Pleural effusions in the neonate

Acute respiratory compromise in the NICU

Acute respiratory compromise (ARC) is a significant and frequent emergency in the Neonatal Intensive Care Unit (NICU), characterized by absent, agonal, or inadequate respiration that necessitates an immediate response. The primary etiologies of ARC in neonates can be categorized into upper and lower airway issues, disordered control of breathing, and lung tissue disease. ARC events are particularly dangerous as they compromise oxygen delivery and carbon dioxide removal, potentially leading to cardiopulmonary arrest. Approximately 1 % of NICU admissions experience cardiopulmonary arrest, and ARC is the primary cause of most events. This article provides a comprehensive review of the etiologies of ARC, including anatomical abnormalities, syndromic disorders, airway obstruction, and pulmonary diseases such as bronchopulmonary dysplasia and pneumonia. Management strategies include the use of continuous positive airway pressure, positive pressure ventilation, and advanced interventions like extracorporeal membrane oxygenation (ECMO) in cases of severe respiratory distress. Additionally, quality improvement initiatives aimed at reducing incidents such as unplanned extubations (UE) are discussed, along with emergency responses to ARC, which often require multidisciplinary collaboration and advanced airway management. The article emphasizes the importance of preparedness, training, and structured emergency protocols to ARC in the NICU to optimize patient care.

Neonatal pleural effusion associated with pulmonary sequestration: A case report

Pleural effusion is rare during neonatal period with an estimated prevalence of 0.06%. It may sometimes uncommonly be secondary to pulmonary sequestration. Besides common conditions like hydrops fetalis, congenital heart disease, congenital chylothorax, chromosomal abnormalities; pulmonary sequestration should also be considered while evaluating the cause for neonatal pleural effusion.

Fusion imaging of single-photon emission computed tomography and magnetic resonance lymphangiography for post-Fontan chylothorax

A preschool male patient with an extensive cardiac surgical history developed refractory chylothorax after a total cavopulmonary connection. Neither lymphoscintigraphy nor single-photon emission computed tomography (SPECT)/computed tomography could identify the lymphatic system leakage sites. Non-contrast heavy T2-weighted magnetic resonance lymphangiography (MRL) was performed to visualize the lymphatic system. Nevertheless, distinguishing lymphatic ducts from other watery structures of the patient remained difficult. Therefore, non-contrast MRL and SPECT images were fused. This hybrid diagnostic tool elucidated the pathophysiology of the prolonged chylothorax; pulmonary lymphatic perfusion syndrome and illustrated the anatomical connection of the thoracic duct and an abnormally dilated lymphatic network in the neck and left hilar regions. Subsequent intranodal lymphangiography with ethiodized oil confirmed these findings. SPECT/MRL may become an alternative modality for revealing the mechanism of prolonged chylothorax by visualizing the lymphatic system when dynamic contrast-enhanced magnetic resonance lymphangiography is unavailable.

Long-term outcome of cases of fetal pleural effusion: A study at a single perinatal center in Japan

PURPOSE

To analyze the long-term prognosis of primary and secondary fetal pleural effusion (FPE).

METHODS

We investigated all cases of FPE in a single University hospital (2005-2020). Cases were classified as primary (cases with only pleural effusion) and secondary (cases with other abnormalities such as chromosomal abnormalities or fetal cardiac failure). We retrospectively reviewed the medical records from the time of diagnosis, to assess medical procedures performed, chromosomal test results, and clinical outcomes.

RESULTS

Among 18 027 deliveries, 17 FPEs were identified (primary FPE: 8, secondary FPE: 9). Most primary FPEs were diagnosed in the second trimester of pregnancy, while all secondary FPEs were diagnosed in the third trimester. Secondary FPE was often associated with chromosomal abnormalities, including trisomy 21. The prognosis of pleural effusion caused by trisomy 21 was relatively good, except for cases with TAM. Cases of secondary FPE without trisomy 21 were of cardiac origin, and the neonatal prognosis was poor. The short-term prognosis was better in the primary FPE group, but long-term follow-up identified conditions such as acute encephalitis with refractory, repetitive partial seizures, developmental delay and attention deficit hyperactivity disorder.

