There can be honest disagreement among experts about the management of RML atelectasis, bronchiectasis and recurrent pneumonia, despite appropriate, intense medical treatment, in young children with a normal immune system. There is general agreement, however that, when localized bronchiectasis, especially of the RML, becomes refractory, more severe or resistant to medical management, lobar resection may be warranted. If I were to describe surgery as a last resort, it would be because it would be definitive therapy, not because it performed in desperation. There has been significant experience with the less surgically invasive video-assisted thorascopic (VATS) surgical approach at a number of major medical centers.
In this circumstance in which your daughter’s pulmonologist seems to be adamantly opposed to surgical resection of her RML, presumably justifiably based on evidence-based medical literature and his personal experience, I believe it would be wise for you to request a second opinion from a pediatric pulmonologist of fine repute, if for no other reason than to put your mind at ease that you have done your best in your daughter’s behalf.
A couple more details..she's had extensive immune system testing. All normal. Allergy tests all negative. Sweat chloride test normal. She's had 3 hospitalizations, first 2 for rsv/pneumonia, the 3rd for metapneumovirus and pneumonia. We've been doing pulmicort and now qvar for the past two years.
Her CT scan was with contrast. Bronchoscopy showed the middle lobe was inflamed and the lavage fluid was tinted pink, indicating inflamation. She has some " tight takeoffs" in this middle lobe, per the pulmonologist