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Case Presentation A 75-year-old woman was referred to the pulmonary office in January 2020 for cough and progressive worsening of shortness of breath over the years. Her medical history was significant for asthma that was diagnosed approximately 10 years earlier, when she first developed dyspnea. A pre-bronchodilator spirometry at that time showed severe airflow obstruction ( Fig 1 ). The patient was incidentally found to have several noncalcified pulmonary nodules on a chest CT scan in 2015, which was obtained as a part of dyspnea workup. She underwent bronchoscopic evaluation with transbronchial biopsy of the largest nodule (1.6 × 1.2 cm) in the right middle lobe. She was diagnosed with low-grade neuroendocrine tumor (typical carcinoid) and had been under surveillance without any progression in the number of nodules or the size of the existing nodules. She was a lifelong nonsmoker and no family history of asthma. Over the years, she received multiple courses of systemic corticosteroids and different inhalers, without any improvement in her symptoms. The patient was frustrated by the lack of perceived benefit, and she discontinued all respiratory medications. She denied any fever, night sweats, exertional chest pain, or seasonal allergies but reported cough, wheezing, and severe exertional shortness of breath. She was unable to walk more than 20 feet at a time. She had no pets at home and did not travel outside the United States. Her only home medications were multivitamins and low-dose aspirin.

A patient with a history of hepatocellular carcinoma was found to have multiple pulmonary metastases. Staged treatments were combined into a single operation session in the hybrid theater, encompassing bronchoscopic microwave ablation of central right upper lobe lesions and uniportal surgical wedge resections of peripheral right middle lobe lesions. All lung metastases were successfully treated with adequate margin clearance. Microwave ablation under the guidance of electromagnetic navigation bronchoscopy in the hybrid theater is a novel contribution to the multimodal operative management of multiple pulmonary neoplasms. It is a unique choice for patients with multilobar, subcentimeter metastases, and with concerns about lung function preservation.

Background: Bronchiectasis causes physical, social, and financial strain on affected patients and results in a significant negative effect on the quality of life of the patient.Objectives: This study was undertaken to find the role of HRCT in diagnosis, regional distribution and characterize bronchiectasis morphologically.Method: A prospective study of sixty patients was done in whom clinically bronchiectasis was suspected and were subjected to HRCT examination. Bronchiectasis was assessed in terms of localization, regional distribution and morphological forms.Results: The mean age for all patients included in the study was 50.7 ± 12.09. The mean age of the male patients was 51.56 ± 12.09 and the mean age of the female patients was 50.16 ± 12.23Out of a total of 60 patients there were 23 (38%) males and 37 (62%) females. 18 patients (30%) had unilateral disease & 42 (70%) had disease in both lungs. Posterior basal segment of left lower lobe was most commonly affected (72%), followed by medial segment of right middle lobe (56%). Cylindrical bronchiectasis was the most common (36%) morphological form of bronchiectasis followed by mixed bronchiectasis. Peripherally visualized bronchi (82%) was the most common findings in our study followed by lack of tapering (75%).Bronchial wall thickening was seen in 72% of patients. Bronchial: pulmonary artery ratio > 1.5 was noted in 63% of patients.Conclusion: Based on our results, it can be concluded that HRCT serves as the best modality in confirming the diagnosis of bronchiectasis. Left lower lobe, especially posterior basal segment is most commonly involved. Bilateral involvement is more common than unilateral involvement peripherally visualized bronchi was the most common findings in our study followed by lack of tapering. Cylindrical bronchiectasis is the most common form of bronchiectasis.