CONCLUSION

Fetal pleural effusion without the presence of chromosomal abnormalities or morphologies has a good short-term prognosis, but the long-term prognosis is poor. Thus, long-term follow-up is necessary for all cases of fetal pleural effusion.

Chylothorax in the neonate-A stepwise approach algorithm

BACKGROUND

Chylothorax in neonates results from leakage of lymph from thoracic lymphatic ducts and is mainly congenital or posttraumatic. The clinical course of the effusion is heterogeneous, and consensus on treatment, timing, and modalities of measures has not yet been established. This review aims to present, along with levels of evidence and recommendation grades, all current therapeutic possibilities for the treatment of chylothorax in neonates.

METHODS

An extensive search of publications between 1970 and 2020 was performed in the PubMed, Cochrane Database of Systematic Reviews, and UpToDate databases. A stepwise approach algorithm was proposed for both congenital and traumatic conditions to guide the clinician in a rational and systematic way for approaching the treatment of neonates with chylothorax.

DISCUSSION AND CONCLUSION

The treatment strategy for neonatal chylothorax generally involves supportive care and includes drainage and procedures to reduce chyle flow. A stepwise approach starting with the least invasive method is advocated. Progression in the invasiveness of treatment options is determined by the response to previous treatments. A practical stepwise approach algorithm is proposed for both, congenital and traumatic chylothoraces.

Congenital Chylothorax of the Newborn: A Systematic Analysis of Published Cases between 1990 and 2018

BACKGROUND

Congenital chylothorax (CCT) of the newborn is a rare entity but the most common cause of pleural effusion in this age-group. We aimed to find the optimal treatment strategy.

MATERIAL AND METHODS

A PubMed search was performed according to the PRISMA criteria. All cases were analyzed according to prenatal, perinatal, and postnatal treatment modalities and follow-ups.

RESULTS

We identified 753 cases from 157 studies published between 1990 and 2018. The all-cause mortality rate was 28%. Prematurity was present in 71%, male gender dominated 57%, mean gestational age was 34 weeks, and birth weight was 2,654 g. Seventy-nine percent of newborns had bilateral CCT, the most common associated congenital anomalies with CCT were pulmonary lymphangiectasia and pulmonary hypoplasia, and the most common chromosomal aberrations were Down, Noonan, and Turner syndromes, respectively. Mechanical ventilation was reported in 381 cases for mean 17 (range 1-120) days; pleural punctuations and drainages were performed in 32% and 64%, respectively. Forty-four percent received total parenteral nutrition (TPN) for mean 21 days, 46% medium-chain triglyceride (MCT) diet for mean 37 days, 20% octreotide, and 3% somatostatin; chemical pleurodesis was performed in 116 cases, and surgery was reported in 48 cases with a success rate of 69%. In 462 cases (68%), complete restitution was reported; in 34 of 44 cases (77%), intrauterine intervention was carried out.

CONCLUSION

Respiratory support, pleural drainages, TPN, and MCT diet as octreotide remain to be the cornerstones of CCT management. Pleurodesis with OK-432 done prenatally and povidone-iodine postnatally might be discussed for use in life-threatening CCT.

Loculated empyema in a neonate successfully treated with chest tube thoracostomy and antibiotics

Empyema thoracis, defined as the accumulation of pus in the pleural space, is a rare entity in the neonatal period. There are very few cases described in the medical literature and there are still no treatment protocols in the management of empyema in neonates. In older infants and children, intrapleural fibrinolytics and surgery are often utilized since treatment of complicated parapneumonic effusions with chest tube and antibiotics alone often fail due to the viscous fluid and presence of loculations. Presented here is a case of a term neonate who exhibited symptoms of respiratory distress on the sixth day of life. Imaging modalities revealed massive left sided pleural effusion with loculations and mass effects. Pleural fluid was grossly pus and exudative in nature. Gram stain revealed gram-positive cocci but culture was negative. Empiric broad-spectrum antibiotics and chest tube drainage were utilized and patient was discharged after forty-seven days of hospital admission. In spite of prolonged hospital stay, patient survived with no complications. Therefore, nonoperative therapy could still be an option for neonates with loculated empyema. The key to success in treatment is immediate identification of effusion, prompt initiation of antibiotics, and early effective chest tube drainage.

