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Lung diseases

Fluid around lung

08/01/2007

Question:

My one year old grandson has fluid buildup around his lung causing it to collapse and push the trachea and heart to one side. Doctor seem stumped on the cause and after draining 470 cc of fluid off, the heart and trachea have gone back in place and the lung is reinflating but they don`t know a cause. what are some possibilites? They thought it might be something related to the milk formula he is on. What are your thoughts. He is still hospitalized.

Answer:

The pleural space is normally a very narrow space between the lungs and chest wall that contains small amount of pleural fluid. The fluid keeps the lung from scrapping against the chest wall with every breath. This fluid is actually being constantly cycled in and out - produced and drained, by the lining of the pleural space. If the balance of these activities gets out of whack - too much fluid is produced, or the drainage system isn't working - fluid builds up in the space. If there is a large amount of fluid, it can squish the lung, and even start pushing the heart and wind pipe (trachea) out of position, which is apparently what occurred with your grandchild. There are a great number of things that can throw off the production/drainage balance. The most common issues that occur in children revolve around infection. . . the inflamed tissue starts oozing more fluid, drainage canals get plugged up with debris, infection builds up, etc. This process is usually diagnosed by studies done on the fluid itself. Other rarer causes of pleural fluid build up include heart failure, liver disease, pancreatic inflammation, kidney disease, low levels of protein in the blood (normal levels are needed to attract fluid from the pleural space back into circulation), and more. Blood tests and X-rays can often help determine whether these problems are the culprits. Especially in a very young child, or in someone who has recently had chest surgery, one-sided, no-signs-of infection, no-kidney-liver-pancreatitis-problems, pleural fluid build up can be due to a problem with the lymphatic drainage system. This is a flimsy tubing system that picks up excess "tissue juice" and transfers it to the veins, thus getting it back in circulation. The lymphatic drainage system is one of the key players in draining fluid from the pleural space. If a child is born with a not-well-connected system, or one of the bigger lymphatics (lymph vessels) gets cut or pinched, the result can be major build up of pleural fluid. If this is happening, the fluid in the pleural space will sometimes appear "chylous" - similar to lymph fluid. In cases were the lymphatics seem to be malfunctioning, there are unfortunately not a lot of easy fixes - it's a matter of waiting to see if the body can self repair. This can take weeks. In the meantime, to try to slow the pleural fluid build-up, special formulas are often prescribed. It turns out that certain kinds of fat markedly increase how much lymph fluid circulates - using formulas with "medium chain triglycerides" as the source of fat slows down lymph production. This cuts down on the "flooding" of the backed-up lymphatics, and slows down how fast the pleural fluid builds up. The change is milk formula your doctors have recommended may be because they are using this strategy (not because they think the child's original formula caused the problem) - ask them.

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Response by:

Elizabeth D Allen, MD Elizabeth D Allen, MD
Clinical Associate Professor of Pediatrics
College of Medicine
The Ohio State University