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THE PLEURA

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THE PLEURA. GENERAL THORACIC SURGERY. SECTION XI. ANATOMY OF THE PLEURA. EMBRYOLOGY. Pleural cavity derivatives of primitive coelom from splitting of the lateral ... – PowerPoint PPT presentation

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Title: THE PLEURA


1
THE PLEURA
  • GENERAL THORACIC SURGERY
  • SECTION XI

2
ANATOMY OF THE PLEURA
  • EMBRYOLOGY
  • Pleural cavity derivatives of primitive
    coelomfrom splitting of the lateral mesoderm
    into splanchnic and somatic layers.
  • The paired cavities separated by three partition
    into three subdivision 1). Pericardial, 2).
    Pleural, 3). Peritoneal cavity.
  • The three partition are 1). Unpaired septum
    transversum, 2) Paired pleuropericardial folds,
    3) Paired pleuroperitoneal folds.
  • 4 weeks of development, laryngotracheal
    outgrowth from the floor of pharynx.
  • 5 week of development, two lung buds begin
    enlarge.

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4
ANATOMY OF THE PLEURA
  • HISTOLOGY
  • The two layers of pleura have the similar
    histologic features.
  • The parietal pleura have stomata.
  • Each layer consists 1) Innermost mesothelial
    cell layer, 2) Submesothelial interstitial
    connective tissue layer, 3) Inner thin elastic
    fiber layer, 4) Outer interstitial connective
    tissue layer, 5) Thick elastic fiber layer. 6)
    Another fatty layer separate the parietal pleura
    and the muscle of chest wall.

5
ANATOMY OF THE PLEURA
  • HISTOLOGY
  • The mesothelial cell vary in thickness, diameter,
    shape. The mesothelial cell demonstrate
    microvilli, tight apical junctions, the gap
    junction, desmosomes, half desmosomes. (
    infrequently on the basal part of the cell
    menbrane)
  • In immunohistochemically, the mesothelial cell
    express low and high-molecular weight cytokeratin
  • Normal mesothelial cell are negative for reaction
    to vimentin, epithelial menbrane antigen,
    carcinoembryonic antigen, factor VIII-related
    antigen.

6
ANATOMY OF THE PLEURA
  • HISTOLOGY
  • Submesothelial layer contains collagen tissue,
    elastic fiber, small blood vesels, lymphatic
    network, nerve fiber. The cell in this layer is
    fibroblast, negative of cytokeratin,
    carcinoembryonic antigen, factor VIII-related
    antigen.

7
ANATOMY OF THE PLEURA
  • HISTOLOGY
  • Visceral and parietal pleura are the same
    thickness, 30-40µm.
  • The parietal pleura has large deiscences or
    stomata, 2-6µm, connect the pleural cavity with
    subpleural lymphstic network and permit egress of
    material into the lymphatics from the pleural
    space.
  • Focal accumulations of macrophages alone the
    pleuripotential mesenchymal lymphoid plasma cell
    in caudal portion of mediastinal pleura may
    functionally related to stomata.

8
ANATOMY OF THE PLEURA
  • GROSS ANATOMY
  • Visceral pleura is closely applied to the lung
    surface, the cleavage plane is absence.
  • It line the major and minor fissure. The minor
    fissure may incomplete to absence in 50.
  • The pulmonary ligment extend from hilar to
    diaphragm is consists of two apposed layer of
    visceral pleura and became continue with the
    parietal pleura.

9
ANATOMY OF THE PLEURA
  • GROSS ANATOMY
  • The parietal pleura lines the chest wall,
    mediastinum, diaphragm, and form the cupola or
    pleura dome at the thoracic inlet bilaterally.
  • The diaphragmatic pleura adheres tightly to the
    diaphragm. The mediastinum pleura adherent
    tightly to pericardium. The cupola, costal pleura
    can dissected from the underlying tissue.
  • The pleura recesses, usually two visible at chest
    PA, termed the 1) Azygoesophageal recess and the
    2) Superior esophageal recess

10
ANATOMY OF THE PLEURA
  • BLOOD SUPPLY
  • Visceral pleura--- Artery supplied by bronchial
    and pulmonary arterial systems. The veins drain
    is pulmonary vein.
  • The parietal pleura--- Artery supply is from
    various systemic arterial supply the chest wall,
    diaphragm, and mediastinum.Vein is to the
    superior vena cava.

11
ANATOMY OF THE PLEURA
  • LYMPHATIC DRAINAGE
  • Subpleural space of the visceral pleura has large
    network of lymphatic channel but rarely
    subpleural lymph node.
  • The intrapulmonary lymph node incidence is 18,
    nearly no node in subpleural space.
  • The lymphatic drainage of the visceral is to the
    pulmonary plexus located in interlobar and
    peribronchial space. The direct subplerual
    lymphatic connection to mediastinal node is
    22-25.
  • Subpleural connections were more in upper lobe
    than in lower lobes.