Fetal pleural effusion and Down syndrome

Fetal pleural effusion is a rare abnormality that results from accumulation of fluid in the chest cavity. It can be classified as primary fetal hydrothorax and secondary fetal hydrothorax. The underlying causes of pleural effusion are still unknown, and the current treatment strategies are mainly based on symptoms. The prognosis of fetal pleural effusion varies significantly, ranging from spontaneous resolution to perinatal death. Recent advances in prenatal diagnostic methods and treatment such as thoracoamniotic shunting have significantly improved the survival rates for patients with or without hydrops.

Retrograde Lymph Flow Leads to Chylothorax in Transgenic Mice with Lymphatic Malformations

Chylous pleural effusion (chylothorax) frequently accompanies lymphatic vessel malformations and other conditions with lymphatic defects. Although retrograde flow of chyle from the thoracic duct is considered a potential mechanism underlying chylothorax in patients and mouse models, the path chyle takes to reach the thoracic cavity is unclear. Herein, we use a novel transgenic mouse model, where doxycycline-induced overexpression of vascular endothelial growth factor (VEGF)-C was driven by the adipocyte-specific promoter adiponectin (ADN), to determine how chylothorax forms. Surprisingly, 100% of adult ADN-VEGF-C mice developed chylothorax within 7 days. Rapid, consistent appearance of chylothorax enabled us to examine the step-by-step development in otherwise normal adult mice. Dynamic imaging with a fluorescent tracer revealed that lymph in the thoracic duct of these mice could enter the thoracic cavity by retrograde flow into enlarged paravertebral lymphatics and subpleural lymphatic plexuses that had incompetent lymphatic valves. Pleural mesothelium overlying the lymphatic plexuses underwent exfoliation that increased during doxycycline exposure. Together, the findings indicate that chylothorax in ADN-VEGF-C mice results from retrograde flow of chyle from the thoracic duct into lymphatic tributaries with defective valves. Chyle extravasates from these plexuses and enters the thoracic cavity through exfoliated regions of the pleural mesothelium.

Congenital pleural effusions: 15 years single-centre experience from North-East England

AIM

The aim of this study is to add to the scant literature on congenital pleural effusions to aid counselling and clinical management decisions.

METHODS

Retrospective case series of 15 years of congenital pleural effusions resulting in live birth in a single tertiary foetal medicine/neonatal centre in North East England.

RESULTS

Data were available for 21 infants. Mortality rates were 43% overall. All spontaneous resolution occurred within 9 d, and active management was used where effusions persisted beyond this.

CONCLUSION

Prematurity was associated with a poor prognosis. Resolution without active management occurred before day 10 and active strategies should be considered by this time.

Bilateral spontaneous chylothorax after severe vomiting in children

Objective:

To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting.

Case description:

Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings.

Comments:

Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.

Bilateral spontaneous chylothorax after severe vomiting in children

OBJECTIVE

To report the case of a child with bilateral chylothorax due to infrequent etiology: thoracic duct injury after severe vomiting.

CASE DESCRIPTION

Girl, 7 years old, with chronic facial swelling started after hyperemesis. During examination, she also presented with bilateral pleural effusion, with chylous fluid obtained during thoracentesis. After extensive clinical, laboratory, and radiological investigation of the chylothorax etiology, it was found to be secondary to thoracic duct injury by the increased intrathoracic pressure caused by the initial manifestation of vomiting, supported by lymphoscintigraphy findings.

