PLEURA &

PERICARDI
UM,
DR NWOSU C.I.A. MA,
MSc, MBBS, MD.

LEARNING OBJECTIVES

TO KNOW THAT :

The lungs and heart develop and invaginate into their respective
sacs which form functional coverings for them(visceral & parietal),
The potential spaces included between the layers of these sacs
may become real spaces in certain disease processes,
The cervical part of Parietal pleura extends into the root of neck
& is vulnerable there
Innervation & vasculature: The visceral part of the coverings of
the heart and lungs tend to be supplied along with the viscera, and
the parietal with the wall (pariety),
Pericardium and Pericardial sinuses are clinically useful spaces
between the great vessels : pericardial effusion and cardiac
tamponade,
Costomediastinal recess is clinically useful in relieving pericardial
effusion,
In stab injuries of the abdomen, and in surgeries of the
kidneys and spleen, the lungs may be injured,

Terminology/vocabulary

Mediastinum ; what is in the middle,

Lungs, lung lobes, lung segments,
Lung hilum, lung root,
Parietal (wall related)/visceral (organ
related),
Suprapleural membrane = fibrous
endothoracic fascia that cover the
cervical pleura,
Pulmonary ligament = a redundant sleeve
of parietal pleura,
Costodiaphragmatic (costophrenic) recess
Costomediastinal recess

THORAC
IC
CAVITY

PLEURA
PLEURA is a serous membrane which is lined by
mesothelium (epithelium that covers all serous
membranes), and associated supporting connective tissue
There are 2 pleural sacs, one on each side of mediastinum,
Pleura is divided into two major types based on location;
parietal or wall pleura & visceral or organ pleura,
Each pleural sac is invaginated from the mediastinal side
by the lung,
Universal : In the same way, the heart, gut
tube/derivatives, testes and ovaries invaginate their
respective sacs,
There are 2 layers of pleura : VISCERAL (organ related) &
PARIETAL (wall related),
The Parietal pleura is described in 4 parts : cervical,
costal, mediastinal & diaphragmatic

Visceral pleura

heart

SURFACE MARKINGS OF
PLEURA

SIMILAR PATHS FROM APEX at MCL:

- an oblique path from lung apex 2- 3cm (2.5cm) above
medial part of clavicle to CC2 level near midline at
manubrosternal joint,
- a straight path from CC2 to CC4
PARTING OF WAYS;
- RT goes straight down from CC4 to CC6 level at xiphisternal
joint,
- LT takes a curved/curvilinear path from CC4 to CC6 level,
FROM CC6 SIMILAR PATHS : both take an oblique path to reach
the 8TH rib at MCL, 10TH rib at MAL, & 12TH rib at
PARAVERTEBRAL LINE,
In surgical exposures behind the pleura, as in operations
in the kidneys, one should be very careful not to enter the
costodiaphragmatic recess,
Knowledge of these recesses also helps in surgical access in
situations of fluid/air collections in pleural & pericardial
cavities,

SL
Bare area of
the pericardial
sac

Anterior View

MAL

MCL

VL

1. The lungs do not completely fill the pulmonary cavities

(interpleural space) peripheral gutter known as
costodiaphragmatic (costophrenic) recesses
2. The costodiaphragmatic recesses appear larger posteriorly, even
though on all sites the difference is 2 ribs,
3. Yet most physicians prefer the mid axillary line (MAL), between
ribs 8 & 10 approach in thoracocentesis,

4. At what phase of respiration were these

views taken?

RIGHT & LEFT COSTOMEDIASTINAL

RECESSES
Pleural
recesses are
potential
spaces for the
expansion of
the lungs
during deep
inspiration.

RIGHT & LEFT COSTODIAPHRAGMATIC

(COSTOPHRENIC) RECESS

PLEURA & PLEURAL

RECESSES TESTED

A pleura is

A. Serous membrane
B. Mucous membrane
C. Superficial fascia
D. Deep fascia
A pleural recess is
A. Ventricles and chambers of the
lung
B. Spaces between serous and
fibrous layers
C. Spaces between parietal and
visceral layers
D. Spaces between viscus and
visceral layer

Which of the following

about costomediastinal
recesses is/are correct
A. there is only one
costomediastinal
recess
B. the right is larger than
the left
C. It is part of the pleural
cavity where the costal
and mediastinal pleura
meet
D. It is located where the
mediastinal meets the
diaphragmatic pleura

PLEURAL EFFUSION IMAGED

Radiologically, this is the first part to be
filled up in pleural effusion : pleural effusion
obliterates the translucency of the space.

