Pediatric emergency medicine trisk 4096 4096
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investment and is separated from the normal lung parenchyma. Sequelae of BPS
can be respiratory, with symptoms of respiratory distress or feeding intolerance,
or circulatory, in which substantial arteriovenous shunting can occur within the
sequestered lobe, leading to high-output cardiac failure. Case reports of
associations between BPS and diaphragmatic abnormalities have been described.
Clinical Recognition
Recurrent respiratory infections often lead to a chest radiograph, which
demonstrates an abnormal lesion. These lesions can appear as hyperaerated
segments of lung, lung containing air–fluid levels in the instance of CPAM (Fig.
124.7 ), or as solid masses in BPS. As mentioned, clinical findings may be
identical to those of a lobar pneumonia. Occasionally, a lesion is discovered in
older patients in the setting of recurrent lobar pneumonia or after an empyema
fails to recover with appropriate management.
Management
Chest radiographs in the PA, lateral, and decubitus positions should be obtained
to evaluate any areas with air–fluid levels. Patients with significant respiratory
symptoms, fever, or significant abnormality on chest film should be admitted for
further evaluation and treatment. When a CPAM or BPS is suspected, a CT scan
with IV contrast (ideally, a CT angiogram) should be obtained to better delineate
the lesion and to identify any possible systemic blood supply. Because the blood
supply may arise from below the diaphragm in up to 20% of cases of BPS, the
scan should include both the chest and the upper abdomen. Arteriography is
seldom necessary with currently available imaging techniques. The CT scan will
likely exclude other conditions that may present similarly, such as a
diaphragmatic hernia, postpneumonic pneumatoceles, or esophageal duplication.
In the setting of infection, any pathogens identified in the sputum should be
treated with appropriate antibiotics. After control of superimposed infection, the
lesion should be resected to prevent recurrent infection. Attempted aspiration of
the cystic lesions or placement of a chest tube is to be avoided because it may
lead to spread of infection into the pleural space.
Surgical resection is indicated for all identified CPAM and BPS lesions. For
young, asymptomatic patients, resection can occur electively. For patients who
present with infection, resection is typically deferred until 6 to 8 weeks after the
resolution of the infection, as resection during the acute phase of inflammation is
associated with a higher rate of complications. Resection can be accomplished
