2.

PHYSIOLOGY
OF
THE PLEURAL SPACE
PLEURAL DISEASES SERIES 08
BY WIDIRAHARDJO

(The pleural pressure represents the balance between inward pull by the elastic recoil of the lung and outward pull of the thoracic cavity. lung and heart motion). are determining to the pleural pressure gradient. potentially to increased of it pressure. Three important structures: lung.2. PHYSIOLOGY OF THE PLEURAL SPACE • PLEURAL PRESSURE The coupling system of the pleural space. heart and the thoracic cavity. .

2. . PHYSIOLOGY OF THE PLEURAL SPACE “ PLEURODYNAMIC”: the capacity of the pleural space to change in the pleural pressure variability.2 cmH2O (the negative or sub atmospheric pressure). commonly by increasing of pleural pressure.1 to -11. The pleural pressure changes were associated with many pleural diseases.8. The normal pleural pressure ranged from .

PHYSIOLOGY OF THE PLEURAL SPACE Intrapleural pressure Negative / sub atmospheric pressure .2.8.2 Cm H2O expiration .1 Cm H2O inspiration 0 Cm H2O -11.

.PHYSIOLOGY OF THE PLEURAL SPACE HOW IMPORTANT IS THE PLEURAL SPACE? The pleural space is important in the cardiopulmonary physiology. as a buffer zone for over loading of fluid in the interstitial of the lung. The fluid that enters the interstitium of the lung is removed by the lymphatics in the parietal pleura.

Peritoneal cavity . PHYSIOLOGY OF THE PLEURAL SPACE • PLEURAL FLUID FORMATION Pleural fluid can originate come from: .Thoracic duct or blood vessel disruption .Interstitial of the lung .2.Pleural capillaries .

2. PHYSIOLOGY OF THE PLEURAL SPACE • Pleural capillaries parietal pleura hydrostatic pressure +24 pleural space +30 +35 visceral pleura -5 +29 +6 0 +29 Oncotic +34 pressure +34 +29 +5 .

PHYSIOLOGY OF THE PLEURAL SPACE • Interstitial of the lung - Usually pathogenic condition High hydrostatic pressure High permeability Related to pulmonary edema Low oncotic pressure .2.

PHYSIOLOGY OF THE PLEURAL SPACE • Peritoneal cavity Pleural fluid accumulation can occur from free fluid in the peritoneal cavity through an opening in the diaphragm. in: .Meigs’ syndrome . dialysis) .peritoneal fluid (ascites.2.urinothorax .hepatic hydrothorax .

.2. PHYSIOLOGY OF THE PLEURAL SPACE • Thoracic duct or blood vessel disruption. lymph will accumulated in the pleural space (chylothorax). The blood can accumulated in the pleural space (hemothorax) when the large blood vessel disrupted by trauma or disease. If the thoracic duct is disrupted. approximately 15 ml a day. Come from capillaries in the parietal pleura. • Origin of normal pleural fluid.

PHYSIOLOGY OF THE PLEURAL SPACE • PLEURAL FLUID ABSORPTION Lymphatic clearance Starling’s law of Trans capillary exchange: no gradient for fluid absorption through visceral pleura. . mediastinal and diaphragmatic pleura.2. The pleural space is in communication with the lymphatic vessels in the parietal pleura by stoma in the parietal pleura. Carbon intrapleural instillation (in monkey) > after 15’ carbon go directly to the costal.

The protein levels not interfere to the lymphatic clearance.2. PHYSIOLOGY OF THE PLEURAL SPACE The rate of clearance was 0.22 – 0. so ± 500 ml/day. these strongly suggest that most pleural fluid is removed through the lymphatic in the parietal pleura. May increased 28 times as high as the normal formation. . Leckie and Tothill).40 is ml/kg/hour (Stewart.

2. If the pleural fluid removed through the capillaries in the visceral pleura. the LDH and protein concentration should have increased a lot. the concentration of LDH and protein only increased slightly. These as evidence that all pleural fluid was removed by bulk flow through the lymphatics. PHYSIOLOGY OF THE PLEURAL SPACE Shinto et all reported that when pleural fluid decreased with diuresis in CHF patient. .

Until mid 1980s. it was thought that the primary route for pleural clearance was through capillaries in the visceral pleura. Indeed.2. cat. water and small size molecules exchanged easily across both pleural surfaces. etc) where is fluid moves across the thin pleura more easily. That is true for species with thin pleura (dog. . PHYSIOLOGY OF THE PLEURAL SPACE Clearance through capillaries in visceral pleura.

PHYSIOLOGY OF THE PLEURAL SPACE Alternative mechanisms for pleural fluid removal Transcytosis contributes to the removal of protein from the pleural space. The labeled albumin and dextran to be proven partially removed by transcytosis. .2.

PHYSIOLOGY OF THE PLEURAL SPACE • PATHOGENESIS OF PLEURAL EFFUSIONS Pleural fluid accumulates when the rate of pleural fluid formation exceeds the rate of pleural fluid absorption.2.Increased pleural fluid formation = Increased interstitial fluid in the lung: left ventricular failure. ARDS. superior vena caval syndrome. General causes of pleural effusions: . lung transplantation and pulmonary embolus. increased levels of vascular endothelial growth factor. = Increased permeability of the capillaries in the pleura: pleural inflammation. parapneumonic effusion. = Increased intravascular pressure in pleura: right or left ventricular failure. .

Decreased pleural fluid absorption = Obstruction of the lymphatic draining the parietal pleura. PHYSIOLOGY OF THE PLEURAL SPACE = Increased pleural fluid protein level = Decreased pleural pressure: atelectasis or increased elastic recoil of the lung. = Disruption of the thoracic duct = Disruption of the blood vessels in the thorax. = Elevation of systemic vascular pressure: SVCS or right ventricular failure. . = Increased fluid in the peritoneal cavity: ascites or peritoneal dialysis.2. .