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Lifestyleconsiderations
WhenpatientswithCFhaveclosecontactwithanotherindividualwithCF,thereisariskofaquiring
relevant bacterial infections (cross-infection). Nonetheless, robust peer support groups and virtual
eventsexistandareencouraged.
People with CF should avoid irritating inhaled fumes, dusts, or chemicals, including second-hand
smoke.
Ahigh-caloriedietwithvitaminsupplementationistypicallyrecommended.
CFpatientsshouldmaintainasmuchactivityaspossible.
Althoughfertility maybedecreased inwomenwithCFsecondarytothickened cervicalmucus,many
womenwithCFhavetoleratedpregnancyaswell.Ideally,pregnanciesshouldbeplannedtooptimize
patientstatusandcoordinatecarewithobstetrics.CFgeneticscreeningshouldbeofferedtopartnersof
patientswithCF.
TreatmentofAcuteExacerbations
CommonCFexacerbationsymptomsincludeincreasedcough,changeinsputum,increasedshortnessof
breath,fevers,weightloss,orreductioninlungfunctiononspirometry.
Wheninahealthcaresetting,allpersonnelshouldimplementcontactprecautions.Ofnote,patientswith
previousisolationofB.cepaciacomplexshouldbecaredforinaseparateareathanthosewithoutthis
species.
Antibioticsarethemaintreatmentforexacerbations.
Typically, cliniciansselectantibioticstowhichthepathogensare susceptible.However inchronic
CFairwayinfection,itmaynotbepossibletoselectantibioticsinwhichallidentifiedpathogensare
susceptible.
P.aeruginosaisthemostfrequentpulmonarypathogen.Thestandardapproachhasbeentousetwo
antipseudomonaldrugs toenhance activity.Acombinationofanantipseudomonal β-lactam and an
aminoglycosideistypicallyrecommendedduringacuteexacerbations.
161
Ofnote,priorstudieshave
demonstratedthatthereisnocorrelationbetweeninvitrosusceptibilitytestingandclinicalresponse
toaparticularantibiotic.
Thedurationofantibiotictherapyisdictatedbytheclinicalresponse.Atleast14daysofantibiotics
aretypicallyneededtotreatanexacerbation.
Patients with CF have atypical pharmacokinetics and often require higher drug doses at more
frequentintervalsduringanacuteexacerbation.
Home IV antibiotic therapy is common, but hospitalization may allow better access to
comprehensive therapy and diagnostic testing. Oral antibiotics are recommended only for mild
exacerbations. The Cystic Fibrosis Foundation (CFF) recommends against the delivery of home
antibioticsunlessresourcesandsupportareequivalenttohospitalsetting.
Thereisinsufficientevidencetorecommendroutineuseofsteroidsintreatmentofacuteexacerbations.
Airwayclearanceshouldbeintensifiedduringanexacerbation.
Chronic therapies such as bronchodilators, Pulmozyme (dornase), hypertonic saline, pancreatic
enzymes,andCFTRmodulatorsshouldbecontinuedduringahospitalization.
Othercomplicationsthatmayrequirehospitalizationinclude:
Hemoptysis: Basic treatment involves correction of coagulation factors, withholding chest
physiotherapy, stopping inhaled antibiotics, andinitiationof IV antibiotics. Refractory cases may
requirebronchialarteryembolization.
Pneumothorax: Unless small pneumothoraces are treated with chest tube placement. Surgical
pleurodesis shouldbeconsideredincasesofrecurrent pneumothorax.Ingeneral, airwayclearance
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measures that utilize positive pressure should be withheld in cases of a large pneumothorax, as
shouldnoninvasiveventilation.
LungTransplantation
CFisthethirdmostcommonindicationforlungtransplantationworldwide.
TheCFFoundationguidelinesrecommendlungtransplantreferralforanypatientwithCFwith:
anFEV1<50%predictedandevidenceofrapiddecline(20%dropinFEV1within12months)
anFEV1<40%andotherevidenceofadvanceddisease(6MW<400m,hypoxia,hypercarbia,PH),
or
anypatientwithFEV1<30%.
AllpatientsundergoingtransplantevaluationshouldbetestedforthepresenceofNTMandB.cepacia
complexinthesputum.ThepresenceofBurkholderiacenocepaciaisconsideredacontraindicationto
lungtransplantationatmosttransplantcenters.
ReferralandFollow-Up
AllpersonswithCFshouldbefollowedatanaccreditedCFcarecenter.