Background: Absence of interlobar collateral ventilation is essential to achieve lobar volume reduction after endobronchial valve (EBV) treatment and can be assessed using the Chartis measurement. However, especially in lower lobe measurements, Chartis can be complicated by the “no-flow phenomenon”, during which a sudden cessation of flow is observed, leading to an unreliable measurement. If this phenomenon occurs in the right lower lobe, when measuring collateral flow over the right major fissure, the entrance to the right middle lobe should be occluded, and the Chartis balloon should be placed in the right upper lobe. Both Watanabe spigots and balloon catheters can be used to achieve occlusion. Objective: Our aim was to demonstrate that right middle lobe occlusion with a blocking device is helpful in obtaining a reliable Chartis outcome in case of the no-flow phenomenon in the right lower lobe. Methods: We performed a retrospective analysis of patients scheduled for EBV treatment in an EBV registry between September 2016 and September 2019. Results: We included 15 patients with severe emphysema (median age 63 years [range 47–73], 73% female, and FEV1 24% [range 19–36] of predicted), who required temporary middle lobe occlusion (12 Watanabe spigot, 3 balloon catheter). After occlusion, a reliable Chartis outcome was obtained in all patients. Conclusion: Temporary middle lobe occlusion using a blocking device is helpful in obtaining a reliable Chartis outcome in case of a right lower lobe no-flow phenomenon.

Emphysema can be examined quantitatively on high-resolution computed tomography (HRCT) by measuring the low-attenuation areas of the lung and has been associated with decrease in lung function in patients with COPD [1]. Previous studies have associated levels of air pollution with emphysema severity of the total lung [2, 3]. However, the relationship between inhaled particulate matter (PM) deposition in the lungs and the degree of emphysema at the lung lobar level remains poorly understood. We examined the association of lung lobe-deposited doses of PM2.5 (particles with a 50% cut-off aerodynamic diameter of 2.5 μm) with the extent of emphysema in different lung lobes of COPD subjects., The novelty of this study is that it identified the associations between PM2.5 deposition in the lung and the degree of emphysema in different lung lobes of COPD patients, especially in the right middle lobe and both upper lobes https://bit.ly/3k21ri0

We report a 33-year-old man who presented with recurrent right pneumothorax. Computed tomography (CT) showed the presence of a large bulla with a maximum diameter of 8 cm in the right middle lobe; he subsequently underwent bullectomy. Histopathology revealed that pulmonary parenchyma adjacent to the bulla represented nodular proliferation of clear cells characterized by a papillary structure resembling placental chorionic villi. Immunohistochemically, clear cells were positive for CD10, suggesting placental transmogrification of the lung (PTL). We reviewed 36 surgical cases of PTL, and only 2 cases (5.6%), including our case, were operated for spontaneous pneumothorax. Bullous lesions secondary to PTL tend to appear as unilateral large cystic masses in non-upper lobes, which is atypical for primary spontaneous pneumothorax (PSP). Although PTL is considered a very rare cause of secondary pneumothorax, we must carefully differentiate this condition.

Middle lobe torsion is an uncommon complication after right upper lobectomy. Clinical features are non-specific. CECT chest and diagnostic bronchoscopy are the essential investigations for the diagnosis. The treatment of choice is urgent re-exploration with either lobectomy or de-rotation with pneumopexy through thoracotomy or video assisted thoracoscopic approach based on the viability of lobe. Strong clinical suspiscion and early surgical intervention are the key points for success. This report highlights the role of video assisted thoracoscopic approach in the management of this rare complication.

The right middle lobe segments (RS4 and RS5) are very small and the technique for segmentectomy is rarely reported. Here, we report 3 cases of thoracoscopic RS4 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method. The VVBA method for thoracoscopic segmentectomy is a simple, safe, and effective procedure for RS4 segmentectomy with clear procedural steps. It overcomes the difficulty in manipulation of incomplete lung fissures and simplifies the surgical procedures.

