The pleura is a membrane that surrounds the lungs and lines the chest cavity. It has two layers - the parietal pleura lining the chest wall and diaphragm, and the visceral pleura attached directly to the lungs. Pleurisy is inflammation of the pleura that causes sharp chest pain worsened by breathing. It is usually caused by viral infection but can result from other lung and heart conditions. Diagnosis involves listening for pleural friction rubs and tests like chest x-rays. Treatment focuses on pain relief, draining excess fluid in the pleural space, and addressing the underlying cause.

1. Pleura
By:
Sharmin Susiwala
TY BPT
CTS

9. • Each lung is invested by an exceedingly delicate serous
membrane, the pleura, which is arranged in the form of a
closed invaginated sac.
 Each pleura has two parts:
 Parietal layer
 Visceral layer
• A portion of the serous membrane covers the surface of the
lung and dips into the fissures between its lobes; it is called
the pulmonary pleura( or visceral pleura).
• The rest of the membrane lines the inner surface of the chest
wall, covers the diaphragm, and is reflected over the
structures occupying the middle of the thorax; this portion is
termed the parietal pleura.
• The two layers are continuous with one another around and
below the root of the lung; in health they are in actual
contact with one another, but the potential space between
them is known as the pleural cavity.

10. Parietal pleura
• The portion of the pleura external to the pulmonary pleura lines
the inner surface of the chest wall, covers the diaphragm, and is
reflected over the structures occupying the middle of the thorax;
this portion is termed the parietal pleura.
• Parietal pleura lines the thoracic wall, covers the superior surface
of the diaphragm and separates the pleural cavity from
the mediastinum.
• Different portions of the parietal pleura have received special
names which indicate their position:
 thus, that portion which lines the inner surfaces of the ribs and
Intercostales is the costal pleura;
 that clothing the convex surface of the diaphragm is
the diaphragmatic pleura;
 that which rises into the neck, over the summit of the lung, is
the cupula of the pleura (cervical pleura); and
 that which is applied to the other thoracic viscera is
the mediastinal pleura.

11. RECESSES OF PLEURA

12. Recesses of pleura
• Costodiaphragmatic Recess:
 The lower area of the pleural cavity into which the lung
expands on inspiration is referred to as the
costodiaphragmatic recess.
 Are slitlike spaces between the costal and diaphragmatic
parietal pleura
 Separated only by a capillary layer of pleural fluid
 During inspiration, the lower margins of the lungs descend
into the recesses
 During expiration, the lower margins of the lungs ascend so
that the costal and diaphragmatic pleurae come together
again
 Pleural effusions collect in the costodiaphragmatic recess
when in standing position.

13. • Costomediastinal Recesses:
 Are situated along the anterior margins of the pleura
 They are slitlike spaces between the costal and the
mediastinal parietal pleurae
 Separated by a capillary layer of pleural fluid
 During inspiration and expiration, the anterior borders
of the lungs slide in and out of the recesses

14. Visceral Pleura
• The visceral pleura is attached directly to the
lungs, as opposed to the parietal pleura, which is
attached to the opposing thoracic cavity.
• The space between these two delicate
membranes is known as the intrapleural space
(pleural cavity).
• The inner pleura (visceral pleura) covers the lungs
and adjoining structures, viz. blood
vessels, bronchi and nerves.

15. Pulmonary Ligament
• The root of the lung is covered in
front, above, and behind by
pleura, and that at its lower border
the investing layers come into
contact.
• Here they form a sort of
mesenteric fold, the pulmonary
ligament, which extends between
the lower part of the mediastinal
surface of the lung and the
pericardium.
• Just above the diaphragm the
ligament ends in a free falciform
border.
• It serves to retain the lower part of
the lung in position.