12
ANATOMY OF THE PLEURA
  • LYMPHATIC DRAINAGE
  • Lymphatic drainage of the parietal pleural is
    into the parietal pleural lymphatic channels, the
    stomata and Kampmeiers foci play an important
    role.
  • The lymphatic network of the chest wall drain
    into internal mammary chain anteriorly and
    intercostals chain posteriorly.
  • The drainage of the diaphragmatic pleura is to
    retrosternal and mediastinal and celiac lymph
    node.

13
ANATOMY OF THE PLEURA
  • NERVE SUPPLY
  • Parietal pleura is innervated by both somatic and
    sympathetic and parasympathetic fiber via the
    intercostal nerve.
  • The diaphragmatic pleura is supplied by phrenic
    nerve.
  • The visceral pleura is devoid of somatic nerve.

14
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • 1. Normal condition no free gases in the pleural
    space.
  • 2. The virtual space between the parietal and
    visceral pleura is under negative pressure
    relation to atmosphere.
  • 3. Normal condition respiratory muscle in
    relaxtion state, the pressure is 5cm-H2O lower
    than surrounding atmosphere. The pressure
    decrease further during inspiration.( Especially
    the airwar obstruction, during Müller maneuver
    the pleural pressure can become negative to lower
    than 100 cm -H2O).

15
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • FACTORS DETERMINING GAS RESORPTION
  • By a simple diffusion from the pleural space into
    the venous blood.this diffusion occurred in both
    directions.
  • No active transport mechanism for gas resoprtion.
  • The only driving forces that determine gas
    resorption are pressure gradients.

16
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • The rate of gas resorption depends on four
    variables
  • 1. Diffusion properties of gas.
  • 2. The pressure gradient for the gas in pleura in
    relation to venous blood.
  • 3. The area contact between pleura gas and
    pleura.
  • 4. Permeability of the pleural surface.
  • Ex the oxygen is resorbed 62 times faster than
    nitrogen, CO2 23 times more soluable than O2.
    water and CO2 are equilibrate.

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18
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • PHASE OF GAS RESORPTION
  • Two phase in gas resorption.
  • Phase 1 equilibration of gases partial pressure.
  • Pahse 2 constant resorption.

19
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • Three potential situation of pneumothorax result
    in different behavior of gas resorpion 1. Close
    rigid cavity
  • Non-reexpandable lung, could remain air
    filled. If the negative pressure is maintained
    fluid eventually seep into pleural cavity and
    gradually fills it, which subsequently solidifies
    and fibroses.

20
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • 2. Closed collapsible cavity
  • The most frequent form of pneumothorax. It
    occurs when gas enter the pleural space, the
    opening responsible for pneumothorax becomes
    occluded, and lung are freely reexpabdable. As
    the gases resorbed no new gas enter the pleural
    space and the reexpansion of lungs compensates
    the volume, prevent the appearance of negative
    intrapleural pressure. It has been estimated that
    6 of pneumothorax is absorbed in 24 hours.

21
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • 3. Open cavity the communication between the
    pleural cavity and the lung or through the
    thoracic wall persist the lung dosent reexpand.

22
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • Different altitude in different barometric
    pressure.
  • Pneumothorax of 1-L volume would increase 33if
    the patient was transported in an airplane
    pressurized at 8000 feet.
  • If a pneumothorax develop in deep sea 30 feet
    below the surface, the volume of pneumothorax
    would double as the diver resurfaces.

23
RESORPTION OF GASES FROM THE PLEURAL SPACE
  • THERAPEUTIC CONSIDERATION
  • 100 O2 is given to patient during a maneuver at
    high risk of creating pneumothorax (ex.
    transthoracic lung biopsy).
  • Reasons
  • 1. The pneumothorax is filled with more soluble
    O2.
  • 2. the pressure greadient between pneumothorax
    and venous blood is larger because the 100 O2
    washes out N2 from alveoli and eventually the
    venous blood.
  • The beneficial effect in relative small and not
    clinically useful.

24
PNEUMOTHORAX
  • ETIOLOGY
  • PRESENTATION
  • DIAGNOSIS
  • TREATMENT

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26
PNEUMOTHORAX
  • The most common cause of primary spontaneous
    pneumothorax is rupture of an apical subpleural
    bleb.
  • The etiology is obscure--- Difference in alveolar
    pressure in upright human between the base and
    the apex.

27
PNEUMOTHORAX
  • Spontaneous pneumothorax is rarely seen befor
    puberty. Children with spontaneous pneumothorax
    often have underlying disease such as cystic
    fibrosis.
  • More common in men (61).
  • More common in smoker.
  • Typical patient is young, tall, thin man in late
    adolescence and early adulthood.

28
PNEUMOTHORAX
  • PRESENTATION
  • Sudden onset chest pain, shortness of breath, not
    in engaging in any unusual or strenuous activity.
  • Spontaneous pneumomeiastinum is invariably
    associated with strenuous exertion such as
    bench-press weight lifting.

