Case Study: Chylothorax

1. Case Study: Chylothorax Victoria Moore

2. Introduction to the Problem • What is chylothorax? • The thoracic duct is a main lymphatic vessel that drains lymph into the blood, and is responsible for transferring about 4 L of lymphatic fluid from the intestinal region up towards the neck or jugular area (Healthline, 2015). • If the thoracic duct becomes obstructed or has a leakage the fluid will secrete into the space around the lungs (Maldonado et al., 2009). • Evidence of triglycerides, fat-soluble vitamins, and chylomicrons found in lymph makes the fluid appear white, and used to diagnose the problem (Lagarde et al., 2005).

3. Continued • There are primary and secondary causes to chylous fluid buildup (Campisi, 2006). Primary conditions are caused by cells proliferating in the lymphatic tissue, or secondary reasons could be explained by extensive abdominal procedures or sometimes found in cancer patients (Campisi et al., 2006). • There are minimal evidence-based studies for the treatment options of chylousascities(Campisi et al., 2006). • TPN and MCT oils • Multiple paracentesis and thoracentesis • Lymphatic corrective surgery

4. Diagnosis and Management • Diagnostic Procedures (Dori, 2014): • MRI • CT scan • Chest X-Ray • Lymphangiography, with contrast dye • Signs and Symptoms (Dori, 2014). • Chest Pain • Shortness of breath • Coughing

5. Diagnosis and Management Continued…. • Dietary Management (Campisi, et al., 2006): • Total parental nutrition has been previously studied and recommended over enteral nutrition, with the use of MCT oils. Medium chain triglycerides have been found to reduce the formation of chyle. Due to the phospholipids being directly sent to the blood stream they do not have to go through the lymphatic system (McCray and Parrish, 2004). • Medical Management (Campisi et al., 2006): • Removing fluid in the pertioneal cavity to release pressure • Removing fluid from the pleural areas

6. Introduction of the Subject • Patient is a 54 y/o female that came to the emergency room in late march with shortness of breath and coughing. A chest-xray was used to determine if the patient should be admitted as an inpatient. The CXR found opacities with mild to moderate pleural effusion primarily on the right side of the pt’s body. • Admitting Diagnosis: Hypoxic Respiratory Failure, Stenotrophomonas PNA, Debility, Right Pleural Effusions, AKI on CKD 3, Anemia of Chronic Disease, BMI>40, Fibromyalagia, Non-Alcoholic steatohepatitis, and bilateral stage 2 pressure ulcer on buttock

7. Food and Nutrition Related History • Pt normally cooked and prepared food for spouse. Both went grocery shopping together. • Self fed • Has been educated on diabetic diet in the past. However normally monitors fat intake, and sugar content of food. • Pt monitors blood glucose and short and long-acting insulin dosage. • Spouse stated that both pt and himself have limited exercise.

8. Anthropometric Measurements Height 5’ 4’’ Weight 288lbs BMI 53.3 IBW 119lbs, 261% IBW Adjusted Body weight 167lbs

9. Biochemical Data • Sodium 132mmol/L (low) • BUN 47mg/dL (high) • Creatinine 1.49mg/dL • Glucose 332mg/dL(high) • Calcium 7.7mg/dL (Low) • Phosphorus 2.3mg/dL (low) • Albumin 1.7gm/dL (low) • RBC 2.46million/cumm (low) • Hgb 8.5 grams/dL (low) • Hct 26.3% (low) • MCV 107 fL (high) • MCHC 34.7PG • RDW 16.2% • Platelet 80k/cumm

10. Medical Tests/Procedures for ChylothoraxDx • 3/29: CXR found stable cardiomegaly with complete opacification of the right hemithorax. Pulmonary vascular congestion is noted on the left with left lower lobe airspace disease/effusion • 3/29: Thoracic ultrasound: very large right effusion with atelectasis of the right lung with good lung flapping. Found significant decrease in right effusion which improved lung aeration after thoracentesis. • 2200ml red grapefruit colored fluid removed

11. Continued… • 3/30: catheter placement via the internal jugular vein: 220ml fluid removal with elevated triglycerides. • 4/1: Diagnosis of recurrent chylothorax: placement of larger tunneled pleural aspira catheter: 1500ml milky fluid removal *Pulmonary recommended every other day of fluid removal