COMMENTS

Except for the neonatal period, chylothorax is an infrequent finding of pleural effusion in children. There are various causes, including trauma, malignancy, infection, and inflammatory diseases; however, the etiology described in this study is poorly reported in the literature.

Prenatal Therapy Improves the Survival of Premature Infants with Congenital Chylothorax

BACKGROUND

Chylothorax is a rare condition among neonates, although it is considered clinically significant, as it is difficult to manage in these patients. In addition, the course of chylothorax varies widely. Therefore, we aimed to elucidate the clinical features and effect of prenatal therapy on the prognosis of congenital chylothorax in neonates.

METHODS

We retrospectively reviewed the medical records of all infants with congenital chylothorax who were admitted to National Taiwan University Hospital, Taipei, Taiwan between January 2000 and December 2012. Their demographic characteristics, as well as their antenatal, perinatal, and postnatal information, were collected for our analysis of the mortality risk.

RESULTS

We found 29 infants who were diagnosed with congenital chylothorax during the study period. The median gestational age at birth was 34 weeks (range, 28-41 weeks), and 71% of the infants presented with hydrops fetalis. Most cases of congenital chylothorax were bilateral (bilateral: 86.2%, unilateral: 13.79%), and the overall survival rate was 59.6%. Among the cases with a prenatal diagnosis at ≤ 34 weeks of gestation, infants who received prenatal therapy had a significantly higher survival rate, compared to infants who did not receive prenatal therapy (76.9% vs. 11%, respectively; p = 0.008).

CONCLUSION

We found that infants whose chylothorax was diagnosed ≤ 34 weeks of gestation, and who subsequently received prenatal therapy, experienced a better perinatal condition and exhibited improved postnatal outcomes.

Thoracoscopic pleural clipping for the management of congenital chylothorax

PURPOSE

Medical management of congenital chylothoraces consists of total parental nutrition and tube thoracostomy. However, these infants are exposed to significant fluid shifts and the related leukopenia carries a high infection risk. The purpose of this review is to describe the technique of parietal pleural clipping as a surgical treatment of congenital chylothorax.

METHODS

The medical records of all patients with a chylothorax diagnosis during the study period of January 2002 to April 2014 were retrospectively reviewed.

RESULTS

Six of 14 infants identified underwent thoracoscopic parietal pleural clipping to disrupt the pleural lymphatic channel flow as visualization of the thoracic duct and lymphatics was not possible. Nearly all surgical patients had bilateral disease (5/6). Resolution of chylous leakage was dramatic following parietal clipping. In the surgical patients, chest tube output 2 days prior to surgery averaged 86.96 ml/kg/day. After parietal clipping, chest tube output dropped to an average of 6.5 ml/kg/day on post op day 2. Thereafter, chest tube output remained low to negligible and chest tubes were removed variably as enteral feeds were started.

CONCLUSIONS

We describe a straightforward technique of thoracoscopic parietal pleural clipping as a safe and successful option for treatment of congenital chylothoraces.

Successful embolization and long-term follow-up of a rare neonatal diaphragmatic hemangioma

Background:

Congenital hemangioma of the diaphragm is an extremely rare disease in childhood.

Methods:

We report a newborn presenting with progressive respiratory distress and massive right hydrothorax due to congenital diaphragmatic hemangioma, requiring sustained ventilation support and chest drainage. The angiography revealed that the giant diaphragmatic hemangioma was supplied by the right internal thoracic, inferior diaphragmatic, and intercostal arteries. The selective embolization of the main feeding vessels was successfully achieved using the Embosphere particulates.

Results:

The clinical long-term follow-up demonstrated the resolution of the symptoms, pleural effusion, and nearly complete regression of the hemangioma at 18 months of age.

Conclusion:

Transcatheter embolization can provide an efficient therapy for symptomatic diaphramatic hemangioma.

