Transcript Case Study Presentation

CASE STUDY: CHYLOTHORAX
Victoria Moore
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).
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
chylous ascities (Campisi et al., 2006).
• TPN and MCT oils
• Multiple paracentesis and thoracentesis
• Lymphatic corrective surgery
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
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
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
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.
Anthropometric Measurements
Height 5’ 4’’
Weight 288lbs
BMI 53.3
IBW 119lbs, 261% IBW
Adjusted Body weight 167lbs
Biochemical Data
• Sodium 132mmol/L (low)
• RBC 2.46million/cumm (low)
• BUN 47mg/dL (high)
• Hgb 8.5 grams/dL (low)
• Creatinine 1.49mg/dL
• Hct 26.3% (low)
• Glucose 332mg/dL(high)
• MCV 107 fL (high)
• Calcium 7.7mg/dL (Low)
• MCHC 34.7PG
• Phosphorus 2.3mg/dL (low)
• RDW 16.2%
• Albumin 1.7gm/dL (low)
• Platelet 80k/cumm
Medical Tests/Procedures for
Chylothorax Dx
• 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
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
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
Patient Past Medical History
• Pancytopenia
• Hepatic Encephalopathy
• Asthma
• Hypercholesterolemia
• Chronic Frontal Sinusitis
• HTN
• CKD 3
• Hypoglycemia
• Cirrhosis
• Hypothyroidism
• T2DM
• Rheumatoid Arthritis
• Peripheral Neuropathy
• Tachycardia
• Diverticulitis of the colon
• Insulin Resistance Syndrome
• Dyslipidemia
• Pleural Effusions
• Pressure Ulcers
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)
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.
Home medications
• albuterol CFC free 90 mcg/inh inhalation aerosol
• albuterol CFC free 90 mcg/inh inhalation aerosol
• l aspirin 81 mg oral tablet
• aspirin 81 mg oral tablet
• Bystolic 5 mg oral tablet
• nitroGLYCerin 0.4 mg sublingual tablet
• codeine-guaifenesin 10 mg-100 mg/5 mL oral
syrup
• Ocean Nasal Moisturizer
• Combivent Respimat CFC free 20 mCg-100
mCg/inh inhalation aerosol
• pantoprazole 40 mg oral delayed release tablet
• Ocean nasal spray 0.65%
• Dulera 200 mcg-5 mcg/inh inhalation aerosol
• Percocet 5 mg-325 mg oral tablet
• Edecrin 25 mg oral tablet
• Plavix 75 mg oral tablet
• gabapentin 600 mg oral tablet insulin glargine
• Qvar 40 mcg/inh inhalation aerosol
• insulin lispro
• Septra DS 800 mg-160 mg oral tablet
• lactulose 10 g/15 mL oral syrup
• Singulair 10 mg oral tablet
• levothyroxine 0.075 mg (75 mCg )oral tablet
• Vitamin D2 50,000 intl units (1.25 mg) oral capsule
• Livalo 2 mg oral tablet
• Zeasorb-AF 2% topical powder
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
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.
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.
Intervention #1
• Pt to meet nutrition needs through TPN and minimal PO intake
1. Pt to meet most of estimated calorie and protein needs through TPN w/o lipids in TPN
• AA15% 500ml, D70% 400ml, L20% None
2. Pt to receive MCT oil
• 15mL MCT 4 x daily
3. Pt will be on Clear Liquid diet
• Ensure Clear with meals to provide pt with 600kcal and 21 g protein
Intervention #2
• Pt to meet nutrition needs through TPN with Vegetarian, <10g fat diet
1. Pt to meet most of estimated calorie and protein needs through TPN, lipids in TPN
every other day
• AA15% 550ml, D70% 400ml, L20% 100ml
2. Pt to be on vegetarian diet
• Pt to be on vegetarian diet to increase PO intake
3. 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.
Intervention #3
• Pt to meet nutrition needs through TPN with 5 carbohydrate control diet, and <10g fat
1. Pt to meet most of estimated calorie and protein needs through TPN, lipids in TPN
every other day
• AA15% 550ml, D70% 50ml, L20% 100ml
2. 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
3. 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.
Intervention #4
• Pt to meet estimated calorie needs with 5 carb control diet with <10g fat once
discharged
1. 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.
2. 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.
3. 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.
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
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
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.
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/conditionsdiseases/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
Characteristics of Chylothorax. Mayo Clinic Proceedings, 84 (2),129-133. doi: 10.1016/S00256196(11)60820-3.
QUESTIONS/COMMENTS