PC1180: A Curious Sequela of Cough and Hyperinflation: Exploring a Presentation of Pediatric Lung Herniation

Introduction: Lung herniation occurs when lung parenchyma extends beyond the usual limits within the thoracic space. It has been described in adult literature and is often associated with trauma or risk factors such as obesity, smoking, and COPD. It is rare in the pediatric population and previous cases have mostly been attributed to congenital anomalies or extrinsic trauma. This report describes a case of transient cervical lung herniation in a four year old presenting with persistent cough.

Case Description: A four year old with a history of asthma initially presented to the ED with wheezing, barky cough and was diagnosed with croup and acute asthma exacerbation. After being treated and discharged home in stable condition, the patient presented to care multiple times due to return of symptoms with similar diagnosis and disposition. Two weeks into the waxing and waning illness course, the patient presented yet again with continued symptoms of cough and post-tussive emesis. Most unsettling to the family was the severity, as the cough was now causing pain, encopresis, loss of sleep, and limiting oral intake.

The child was afebrile with normal vitals, intermittent barky cough with an otherwise normal exam. CXR revealed no focal consolidation but showed right apical lung herniation with mass effect and leftward tracheal displacement (Figure 1). Pediatric surgery was consulted and recommended non-contrast CT which showed no herniation. Radiology recommended follow up with fluoroscopic Xray which revealed transient herniation of the right upper lung into the lower neck with cough, but complete reduction in between without significant mass effect on the airway (Figure 2). The patient was again treated, observed overnight, and remained stable for discharge after 24hrs of observation.

Discussion: This young child was diagnosed with transient lung herniation in setting of severe cough. Though this particular case was benign and self-limited, lung herniation should be considered when there is history of exposure to increased intrathoracic pressure, especially in individuals with underlying obstructive lung disease. Key physical exam components include airway assessment, lung auscultation, and palpation for bulging neck or thoracic masses, particularly to rule out surgical emergencies of lung tissue incarceration or airway compromise due to tracheal compression. A suspected diagnosis warrants prompt radiologic evaluation with dynamic imaging such as fluoroscopic Xray and surgical evaluation. Transient defects in hemodynamically stable children may be managed expectantly, while fixed defects require surgical repair.

Conclusion: There are few reports of pediatric lung herniation in the existing literature and this case describes an uncommon acquired presentation in a preschool aged patient, highlighting inciting factors with appropriate steps for evaluation. This rare phenomenon is important to recognize for potential emergent complications including airway compromise or damage to the lung tissue itself.