Patients with CF generally follow-up as an outpatient every 3 months with PFTs and yearly
laboratoriesincludingvitaminlevelsandscreeningforCF-relateddiabetes.
A multidisciplinary team ofCFspecialists, including physicians,nutritionists,respiratorytherapists,
andsocialworkers,aidintheroutinecareofthesepatients.
Outcome/Prognosis
Predictors of increased mortality include advanced age, female gender, low weight, low FEV1,
pancreatic insufficiency, diabetes mellitus, infection with B. cepacia, and higher frequency of acute
exacerbations.
Withimprovedtherapy,themediansurvivalhasbeenextendedtoover47years.
153
PatientEducation
High-qualityinformationcanbefoundattheCFFwebsite(www.cff.org).
SolitaryPulmonaryNodule
GENERALPRINCIPLES
Thegoalofacarefulevaluationofthesolitarypulmonarynodule(SPN)istodetermineifthelesionis
morelikelytobemalignantorbenign.
Alesion>3cmhasahighlikelihoodofmalignancyandshouldbetreatedassuch,whereaslesions
<3cmneedmorecarefulassessment.
Nodules with benign characteristics should be closely followed so that invasive procedures with
associatedriskscanbeavoided.
Identifying early lung cancer is of the utmost importance because there is a >60% survival rate of
patientswhohaveamalignantSPNremoved.
162
Definition
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AnSPNisdefinedasaroundedlesion<3cmindiameter.Itiscompletelysurroundedbylung
parenchyma,unaccompaniedbyatelectasis,intrathoracicadenopathy,orpleuraleffusion.Pulmonary
nodules<8mmremainwithinthisdefinition;however,thereisevidencetosuggestthatthesenodules
havealoweroverallmalignancyrisk.
162
Epidemiology
A2015,California-based,integratedhealthcaresystem’sreviewestimatedtheincidenceofpulmonary
nodulestobeover1.5million.Thisvalueissusceptibletoerrorsassociatedwiththisformof
methodology.However,itdoeshighlightthattheincidenceofSPNhasincreasedwithchangesinclinical
practicefollowingtheNationalLungScreeningTrial.
163
Etiology
Although underlying etiologies for pulmonary nodules are varied, the most important designation
clinicallyisdecipheringbetweenamalignantandanonmalignantprocess.
Malignancy accounts for approximately 40% of SPNs, although this may vary geographically
dependingontheprevalenceofnonmalignantprocessessuchashistoplasmosis.
Granulomas (both infectious and noninfectious) may account for 50% of undiagnosed SPNs,
dependingontheprevalenceofcancerintheparticularpopulation.
Theremaining10%arecomposedofbenignneoplasms,suchashamartomas(5%)andamultitudeof
othercauses.
RiskFactors
SmokingisthemostimportantassociatedriskfactorforalmostallmalignantSPNs.
Forinfectiousetiologies,animmunocompromisedstatepromotesanincreasedrisk.
LungCancerScreening
Screeninghigh-riskpatientsusinglow-dosechestCTresultedina20%relativereductioninmortality
fromlungcancercomparedtoscreeningwithCXR.
164
DIAGNOSIS
DiagnosisoftheSPNismaderadiographically,usuallyviaCXRorCTscan.
Mostfrequently,thenoduleisnotedincidentallyonastudyperformedforotherreasons(e.g.,chronic
cough,chestpain,shortnessofbreath).
ClinicalPresentation
ThemajorityofSPNsarediagnosedincidentallybyradiographictestsdoneforotherreasons,sothere
maynotbeovertsymptoms.
Thereareinstanceswhenanodulemayprecipitatecough,chestpain,hemoptysis,orsputumproduction
dependingontheetiologyandlocationoftheSPN.
HISTORY
Asktypicalscreeningquestionsformalignancyincludingweightlossandnightsweats.
Hemoptysis may indicate malignancy but may also prompt investigations for ANCA-associated
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vasculitis,TB,andhereditaryhemorrhagictelangiectasia(HHT).
AskaboutarthritisandarthralgiasforpossibleundiagnosedCTDorsarcoidosis.
Takeanexposurehistoryincludingrecenttravelhistory relatedtoendemic mycoses(histoplasmosis,
coccidioidomycosis,etc.)aswellaspossibleTBexposures.
Ahistoryofpreviousmalignanciesincreasestheriskofmetastaticdiseaseofthelung.
