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ANSWER

There are persistent moderate, bilateral pleural effusions. There has been significant interval increase in the right-sided pleural effusion. The left lower lobe atelectasis continues to persist. There is increasing vessel haziness bilaterally. There are chest tubes bilaterally.

FURTHER HISTORY

A conservative approach was restarted including a MCT diet with vitamin supplements. After 1 week, this management proved to be unsuccessful. As a result, a trial with TPN with nothing by mouth was started. A decrease in the chylous drainage was noted. However, with restarting of the MCT feeds, a re-accumulation of the chylothorax occurred.

COMMENTS FROM THE VIDEO CONFERENCE:

1) What were the pressures tried on the chest tube?
A) A variety of pressures on the chest tube suction were tried. None of the changing pressures affected the drainage from the chest tube.

2) If a constant suction pressure is maintained on the chest tube, this encourages chylothorax as it creates a constant negative intra-pleural pressure.
A) The patient was discharged from the NICU without any drainage or chest tubes. Despite no drainage, JB presented back to the PICU with bilateral pleural effusions. Its unclear whether the RSV infection cuased the re-accumulation of the chylothorax or not.

FURTHER HISTORY

As a result of the persistent re-accumulation of chyle with feeds, intravenous somatostatin was tried. There was no change in drainage noted.

Somatostatin and Chylothorax (4,5)
For persistent chylothorax, somatostatin has been used to decrease chylothorax drainage. Although the mechanism of action is unclear, some of the potential mechanisms include:
– Decreased post prandial triglyceride levels
– Decreased hepatic venous pressure
– Mild sustained decreased splanchnic flow
– Decreased chylomicron flow from the gut
– Decreased protein loss.

Additionally, some investigators have postulated that somatostatin causes vasoconstriction of lymphatic vessels. A 4-month post-operative cardiac patient suffered from a persistent chylous drainage for 3 weeks. A somatostatin infusion was started and continued for 14 days with eventual resolution of effusion. A separate case series of 4 adult patients with persistent chylothorax (not candidates for a thoracotomy) were treated with a continuous infusion of somatostatin. None of the patient experienced any side effects and 3 had resolution of their chylothorax.

FURTHER HISTORY


Unfortunately for our patient, he had a persistent chylothorax despite maximal conservative therapy including a somatostatin infusion

Predictors of failure of Conservative management (6)
Within multiple trials, a number of patient factors have been identified that predict failure of conservative chylothorax management. Predominantly, increased lymphatic pressure is the common final pathway. This can occur as a result of: increased right sided heart pressures, caval-pulmonary anastomosis procedures or central venous thrombosis.


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