male child, with a birth weight of 3.6 kg, presented with sudden onset respiratory distress. There was no accidental foreign body inhalation or oil instillation. Plain X-ray chest showed bilateral emphysematous involvement (left upper lobe and right middle lobe), left more severe than the right as evidenced by the mediastinal shift and lung herniation (Figure 1 A). The child was resuscitated and supported with oxygen. In view of worsening respiratory distress, the child was intubated and ventilated. Intravenous antibiotics were commenced to treat the associated pneumonia. Over a period of 1 week, the ventilator settings could not be weaned, pointing to the surgical lesion as the obvious cause. Chest computed tomography (CT) was consistent with bilobar emphysematous involvement without any obvious extraluminal bronchial compression. As the left upper lobe was acting as a space occupying lesion causing lung herniation to the opposite side, left upper lobectomy was planned.
Written informed high risk consent was obtained from the parents. In view of the technically demanding procedure and the urgency of the situation, open lobectomy was preferred over video assisted thoracoscopic surgery. Lobectomy was performed by a conventional left posterolateral thoracotomy via the 4th intercostal space (Figure 2). As single lung ventilation in a neonate was deemed unwarranted, a standard endotracheal tube was used. The pulmonary vein and artery to the lobe were identified and ligated individually. The upper lobe bronchial stump was oversewn with 5/0 Prolene sutures. The left lower lobe expanded well after removal of the upper lobe. After an uneventful post-operative course, the child was extubated on day 1. He continued to remain stable without respiratory distress and was discharged home on post-operative day 5. As the child was well, the right middle lobectomy was deferred and observation advised. However, the child developed distress after 10 days and was re-admitted. The right middle lobe was prominently emphysematous on the plain X-ray chest, with satisfactory left lower lobe expansion filling the hemithorax. The child required intubation and ventilation for the distress. Following a week of stabilization and intravenous antibiotics, the child was taken up for surgery. After written informed high risk consent, he underwent a right middle lobectomy by standard right posterolateral thoracotomy. The vessels and the bronchial stump to the...


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