PatientswhoareimmunosuppressedfromHIV,organtransplant,orchronicsteroidshaveincreasedrisk
ofinfectiouscauses.
Smokingis linked to85% oflung cancers. A patient’s riskoflung cancer decreases significantly5
yearsaftersmokingcessation,butnevertrulyreturnstobaseline.
An occupational history is importantincluding possible exposure to asbestosis (associated with not
only mesothelioma but also non–small-cell lung cancer), silica, beryllium, radon, and ionizing
radiation,amongothers.
PHYSICALEXAMINATION
AlthoughtherearenospecificphysicalexaminationfindingsrelatedtoSPNs,evidenceforunderlying
etiologiesmightbediscoveredwithathoroughexamination.
Notethatsignsofweightlossorcachexiaaresuggestiveofmalignancy.
Doa thorough lymph node examination.Acervical lymph node might provide aneasy diagnostic
targettodeterminetheetiologyofanSPN.
Performabreastexaminationinwomenandtesticularexaminationinyoungmen.
Acarefulskinexaminationmayrevealtelangiectasias,erythemanodosum,rheumatoidnodules,orother
findingsthatmightsuggestacause.
RiskStratification
The first step in managing an SPN is to stratify the patient in terms of malignancy risk: low-,
intermediate-, or high-risk categories (Table 10-12). Risk stratification can be accomplished either
qualitatively via clinical judgment or quantitatively using validated risk assessment tools. These
approachesappeartobecomplementary.
165
TABLE10-12
ASSESSMENTOFTHEPROBABILITYOFMALIGNANCY
Assessment
Criteria
Low(<5%) Intermediate
(5%–65%)
High(>65%)
Clinicalfactors
alone(determined
byclinicaljudgment
and/oruseof
validatedmodel)
Young,lesssmoking,noprior
cancer,smallernodulesize,regular
margins,and/ornon–upperlobe
location
Mixtureof
lowandhighprobability
features
Older,heavy
smoking,prior
cancer,largersize,
irregularspiculated
margins,and/or
upper-lobelocation
FDG–PETscan
results
Low–moderateclinicalprobability
andlowFGD–PETactivity
Weakor
moderate
FDG–PET
scanactivity
Intensely
hypermetabolic
nodule
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Nonsurgicalbiopsy
results
(bronchoscopyor
TTNA)
Specificbenigndiagnosis Nondiagnostic Suspiciousfor
malignancy
CTscan
surveillance
Resolutionornear-complete
resolution,progressiveor
persistentdecreaseinsize,orno
growthover≥2y(solidnodule)or
≥3–5y(subsolidnodule)
Nonapplicable Clearevidenceof
growth
FDG,18-fluorodeoxyglucose;PET,positronemissiontomography;TTNA,transthoracicneedleaspiration.
ReprintedfromGouldMK,DoningtonJ,LynchWR,etal.Evaluationofindividualswithpulmonarynodules:whenisitlungcancer?
Diagnosisandmanagementoflungcancer,3rded—AmericanCollegeofChestPhysiciansevidence-basedclinicalpractice
guidelines.Chest.2013;143(5):e93s-e120s.Copyright©2013TheAmericanCollegeofChestPhysicians.Withpermission.
Once the risk of malignancy has been established, further management can proceed, as outlined in
Figure10-6.
Figure10-6 Diagnosticandtherapeuticmanagementoflow-andintermediate-riskpulmonarynodules.PET,positronemission
tomography;SPN,solitarypulmonarynodule;yrs,years.
DifferentialDiagnosis
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Pulmonarynodulesaredividedprimarilyintomalignantorbenignetiologies,withbenignprocesses
furtherdividedintoinfectiousornoninfectiouscauses(Table10-13).