12. Nutrition-Focused Physical Findings • Alert and oriented to time place and person, obesity present • CVS: Regular rate and rhythm • Chest: reduced air entry b/l. crackles present on the right side • GI : Soft non tender • Neuro: moving all 4 extremities, power appear to be normal • Skin : no rash • Musculoskeletal: no evidence of joint swelling or tenderness

13. Patient Past Medical History • Pancytopenia • Asthma • Chronic Frontal Sinusitis • CKD 3 • Cirrhosis • T2DM • Peripheral Neuropathy • Diverticulitis of the colon • Dyslipidemia • Hepatic Encephalopathy • Hypercholesterolemia • HTN • Hypoglycemia • Hypothyroidism • Rheumatoid Arthritis • Tachycardia • Insulin Resistance Syndrome • Pleural Effusions • Pressure Ulcers

14. Patient Social History • Denies alcohol use • Home/Environment Assessment: Lives with Spouse. • Living situation: Home/Independent. • Alcohol abuse in household: No. • Substance abuse in household: No. • Smoker in household: Yes. Family pmhx • Breast Cancer, T2DM (Aunts) • Colon Cancer (Mother) • Lung Cancer (Father)

15. Social History Continued Injuries/Abuse/Neglect in household: No. Feels unsafe at home: No. Safe place to go: Yes. Agency(s)/Others notified: No. Family/Friends available for support: Yes. • Concern for family members at home: No. Major illness in household: No. • Financial concerns: No. • Substance Abuse Assessment: Denies • Tobacco Use: Never Smoker.

16. Home medications • albuterol CFC free 90 mcg/inh inhalation aerosol • l aspirin 81 mg oral tablet • Bystolic 5 mg oral tablet • codeine-guaifenesin10 mg-100 mg/5 mL oral syrup • CombiventRespimat CFC free 20 mCg-100 mCg/inh inhalation aerosol • Dulera200 mcg-5 mcg/inh inhalation aerosol • Edecrin25 mg oral tablet • gabapentin 600 mg oral tablet insulin glargine • insulin lispro • lactulose 10 g/15 mL oral syrup • levothyroxine 0.075 mg (75 mCg )oral tablet • Livalo2 mg oral tablet • albuterol CFC free 90 mcg/inh inhalation aerosol • aspirin 81 mg oral tablet • nitroGLYCerin0.4 mg sublingual tablet • Ocean Nasal Moisturizer • Ocean nasal spray 0.65% • pantoprazole 40 mg oral delayed release tablet • Percocet 5 mg-325 mg oral tablet • Plavix 75 mg oral tablet • Qvar40 mcg/inh inhalation aerosol • SeptraDS 800 mg-160 mg oral tablet • Singulair10 mg oral tablet • Vitamin D2 50,000 intl units (1.25 mg) oral capsule • Zeasorb-AF 2% topical powder

17. Estimated Needs: • Calorie needs: 75.7kg x 25kcal/day = 1890kcal • Protein needs 75.7kg x >1.1g protein/day = 83g protein • Fluid needs: 75.7kg x 30ml fluid/day = 2270ml fluid

18. Nutrition Diagnosis Problem: Inadequate Oral Intake Related to Etiology: Recurrent chylothorax As Evidenced by Signs and Symptoms: 1.5 L drainage of cloudy fluid, need for nutrition support and clear liquid diet.

19. Nutrition Prescription • Patient will meet estimated protein and calorie needs mainly through TPN to control the rate of chyle formation with clear liquid diet until chlye output lessens then will increase PO intake and decrease rate of TPN. Pt to be on a 5 carbohydrate control diet for T2DM, with <10g of fat intake per MD orders.

20. Intervention #1 • Pt to meet nutrition needs through TPN and minimal PO intake • Pt to meet most of estimated calorie and protein needs through TPN w/o lipids in TPN • AA15% 500ml, D70% 400ml, L20% None • Pt to receive MCT oil • 15mL MCT 4 x daily • Pt will be on Clear Liquid diet • Ensure Clear with meals to provide pt with 600kcal and 21 g protein

21. Intervention #2 • Pt to meet nutrition needs through TPN with Vegetarian, <10g fat diet • Pt to meet most of estimated calorie and protein needs through TPN, lipids in TPN every other day • AA15% 550ml, D70% 400ml, L20% 100ml • Pt to be on vegetarian diet • Pt to be on vegetarian diet to increase PO intake • Pt to have <10g fat restriction • Pt to be on <10g fat restriction to minimize the intake of LCT to limit the production of chyle.