Chylothorax and chylous ascites: management and pitfalls

Leakage of lymph from the lymphatic ducts causes chylothorax (CT) or chylous ascitis (CA). This may happen for unknown reasons during fetal life or after birth and may also be caused by trauma after thoracic surgery or by other conditions. Fetal CT and CA may be lethal particularly in cases with fetal hydrops that sometimes benefit of intra-uterine instrumentation. After birth, symptoms are related to the amount of accumulated fluid. Sometimes, severe cardio-respiratory compromise prompts active therapy. Most patients with CT or CA benefit from observation, rest, and supportive measures alone. Drainage of the fluid may be necessary, but then loss of protein, fat, and lymphoid cells introduce new risks and require careful replacement. Low-fat diets with MCT and parenteral nutrition decrease fluid production while allowing adequate nutritional input. If lymph leakage does not stop, secretion inhibitors like somatostatin or octreotide are prescribed, although there is only weak evidence of their benefits. Imaging of the lymphatic system is indicated when the leaks persist, but this is technically demanding in children. Shunting of the lymph from one body space to another by means of valved catheters, embolization of the thoracic duct, and/or ligation of the major lymphatics may occasionally be indicated in cases refractory to all other treatments.

Mid-term follow-up of neonatal pleural effusion

OBJECTIVES

To investigate the clinical course and mid-term prognosis of neonates admitted with pleural effusion.

METHODS

Case records of 38 neonates admitted with pleural effusion were retrieved and analyzed.

RESULTS

16 (42%) patients had congenital and 22 (58%) patients had acquired causes of pleural effusion. The most common causes of congenital pleural effusion and acquired pleural effusion were chylothorax (18%) and congestive heart failure (13%), respectively. Poorer outcome was observed with fetal hydrops, preterm birth (<34 weeks) and associated defects.

CONCLUSION

Most of the neonates with pleural effusion have good outcome in the mid-term follow-up.

Outcomes of fetal intervention for primary hydrothorax

OBJECTIVE

Primary hydrothorax is a rare congenital anomaly with outcomes ranging from spontaneous resolution to fetal demise. We reviewed our experience with fetuses diagnosed with primary hydrothorax to evaluate prenatal management strategies.

METHODS

We reviewed the records of patients evaluated for fetal pleural effusions at our Fetal Treatment Center between 1996 and 2013. To define fetuses with primary hydrothorax, we excluded those with structural or genetic anomalies, diffuse lymphangiectasia, immune hydrops, and monochorionic diamniotic twin gestations.

RESULTS

We identified 31 fetuses with primary hydrothorax, of whom 24 had hydrops. Hydropic fetuses were more likely to present with bilateral effusions. Of all fetuses with primary hydrothorax, 21 had fetal interventions. Survival without hydrops was 7/7 (100%), whereas survival with hydrops depended on whether or not the patient had fetal intervention: 12/19 (63%) with intervention and 1/5 (20%) without intervention. Premature delivery was common (44%) among those who had fetal intervention.

CONCLUSIONS

Fetal intervention for primary hydrothorax may lead to resolution of hydrops, but preterm birth and neonatal demise still occur. Understanding the pathophysiology of hydrops may provide insights into further prenatal management strategies, including targeted therapies to prevent preterm labor.

Chylothorax in infants and children

Chylothorax, the accumulation of chyle in the pleural space, is a relatively rare cause of pleural effusion in children. It can cause significant respiratory morbidity, as well as lead to malnutrition and immunodeficiency. Thus, a chylothorax requires timely diagnosis and treatment. This review will first discuss the anatomy and physiology of the lymphatic system and discuss various causes that can lead to development of a chylothorax in infants and children. Then, methods of diagnosis and treatment will be reviewed. Finally, complications of chylothorax will be reviewed.

