RT Book, Section
A1 Taylor, Joshua T.
A1 Smith, Maurice A.
A2 Yuh, David D.
A2 Vricella, Luca A.
A2 Yang, Stephen C.
A2 Doty, John R.
SR Print(0)
ID 1104587527
T1 Benign Pleural Disorders
T2 Johns Hopkins Textbook of Cardiothoracic Surgery
YR 2014
FD 2014
PB McGraw-Hill Education
PP New York, NY
SN 978-0-07-166350-2
LK accesssurgery.mhmedical.com/content.aspx?aid=1104587527
RD 2024/04/23
AB 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.PathophysiologyThe  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  featuresPatients  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.DiagnosticsDiagnosing  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.ManagementBenign  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  prognosisThe  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.  However,  with  prompt  and  appropriate  treatment,  patients  can  be  managed  effectively,  and  morbidity  and  mortality  rates  reduced  significantly.