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The pleural space can be affected pathologically by liquid, gas, or solid components, all of which can alter respiratory function. These processes may result from benign or malignant conditions, including infectious, inflammatory, or traumatic etiologies, as well as primary and secondary malignancies. This chapter provides a brief overview of the clinical presentation, diagnosis, etiology, and treatment of pleural conditions.


The pleural space lies within the layer of pleura that covers the lung and the pleural layer that lines the chest wall, diaphragm, and mediastinum. The pleural layers are composed of a monolayer of mesothelial cells supported by a thin membrane of collagen and elastin connective tissue.1 The pleural surfaces are categorized as the visceral and parietal pleurae. The interior surface, termed the visceral pleura, covers the lung and extends into the major and minor fissures. The exterior surface, termed the parietal pleura, lines the chest wall, mediastinum, and diaphragm (Fig. 128-1). An analogous representation of this configuration can be created by invaginating an inflated balloon with one’s fist (Fig. 128-2). The portion of the balloon that covers the hand is analogous to the interior visceral pleural surface, and the exterior surface of the balloon represents the parietal pleural surface. The transition from visceral to parietal pleura occurs at the hilum of the lung. Inferior to the hilum, the anterior and posterior leaves of the visceral pleura fuse together at the inferior pulmonary ligament and anchor the medial aspect of the lower lobe to the mediastinum. The sulci, or sinuses, of the pleural space are defined by various structures and related to the upward bowing of the diaphragm into the hemithorax: the costophrenic sinus, the costomediastinal sinuses anteriorly and posteriorly, and the mediastinophrenic sinus medially. As the diaphragm descends with inspiration, these sinuses are occupied with inflated lung.

Figure 128-1

A. The double-layered pleural sac mimics the topography of the lungs, including the fissures. The exterior surface exposed to the chest wall, diaphragm, and mediastinum is termed the parietal pleura. The interior surface adjacent to the lung is called visceral pleura. B. The transition between parietal and visceral pleura occurs at the hilum. C. The anterior and posterior leaves of the visceral pleura fuse together at the inferior pulmonary ligament.

Figure 128-2

There are two pleural sacs, one covering each lobe of the lung. The anatomy of this double-layered structure can be best appreciated by imagining one’s fist invaginating a balloon. The hilum is at the wrist.

The pleural space develops between the fourth and seventh weeks of gestation. The lateral plate of the embryologic mesoderm differentiates into the splanchnopleure and the somatopleure, which give rise to the visceral pleura ...

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