Successful pleurodesis with OK-432 in preterm infants with persistent pleural effusion

OK-432 (picibanil) is an inactivated preparation of Streptococcus pyogenes that causes pleurodesis by inducing a strong inflammatory response. Intrapleural instillation of OK-432 has recently been used to successfully treat neonatal and fetal chylothorax. Here we report a trial of intrapleural instillation of OK-432 in two preterm infants who were born with hydrops fetalis and massive bilateral pleural effusion. Both cases showed persistent pleural effusion, refractory to conservative treatment, up to postnatal days 26 and 46, respectively. An average of 80 to 140 mL of pleural fluid was drained daily. In case 1, the infant was treated with OK-432 during the fetal period at gestation 28 weeks and 4 days of gestation, but showed recurrence of pleural effusion and progressed into hydrops. Within two to three days after OK-432 injection, the amount of pleural fluid drainage was dramatically decreased and there was no reaccumulation. We did not observe any side effects related to OK-432 injection. We suggest that OK-432 should be considered as a therapeutic option in infants who have persistent pleural effusion for more than four weeks, with the expectation of the early removal of the chest tube and a good outcome.

Is octreotide treatment useful in patients with congenital chylothorax?

BACKGROUND

Congenital chylothorax (CC) is a severe congenital disorder characterized by the collection of chyle in the pleural space. Recent case reports suggest that the use of octreotide in the treatment of CC may be useful.

OBJECTIVE

To evaluate the effect of octreotide on pleural effusions in CC.

METHODS

Hospital records of 7 patients with a CC, who were admitted to the Neonatal Intensive Care Unit of the Radboud University Nijmegen Medical Centre between 2006 and 2010 and were treated with octreotide, were retrospectively evaluated.

RESULTS

There was no clear and consistent effect of octreotide treatment on pleural effusions. Pleural effusions eventually decreased in all patients after reaching a dose of 5-6 μg/kg/min, but this could also reflect the natural history of CC. Out of 7 patients, 4 were diagnosed with persistent pulmonary hypertension of the newborn. No other known side effects of octreotide were found. There was a mortality rate of 30%.

CONCLUSIONS

No clear and consistent effect of octreotide was identified. Pulmonary hypertension was a common problem in this patient group. It is not clear whether or not this was caused or maintained by octreotide treatment. A randomized controlled trial is needed to investigate the safety and usefulness of octreotide. Until then, clinicians should be careful in using octreotide, especially when persistent pulmonary hypertension is present.

Common etiologies of neonatal pleural effusion

BACKGROUND

Pleural effusion is rare and includes several disease entities in the neonatal period. The aim of this study was to investigate the etiology, management, and outcome of neonatal pleural effusions.

METHODS

We retrospectively collected all neonates who were admitted to the neonatal intensive care unit of Chung Shan Medical University Hospital, Taichung, Taiwan, with discharge diagnosis of pleural effusion, chylothorax, hydrothorax, hemothorax, and empyema, from January 1999 to December 2009. The characteristics, etiology, management, and outcome were analyzed.

RESULTS

There were 21 patients identified, 16 males (76%) and 5 females (24%). Eight patients (38%) had primary and 13 patients (62%) had secondary etiologies. The etiologies included four parapneumonic effusions or empyema (19%); nine chylothorax (42.8%) with four congenital and five iatrogenic after thoracic surgery; three percutaneously inserted central venous catheter extravasation (14%); one umbilical venous catheter extravasation (4.7%); three hydrops fetalis (14%); and one congestive heart failure (4.7%). Fifteen patients (71%) needed chest tube placement. Conservative management with complete cessation of enteral feedings and use of total parenteral nutrition followed with infant formula containing medium-chain triglyceride was successful in six of the patients (67%) with chylothorax. There were two patients (22%) with chylothorax who received somatostatin administration; one was successful and the other one failed. Thoracic duct ligation was performed uneventfully in two patients with acquired chylothorax. There were three mortalities (14.3%) in this study, which were related to causes other than pleural effusion.

CONCLUSIONS

Pleural effusions in the neonatal stage may result from chylothorax, hydrops fetalis, extravasation of percutaneously inserted central venous catheter, parapneumonic effusion, congestive heart failure, or other less frequently occurring conditions. Diagnostic chest tap is required for subsequent management. Good outcome is the rule except in hydrops fetalis, which carries high mortality rate.