16. Nerve Supply
 Parietal pleura:::
 The parietal pleura is sensitive to pain, temperature, touch and
pressure, and is supplied as follows:
 The costal pleura is segmentally supplied by the intercostal nerves
 The mediastinal pleura is supplied by the phrenic nerve
 The diaphragmatic pleura is supplied over the domes by the
phrenic nerve and around the periphery by the lower six
intercostal nerves
 Visceral pleura:::
 The visceral pleura covering the lungs is sensitive to stretch
 It is insensitive to common sensations such as pain and touch
 It receives an autonomic nerve supply from the pulmonary plexus

17. Pleural Fluid
 The pleural space normally contains 5 to 10 ml of clear fluid
 It lubricates the opposing surfaces of the visceral and parietal
pleurae during respiration
 The formation of the fluid results from hydrostatic and osmotic
pressures between the capillaries
 The pleural fluid is normally absorbed into the capillaries of the
visceral pleura
 Any condition that increases the production of the fluid or impairs
the drainage of the fluid results in the abnormal accumulation of
fluid, called pleural effusion
 The presence of 300 ml of fluid in the costodiaphragmatic recess in
an adult is sufficient to enable its clinical detection
 The clinical signs include decreased lung expansion on the side of
the effusion, with decreased breath sounds and dullness on
percussion over the effusion

19. Diseases of Pleura

20. Pleurisy

21. • Definition:
“Pleurisy (also known as pleuritis) is an inflammation of the pleura, the
lining of the pleural cavity surrounding the lungs.”
• Signs and symptoms:
 The main symptom of pleurisy is a sharp or stabbing pain in the chest
that gets worse with deep breathing, coughing, sneezing or laughing.
 The inflamed pleural layers rub against each other every time the
lungs expand to breathe in air. This can cause severe sharp pain with
inhalation (also called pleuritic chest pain).
 The pain may stay in one place, or it may spread to the shoulder or
back. Sometimes it becomes a fairly constant dull ache.
 Depending on its cause, pleurisy may be accompanied by other
symptoms:
 Shortness of breath
 Cough
 Fever and chills

22.  Rapid, shallow breathing
 Unexplained weight loss
 Sore throat followed by pain and swelling in the joints
 Diarrhea
 Ventricular tachycardia
 Coughing up blood
• Causes:
o Viral infection is the most common cause of pleurisy.
o However, many different conditions can cause pleurisy:
• Pneumothorax
• Bacterial infections like pneumonia and tuberculosis
• Autoimmune disorders like systemic lupus erythematosus (or drug-induced
lupus erythematosus) and rheumatoid arthritis
• Lung cancer and lymphoma
• Other lung diseases like Cystic
Fibrosis, sarcoidosis, asbestosis, lymphangioleiomyomatosis,
and mesothelioma
• Pulmonary embolism, a blood clot in the blood vessels that go into the
lungs

23. • Inflammatory bowel disease
• Familial Mediterranean fever, an inherited condition that often causes fever and
swelling in the abdomen or lung
• Infection from a fungus or parasite
• Heart surgery, especially coronary artery bypass grafting
• High blood pressure
• Chest injuries
• Aortic dissection
• Can occur with no illness or infection
• Some cases of pleurisy are idiopathic
• Diagnosis:
A diagnosis of pleurisy or another pleural condition is based on medical histories, physical
exams, and diagnostic tests. The goals are to rule out other sources of the symptoms
and to find the cause of the pleurisy so the underlying disorder can be treated.
• Physical exam---
• A doctor uses a stethoscope to listen to the breathing.
• This detects any unusual sounds in the lungs.
• A person with pleurisy will have inflamed layers of the pleura that make a rough,
scratchy sound as they rub against each other during breathing. This is called pleural
friction rub, and it is a likely sign of pleurisy.

