2.

PHYSIOLOGY
OF
THE PLEURAL SPACE
PLEURAL DISEASES SERIES 08
BY WIDIRAHARDJO

2. PHYSIOLOGY OF THE PLEURAL

SPACE

PLEURAL PRESSURE
The coupling system of the pleural
space,
potentially to increased of it pressure.
Three important structures: lung, heart
and the thoracic cavity, are determining
to the pleural pressure gradient.
(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).

2. PHYSIOLOGY OF THE PLEURAL

SPACE

PLEURODYNAMIC: the capacity

of the pleural space to change in
the pleural pressure variability.
The normal pleural pressure ranged
from - 8,1 to -11,2 cmH2O (the
negative or sub atmospheric
pressure).
The pleural pressure changes were
associated with many pleural
diseases, commonly by increasing
of pleural pressure.

2. PHYSIOLOGY OF THE PLEURAL SPACE

Intrapleural pressure
Negative / sub atmospheric pressure

- 8,1 Cm H2O

inspiration

0 Cm H2O

-11,2 Cm H2O

expiration

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.

2. PHYSIOLOGY OF THE PLEURAL

SPACE

PLEURAL FLUID FORMATION

Pleural fluid can originate come
from:
- Pleural capillaries
- Interstitial of the lung
- Peritoneal cavity
- Thoracic duct or blood vessel
disruption

2. PHYSIOLOGY OF THE PLEURAL

SPACE

Pleural capillaries
parietal pleura
hydrostatic
pressure
+24

pleural space
+30

+35

visceral pleura
-5

+29

+6

+29
Oncotic
+34
pressure

+34

+29
+5

2. 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:
- hepatic hydrothorax
- Meigs syndrome
- peritoneal fluid (ascites, dialysis)
- urinothorax

2. PHYSIOLOGY OF THE PLEURAL

SPACE

Thoracic duct or blood vessel

disruption.
If the thoracic duct is disrupted, 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.

Origin of normal pleural fluid.

Come from capillaries in the parietal

pleura, approximately 15 ml a day.

2. PHYSIOLOGY OF THE PLEURAL

SPACE

PLEURAL FLUID ABSORPTION

Lymphatic clearance
Starlings law of Trans capillary
exchange: no gradient for fluid
absorption through visceral pleura.
Carbon intrapleural instillation (in
monkey) > after 15 carbon go directly
to the costal, mediastinal and
diaphragmatic pleura.
The pleural space is in communication
with the lymphatic vessels in the
parietal pleura by stoma in the parietal
pleura.

2. PHYSIOLOGY OF THE PLEURAL SPACE

The rate of clearance was 0,22

0,40 is ml/kg/hour (Stewart, Leckie
and Tothill), so 500 ml/day.
The protein levels not interfere to
the lymphatic clearance, 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.

2. PHYSIOLOGY OF THE PLEURAL

SPACE

Shinto et all reported that when

pleural fluid decreased with diuresis
in CHF patient, the concentration of
LDH and protein only increased
slightly.
If the pleural fluid removed
through the capillaries in the
visceral
pleura, the LDH and
protein concentration should have
increased a lot. These as evidence
that all pleural fluid was removed by
bulk
flow through the lymphatics.

2. PHYSIOLOGY OF THE PLEURAL

SPACE

Clearance through capillaries in visceral

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

2. 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.

General causes of pleural effusions:

- Increased pleural fluid formation
= Increased interstitial fluid in the lung: left
ventricular failure, parapneumonic effusion,
ARDS, lung transplantation and pulmonary
embolus.
= Increased intravascular pressure in pleura:
right or left ventricular failure, superior vena
caval syndrome.
= Increased permeability of the capillaries in the
pleura: pleural inflammation, increased levels
of vascular endothelial growth factor.

2. PHYSIOLOGY OF THE PLEURAL

SPACE

= Increased pleural fluid protein level

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