Prognosis beyond 5 years after segmentectomy for non-small cell lung cancer (NSCLC) has not been well studied.This study is a retrospective analysis of a previous prospective cohort study of patients with peripheral cT1 N0 M0 NSCLC who underwent segmentectomy between 2005 and 2009. Exclusion criteria were right middle lobe tumors, multiple tumors in same lobe, patients having considerable risk for segmentectomy, and patients requesting lobectomy rather than segmentectomy. The median follow-up period was 108 months. Study outcomes included overall survival, recurrence-free probability, and local recurrence.Of 179 patients with cT1 N0 M0 who were treated by segmentectomy, clinical T stages were Tis in 57 patients, T1mi or T1a in 34, T1b in 57, and T1c in 31. All tumors were pathologic N0 tumors. The 10-year recurrence-free probability rates in each clinical stage were 100% in Tis, 97% in T1mi or T1a, 90% in T1b, and 69% in T1c, which were significantly lower in advanced T stages (p0.001). Fourteen patients (8%) experienced recurrences after segmentectomy; these were local in 8 patients (five recurrences at the surgical margin and three in the preserved lobe) and nonlocal in 6 patients. Six of the eight local recurrences developed more than 5 years after segmentectomy. All eight local recurrences were treated by local therapy, resulting in 6 patients surviving without disease at 55 months of median follow-up after the additional treatments.Although segmentectomy may be a viable curative option for treating T1 N0 M0 NSCLC, monitoring for local recurrence should be continued beyond 5 years after segmentectomy to avoid missing opportunities to effect a cure.

Objectives Clinical manifestations of lipoid pneumonia (LP) vary depending on the causative agents or underlying causes. The aim of the present study was to investigate the clinical and radiological features of LP, classified according to etiologic agents. Methods The clinico-radiological characteristics of LP patients were retrospectively compared among groups: exogenous versus idiopathic and squalene versus omega-3-acid ethyl esters (O-3-AEE) versus idiopathic. Idiopathic group was defined as LP with no proven or reported etiological evidence. Results Twenty-two patients met the diagnostic criteria for LP: squalene (9 [41%]), O-3-AEE (6 [27%]), olive oil (1 [5%]), and idiopathic (7 [32%]). Compared with the exogenous group, the idiopathic group showed a higher recurrence rate; higher frequencies of bronchial anthracofibrosis (BAF) and bronchoalveolar lavage (BAL) lymphocytosis; and a higher rate of crazy-paving pattern and lower rate of consolidation on computed tomography scan. In three-group tests, compared with the O-3-AEE group, the squalene group exhibited a significantly higher percentage of neutrophils and a higher rate of right middle lobe (RML) involvement. Conclusions In comparison with the exogenous group, the idiopathic group demonstrated BAL lymphocytosis, higher rates of recurrence and BAF, and a higher rate of crazy-paving pattern. Compared with the O-3-AEE group, the squlaene group showed a higher percentage of BAL neutrophils and predominant RML involvement.

The aims were to study the pattern of right bronchial tree with multi-detector CT. 238 patients were enrolled. The three-dimensional bronchial tree images were acquired using the post-processing technique of CT. There were mainly four types for right superior lobe bronchial tree, i.e., (140/238, B1–B2–B3); (44/238, B1 + 2, B3); (28/238, B2, B3); (22/238, B1, B2 + 3). There were two types for right middle lobe bronchial tree, i.e. (229/238, B4, B5); trifurcation of right middle lobe bronchi (9/238). There were mainly four types for right inferior lobe bronchial tree, i.e., (135/238, B6, B7, B8, B9, B10); (42/238, B6, B7, B8, B10); (25/238, B6, B7, B8 + 9, B10); (21/238, B6, B7, B8-B9-B10). The present study describes variations in the anatomy of the right bronchial tree, and reveals that there were mainly four types for right superior lobe bronchial tree, two types for right middle lobe bronchial tree, and four types for right inferior lobe bronchial tree.

Bronchopleural fistula (BPF) is associated with high morbidity if left untreated. Although rare, the frequency of BPF in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is becoming recognized in medical literature. We present a case of a 64-year-old male with BPF with persistent air leak due to SARS-CoV-2 pneumonia treated with Spiration Valve System endobronchial valve (EBV). An EBV was placed in the right middle lobe with successful cessation of air leak. In conclusion, the use of EBVs for BPF with persistent air leaks in SARS-CoV-2 patients who are poor surgical candidates is effective and safe.

Pulmonary carcinoids originate from neuroendocrine cells of the lung and comprise 0.5%–5% of all lung malignancies. Endobronchial carcinoids are rare, low-grade malignant tumors that occasionally coexist with other infectious diseases, including tuberculosis and nontuberculous mycobacterial infection. We treated a 63-year-old woman who presented with a right middle lobe obstruction. A chest computed tomography scan demonstrated a mass-like lesion in the right middle lobe with mediastinal lymphadenopathy. She underwent an exploratory operation after 2 weeks of antibiotic treatment. The pathology revealed a right middle lobe bronchial carcinoid tumor and aspergillosis. Chest computed tomography scans have revealed no recurrence of the carcinoid or aspergillosis during the 5-year follow-up.

