Chest
Volume 116, Issue 3, September 1999, Pages 682-687
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Clinical Investigations
The Pleura
Chylothorax in Children: Guidelines for Diagnosis and Management

https://doi.org/10.1378/chest.116.3.682Get rights and content

Study objective

To establish guidelines for the diagnosis and management of chylothorax in children.

Design

Retrospective study.

Patients

Fifty-one patients with a diagnosis of chylothorax. Twelve patients were excluded because of incomplete data or incorrect diagnosis. The following parameters were analyzed: triglyceride level, total cell number, and lymphocyte percentage; amount of pleural effusion on day of diagnosis, day 5, and day 14; and total time of pleural effusion. Prospectively, the same parameters were analyzed in a control group of 10 patients with pleural drainage.

Intervention

Patients with chylothorax were treated primarily with fat-free oral nutrition; if chyle did not stop, total parenteral nutrition with total enteric rest was started. If conservative therapy was not successful, pleurodesis was performed.

Results

In children with chylothorax triglyceride, triglyceride content ranged from 0.56 to 26.6 mmol/L; all values except one were > 1.1 mmol/L. In 36 of 39 patients (92%), the cell count was > 1,000 cells/μL. In 33 of 39 patients (85%), lymphocytes were > 90%. In patients without chylothorax triglyceride, triglyceride levels ranged from 0.1 to 0.71 mmol/L (median, 0.38 mmol/L) and cell count was from 20 to 1400 cells/μL (median, 322 cells/μL), with a maximum of 60% lymphocytes. With fat-free nutrition, chyle disappeared in 29 of 39 patients. Five patients died, and five required pleurodesis.

Conclusions

Pleural effusion in children is chyle when it contains > 1.1 mmol/L triglycerides (with oral fat intake) and has a total cell count ≥ 1,000 cells/μL, with a lymphocyte fraction > 80%. Chylous effusions usually last long; however, after 6 weeks, the majority of the effusions (29 of 39 patients) had ceased. Late surgical interventions reduce the number of thoracotomies substantially, but can lead to very long hospitalization times. Early surgical interventions (after < 3 weeks) lead to a high number of thoracotomies, but certainly reduce hospitalization time.

Section snippets

Materials and Methods

We retrospectively analyzed all patients with the diagnosis of chylothorax in our hospital database from the years 1985 to 1996. There were a total of 51 patients having this diagnosis, but we had to exclude 10 patients because of insufficient documentation. An additional two patients were excluded because an analysis of the available data dismissed the diagnosis of chylothorax.

The diagnosis of chylothorax was made according to the proposal of Staats et al4 and Straaten et al7: triglyceride

Results

There were 29 boys and 10 girls with the diagnosis of chylothorax. Their ages ranged from 5 days to 10.5 years old (median, 2.1 years old). The 10 patients in the control group were from 6 days to 7 years old (median, 1.3 years old). All received regular formula.

Thirty-three patients (85%) developed chylothorax after cardiac surgery. From the remaining six patients, two developed chylothorax after pneumonia. One of these patients had Down's syndrome; the second patient was a newborn baby with

Discussion

Chyle is lymphatic fluid enriched with fat secreted by intestinal cells. It is collected and then transported via the thoracic duct into the circulation. Measuring fat content and demonstrating the predominance of lymphocytes in pleural effusion serves to prove chyle. We used the definition of Staats et al4 to define chyle in our patients.

In our 39 patients, the diagnosis of chylothorax was confirmed by pleural effusion with a triglyceride level > 1.1 mmol/L and a cell count >1,000 cells/μL

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