TABLE10-13
DIFFERENTIALDIAGNOSISOFTHESOLITARYPULMONARYNODULE(SPN)
Malignant
Primarypulmonarycarcinoma(80%ofallmalignantSPNs)
Primarypulmonarylymphoma
Primarypulmonarycarcinoid
Solitarypulmonarymetastasis
Melanoma, osteosarcoma,testicular,breast, prostate, colon, and renal cell
carcinoma
Benign
neoplasms
Hamartoma(accountsformostbenignneoplasticSPNs)
Arteriovenousmalformations(considerHHT)
Others, including neural tumors (schwannoma, neurofibroma), fibroma, and
sclerosinghemangioma
Granulomas Infectious
Mycobacterial disease (most commonly TB) and fungal infections
(histoplasmosis, coccidioidomycosis, blastomycosis, cryptococcosis,
aspergillosis)
Noninfectiousgranulomasassociatedwithvasculitis
Granulomatosiswithpolyangiitis,eosinophilicgranulomatosiswithpolyangiitis
Noninfectiousgranulomasnotassociatedwithvasculitis
Sarcoidgranulomatosis,hypersensitivitypneumonitis,andberylliosis
Other
etiologies
Infectious
Bacterial(nocardiosis,actinomycosis,roundpneumonia),measles,abscess,
septicembolus
Noninfectious
Lipoid pneumonia, amyloidosis, subpleural lymph node, rheumatoid nodule,
pulmonary scar or infarct, congenital malformations (bronchogenic cyst,
sequestration),skinnodule,ribfracture,pleuralthickeningfrommassorfluid
HHT,hereditaryhemorrhagictelangiectasia.
DiagnosticTesting
LABORATORIES
Routine laboratory testing is seldom helpful unless the history and physical examination strongly
suggestanetiology.
IfCTDsorvasculitidesaresuspected,performappropriatetesting.
Hyponatremiamay suggestsyndrome ofinappropriate antidiuretic hormoneassociatedwithprimary
lungcancer,aswellasotherpulmonaryprocesses.
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Hypercalcemiamightsuggestlungcanceraswellassarcoidosis.
Anemiamayindicatechronicpulmonaryhemorrhage(e.g.,HHT)orachronicinflammatorydisease.
Microbiologicstudies,particularlysputumculture,mayaidinthediagnosisofaninfectiousSPN.
Sputumcytologyhaslimitedusebecauseyieldislowforperipherallylocated,smalllesions.
IMAGING
ThemainstayofdiagnosticevaluationofanSPNisviaradiographicstudies,primarilyCXR,chestCT,
andpositronemissiontomography(PET)scan.
CXR:
ApreviousCXRisanimportanttoolintheinitialevaluationofanSPN.
IfanSPNhasbeenpresentandunchangedonCXRfor>2years,thenfurtherevaluationmaynotbe
warranted. Subsolid lesions should be followed for longer periods because the volume-doubling
timeisextendedincertaintypesofnon–small-celllungcancers.
If an SPN appears on a new radiograph in <30 days, it is likely not malignant and most likely
infectiousorinflammatory.
There are radiographicfindings thatmakeit more likelythata lesion is benign (calcifications, a
laminatedappearance)ormorelikelymalignant(spiculated,irregularborder)(seeTable10-12).
TheCXRis easytoobtainanddeliversalowdose ofradiation;however,ithaslimitationsinthe
initialcharacterization,andcarefulcomparisonsovertimearerequiredforSPNevaluation.
ChestCT:
ChestCTis now considered themost important radiologicexaminationfor SPNevaluation. With
fewexceptions,anSPNrequiresassessmentbyCT.
Accuratevolumetricmeasurementoflesionsizeallowsprecisecomparisontodeterminestabilityor
growth.
Imagingallowsacarefulexaminationofmediastinallymphnodes.
Thin cuts through the lesion are more sensitive than CXR for characterizing calcifications and
laminationaswellasthemarginsofthelesion.
PETscan:
18-Fluorodeoxyglucose–PETcanhelpdistinguishmalignantandbenignlesions.
PEThasasensitivityof80%–100%andspecificityof79%–100%fordetectingmalignancy.
False negatives can occur in bronchoalveolar carcinoma, carcinoid, and mucinous neoplasms,
whereas false positives are common in nonmalignant “inflammatory” conditions (infectious and
autoimmuneprocesses).
Ahigherincidenceofbothfalse-positiveandfalse-negativeresultsoccursinnodules<10mm,thus
discouragingtheuseofPETscaninthissituation.
166
PETscanismostcommonlyusedinthe evaluationoflow- tomoderate-riskindeterminatenodules
forfurtherriskstratification(seeFigure10-6).
Contrast-enhancedCT:
TechniquesareavailableforusingcontrastenhancementandmeasurementofHounsfieldunitstorisk
stratifyanSPNformalignancy.
A multicenter analysis demonstrated high sensitivity but relatively low specificity for identifying
malignantnodules.
167
This methodmaybe animportant tool for riskassessmentofanindeterminateSPNincenters that
haveexperiencewiththetechniques.
DIAGNOSTICPROCEDURES
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Ifanoduleisconsideredhighriskandthepatientisanappropriatesurgicalcandidate,thenthe
bestapproachistoforegobiopsyandpursueresection.