A 30-year-old male patient presented with history of haemoptysis associated with cyanosis and clubbing. Chest computed tomography revealed a simple-type pulmonary arteriovenous fistula in the right middle lobe. Operative finding showed a bulging arteriovenous fistula covered with a thin layer of pleura. Right middle lobectomy was performed. He had an uneventful postoperative recovery. Bulging out of arteriovenous fistula out of lung tissue is a rarity and carries risk of rupture.

Isolated right middle lobe (RML) lung volume reduction using endobronchial valves can lead to significant improvements in appropriately selected patients, with highly hyperinflated RML and preserved upper and lower lobes https://bit.ly/3rICgTn

A 63-year-old, nonsmoking man presented with dry cough and fever of 2 days’ duration. On enquiry, he also complained of dyspnoea on exertion of modified Medical Research Council grade 1 for 2 months. There were no other respiratory complaints. He was diagnosed with a progressive supranuclear palsy-type parkinsonian disorder 2 years ago. He was taking levodopa (100 mg) plus carbidopa (25 mg) thrice daily for that condition. There was no significant occupational history, family history or similar illness in the past. He was conscious and oriented with a pulse of 84 per min, blood pressure of 124/76 mmHg, respiratory rate of 16 per min and oxygen saturation of 96%. A respiratory system examination revealed dull notes and reduced breath sounds in the right basal region. Upon neurological examination, he had a mask-like face and speech abnormality., Combined collapse of the right middle lobe and lower lobe requires CT scan for confirmation. Excessive dynamic airway collapse (EDAC) can cause lobar collapse. Surgical intervention is required in EDAC only in symptomatic patients with >95% collapse. https://bit.ly/2UXTuw7

We report the thoracoscopic RS5 segmentectomy with VVBA (V, vein; V, ventilation; B, bronchus; A, artery) method and confirmed that the segmental plane visualized by vein-first resection is slightly narrower than the traditional artery-first resection.

We used the lung ultrasound score (LUSS) to analyze the ultrasound images and assess the lesions and aeration loss in 12 lung regions of 11 COVID-19 neonates born to mother with COVID-19 and 11 age- and gender-matched controls. In the COVID-19 group, 132 regions were reviewed and 83 regions (62.8%) detected abnormalities. Compared with controls, COVID-19 neonates showed more increased B-lines (83 regions), abnormal A-lines (83 regions), abnormal pleural line (29 regions) and subpleural consolidation (5 regions). among which 49 regions (37%) were normal, 73 regions (55%) scored 1, and 10 regions (8%) scored 2. The LUSS was significantly higher in COVID-19 group. All the lesions were bilateral, multiple regions involved, and mainly located in bilateral lower lobes and right middle lobe. The intra-observer and inter-observer reproducibility of LUSS were excellent. Lung ultrasound is a noninvasive and convenient method for the assessment of neonatal COVID-19 pneumonia and presents typical signs. LUSS provides valuable semi-quantitative information about the lesion distribution and severity.

Introduction: Minimally invasive surgery greatly contributes to the physical growth and development of children. Thoracoscopic surgery has many advantages in comparison with open surgery,1 includin...