24. • Diagnostic tests---
1. Chest x-ray
• A chest x-ray takes a picture of the heart and lungs. It may show air or fluid in the
pleural space. It also may show what's causing the pleurisy –for example;
pneumonia, a fractured rib, or a lung tumor.
• Sometimes an x-ray is taken while lying on the painful side. This may show fluid
that did not appear on the upright x-ray as well as showing changes in fluid
position.
2. Computed tomography (CT) scan
• A CT scan provides a computer-generated picture of the lungs that can show
pockets of fluid. It also may show signs of pneumonia, a lung abscess, or a tumor.
3. Ultrasound
• Ultrasonography uses sound waves to create an image. It may show where fluid is
located in the chest. It also can show some tumors. Although ultrasound may
detect fluid around the lungs, also known as a pleural effusion, sounds beams
cannot penetrate through air or bone. Therefore, an actual picture of the lungs
cannot be obtained with ultrasonography.
4. Magnetic resonance imaging (MRI)
• Magnetic resonance imaging(MRI), also called nuclear magnetic resonance (NMR)
scanning, uses powerful magnets to show pleural effusions and tumors.
5. Blood tests
• Blood tests can detect bacterial or viral infection, pneumonia, rheumatic fever,
a pulmonary embolism, or lupus.

25. 6. Arterial blood gas
• In arterial blood gas sampling a small amount of blood is taken from an artery
usually in the wrist. The blood is then checked for oxygen and carbon
dioxide levels. This test shows how well the lungs are taking in oxygen.
7. Thoracentesis
• The person sits upright and leans on a table. Excess fluid from the pleural space is
drained into a bag.
• Once the presence and location of fluid is confirmed, a sample of fluid can be
removed for testing. The procedure to remove fluid in the chest is called
thoracentesis.
• The doctor inserts a small needle or a thin, hollow, plastic tube through the ribs in
the back of the chest into the chest wall and draws fluid out of the chest.
• Thoracentesis can be done in the doctor's office or at the hospital. Ultrasound is
used to guide the needle to the fluid that is trapped in small pockets around the
lungs.
• Thoracentesis usually does not cause serious complications. Generally, a chest x-ray
is done after the procedure to evaluate the lungs.
8. Pleural biopsy
• If tuberculosis or lung cancer is a suspected cause of your condition, your doctor
may perform thoracentesis with pleural biopsy — removal of a sample of tissue to

26. Thoracentesis

27. • be examined in a pathology laboratory. The biopsy needle has a small
hook on the end that lifts away a small piece of tissue. Your doctor may
use ultrasound guidance for this procedure as well.
9. Thoracoscopy.
• This procedure, performed while you're under a general anesthetic,
allows a surgeon to see inside your chest and obtain a sample of
pleural tissue. First, the surgeon makes one or more small incisions
between your ribs. A tube with a tiny video camera is then inserted
into your chest cavity - a procedure sometimes called video-assisted
thoracoscopic surgery (VATS). Tools designed for this type of surgery
allow your surgeon to cut away tissue for testing.
• Treatment:
 Treatment has several goals:
1. Remove the fluid, air, or blood from the pleural space
2. Relieve symptoms
3. Treat the underlying condition

28. • Procedures
• If large amounts of fluid, air, or blood are not removed from the pleural space, they may put
pressure on the lung and cause it to collapse.
• The surgical procedures used to drain fluid, air, or blood from the pleural space are as
follows:
• During thoracentesis, a needle or a thin, hollow, plastic tube is inserted through the ribs in
the back of the chest into the chest wall. A syringe is attached to draw fluid out of the chest.
This procedure can remove more than 6 cups (1.5 litres) of fluid at a time.
• When larger amounts of fluid must be removed, a chest tube may be inserted through the
chest wall. The doctor injects a local painkiller into the area of the chest wall outside where
the fluid is. A plastic tube is then inserted into the chest between two ribs. The tube is
connected to a box that suctions the fluid out. A chest x-ray is taken to check the tube's
position.
• A chest tube also is used to drain blood and air from the pleural space. This can take several
days. The tube is left in place, and the patient usually stays in the hospital during this time.
• Sometimes the fluid contains thick pus or blood clots, or it may have formed a hard skin or
peel. This makes it harder to drain the fluid. To help break up the pus or blood clots, the
doctor may use the chest tube to put certain medicines into the pleural space. These
medicines are called fibrinolytics. If the pus or blood clots still do not drain out, surgery may
be necessary.
• Medications
• A couple of medications are used to relieve pleurisy symptoms:

