The pleural cavity, pleural space, or interpleural space is the

potential space In anatomy, a potential space is a space between two adjacent structures that are normally pressed together (directly apposed). Many anatomic spaces are potential spaces, which means that they are potential rather than realized (with their realiz ...

between the

pleurae The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls. The inner pleura, called the visceral pleura, covers the surface of each lung and dips be ...

of the pleural sac that surrounds each

lung The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication between the

membranes A membrane is a selective barrier; it allows some things to pass through but stops others. Such things may be molecules, ions, or other small particles. Membranes can be generally classified into synthetic membranes and biological membranes. Bi ...

, and also to create a

pressure gradient In atmospheric science, the pressure gradient (typically of air but more generally of any fluid) is a physical quantity that describes in which direction and at what rate the pressure increases the most rapidly around a particular location. The p ...

. The serous membrane that covers the surface of the lung is the

visceral pleura The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls. The inner pleura, called the visceral pleura, covers the surface of each lung and dips b ...

and is separated from the outer membrane the

parietal pleura The pulmonary pleurae (''sing.'' pleura) are the two opposing layers of serous membrane overlying the lungs and the inside of the surrounding chest walls. The inner pleura, called the visceral pleura, covers the surface of each lung and dips be ...

by just the film of pleural fluid in the pleural cavity. The visceral pleura follows the fissures of the lung and the

root of the lung The root of the lung is a group of structures that emerge at the hilum of each lung, just above the middle of the mediastinal surface and behind the cardiac impression of the lung. It is nearer to the back (posterior border) than the front (ant ...

structures. The parietal pleura is attached to the mediastinum, the upper surface of the diaphragm, and to the inside of the

ribcage The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels. The sternum, together known as the thoracic cage, is a sem ...

Structure

human Humans (''Homo sapiens'') are the most abundant and widespread species of primate, characterized by bipedalism and exceptional cognitive skills due to a large and complex brain. This has enabled the development of advanced tools, culture, ...

s, the left and right lungs are completely separated by the mediastinum, and there is no communication between their pleural cavities. Therefore, in cases of a unilateral

pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...

, the contralateral lung will remain functioning normally unless there is a

tension pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve i ...

, which may shift the mediastinum and the

trachea The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air- breathing animals with lungs. The trachea extends from the ...

, kink the

great vessels Great vessels are the large vessels that bring blood to and from the heart. These are: *Superior vena cava *Inferior vena cava *Pulmonary arteries * Pulmonary veins *Aorta Transposition of the great vessels is a group of congenital heart defec ...

and eventually collapse the contralateral cardiopulmonary circulation. The visceral pleura receives its blood supply from the parenchymal

capillaries A capillary is a small blood vessel from 5 to 10 micrometres (μm) in diameter. Capillaries are composed of only the tunica intima, consisting of a thin wall of simple squamous endothelial cells. They are the smallest blood vessels in the body: ...

of the underlying lung, which have input from both the

pulmonary The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of ...

and the

bronchial circulation The bronchial circulation is the part of the circulatory system that supplies nutrients and oxygen to the cells that constitute the lungs, as well as carrying waste products away from them. It is complementary to the pulmonary circulation that brin ...

. The parietal pleura receives its blood supply from whatever structures underlying it, which can be

branch A branch, sometimes called a ramus in botany, is a woody structural member connected to the central trunk of a tree (or sometimes a shrub). Large branches are known as boughs and small branches are known as twigs. The term ''twig'' usually ...

ed from the

aorta The aorta ( ) is the main and largest artery in the human body, originating from the left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries (the common iliac arteries). The aorta distributes o ...

( intercostal, superior phrenic and

inferior phrenic arteries The inferior phrenic arteries are two small vessels which supply the diaphragm. They present much variety in their origin. Structure Origin The inferior phrenic arteries usually arise between T12 and L2 vertebrae. They may arise separately ...

), the internal thoracic (

pericardiacophrenic The pericardiacophrenic artery is a long slender branch of the internal thoracic artery. It anastomoses with the musculophrenic and superior phrenic arteries. Location The pericardiacophrenic artery branches from the internal thoracic artery. ...

