Pleura is a thin membrane that surrounds and protects the lungs. A pleural disease is a broad term used to describe any disorder that affects that pleura.

This study guide provides an overview of the common pleural diseases that you must be familiar with as a Respiratory Therapist. It also contains helpful practice questions on this topic.

What is the Pleural Space?

The pleura is a protective tissue that lines the lungs and thoracic cavity. There are two types of pleura:

  1. Visceral pleura
  2. Parietal pleura

The visceral pleura surrounds the surface of the lungs and interlobar fissures. The parietal pleura covers the entire surface of the diaphragm and thoracic cavity.

Pleural cavity lungs trachea (pleura)

Types of Pleural Diseases

There are two primary diseases that occur in the pleural space:

  1. Pleural effusion
  2. Pneumothorax

We created separate study guides for each disorder, which can be found by using the links above.

Pleural Effusion

Pleural effusion is a respiratory condition characterized by an abnormal accumulation of fluid in the pleural space. Several conditions can cause a pleural effusion; however, congestive heart failure (CHF) is the most common.

Pneumothorax

Pneumothorax is a respiratory condition that occurs when air leaks into the pleural space of the thoracic region and results in a collapsed lung. When an air leak occurs, it alters the pressure that keeps the lungs inflated, which results in a collapse.

A pneumothorax can result from an open injury to the chest wall or from a nontraumatic event in which the cause is unknown.

Pleural Disease Practice Questions:

1. What are the two most common pleural diseases that you should know about as a respiratory therapist?
Pleural effusion and pneumothorax

2. When do pleural effusions form?
When excess pleural fluid is produced by the lung or chest wall in sufficient quantities to overcome the resorptive capacity of the pleural lymphatic vessels

3. Pleural fluid analysis is the key to what?
It is the key to understanding the specific cause of any pleural effusion.

4. Transudates have a pleural fluid total protein level of what?
Less than 0.5 and an LDH level of less than 0.6 of the respective serum values

5. What are the common causes of a transudative effusion?
The common causes include CHF, nephrosis, and cirrhosis.

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6. Pleural fluid drainage returns approximately one-third of the lung volume as measured by what?
FVC; the other two-thirds of fluid drainage allows the diaphragm to rise and the chest wall to normalize.

7. Is a pneumothorax size underestimated or overestimated with a one-dimensional view of the chest?
It is underestimated. Measurement accuracy requires a three-dimensional perspective.

8. Are the risk factors for a pneumothorax and pneumomediastinum the same?
Yes, air ruptures a pleural membrane in a pneumothorax, and air passes through the lung hilum in a pneumomediastinum.

9. Pleural effusions associated with CHF are usually bilateral or unilateral?
Bilateral

10. What does chest tube flow depend on?
It depends on tube size, stopcock size, and collection system resistance.

11. Breath-by-breath measurement of an air leak can be approximated by what?
By the difference between inspired and expired volumes (in the absence of endotracheal cuff leaks)

12. The mode of ventilation that produces the least fistula airflow is the most likely to produce what?
Healing

13. What are the methods to decrease bronchopleural fistula airflow?
Lowering the tidal volume, respiratory rate, PEEP, and avoiding auto-PEEP. In more severe cases, positioning the affected lung down, double-lumen tube ventilation, adding PEEP valves to the chest tube, inspiratory chest tube occlusion, or thoracic surgery should be considered

14. What is a bronchopleural fistula?
Any air communication from the lungs to pleural space

15. What is an empyema?
A collection of pus in the pleural space

16. What is an exudative pleural effusion?
Any pleural effusion high in protein or lactate dehydrogenase, which implies inflammation or vascular injury on the pleural surface

17. What is a hemothorax?
Presence of blood within the pleural space

18. What is the parietal pleura?
Membrane covering the surface of the chest wall, mediastinum, and diaphragm that is continuous with the visceral pleura around the lung hilum.

