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The Pleura
•Serous layer of mesothelium that invest &enclose each lung•Visceral pleura – lines the lung itself •Parietal pleura – lines the chest wall•Pleural cavity – contains a layer of serous pleural fluid for lubrication (
100mL produced and absorbed daily )
THE PARIETAL PLEURA
•Costal pleura – in the ribs•Mediastinal pleura•Diaphragmatic pleura – on top of the diaphragm•Cervical pleura/suprapleural membraneLeft:
•
Pleural reflection moves laterally
fromthe midline
then inferiorly up to the 6
th
costal cartilage
•
Left lung is more deeply indented by thecardiac notchRight:
•
Pleural reflection continues inferiorlyfrom 4
th
to 6
th
costal cartilage
•
Lung parallels pleural reflection closely
Pleural reflection pass:-lateral at 6
th
rib-reach the Midclavicular line at 8
th
costal cartilage-10
th
rib at Midaxillary line-12
th
rib at the scapular line Inferior Margin of the lungs reach:-Midclavicular line at 6
th
rib-Midaxillary line at 8
th
rib-Scapular line at 10
th
ribClinical Importance: Posteriorly the pleural may go beyond the costal margin – Prone to injury during abdominal surgery During kidney surgery, injury to the pleura mayoccur and cause air to enter into the thoracic or pleural cavitySurgical pleurae/Pleural Cupola – covering inthe apical area
‐
Right and left
Gross Anatomy Lungs and Pleurae
2
‐
Most superior part is below the 1
st
rib but never above the neck of the 1
st
rib
‐
Extends in the superior thoracic apertureto go to the neck
‐
Dome shaped groove
‐
Because of position,if there is injury toneck (laceration, gunshot wound, ice pick), the pleural may also be injured and also the underlying lung. Pleura reflection ends 2 finger breaths above themost inferior costal margin
Pleural Recesses
•On full inspiration – lungs fill up cavities•Quiet respiration – 3 parts not occupied•Area of acute P R – “parietal on parietal pleurareflection”-R&L Costodiaphragmatic recesses-Costomediastinal Recess
Disorders of the Pleura
Hydrothorax-fluid accumulation in the thorax or pleural cavity
-can be anything ie. blood, chyle, pus
-as fluid increases the lungs will be morecollapsed and near the hilum-if you want to breath you can’t utilize the whole parenchyma because its squished -the fluid prevents expansion
Classic signs:•Dullness on percussion•Decreased breath sounds•Mediastinal displacement- (
organs are pushed to the other side)
•Transudate vs Exudate•Total protein 0.5•LDH 0.6•Unilateral or Bilateral
Transudate(
high pressure)
Exudate
Common causes:•Congestive heartfailure•Renal insufficiency•CirrhosisTreat the primarycause- Correct fluid balanceCommon causes:•Infection•Malignancy•Treatment:•Drainage•Antibiotics (for parapneumonic effusionsand empyemas)•Pleurodesis (for malignant effusions)
Thoracentesis
•
Draining the fluid in the thorax w/ aneedle
•
Patient’s back to Physician w/ elbowsforward & raised 90°
•
Allows to move scapula tip laterally – away from field of puncture
•
Insert needle on appropriate ICS~top of rib (
decrease chances of hitting the VAN bundle)
Pneumothorax
-normal parenchyma balloons
•
Usually due to rupture of subpleural cystor bulla
•
Air in the pleural space
•
Primary:
it just happened
•
Secondary:
pt has an already existing lung problem
•
Pt is usually dyspneic, breath soundsabsent or decreased
•
Other PE…???
Tachypnia, eyes areenlarged, engorged neck vein
Gross Anatomy Lungs and Pleurae
3
•
Diagnosis is confirmed with chest xray•Treatment: –Drainage with a chest tubeFor persistent air leaks or recurrences: –Video Assisted Thoracoscopic Surgery (VATS) –Thoracotomy –Oversewing of bleb –Pleural scarification/abrasion
Hemothorax
•
Accumulation of blood in the thorax
•
Usually seen in chest trauma, blunt or penetrating
•
Anticoagulant therapy
•
Treatment
•
Chest tube drainage
•
For trauma cases:
Thoracotomy for control of hemorrhage (>200ml/hr drainage)
•
Blood can rise and fill upthe whole lungsuntil it collapse.
Empyema Thoracis -
pus
•
Develops from untreated or inadequatelytreated parapneumonic effusions
•
Post op patients (lung resections or pleural procedures)*
pus has its own lining
•
Empyemectomy - removing the pus as awhole
•
Decortication – prolonged cases; pus hashardened;
stripping the lining out of the lung in order for the lungs to expand again
Chylothorax
•
Accumulation of lymph in the pleural cavity
•
Tumor
•
Injury to Thoracic Duct (
the aqueduct of thelymph
)
•
If persistent beyond 3 to 4 weeks
•
Ligation of Thoracic Duct
•
Talc PleurodesisPleuroperitoneal shunt –
direct chyle tothe peritoneum to the abdomen to beabsorbed
The Lungs
•
Essential organs of respiration
•
Normally light, soft & spongy
•
Left & Right separated fr @ other bymediastinum
•
Attached: heart & trachea by the “root of thelung”Inferior Pulmonary ligament
-cardiopulmonary machine - lung surgery-in newborns: light and spongy-mediastinum in the middle - no communicationbet. R&L lungsTrachea connects to the lung itself
Surface Anatomy
•
Cervical pleurae & apices
•
Pass through superior thoracic apertureinto the supraclavicular fossa
•
Anterior borders of lungs
•
Adjacent to anterior lines of reflection of the parietal pleura up to level of 4
th
costalcartilages
FissuresOblique
- extends from spinous process of T2 vertebra to6
th
costal cartilage- Coincides w/3 vertebral border of scapula whenarm is elevated
Horizontal
- is at the 4
th
rib & costal cartilage anteriorlyGross Anatomy Lungs and Pleurae
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