29
PNEUMOTHORAX
  • Special mention of secondary spontaneous
    pneumothorax associated with AIDS with
    Pneumocystitis pneumonia .
  • The most common sarcomna contributing to
    pneumothorax are osteosarcoma and synovial
    sarcoma.

30
PNEUMOTHORAX
  • Spontaneous rupture of esophagus present as
    pneumothorax without gastrointestinal symptoms.
  • Pneumothora accompanying pleural fluid,
    atelectasis. spontaneous pneumothorax with COPD
    especially with bullae formation is troublesome,
    tolerate poorly even small degree of collapse.
  • Catamenial pneumothorax, occurred first three
    days of menses, nonovulatory states such as
    pregnancy and oral contraceptive use were not
    associated with pneumothorax.

31
PNEUMOTHORAX
  • Lung cancer with pneumothorax only 0.03 to 0.05.
  • Lymphangioleiomyomatosis seen in young women.
  • Acquired pneumothorax is most often iatrogenic,
    chest tube dysfunction.
  • Barotraumas pneumothorax is patient receving
    positive-pressure ventilation---treated by
    intervention rather than observation, indication
    for tube thoracostomy.

32
PNEUMOTHORAX
  • Tension pneumothorax
  • Symptoms and sign tachycardia, sweating,
    hypotention, mediastinal shift.
  • Clinical diagnosis of tension pneumothorax made
    on basis of appropriate history and physical
    findings is adequate to allow for emergency
    placement o chest tube without confirmatory chest
    radiography.

33
PNEUMOTHORAX
  • DIAGNOSIS standard procedure is making chest x
    ray posteroanterior projection.
  • Should upright position, may miss a pneumothorax
    in semisupine portable anteroposterior view.
  • Lateral decubitus view if patient cant be
    upright.
  • The percentage of collapse is underestimated.
    Artifact skin fold.
  • CT, cost effective.

34
PNEUMOTHORAX
  • Small fluid collections frequently encountered if
    pneumothorax over 24 hours.
  • The fluid always clear.
  • Large effusion often bloody and suggest a torn
    vascular adhesion, may require immediate
    operation to control bleeding.

35
PNEUMOTHORAX
  • Important to exclude a giant bullae in
    differential diagnosis because the tube drainage
    if such bullae is unrewarding.
  • Patient with pneumothorax should not be
    encouraged to travel by air.

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37
PNEUMOTHORAX
  • 1.5 of the air is reabsorbed over each 24 hours.
  • Tube thoracostomy for pneumothorax over 30 or
    for patient with heart disease or COPD.
  • Tube place at anterior and mid-axillary line,
    less muscle tissue has to be traversed.
  • Anterior tube through second intercostal space,
    provide excellent apical air clearance but
    avoided in women.

38
PNEUMOTHORAX
  • The tube is placed by clump or trocar.
  • The trocar technique for its speed and
    convenience.
  • Pleur-evac drainage set to water-seal and gentle
    suction 20 cmh2op.
  • Routine suction may cause reexpansion pulmonary
    edema.
  • Chance of recurrence 20-50.

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41
PNEUMOTHORAX
  • Various agents for induce pleural symphysis
    siver nitrate, talc, hypertonic glucose, urea,
    oil, nitrogen mustard, various antibiotics.
  • Intrapleural tetracycline instillation could
    reduce the incidence of recurrence but difficulty
    to obtain.
  • Talc should be reserved for malignant effusion,
    not benign pneumothorax.

42
PNEUMOTHORAX
  • Open operation by limited lateral or axillary
    incision with bleb excision and pleural abrasion
    or limited apical pleurectomy--- excellent
    result, low recurrence.
  • Video-assisted thoracic surgery(VATS).
  • The recurrence rate is more high in VATS than
    other minithoracotomy.

43
PNEUMOTHORAX
  • Complete parietal pleurectomy should be reserved
    for open treatment failure, for postpneumonectomy
    patient with first pneumothorax and for old
    patient usually with COPD.
  • Bilateral pneumothorax could be treated for
    bilateral via median sternotomy.

44
PNEUMOTHORAX
  • Goal of surgical treatment is to find the
    offending bleb, remove it, encourage adhesion
    formation but not too dense an adhesion.
  • If no bleb is found, the apex of the upper lobe
    should be staple off.

45
PNEUMOTHORAX
  • Surgical treatment of AIDS patient usually
    persistent air leak.
  • Thoracoscope approach with fibrin glue
    derivative.
  • YAG laser, Heimlich valves.
  • Persistent air leak who is poor operative
    risk,could be treated by using closed by
    pneumoperitoneum.
  • Conclusion If surgical treatment is going to be
    necessary the sooner it is performed, the sooner
    that patient can resume a routine life style.
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