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Chylothorax

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Chylothorax

Chyle is a milky white fluid that contains protein, fat, cholesterol, lymphocytes, and electrolytes. It also contains a high amount of fibrinogen. Chlyle originates in the gut and is carried into the gastrointestinal tract, before traveling to the thoracic duct and reentering the vascular system near the left subclavian and internal jugular veins. Between 60% and 70% of ingested fat enters the bloodstream via the thoracic duct. Chyle is bacteriostatic and sterile because of its high lymphocyte count. 

Chylothorax occurs when chyle collects in the thoracic cavity and cannot drain from the thoracic duct into the subclavian vein. In children, it usually arises after throracic, particularly cardiothoracic, surgery, but is sometimes congenital. Evidence of chylothorax may not occur until 2–10 days following injury, but it sometimes is latent for several months following surgery. In adults, it is usually a symptom of lymphoma, especially non-Hodgkins. Cirrhosis, pancreatitis, tuberculosis, sarcoidosis, amyloidosis, neck trauma, and filariasis also may lead to the development of chylothorax. 

Risks of chylothorax
Chylothorax carries a significant risk of death, usually brought on by respiratory failure.

Management of chylothorax
Management includes:

  • Total parenteral nutrition or a very-low-fat enteral feeding to reduce lymph flow
  • Thoracentesis
  • Chest tube placement
  • Pleurodesis—sclerosing the pleura to the lung
  • Pleuroperitoneal shunt—removes the fluid from the thoracic cavity to the abdominal cavity, where it is reabsorbed
  • Surgical ligation of the thoracic duct
  • Octreotide (synthetic analogue of somatostatin) or somatostatin, infusion to control intestinal absorption of fats and intestinal blood flow and motility
  • Chemoradiation in patients with malignancies who cannot undergo surgery
  • Diuretics, usually spironolactone

Nutritional management of chylothorax
Nutritional management includes the following recommendations:

  • Giving total parenteral nutrition, fat-free enteral feeding, or enteral feeding of a formula that is very low in long-chain fatty acids
  • Using  medium-chain fatty acids, because they do not enter the lymphatic system; one study showed that trioctanoin is preferred over decanoic 
  • Including in a child’s diet no more that 1 gram (g) of long-chain triglycerides (LCT)/year of age, <20 g/day
  • Making sure to provide enough essential fatty acids to prevent deficiency
  • Providing patients who are eating with a very-low-fat diet that has adequate energy and is high in fruits, vegetables, rice, cereals, and fat-free sources of protein, such as skim milk and egg whites
  • Having a diet that is free of meat, fish, and poultry, which is likely necessary until the chylothorax has resolved
  • Adding a vitamin and mineral supplement is necessary
  • Offering the patient specialized nutritional management for 4–8 weeks (typically needed) 

Note: If a patient undergoes thoracentesis or chest tube placement, important proteins and fluids often are lost. Calculations show that the average patient losing 1 liter (L) of chyle/day would lose 420 g of fat and 420 g of protein within 1 week. 

 

References and recommended readings
cademy of Nutrition and Dietetics. Nutrition Care Manual®. Available to subscribers at: www.nutritioncaremanual.org. Accessed August 24, 2012.

Adams SD. Chylothorax. Available at: http://www.emedicine.com/med/topic381.htm. Accessed August 24, 2012. 

Buttiker V, Fanconi S, Burger R. Chylothorax in children. Chest [serial online]. 1999;116:682-687.

Cardillo K. Nutrition interventions for chylous effusions. Support Line. 2001;23:18-23.

Mikroulis D, Didilis V, Bitzikas G, Bougioukas G. Octreotide in the treatment of chylothorax. Chest. 2002;121:2079-2081.

Suddaby EC, Schiller S. Management of chylothorax in children. Pediatr Nurs. 2004;30:290-295.

 

Review Date 8/12
G-0691

 

G_0691_Chylothorax.doc

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