19. What is a pleural effusion?
Abnormal collection of fluid within the pleural space

20. What is used to remove fluid from a pleural effusion?
Chest tube and thoracentesis

21. What is a primary spontaneous pneumothorax?
A pneumothorax that occurs without underlying lung disease

22. What is re-expansion pulmonary edema?
Pulmonary edema that forms after rapid re-expansion of a lung that has been compressed with pleural fluid or pneumothorax

23. What is a secondary spontaneous pneumothorax?
A pneumothorax that occurs because of underlying lung disease

24. What is a stomata?
Small holes within the parietal pleura that are the main route for pleural fluid to exit

25. What is a thoracentesis?
Surgical perforation of the chest wall and pleural space with a needle for diagnostic or therapeutic purposes or for removal of a specimen for biopsy

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26. What is a transudative pleural effusion?
Pleural effusion low in protein or lactate dehydrogenase, usually caused by congestive heart failure, nephrosis, or cirrhosis

27. What is ascites?
The accumulation of fluid in the abdomen

28. What is atelectasis?
When segments of the lung collapse, intrapleural pressure becomes more negative and can produce small effusions

29. What is the primary cause of a transudative pleural effusion?
CHF

30. How is chest radiography used for a pleural diseases?
It is most common in detecting a pleural effusion obtained best in the upright position to show a pleural fluid meniscus at the costophrenic angles.

31. How is CHF relevant to pleural diseases?
It is the most common cause of a clinical pleural effusion. It stems from the elevation of pressure in the left atrium and pulmonary veins.

32. How is computed tomography relevant to pleural diseases?
CT scanning of the chest is the most sensitive study for the identification of a pleural effusion.

33. Which side are pleural effusions more common on?
Right

34. Can a pleural effusion cause atelectasis?
Yes, because the fluid limits the ability of the thorax to expand.

35. What unit are chest tubes measured in?
French (Fr)

36. Where is the needle for a thoracentesis inserted?
Just above the rib

37. What is lateral decubitus chest radiography used for?
It can help define the presence or absence of pleural effusion.

38. How many bottles are in a standard chest tube drainage system?
3

39. What does it mean if tidaling does not occur in the water seal chamber?
It means that there could be a kink, clamp, or occlusion in the tubing.

40. What are the common causes of penetrating chest trauma?
Gunshot wounds and knife punctures

41. What is pleurisy?
A respiratory condition characterized by pain and inflammation in the pleura that usually results from a viral infection

42. What is pleurodesis?
A procedure that is performed to obliterate the pleural space

43. How would you describe chest pain from a pneumothorax?
Sharp and abrupt

44. What are the findings of a tension pneumothorax?
Mediastinal shift, decreased venous return, decreased cardiac output, hypotension, tachycardia, and hypoxemia

45. What is the treatment for a tension pneumothorax?
Emergency decompression of the chest

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46. Chest palpitation during pleural diseases would reveal what?
Dull percussion note

47. What is the most common type of traumatic pneumothorax?
Iatrogenic pneumothorax

48. What are the risk factors of a Thoracentesis?
Intercostal artery laceration, infection, and pneumothorax

49. Which pleura surrounds the surface of the lungs and interlobar fissures?
Visceral pleura

50. Which pleura covers the entire surface of the diaphragm and thoracic cavity?
Parietal pleura

Medical Disclaimer: This content is for educational and informational purposes only. It is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Please consult with a physician with any questions that you may have regarding a medical condition. Never disregard professional medical advice or delay seeking it because of something you read in this article. We strive for 100% accuracy, but errors may occur, and medications, protocols, and treatment methods may change over time.

References

The following are the sources that were used while doing research for this article:

  • Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019. [Link]
  • Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020. [Link]
  • Light, R. “Pleural Diseases.” PubMed, May 1992, pubmed.ncbi.nlm.nih.gov/1572232.
  • “The Past, Current and Future of Diagnosis and Management of Pleural Disease.” National Center for Biotechnology Information, U.S. National Library of Medicine, Dec. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4700377.
  • Cancer Research UK, CC BY-SA 4.0, via Wikimedia Commons

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