Purpose To examine the diagnosis and treatment of traumatic bronchial rupture in children at the Children’s Hospital of Chongqing Medical University, Chongqing, China. Methods The diagnosis and treatment of eight cases of traumatic bronchial rupture were analyzed retrospectively from January 2014 to December 2019 in our hospital. Results Diagnosis of the eight patients was clear after a chest CT with three-dimensional reconstruction techniques and fiberoptic bronchoscopy; six of the patients had a delay in diagnosis of at least 2 weeks. Among the patients, six had left bronchus rupture, and the other two had right bronchus rupture. All eight patients received surgery; seven patients received a bronchial end-to-end valgus anastomosis, and one received right middle lobe lobectomy. There were no deaths in this group, and all patients were cured and discharged. Follow-up was conducted for 3 months to 2 years; the patients who received surgery showed mild bronchostenosis within 2 weeks after the trauma, and the other six patients showed moderate bronchostenosis upon CT examination. Conclusion Being alert to bronchial rupture after trauma in children is helpful for diagnosis. Chest CT with three-dimensional reconstruction techniques and fiberoptic bronchoscopy are the most valuable diagnostic methods. The patients can show excellent results if the operation for a continuous valgus anastomosis of the posterior wall and interrupted end-to-end valgus anastomosis of the anterior wall on the ruptured side is performed in the early stage of traumatic bronchial rupture.

Robotic-assisted thoracoscopic surgery has increased in popularity during the past two decades because it offers 3-dimensional optics, increased instrument and wrist flexibility compared to classical video-assisted thoracoscopic surgery, and, for patients, improved quality of life and shorter hospital stays compared to open surgery. In this video tutorial, we demonstrate a robotic-assisted thoracoscopic surgery lobectomy in a patient with a tumor in the right middle lobe. The patient had an excellent recovery with no perioperative or postoperative complications.

Middle lobe syndrome (MLS) is defined as recurrent or chronic collapse of the middle lobe of the right lung. Although it was first described in 1984 by Graham et al., yet there are limited reviews on MLS especially in children as a result of vast etiologies, wide spectrum of presentation and lack of a consistent clinical definition. Herein, we present a case of MLS in a 7-year-old child who was presented after suffering from repeated chest infections for more than 3 years. Keywords: Atelectasis, Lingual syndrome, Middle lobe syndrome

Chronic lung disease due to non-tuberculous mycobacteria (NTM)—most often due to organisms belonging to the Mycobacterium avium complex (MAC)—is increasingly prevalent in the United States and many parts of the world. In the non-cystic fibrosis population, NTM lung disease disproportionately affects middle-aged and elderly individuals, and is often recalcitrant to treatment.

Reports of right middle lobe segmentectomy are rare. We report here that anatomical right middle lobe segmentectomy is a relatively simple surgical procedure and can achieve good expansion of the remnant lung for patients with a relatively large right middle lobe.

Background Lung cancer in the right middle lobe has a poorer prognosis than tumors located in other lobes. The optimal surgical procedure for early-stage non-small cell lung cancer (NSCLC) in the right middle lobe has not yet been elucidated. The aim of this study was to compare survival rates after lobectomy and sublobar resection for early-stage right middle lobe NSCLC. Methods Patients who underwent lobectomy or sublobar resection for stage IA right middle lobe NSCLC tumors ≤ 2 cm between 2004 and 2014 were identified from the Surveillance, Epidemiology and End Results database of 18 registries. Cox regression model analysis was used to evaluate the prognostic factors. The lung cancer-specific survival (LCSS) and overall survival (OS) rates between the two groups were compared. Results A total of 861 patients met our criteria, including 662 (76.9%) patients who underwent lobectomy and 199 (23.1%) patients who underwent sublobar resection. No statistical differences in LCSS and OS rates were identified between the groups of patients with stage IA right middle lobe NSCLC ≤ 1 cm. For tumors > 1-2 cm, lobectomy was associated with more favorable LCSS and OS rates compared to sublobar resection. Conclusion Lobectomy and sublobar resection deliver a comparable prognosis for patients with stage IA right middle lobe NSCLC ≤ 1 cm. For tumors > 1-2 cm, lobectomy showed better survival rates than sublobar resection.

We present the case of a 72-year-old man with hemoptysis after a thoracic projectile injury, which occurred while mowing the lawn. Chest radiograph followed by a computed tomography angiogram revealed a metallic foreign body in the right middle lobe of the lung. The patient underwent a right anterolateral thoracotomy where the object was successfully retrieved. The patient had an uneventful postoperative recovery.