, anterior intercostal and

musculophrenic The intercostal arteries are a group of arteries that supply the area between the ribs ("costae"), called the intercostal space. The highest intercostal artery (supreme intercostal artery or superior intercostal artery) is an artery in the human ...

branches), or their anastomosis. The visceral pleurae are innervated by

splanchnic nerve The splanchnic nerves are paired visceral nerves (nerves that contribute to the innervation of the internal organs), carrying fibers of the autonomic nervous system ( visceral efferent fibers) as well as sensory fibers from the organs ( visceral a ...

s from the

pulmonary plexus The pulmonary plexus is an autonomic plexus formed from pulmonary branches of vagus nerve and the sympathetic trunk. The plexus is in continuity with the deep cardiac plexus. Structure It innervates the bronchial tree and the visceral pleura. ...

, which also innervates the lungs and bronchi. The parietal pleurae however, like their blood supplies, receive nerve supplies from different sources. The costal pleurae (including the portion that bulges above the

thoracic inlet The superior thoracic aperture, also known as the thoracic outlet, or thoracic inlet refers to the opening at the top of the thoracic cavity. It is also clinically referred to as the thoracic outlet, in the case of thoracic outlet syndrome. A low ...

) and the periphery of the diaphragmatic pleurae are innervated by the intercostal nerves from the enclosing

rib cage The rib cage, as an enclosure that comprises the ribs, vertebral column and sternum in the thorax of most vertebrates, protects vital organs such as the heart, lungs and great vessels. The sternum, together known as the thoracic cage, is a sem ...

, which branches off from the T1-T12

thoracic spinal cord A spinal nerve is a mixed nerve, which carries motor, sensory, and autonomic signals between the spinal cord and the body. In the human body there are 31 pairs of spinal nerves, one on each side of the vertebral column. These are grouped into the ...

. The mediastinal pleurae and central portions of the diaphragmatic pleurae are innervated by the phrenic nerves. which branches off the C3-C5 cervcial cord. Only the parietal pleurae contain somatosensory nerves and are capable of perceiving pain.

Development

During the third week of embryogenesis, each lateral mesoderm splits into two layers. The

dorsal Dorsal (from Latin ''dorsum'' ‘back’) may refer to: * Dorsal (anatomy), an anatomical term of location referring to the back or upper side of an organism or parts of an organism * Dorsal, positioned on top of an aircraft's fuselage * Dorsal c ...

layer joins the overlying

somite The somites (outdated term: primitive segments) are a set of bilaterally paired blocks of paraxial mesoderm that form in the embryonic stage of somitogenesis, along the head-to-tail axis in segmented animals. In vertebrates, somites subdivide ...

s and ectoderm to form the

somatopleure In the anatomy of an embryo, the somatopleure is a structure created during embryogenesis when the lateral plate mesoderm splits into two layers. The outer (or somatic) layer becomes applied to the inner surface of the ectoderm, and with it (part ...

; and the

ventral Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position prov ...

layer joins the underlying endoderm to form the

splanchnopleure In the anatomy of an embryo, the splanchnopleuric mesenchyme is a structure created during embryogenesis when the lateral mesodermal germ layer splits into two layers. The inner (or splanchnic) layer adheres to the endoderm, and with it forms the ...

. The dehiscence of these two layers creates a fluid-filled cavity on each side, and with the ventral infolding and the subsequent midline fusion of the

trilaminar disc A trilaminar embryonic disc (or trilaminary blastoderm, or trilaminar germ disk) is an early stage in the development of triploblastic organisms, which include humans and many other animals. It is the next stage from the earlier bilaminar embryoni ...

, forms a pair of

intraembryonic coelom In the development of the human embryo the intraembryonic coelom (or somatic coelom) is a portion of the conceptus forming in the mesoderm during the third week of development. During the third week of development, the lateral plate mesoderm split ...

s anterolaterally around the

gut tube The gastrointestinal tract (GI tract, digestive tract, alimentary canal) is the tract or passageway of the digestive system that leads from the mouth to the anus. The GI tract contains all the major organs of the digestive system, in humans and ...

during the fourth week, with the splanchnopleure on the inner cavity wall and the somatopleure on the outer cavity wall. The

cranial Standard anatomical terms of location are used to unambiguously describe the anatomy of animals, including humans. The terms, typically derived from Latin or Greek roots, describe something in its standard anatomical position. This position pro ...

end of the intraembryonic coeloms fuse early to form a single cavity, which rotates invertedly and apparently ''descends'' in front of the thorax, and is later encroached by the growing primordial heart as the

pericardial cavity The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...