Congenital chylothorax in a late preterm infant and successful treatment with octreotide

Chylothorax is defined as abnormal accumulation of lymphatic fluid in the pleural space and is a rare condition in neonates. Chylothorax causes respiratory and nutritional problems and a significant mortality rate. Octreotide is a long-acting somatostatin analog that can reduce lymphatic fluid production and has been used as a new strategy in the treatment of chylothorax. Here, we report a premature baby with severe bilateral pleural effusion diagnosed by prenatal ultrasound and subsequently confirmed to be congenital chylothorax after birth. This newborn baby was initially treated with bilateral chest tube insertion to relieve severe respiratory distress. However, the chylothorax recurred after a medium-chain-triglyceride-enriched formula was initiated. The accumulation of chylothorax diminished after the administration of octreotide. Therefore, octreotide may allow the patient to avoid invasive procedures, such as reinsertion of chest tubes or surgery.

Pleural effusion in a neonate

A premature neonate who developed respiratory distress in the first few days of life was found to have a pleural effusion, which reaccumulated following drainage. The effusion was demonstrated to be a chylothorax. He required multiple chest drains and was started on a medium chain triglyceride formula feed. This brought about a full resolution of the effusions and he made a complete recovery.

Nonimmune hydrops fetalis part I: etiology and pathophysiology

Nonimmune hydrops fetalis (NIHF) is a condition in which excess fluid has accumulated in the fetal interstitial spaces as a result of one or more nonimmune factors. A plethora of maternal, placental, and fetal disease processes have been associated with NIHF. Knowledge of the various etiologies of NIHF and how the disease process affects fluid homeostasis is important for planning patient care and counseling families of patients diagnosed with nonimmune hydrops fetalis. This article discusses the mechanisms governing fluid distribution in the extracellular spaces, examines the various etiologies associated with NIHF, and describes the pathogenesis of NIHF for each etiologic category.

Congenital primary hydrothorax: effect of thoracoamniotic shunting on neonatal clinical outcome

BACKGROUND

Spontaneous regression in the foetal period has been described for congenital hydrothorax. Hydrothorax may become larger and bilateral with hydrops and pulmonary hypoplasia. Prenatal thoracentesis and thoracoamniotic shunting of massive hydrothorax are indicated to decrease perinatal morbidity. In the neonatal period, persistent hydrothorax may require intensive care.

OBJECTIVE

To investigate neonatal outcome after thoracoamniotic shunting for congenital primary hydrothorax with hydrops/ polydramnios.

METHODS

Retrospective study on the postnatal management of a cohort of 28 congenital primary hydrothorax cases after thoracoamniotic shunting (January 2000-August 2005).

RESULTS

Congenital hydrotorax without major structural anomalies complicated by polidramnios and/or hydrops<34 weeks' gestation were the criteria accepted for thoracoamniotic shunting. There were neither pregnancy terminations nor utero deaths. Although 64% of cases were complicated by severe neonatal respiratory insufficiency, neonatal mortality rate was low (21.4%) if compared with literature. Univariate analysis identified 'birth at gestational age (GA)<35 weeks' and 'time between prenatal shunting and birth' as predictive factors for needing of ventilation. Multivariate analysis identified 'birth at GA<35 weeks' as the only independent predictor for needing ventilation. (OR=0.08, CI 95%=0.01-0.96, p=0.046). No risk factors for death or adverse neurological outcomes were reported.

CONCLUSIONS

Congenital hydrothorax although corrected by thoracoamniotic shunting is complicated by severe respiratory distress. The neonatal outcome may be improved limiting degree of prematurity; the presence of thoracoamniotic shunt is not per se an indication of premature birth, at least until GA>35 weeks and adequate pulmonary maturity is reached.

