Albumin and Chylothorax

[Mo7]

Question to the group: How do you approach the management of chylothorax in your unit, particularly with regard to fluid replacement, nutritional support, and the use of albumin? It would be helpful to learn about your protocols and hear your experiences in managing similar cases. Your contributions could really help foster a more evidence-based discussion on best practices!

For example, do you use albumin to increase oncotic pressure, aiming to draw fluid out of the extracellular compartment? Or do you administer albumin in cases of hypoalbuminaemia to support overall nutritional status?

Alternatively, do you believe that albumin has little to no role in chylothorax management, and that the focus should primarily be on enteral diets(Monogen), total parenteral nutrition (TPN), and fluid balance?

 

I am looking forward to hearing your thoughts and practices!

[NHowold]

Mct rich, otherwise low fat diet. We start with parenteral nutrition, but use breastmilk if feeding starts to get possible. Just store the milk in the fridge, remove fat before feeding and replace with MCT oils. 

[Mo7]

4 hours ago, NHowold said:

Mct rich, otherwise low fat diet. We start with parenteral nutrition, but use breastmilk if feeding starts to get possible. Just store the milk in the fridge, remove fat before feeding and replace with MCT oils. 

Hi NHowold,

 

Thank you for your response. We typically use Monogen (MCT-rich milk), and I appreciate the tip on how to remove fat from breast milk. I’m curious about your practice regarding albumin—if albumin levels are below the normal range, do you administer intravenous albumin?

 

I am looking forward to hearing your thoughts.

 

Best regards,

[Gustaf Lernfelt]

We recently had a case born with hydrops secondary to chylothorax where we replaced 2/3 of losses with 50 percent plasma, 50 percent Ringer’s. Careful increase of feeding with Monogen, evaluating possible increase in fluid losses. Albumin intermittently.

[uvbogden]

If feedings are appropriate, an initial trial of MCT-rich, otherwise low fat, feedings is given. If chylothorax doesn't resolve in a week or so, the infant is made NPO and provided nutrition with TPN. If chylothorax continues to drain for more than 2-3 weeks, a trial of octreotide, which decreases chyle flow, might be considered on a case by case basis, knowing it can also reduce G.I. bloodflow. Neonates with prolonged chylothorax failing to resolve with all previous measures may be considered for chemical pleurodesis with agents such as povidone iodine or doxycycline. Alternatively, Pediatric Surgery consultation might be obtained in consideration of possible thoracic duct ligation or embolization. Blocking the main channel, into which most lymphatics flow, just above the level of the diaphragm, can stop the chyle leakage that occurs higher in the thoracic duct where chyle enters the pleural space. Lymph flow continues via collateral lymphatics

Fluid losses are replaced and electrolytes are managed as needed. If serum albumin falls below normal, IV albumin or FFP is given (clotting factors can also become depleted). IVIg can be given for low immunoglobulins. Even a few days of chylothorax drainage can remove a significant number of lymphocytes, and lymphopenia can put the neonate at risk for infection, especially those that require intubation/mechanical ventilation, and have indwelling central lines and chest tubes. Other than monitoring circulating lymphocyte numbers and observing for signs of infection, I'm wondering what others do to deal with this complication of chylothorax. If you encounter severe lymphopenia, do you consider prophylactic antibiotics? If so which would you choose, and do you then worry about opportunistic fungal infection?

[Mo7]

Hi Uvbogden,

Thanks for your detailed message. I completely agree with your approach regarding the replacement of immunoglobulins and clotting factors. Replacing clotting factors during procedures or active bleeding makes sense, given their direct impact on clinical outcomes. However, I am sceptic when it comes to albumin replacement.

 

The key question is: what is the clinical goal of replacing albumin? If the primary aim is simply to correct the numbers, it becomes problematic, especially when considering the difficulty in keeping albumin within the vascular compartment due to capillary leak, which can lead to fluid shifts and potential complications. Moreover, the half-life of albumin is about three weeks, meaning that serum albumin levels don’t accurately reflect the current nutritional state, making it a poor indicator of real-time nutritional adequacy. Relying on frequent albumin infusions just to maintain levels within a “normal” range could result in unnecessary interventions without a clear evidence-based benefit.

 

From what I’ve seen, there’s limited evidence supporting routine albumin replacement in cases like chylothorax unless there’s a specific clinical indication, such as severe hypoalbuminemia contributing to oedema or fluid imbalance that cannot be corrected by other means. Most reviews focus on nutritional management (MCT-rich feeds, low-fat diet)and, if unresolved, escalation to TPN, octreotide, and potentially surgical options like thoracic duct ligation. I haven’t come across strong evidence advocating for regular albumin infusions as part of routine management.

Curious to hear what others are doing in similar cases

 

Best regards,

[Gustaf Lernfelt]

Normalizing albumin could be aiming too high, but isn’t there a limit somewhere where you get a little uncomfortable as a doctor even though there isn’t much of an edema?  I don't know where this threshold should be, how the evidence looks, or how low albumin could be accepted in relation to other functions besides oncotic pressure in a neonate, and would need to look that up. Does anyone have any thoughts on this?

UpToDate recommends maintaining levels above 2 to 2.5 g/dL in this situation (article: Management of chronic pleural effusions in the neonate).

As for AB-prophylaxis our immunodeficiency Professor recommended the use of trimethoprim / sulfamethoxazole in this specific case. UpToDate does not recommend routine use, but trim/sulfa in cases of severe lymphopenia (e.g. CD4 <200 c/mikroL). We have comparably few problems with antibiotic resistance in Sweden, this could possibly be insufficient in other countries.

The UpToDate-article mentioned above offers a quite comprehensive review of management of chylothorax from a team at University of Alabama at Birmingham, and was last updated Oct 18 2024. I found it quite helpful! 😊

Thank you for starting this subject BTW!

[Mo7]

Thank you for sharing your thoughts and the helpful references!  You raise a really good point—while aiming to normalise albumin may not always be necessary, there probably is a threshold where we’d start feeling uneasy, even in the absence of significant oedema. The tricky part, as you pointed out, is defining that threshold and understanding how low we can let albumin levels go before it starts affecting other physiological functions beyond oncotic pressure, especially in neonates.

The UpToDate recommendation to maintain albumin levels above 2 to 2.5 g/dL is certainly a reasonable guideline. However, it’s intriguing to consider whether we should apply this universally or modify it based on individual circumstances, such as the severity of lymphatic loss or nutritional deficiencies. Additionally, did UpToDate mention anything about the use of Pre-albumin as a more accurate measure of nutritional status (I believe its half-life is three days)? 

I’ve attached a review of the general use of albumin. The authors believe it’s a practical point to administer albumin in chylothorax. However, they also point out that recent protocols don’t mention albumin and instead focus on fluid replacement, MCT diet, TPN, and octreotide. 

Thanks again for contributing to this discussion—this is turning into a great learning exchange! 😊

Shalish et al. - 2017 - Uses and misuses of albumin during resuscitation a.pdf