CHYLOTHORAX EFFUSION OF LYMPH

Chylothorax : Effusion of lymph (chyle) into the pleural cavity is known as chylothorax. Chyle is clear-milky fluid with an elevated total protein and albumin level, a specific gravity above 1.012, the presence of WBC with lymphocyte predominance (80%), and elevated triglyceride (chylomicrons). In children is a potentially life-threatening disorder that has profound respiratory, nutritional (hypoalbuminemia), electrolyte (hyponatremia) and immunologic (lymphopenia, hypogammaglobulinemia, T-cell depletion) effects. Chylothorax has a congenital (mediastinal lymphangiomatosis), acquired or idiopathic origin. Acquired chylothorax is most commonly found; the result of a direct lesion of the thoracic duct or lymphatic vessels by trauma (thoracotomy, central venous catheters or chest tubes insertions), during cardiac surgery, mediastinal malignancy (neuroblastoma) or infection, repair of a diaphragmatic hernia or associated with superior vena cava obstruction (thrombosis).

Initial management consists of:
1- chest tube drainage after failed thoracentesis (pleural space tamponade),

2- medium-chain triglyceride enriched formula for a week (lymphatic decompression),

3- TPN if chylothorax increases or persists. More protracted course (4 week medical tx) will require surgery to locate and suture ruptured subpleural lymphatics, ligate the thoracic duct, do chemical pleurodesis or place a pleuroperitoneal shunt. Those associated with venous obstruction or increase right sided cardiac pressure produce more volume, persist longer and are more difficult to manage.