Nonchylous idiopathic pleural effusion in the newborn

Congenital isolated pleural effusion is a rare cause of respiratory distress in neonates. It is usually chylous. Herein, we report a rare case of nonchylous congenital idiopathic pleural effusion.

Chylothorax: diagnosis and management in children

Chylothorax is the accumulation of chyle in the pleural space, as a result of damage to the thoracic duct. Chyle is milky fluid enriched with fat secreted from the intestinal cells and lymphatic fluid. Chylothorax in children, is most commonly seen as a complication of cardiothoracic surgery but may occur in newborns or conditions associated with abnormal lymphatics. The diagnosis is based on biochemical analysis of the pleural fluid, which contains chylomicrons, high levels of triglycerides and lymphocytes. Investigations to outline the lymphatic channels can prove helpful in some cases. Initial treatment consists of drainage, dietary modifications, total parenteral nutrition and time for the thoracic duct to heal. Somatostatin and its analogue octreotide may be useful in some cases. Surgery should be considered for patients who fail these initial steps, or in whom complications such as electrolyte and fluid imbalance, malnutrition or immunodeficiency persist. Surgical intervention may be attempted thoracoscopically with repair or ligation of the thoracic duct.

Congenital chylothorax: clinical course and prognostic significance

OBJECTIVE

To determine the underlying etiology, associated malformations, clinical course, and prognostic significance of congenital chylothorax.

STUDY DESIGN

A retrospective analysis of 11 neonates admitted to our neonatal intensive care unit with congenital chylothorax between January 2000 and June 2008. The post-discharge clinical and developmental course was evaluated by a telephone survey performed in July 2008.

RESULTS

Antenatal diagnosis was established in 9 out of 11 infants by ultrasound examination; 5 had intrauterine pleural drainage. Eight infants had either structural or chromosomal abnormalities. The postnatal treatment included mechanical ventilation, drainage of pleural fluid and feeding with enriched medium chain triglyceride formula. Somatostatin was administered in one case. Six patients developed nosocomial infections. Two patients died after resolution of the chylothorax from deteriorating renal failure. Seven patients were traced for follow up and six of them achieved age appropriate developmental milestones.

CONCLUSION

The recovery from chylothorax and future prognosis were dependent on the underlying etiology. Chylothorax was often a secondary event, with apparently favorable clinical and developmental prognosis when the underlying or/and associated condition was treatable.

Massive chylothorax in small babies

PURPOSE

Perceptions on the role and timing of surgical intervention for high-output or massive chylothorax in small and premature babies remain varied. We reviewed our experience with this challenging group of patients to help refine our thinking and devise a more consistent strategy for management.

METHODS

We conducted a retrospective analysis of all patients in our institutions' neonatal populations diagnosed with chylothorax from June 2000 to April 2008.

RESULTS

Of a total of 23 patients (birth weight, 0.54-4.5 kg; gestational age, 23-41 weeks), 17 were treated conservatively, and 6 with massive chylothorax (>50 mL/kg per day) were treated surgically. Surgical treatment varied, including en masse thoracic duct ligation, mechanical pleurodesis, and application of fibrin glue. Survival in the surgically treated group was 83% vs 59% in the conservatively treated group. Median duration of chest tube drainage was 5 days (postoperative, range, 4-16) in the surgically treated group vs 14 days (range, 1-68) in the conservatively treated group.

CONCLUSION

Surgery has a definitive role in the care of small babies with massive chylothorax. Daily output exceeding 50 mL/kg per day with no or minimal response to 3 days of maximal medical therapy may indicate a potential therapeutic benefit of surgery.

Lymphatics in lung disease

The lymphatic circulation appears to be a vital component in lung biology in health and in disease. Animal models have established the role of the lymphatic circulation in neoplastic and inflammatory diseases of the lung, such as asthma and cancer, and allowed for the understanding of the molecular controls of lymphangiogenesis in normal lung development. Understanding the role of lymphatics in human lung disease appears likely to contribute to the understanding of the pathogenesis of disease and the development of novel therapeutic targets.