AnyincreaseinsizeordensityofanSPNonserialimagingwarrantsadditionalinvestigation.
Ifalesionhaslow-riskcharacteristics,thereisnoindicationtopursuebiopsyandsubjectingapatient
toanunneededrisk.
Nonsurgicalbiopsyviabronchoscopyortransthoracicneedleaspiration(TTNA)istypicallyindicated
for patients with a nodule, which has intermediate risk for lung cancer. In addition, for patients in
whom surgery represents significant risk secondary to comorbidities, a nonsurgical biopsy may be
indicatedtodemonstratemalignancypriortosurgeryornonsurgicaltherapy.
There are primarilytwo options for biopsyof anSPN:TTNA andflexible bronchoscopy. Choosing
eithermodalityisbasedonnoduleandpatientfactors,aswellasinstitutionalexperience.Thesefactors
includenodulesize,location,andfindingofemphysemaonCTchest.
Thistechnique isusuallyperformedunderthe guidanceoffluoroscopy,ultrasound,orCT(more
common).
This approach is most commonly used for nodules with a peripheral location and without
anatomicimpedimenttoabiopsyneedle.
SensitivityofTTNAforthediagnosisoflungcanceris80%–90%inselectedpatients.
SpecificityforidentifyingmalignancyishighwithTTNA;however,thereisasignificantrateof
nondiagnostic biopsies, and sensitivity depends on many factors, including nodule size and
distancefromthepleura.
Anondiagnosticbiopsydoesnotruleoutmalignancy.
ThecomplicationsofTTNA arebleeding (1%),pneumothorax(15%), and6%–7% incidenceof
pneumothoraxrequiringchesttubedrainage.
168
TTNA alone does not provide any additional information regarding the patient’s pathological
staging.
Bronchoscopy:
Conventionalflexiblebronchoscopyisbestsuitedforcentralairwaylesionsandhasasensitivity
of88%inmalignancy.Advancedbronchoscopictechniquesarerecommendedinthediagnosisof
peripherallesionswheretheirdiagnosticyieldissuperiortothatofconventionalbronchoscopy.
Advanced bronchoscopic modalities include radial probe endobronchial ultrasound and
electromagneticnavigation,withsensitivitiesof73%and71%,respectively,forthedetectionof
malignancyinperipheralnodules.
Complete mediastinal and hilar lymph node examination for pathological staging may also be
performedduringbronchoscopyforperipherallesiondiagnosis,obviatingtheneedforadditional
procedures.
Thecomplicationsofbronchoscopyarebleeding(2%–5%)andpneumothorax(2%–4%).
168
TREATMENT
Managementoflow-andintermediate-riskSPNsisoutlinedinFigure10-6.
Overall treatmentstrategyis to identify lesionswith significant malignancyriskand pursue surgical
resectionwhenpossible.
If a specific etiology for the SPNis diagnosed (e.g.,aCTDor infection),then treatmentis targeted
towardtheunderlyingprocess.
NonpharmacologicTherapies
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Althoughsurgicalresectionispreferableinpatientswitheitherahigh-risklesionorbiopsy-proven
malignancy,ifsurgicalresectionisnotanoption,othereffectivetherapiesexist.
Stereotacticradiationiscurrentlythemostwidelyusedtherapyinthisclinicalsituation.Thismode
ofexternalbeamtherapyaimstodecreasecollateralradiation–induceddamagetoadjacentlungtissue.
Therearemoreexperimentalapproaches,includingbrachytherapyandradiofrequencyablation,which
arecurrentlyunderdevelopment.
SurgicalManagement
SurgicalresectionofanindeterminateSPNisindicatedinthefollowingsituations:
Theclinicalprobabilityofmalignancyismoderatetohigh(>60%).
ThenoduleishypermetabolicbyPETimaging.
Thenodulehasbeenprovenmalignantbybiopsy.
Patientpreferenceforsurgerywherethepatientisanappropriatesurgicalcandidate.
Acombinationofsurgicaltechniques,includingVATS,mediastinoscopy,andthoracotomy,canleadto
diagnosis (via intraoperative frozen section),staging, and potential cure duringa single induction of
anesthesia.
Monitoring/Follow-Up
Foralow-orintermediate-riskpulmonarynoduleforwhichresectionisnotwarranted(seeFigure10-
6),desired,orpossible,routinefollow-upwithchestCTisstandardpractice.
