Congenital lobar emphysema: Pitfalls in diagnosis.

Sir,

I read with interest the article titled “Congenital lobar emphysema: Pitfalls in diagnosis”[1] and would like to furnish the following comments. Congenital lobar emphysema (CLE) is an uncommon life-threatening pulmonary abnormality that is characterized by progressive hyperinflation of one or more of the pulmonary lobes due to intrinsic or extrinsic airway obstruction and lead to the creation of a “ball-valve” mechanism in which a greater volume of air enters the affected lobe during inspiration than leaves during expiration, leading to air trapping as it is end result.

Lobectomy is the universally accepted treatment of CLE with severe symptoms. However, trained pediatric thoracic surgeons are not everywhere available.

I had a case of symptomatic CLE that had been diagnosed when he was 25-day-old with affecting his right upper lobe. I had done fiberoptic flexible bronchoscopy under only mild sedation induced by low dose of propofol and noticed that his anterior (B2) bronchus was narrow, flaccid, and showed an expiratory check valve obstruction [Figure 1].

Figure 1

Bronchoscopy view of narrow and flaccid right upper lobe (B2) bronchus

By passing and inflating an angioplasty balloon through bronchoscope working channel, I had succeeded to release the air that was trapped in the right upper lid [Figure 2]. Following the procedure clinical and radiological manifestations of the infant were resolved completely without any complications.

Figure 2

Right B2 bronchus after dilatation

Based on my experience, fiberoptic flexible bronchoscopy can be used as a tool for diagnosis and relief of obstruction. In certain situations including expertise bronchoscopist and good facilities, performing bronchoscopy may be lifesaving with less surgical complication, especially in places and settings where emergency lobectomy cannot be arranged.

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