22. Intervention #3 • Pt to meet nutrition needs through TPN with 5 carbohydrate control diet, and <10g fat • Pt to meet most of estimated calorie and protein needs through TPN, lipids in TPN every other day • AA15% 550ml, D70% 50ml, L20% 100ml • Pt to have 5 carb control diet • Pt to be on 5 carb control diet for more food options and to help control elevated blood glucose • Pt to have <10g fat restriction • Pt to be on <10g fat restriction to minimize the intake of LCT to limit the production of chyle.

23. Intervention #4 • Pt to meet estimated calorie needs with 5 carb control diet with <10g fat once discharged • Pt to measure chyle fluid • Pt to understand the importance of measuring chyle fluid to note progress in recovery, in order to have chest tube removed. • Pt to follow 5 carb control diet • Pt to understand the importance of consuming only 5 carb choices per meal to help control blood glucose. • Pt to follow low fat diet until chest tube is removed • Pt to consume about < 10 grams of fat per day to limit the production of chyle.

24. Monitoring and Evaluation • RD follow up for PO intake • Initially pt did not like MCT oils. • RD ordered Prostat with meals, then discontinued due to low tolerance. • Pt was eating 100% of meals consistently through admission. • RD provided low fat diet education, as well as stressing the importance of watching carbohydrate intake at home. • Write Manage TPN daily to meet estimated calorie and protein needs • Monitor daily labs: pt consistently had elevated blood glucose. • Discussed pt and labs with pharmacist

25. Conclusion Diagnosis: • Diagnosed with recurrent chylothorax with significant chlye formation, due to thoracic duct secreting lymphatic fluid into the pleural space. • Interventions: • Pt received TPN with clear liquid diet to monitor Chyle production • Monitoring and Evaluation: • Pt was consuming 100% of meals prior to discharge • Daily follow up on labs, PO intake, and TPN tolerance • Provided pt with T2DM and low fat diet education materials

26. Conclusion • Two days after initial discharge with Dx of recurrent chylothorax with only 75ml chyle output, patient was readmitted when husband found pt to be difficult to arouse, and confused when awake. Pt admitted with elevated ammonia levels and astereixis (hand flapping). • Pt was on 4 carbohydrate control diet, low fat diet modifier, with improvement of chyle drainage. • EGD revealed GI bleed on second admission. • Pt recently discharged.

27. Resources • Campisi, C., Belline, C., Eretta, C., Zilli, A., Rin, E., Davini, D.,… Boccardo, F.(2006). Diagnosis and management of primary chylous ascites. Journal of Vascular Surgery, 43 (6), 1244-1248. doi: 10.1016/j.jvs.2005.11.064 • Dori, Y. (2014, 31 July) Chylothorax. Retrieved from: http://www.chop.edu/conditions- diseases/chylothorax#.V1de27Q-DGI • Healthline Medical Team. (2015, 2 March). Thoracic Duct. Retrieved from: http://www.healthline.com/human-body-maps/thoracic-duct • McCray, S., Parrish, C. R. (2004). When chlye leaks: nutrition management options. Practical Gastroenterology, 17, 60-76. Retrieved from: http://www.nutricritical.com.br/core/files/figuras/file/Chyle%20leaks.pdf • http://www.daviddarling.info/encyclopedia/T/thoracic_duct.html (picture) • Largarde, S. M., Omloo, J. M. T., Jong, K., Busch, O. R. C., Obertop, H., Lanschot, J. J. B. (2005). Incidence and management of chlye leakage after esophagectomy. The Society of Thoracic Surgeions, 80, 449-454. doi: 10.1016/j.athoracsur.2005.02.076 • Maldonado, F., Hawkins, F. J., Daniels, C. E., Doerr, C. H., Decker, P. A., Ryu, J. H. (2009). Pleural Fluid Characteristicsof Chylothorax. Mayo ClinicProceedings, 84 (2),129-133. doi: 10.1016/S0025- 6196(11)60820-3.

28. Questions/Comments