Follow-upofSPNdependsonwhetheritisasolidorsubsolidnodule.Solidnodulesrequire2years
ofsurveillance,andsubsolidnodulesrequireadditionalyearsofsurveillancetodocumentstability.
Theupdated2017FleischnerSocietyrecommendationsaimtowarddecreasingthenumberofchestCT
scans for incidentally detected SPN follow-up and to provide greater flexibility to clinicians and
patientsforshareddecision-making.
169
PleuralDiseases
GENERALPRINCIPLES
The pleural lining is a serous membrane covering the lung parenchyma, chest wall, diaphragm, and
mediastinum.
Thepresenceofexcessfluidoranyamountofgasinthepleuralspaceisabnormal.
The pleural membranecovering thesurface ofthe lung is knownas thevisceral pleura;theparietal
pleuracoverstheremainingstructures.
In betweenthe visceral and parietal pleura ofeachlung is thepleural space, a potential space that
containsathinlayeroffluidofapproximately10mLinvolume.
Theparietalpleurasecretesapproximately2400mLoffluiddaily,whichisreabsorbedbythevisceral
pleura.
170
Definition
Apleuraleffusionisanaccumulationof>10mLoffluidinthepleuralspace.
Ahemothoraxreferstoapleuraleffusionthatmainlycomprisesblood.
171
Chylothoraxis a collection ofchyle withinthe pleural space. Chyle is a milky fluidconsisting of
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lymphandfatdroplets.
172
A parapneumonic effusion is fluid collection in the pleural space as a result of a
pneumonia/consolidation or bronchiectasis. The three types of parapneumonic effusions include
uncomplicatedeffusion,complicatedeffusion,andempyema.
173,174
Anempyemareferstoinfectedfluidwithinthepleuralspace.
Apneumothoraxisacollectionofairinthepleuralspace.
Primaryspontaneouspneumothoraxoccurswhenthelungparenchymaisnormalwithoutanyobvious
underlyinglungdisease.
175
Secondaryspontaneouspneumothoraxisacomplicationofunderlyingparenchymallungdisease.
175
Sometimes if air is trapped in the pleural space under high pressure, a tension pneumothorax
develops,whichcanbefatalifnotrecognizedandtreated.
176,177
Epidemiology
MorethanonemillioncasesofpleuraleffusionoccurannuallyintheUS.
Itisestimatedthatmalignantpleuraleffusionaffectsabout150,000peopleayearintheUS.Congestive
heartfailureandparapneumoniceffusionarethepredominantetiologiesofpleuraleffusionintheUS.
174
Incidenceofpneumothoraxvarieswidelybygender,country,andrace.
Etiology
Pleuraleffusionshaveavarietyofcausesandarelistedbelow(Table10-14).
Empyemaisgenerallycausedbyextensionofaninfectionofthelungorsurroundingtissue.
Common microbial pathogens are S. aureus, Streptococcus species, H. influenza, and oral
anaerobes.
Empyemas are frequently polymicrobial in cases where aspiration is suspected, commonly
becauseoforalflora.
Thethreemajorgroupedcausesofchylothoraxaremalignancy(50%ofcases),
172,178
trauma(25%),
andidiopathic(15%).
179
OtherrarecausessuchasLAM
180
andtraumatothoracicductaccountfor
10%.
Seventy-five percent of chylous effusions associated with malignancy are due to lymphomarelatedobstructionofpleurallymphaticspreventingreabsorptionofpleuralfluid.
172
Trauma as a causative factor of chylothorax includes any cardiothoracic surgical procedure. It
maytake1–2weekspostsurgeryforthechylothoraxtobecomeapparent.
Inanumberofcases,chylothorax resultsfromtransdiaphragmatic leakageofchylousascites.
172
Causesofchylousascitesincludenephroticsyndrome,hypothyroidism,andcirrhosisoftheliver.
172
Hemothoraxmayresultfromtraumaoraniatrogenicetiologyandarerarelyspontaneous.
171
Othercausesofpleuraleffusionincludeheartfailure,anasarca,andpulmonaryembolism.
Secondary pneumothorax is often seen in chronic obstructive pulmonary disease, AIDS, CF, TB, P.
jiroveciipneumonia,sarcoidosis,pulmonaryfibrosis,asthma,Marfandisease,LAM,PLCH,trauma,or
anycavitaryorcysticlungdisease.
TABLE10-14
CAUSESOFPLEURALEFFUSION
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