. The caudal portions of the coeloms fuse later below the umbilical vein to become the larger

peritoneal cavity The peritoneal cavity is a potential space between the parietal peritoneum (the peritoneum that surrounds the abdominal wall) and visceral peritoneum (the peritoneum that surrounds the internal organs). The parietal and visceral peritonea are lay ...

, separated from the pericardial cavity by the

transverse septum The septum transversum is a thick mass of cranial mesenchyme, formed in the embryo, that gives rise to parts of the thoracic diaphragm and the ventral mesentery of the foregut in the developed human being and other mammals. Origins The septum tr ...

. The two cavities communicate via a slim pair of remnant coeloms adjacent to the upper

foregut The foregut is the anterior part of the alimentary canal, from the mouth to the duodenum at the entrance of the bile duct. Beyond the stomach, the foregut is attached to the abdominal walls by mesentery. The foregut arises from the endoderm, deve ...

called the pericardioperitoneal canal. During the fifth week, the developing

lung bud The lung bud sometimes referred to as the respiratory bud forms from the respiratory diverticulum, an embryological endodermal structure that develops into the respiratory tract organs such as the larynx, trachea, bronchi and lungs. It arises from ...

s begin to invaginate into these canals, creating a pair of enlarging cavities that encroach into the surrounding somites and further displace the transverse septum caudally — namely the pleural cavities. The mesothelia pushed out by the developing lungs arise from the splanchnopleure, and become the

e; while the other mesothelial surfaces of the pleural cavities arise from the somatopleure, and become the

e. The tissue separating the newly formed pleural cavities from the pericardial cavity are known as the ''pericardiopleural membranes'', which later become the side walls of the

fibrous pericardium The pericardium, also called pericardial sac, is a double-walled sac containing the heart and the roots of the great vessels. It has two layers, an outer layer made of strong connective tissue (fibrous pericardium), and an inner layer made of ...

. The transverse septum and the displaced somites fuse to form the ''pleuroperitoneal membranes'', which separates the pleural cavities from the peritoneal cavity and later becomes the diaphragm.

Function

The pleural cavity, with its associated pleurae, aids optimal functioning of the lungs during

breathing Breathing (or ventilation) is the process of moving air into and from the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxygen. All aerobic creatures need oxygen for cellular ...

. The pleural cavity also contains pleural fluid, which acts as a

lubricant A lubricant (sometimes shortened to lube) is a substance that helps to reduce friction between surfaces in mutual contact, which ultimately reduces the heat generated when the surfaces move. It may also have the function of transmitting forces, t ...

and allows the pleurae to slide effortlessly against each other during respiratory movements.

Surface tension Surface tension is the tendency of liquid surfaces at rest to shrink into the minimum surface area possible. Surface tension is what allows objects with a higher density than water such as razor blades and insects (e.g. water striders) to f ...

of the pleural fluid also leads to close apposition of the lung surfaces with the chest wall. This relationship allows for greater inflation of the

alveoli Alveolus (; pl. alveoli, adj. alveolar) is a general anatomical term for a concave cavity or pit. Uses in anatomy and zoology * Pulmonary alveolus, an air sac in the lungs ** Alveolar cell or pneumocyte ** Alveolar duct ** Alveolar macrophage * ...

during breathing. The pleural cavity transmits movements of the ribs muscles to the lungs, particularly during heavy breathing. During inhalation the

external intercostals The external intercostal muscles, or external intercostals (Intercostales externi) are eleven in number on both sides. Structure The muscles extend from the tubercles of the ribs behind, to the cartilages of the ribs in front, where they end ...

contract, as does the diaphragm. This causes the expansion of the chest wall, that increases the volume of the lungs. A negative pressure is thus created and inhalation occurs.

