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Key Concepts

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The pleura are anatomically and physiologically distinct structures. The pleural cavities are formed early during embryonic development from the intraembryonic coelom. Anatomically, the pleura are divided into two structures: the visceral and the parietal pleura. The visceral pleura lines the lungs and is intimately invested with the lung parenchyma. The parietal pleura lines the chest wall, diaphragm, mediastinum, and the superior portion of the lungs.

  • Pathophysiology

    • The pleura and pleural fluid production are tightly regulated anatomical and physiologic entities. The pleura function as serous membranes that line the lungs and chest wall by creating a sealed space between the lungs and atmosphere, allowing for the development of distinct intrathoracic pressures necessary for respiration and the production of pleural fluid. Pleural fluid serves as a lubricant as well as a mechanical coupler between the chest wall and the lungs during respiration. The pleural cavity is a potential space that exists until various pathologic processes interrupt the normal anatomy or physiology of the space, exposing the cavity. Air, excess pleural fluid, chyle, infections, and fibrous tissue are all potential pathologic entities that can disrupt the pleura and pleural space.

  • Clinical features

    • Patients presenting with pleural disorders often complain of a myriad of symptoms; however, most commonly patients will present with one or more of the following: dyspnea, chest pain, and cough. The history and physical examination help to differentiate the etiology of these symptoms. Questions that investigate the onset and duration of these symptoms, their character, and past medical and surgical history can all be illuminating. The physical examination is indispensable in investigating pleural diseases. Dullness or hyperresonance on percussion, decreased or increased tactile fremitus, breath sounds, and visual inspection of the chest wall and respiratory pattern can further refine the diagnosis.

  • Diagnostics

    • Diagnosing pleural disorders often starts with a standard posteroanterior and lateral chest x-ray. The lungs, chest wall, and mediastinum are visualized, and if a pathologic process occurs, the pleural cavity is also visualized. More advanced visualization techniques such as a computed tomography (CT) scan and ultrasound may be necessary to further define the process. In some cases, invasive techniques (i.e., thoracentesis in pleural effusions) are required to finalize a diagnosis.

  • Management

    • Benign pleural disorders are a diverse group of diseases that require complex management and often a combination of both medical and surgical approaches. For example, for pneumothoraces, conservative management involves evacuating the pleural space. If conservative management fails or there is worsening of the disease or recurrence, the patient proceeds to surgical therapy. Conservative management attempts to decrease the disruption within the pleural space and treat the underlying cause. Surgery is often reserved for refractory cases or patients with contraindications to conservative management.

  • Outcomes and prognosis

    • The term “benign” is misleading in describing nonmalignant pleural disorders. If left untreated or not properly treated, these diseases can lead to significant morbidity and even mortality. Some disease processes do recur and ultimately require more extensive surgical management or chronic conservative treatment. ...

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