We report herein a case of nonmalignant middle lobe atelectasis of the right lung resulting in significant stenosis of the airway. The new short self-expandable metallic stents (SEMS) were used to perform temporary stenting and expansion of the right middle lobe airway. SEMS have been used to treat airway obstructions in the trachea, as well as the right and left carina, but few studies have looked at placing SEMS at the level of the bronchi, especially right middle lobe bronchus.

A 53‐year‐old man was admitted to our hospital with a history of a right lung nodule which had gradually increased in size. Wedge resection of the right middle lobe using video‐assisted thoracoscopic surgery (VATS) was performed and revealed a yellowish, soft, well circumscribed nodule. Histological analysis confirmed the diagnosis of an uncommon lipolymph node. The patient recovered well from surgery, and there has been no recurrence in the lung for over one‐year of follow‐up. To the best of our knowledge, this is the first report of a lipolymph node in the lung., Lipolymph nodes are defined as enlargement of lymph nodes caused by abnormal accumulation of fat, due to mature, benign adipocytes within lymph node capsules. To the best of our knowledge, this is the first report of a lipolymph node in the lung. Although rare and benign, lipolymph nodes should be considered in the differential diagnosis of pulmonary nodules.

A 62-year-old woman was referred to the pulmonary office for an incidentally identified solitary pulmonary nodule. The patient underwent CT of the abdomen and pelvis for evaluation of epigastric abdominal pain and was found to have a pulmonary nodule in the lateral segment of the right middle lobe (

BACKGROUND The nodular bronchiectatic (NB) form of non-tuberculous mycobacteria (NTM) lung disease usually involves the right middle lobe (RML) and the left upper lobe lingular segment. However, the reason underlying this preference is not known. METHODS Fifty patients with NB NTM lung disease who had both positive NTM culture(s) and NB lesions in the RML or lingular segment on computed tomography (CT) of the chest, and 100 healthy subjects matched for sex, age, height and body weight with normal chest CT, were randomly selected. Using reconstructed curved multiplanar reformation (MPR) images, the lengths, diameters and angles of the RML and lingular bronchi were measured. RESULTS Of the 150 individuals, 64% were female; the mean age was 55 years. The angles of the bronchi were significantly more acute in patients than in healthy subjects, both in the RML (patients, mean 46.75° ± standard deviation 8.87° vs. healthy subjects, mean 51.73° ± 7.76°; P = 0.001) and in the lingular segments (patients, mean 26.94° ± 8.16° vs. healthy subjects, mean 34.65° ± 9.75°; P < 0.001). In addition, the angles of the bronchi in the involved segments were more acute than those in the non-involved segments, both in the RML and the lingular segments. There were no differences in the lengths and bronchi diameters between groups. CONCLUSIONS An acute angle (obtuse slope) of RML/lingular bronchi could be an anatomical risk factor for NB NTM lung disease.

Objectives General thoracic surgeons must be familiar with anatomical variation in the pulmonary vessels and bronchi. Here, we analyzed the bronchovascular pattern of the right middle lobe (RML) and right lower lobe (RLL) of the lung using three-dimensional CT angiography and bronchography (3DCTAB). Methods We reviewed the anatomical patterns of the pulmonary vessels and bronchi in 270 patients using 3DCTAB images. Results The branching patterns of vessels and bronchi of RML and S6 were classified according to the number of stems. The single-stem type was the most common, except in the artery of the RML, for which the two-stem type was the most common. The artery and bronchus of S*, which is an independent segment between S6 and S10, were observed in 20.4% of cases. The branching pattern of A7 (B7) was classified into four types. The A7a (B7a) type was observed in 74.8% of cases, and was the most common. The branching pattern of the artery and bronchus of S8−10 was classified into five and three types, respectively. The A8 and A9 + A10 type, and the B8 and B9 + B10 type, were observed in 68.1 and 80.4% of cases, respectively, and were the most common types. The branching pattern of V8−10 was more complex than that of A8−10 and B8−10. Conclusion We explored the bronchovascular patterns of RML and RLL and their frequencies using a large number of 3DCTAB images. Our data can be used by thoracic surgeons to perform safe and precise lung resections. Electronic supplementary material The online version of this article (doi:10.1007/s11748-017-0754-4) contains supplementary material, which is available to authorized users.