29. • Paracetamol (acetaminophen) or anti-inflammatory agents to control pain and decrease
inflammation. Only indomethacin (brand name Indocin) has been studied with respect to
relief of pleurisy.[2]
• Codeine-based cough syrups to control a cough
• There may be a role for the use of corticosteroids (for tuberculous
pleurisy), tacrolimus (Prograf) and methotrexate (Trexall, Rheumatrex) in the treatment of
pleurisy.
• Lifestyle changes
• Lying on the painful side may be more comfortable
• Breathing deeply and coughing to clear mucus as the pain eases.
• Getting rest
• Treating the cause
• Ideally, the treatment of pleurisy is aimed at eliminating the underlying cause of the disease.
• If the pleural fluid is infected, treatment involves antibiotics and draining the fluid. If the
infection is tuberculosis or from a fungus, treatment involves long-term use of antibiotics or
antifungal medicines.
• If the fluid is caused by tumors of the pleura, it may build up again quickly after it is drained.
Sometimes antitumor medicines will prevent further fluid buildup. If they don't, the doctor
may seal the pleural space. This is called pleurodesis. Pleurodesis involves the drainage of all
the fluid out of the chest through a chest tube. A substance is inserted through the chest
tube into the pleural space. This substance irritates the surface of the pleura. This causes the
two layers of the pleura to squeeze shut so there is no room for more fluid to build up.

30. • Chemotherapy or radiation treatment also may be used to reduce the size of the
tumors.
• If congestive heart failure is causing the fluid buildup, treatment usually includes
diuretics and other medicines.
• The most common and known treatment for pleurisy is generally to carry on as
normal, ibuprofen and amoxicilin being common treatments prescribed by doctors.
Milder forms of Pleurisy can be noticed by less inflammatres of the arms and legs.
If this is the case Pleurisy will clear of all symptoms within two weeks.
• Complications:
• Pleurisy is often associated with complications that affect the pleural space.
• Pleural effusion
• In some cases of pleurisy, excess fluid builds up in the pleural space. This is called
a pleural effusion. The buildup of fluid usually forces the two layers of the pleura
apart so they don't rub against each other when breathing. This can relieve the
pain of pleurisy. A large amount of extra fluid can push the pleura against the lung
until the lung, or a part of it, collapses. This can make it hard to breathe.
• In some cases of pleural effusion, the extra fluid gets infected and turns into
an abscess. This is called an empyema.
• Pleural effusion involving fibrinous exudates in the fluid may be called fibrinous
pleurisy. It sometimes occurs as a later stage of pleurisy.
• A person can develop a pleural effusion in the absence of pleurisy. For example,
pneumonia, heart failure, cancer, or a pulmonary embolism can lead to a pleural
effusion.

31. • Pneumothorax
• Air or gas also can build up in the pleural space. This is called a pneumothorax. It
can result from acute lung injury or a lung disease like emphysema. Lung
procedures, like surgery, drainage of fluid with a needle, examination of the lung
from the inside with a light and a camera, or mechanical ventilation, also can cause
a pneumothorax.
• The most common symptom is sudden pain in one side of the lung and shortness of
breath. A pneumothorax also can put pressure on the lung and cause it to collapse.
• If the pneumothorax is small, it may go away on its own. If large, a chest tube is
placed through the skin and chest wall into the pleural space to remove the air.
• Hemothorax
• Blood also can collect in the pleural space. This is called hemothorax. The most
common cause is injury to the chest from blunt force or surgery on the heart or
chest. Hemothorax also can occur in people with lung or pleural cancer.
• Hemothorax can put pressure on the lung and force it to collapse. It also can cause
shock, a state of hypoperfusion in which an insufficient amount of blood is able to
reach the organs.