Pleural fluid

Pleural fluid is a

serous fluid In physiology, serous fluid or serosal fluid (originating from the Medieval Latin word ''serosus'', from Latin ''serum'') is any of various body fluids resembling Serum (blood), serum, that are typically pale yellow or transparent and of a benign ...

produced by the serous membrane covering normal pleurae. Most fluid is produced by the exudation in parietal circulation (

intercostal arteries The intercostal arteries are a group of arteries that supply the area between the ribs ("costae"), called the intercostal space. The highest intercostal artery (supreme intercostal artery or superior intercostal artery) is an artery in the human ...

) via

bulk flow Mass flow, also known as mass transfer and bulk flow, is the movement of fluids down a pressure or temperature gradient,Moyes & Schulte (2008). Principles of Animal Physiology. Pearson Benjamin Cummings. San Francisco, California particularly in ...

and reabsorbed by the

lymphatic system The lymphatic system, or lymphoid system, is an organ system in vertebrates that is part of the immune system, and complementary to the circulatory system. It consists of a large network of lymphatic vessels, lymph nodes, lymphatic or lymphoid o ...

. Thus, pleural fluid is produced and reabsorbed continuously. The composition and volume is regulated by mesothelial cells in the pleura. In a normal 70 kg human, a few milliliters of pleural fluid is always present within the intrapleural space. Larger quantities of fluid can accumulate in the pleural space only when the rate of production exceeds the rate of reabsorption. Normally, the rate of reabsorption increases as a physiological response to accumulating fluid, with the reabsorption rate increasing up to 40 times the normal rate before significant amounts of fluid accumulate within the pleural space. Thus, a profound increase in the production of pleural fluid—or some blocking of the reabsorbing lymphatic system—is required for fluid to accumulate in the pleural space.

Pleural fluid circulation

The hydrostatic equilibrium model, viscous flow model and capillary equilibrium model are the three hypothesised models of circulation of pleural fluid. According to the viscous flow model, the intra pleural pressure gradient drives a downward viscous flow of pleural fluid along the flat surfaces of ribs.The capillary equilibrium model states that the high negative apical pleural pressure leads to a basal-to-apical gradient at the mediastinal pleural surface, leading to a fluid flow directed up towards the apex (helped by the beating heart and ventilation in lungs).Thus the recirculation of fluid occurs. Finally there's a traverse flow from margins to flat portion of ribs completes the fluid circulation. Absorption occurs into lymphatic vessels at the level of the diaphragmatic pleura.

Clinical significance

Pleural effusion

A pathologic collection of pleural fluid is called a

pleural effusion A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...

. Mechanisms: #

Lymphatic Lymph (from Latin, , meaning "water") is the fluid that flows through the lymphatic system, a system composed of lymph vessels (channels) and intervening lymph nodes whose function, like the venous system, is to return fluid from the tissues to ...

obstruction # Increased

capillary A capillary is a small blood vessel from 5 to 10 micrometres (μm) in diameter. Capillaries are composed of only the tunica intima, consisting of a thin wall of simple squamous endothelial cells. They are the smallest blood vessels in the body: ...

permeability # Decreased plasma colloid osmotic pressure # Increased capillary venous pressure # Increased negative intrapleural pressure Pleural effusions are classified as exudative (high protein) or transudative (low protein). Exudative pleural effusions are generally caused by infections such as pneumonia (parapneumonic pleural effusion), malignancy, granulomatous disease such as tuberculosis or coccidioidomycosis, collagen vascular diseases, and other inflammatory states. Transudative pleural effusions occur in congestive heart failure (CHF), cirrhosis or nephrotic syndrome. Localized pleural fluid effusion noted during pulmonary embolism ( PE) results probably from increased capillary permeability due to cytokine or inflammatory mediator release from the platelet-rich thrombi.

Pleural fluid analysis

When accumulation of pleural fluid is noted, cytopathologic evaluation of the fluid, as well as clinical microscopy, microbiology, chemical studies, tumor markers, pH determination and other more esoteric tests are required as

diagnostic Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engine ...

tools for determining the causes of this abnormal accumulation. Even the gross appearance, color, clarity and odor can be useful tools in diagnosis. The presence of heart failure, infection or malignancy within the pleural cavity are the most common causes that can be identified using this approach.

Gross appearance

* Clear straw-colored: If transudative, no further analysis needed. If exudative, additional studies needed to determine cause (cytology, culture, biopsy). * Cloudy, purulent, turbid: Infection, empyema, pancreatitis, malignancy. * Pink to red/bloody: Traumatic tap, malignancy, pulmonary infarction, intestinal infarction, pancreatitis, trauma. * Green-white, turbid: Rheumatoid arthritis with pleural effusion. * Green-brown: Biliary disease, bowel perforation with ascites. * Milky-white or yellow and bloody: Chylous effusion. * Milky or green, metallic sheen: Pseudochylous effusion. * Viscous (hemorrhagic or clear): Mesothelioma. * Anchovy-paste (or 'chocolate sauce'): Ruptured amoebic liver abscess.

Microscopic appearance

Microscopy may show resident cells (mesothelial cells, inflammatory cells) of either benign or malignant etiology. Evaluation by a cytopathologist is then performed and a morphologic diagnosis can be made. Neutrophils are numerous in

pleural empyema Pleural empyema is a collection of pus in the pleural cavity caused by microorganisms, usually bacteria. Often it happens in the context of a pneumonia, injury, or chest surgery. It is one of the various kinds of pleural effusion. There are three ...

. If lymphocytes predominate and mesothelial cells are rare, this is suggestive of tuberculosis. Mesothelial cells may also be decreased in cases of rheumatoid pleuritis or post-pleurodesis pleuritis. Eosinophils are often seen if a patient has recently undergone prior pleural fluid tap. Their significance is limited.De Mais, Daniel. ASCP Quick Compendium of Clinical Pathology, 2nd. Ed. ASCP Press, Chicago, 2009. If malignant cells are present, a pathologist may perform additional studies including

immunohistochemistry Immunohistochemistry (IHC) is the most common application of immunostaining. It involves the process of selectively identifying antigens (proteins) in cells of a tissue section by exploiting the principle of antibodies binding specifically to an ...

to determine the etiology of the malignancy.

Chemical analysis

Chemistry studies may be performed including pH, pleural fluid:serum protein ratio, LDH ratio, specific gravity, cholesterol and bilirubin levels. These studies may help clarify the etiology of a pleural effusion (exudative vs transudative). Amylase may be elevated in pleural effusions related to gastric/esophageal perforations, pancreatitis or malignancy. Pleural effusions are classified as exudative (high protein) or transudative (low protein). In spite of all the diagnostic tests available today, many pleural effusions remain

idiopathic An idiopathic disease is any disease with an unknown cause or mechanism of apparent wikt:spontaneous, spontaneous origin. From Ancient Greek, Greek ἴδιος ''idios'' "one's own" and πάθος ''pathos'' "suffering", ''idiopathy'' means approxi ...

in origin. If severe symptoms persist, more invasive techniques may be required. In spite of the lack of knowledge of the cause of the effusion, treatment may be required to relieve the most common symptom,

dyspnea Shortness of breath (SOB), also medically known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathing, breathe well enough. The American Thoracic Society defines it as "a subjective experience of brea ...

, as this can be quite disabling.

Thoracoscopy Thoracoscopy is a medical procedure involving internal examination, biopsy and/or resection/drainage of disease or masses within the pleural cavity, usually with video assistance. Thoracoscopy may be performed either under general anaesthesia o ...

has become the mainstay of invasive procedures as closed pleural biopsy has fallen into disuse.

Disease

Diseases of the pleural cavity include: *

Pneumothorax A pneumothorax is an abnormal collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and shortness of breath. In a minority of cases, a one-way valve ...

: a collection of air within the pleural cavity *

Pleural effusion A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.6 millilitre per kilog ...

: a fluid accumulation within the pleural space. *

Pleural tumors The pleural cavity, pleural space, or interpleural space is the potential space between the pleurae of the pleural sac that surrounds each lung. A small amount of serous pleural fluid is maintained in the pleural cavity to enable lubrication bet ...