Normal

Pleural effusion

PLEURAL EFFUSION IMAGED

WHY POSTERIOR
THORACOCENTESIS IS NOT A
VIABLE OPTION
A STAB WOUND & IATROGENIC
INJURY
LUNG

D
K
s

THORACOCENTESIS
A thoracocentesis for pleural
effusion at the midaxillary line is
best performed in which
intercostal spaces?
A. Sixth and seventh
B. Seventh and eighth
C. Eighth and ninth
D. Ninth and tenth

PERICARDIUM
Pericardium is a
fibro serous sac
which encloses the
heart and the roots Branches of
aortic arch
of the great
vessels,
It is situated in the
middle
mediastinum,
There are two sacs Sternum
of pericardium:
- outer single-layered
fibrous
pericardium, &
- inner double
layered serous
pericardium.

Trachea

First rib

Left lung

Fibrous
pericardium
Thoracic
Diaphragm

FIBROUS & SEROUS

PERICARDIUM
3 LAYERS OF PERICARDIUM : fibrous (single) &
Serous (double),
FIBROUS :

It is a conical, single-layered , tough, fibrous sac, and supports the delicate

serous parietal layer to which it is firmly adherent,
Its apex fuses with roots of the great vessels and pre-tracheal fascia, and its
base is broad and inseparably blended with the central tendon of the
diaphragm,
The fibrous pericardium is attached to the posterior surface of the sternum
superiorly and inferiorly by superior and inferior sterno - pericardial ligaments,
The phrenic nerves are embedded in the fibrous pericardium, and on each
side, the fibrous pericardium is related to mediastinal pleura,

SEROUS : DOUBLE LAYERED (lined by mesothelium)

Outer parietal layer is fused inseparably with fibrous pericardium, and the
inner visceral pericardium forms the epicardium of the heart,
The two layers are continuous at the root of the great vessels,
Between the parietal and visceral layers is the potential space known as the
pericardial cavity,; contains a thin film of fluid that allows movement of the
heart,

PERICARDIUM

Phrenic
nerve

Pericardia
l branch

Intercostal
nerve

INNERVATION
OF
PERICARDIUM

CLINICAL APPLICATION OF
PERICARDIAL SINUSES
TRANSVERS
E : ligation in
cardiac
surgery &
stoppage of
bleeding
OBLIQUE :
dead space
for LT atrium
APPLICATION ;
Surgery
Potential
space

CLINICAL APPLICATION OF
PERICARDIAL SINUSES

TRANSESOPHAGEAL ECHOCARDIOGRAPHY

TWO SICK HEARTS COMPARED

Radiologic appearance = water

bottle

Cardiomegaly

PERICARDIOCENTESIS
CAUTION : Any patient who
comes in with shock and
penetrating chest injury has
cardiac involvement until
otherwise proven,
ACUTE/CHRONIC : can take only
100 ml to produce acute features,
but chronic type as in
hypothyroidism, can take as much
as 500 ml or more to produce
symptoms,
BECKS TRIAD : Cardiac
tamponade presents with a triad of
Hypotension, Jugular distension &
muffled heart sounds,
PERICARDIOCENTESIS :
infrasternal angle

PERICARDIOCENTES
IS
DRAINAGE

Drainage of fluid from

pericardial sac with a widebore needle inserted through
the :
- left 5th or 6th ICS near the
sternum, in the area of the
cardiac notch of left lung =
bare area,
- infrasternal angle : needle is
passed supero-posteriorly,
aiming at the left shoulder :
. Stay left and medial
. Stay low (infrasternal)
. Angle up

TEST ON DRAINAGE
Insertion of a needle for
pericardiocentesis is best
performed through which
route?
A. 5th right intercostal space
B. 5th left intercostal space
C. 6th right intercostal space
D. 6th left intercostal space
E. Left infrasternal angle
E. Right infrasternal angle

PNEUMOTHO
RAX
DEFINITION : presence of air in pleural space
TYPES :1. spontaneous, traumatic & tension
Spontaneous : occurs without antecedent
trauma
- primary :no underlying lung disease
- secondary : presence of underlying lung
disease
Traumatic : due to penetrating or nonpenetrating injury
Tension : a one-way valve that
maintains a positive pressure in the
pleural space high throughout the
respiratory cycle. Positive pleural
pressure is a medical emergency
because it is life-threatening,
PHYSICAL FINDINGS : hemithorax is
enlarged, and mediastinum is pushed
MANAGEMENT : insert a wide-bore needle
immediately in the 2nd ICS anteriorly, and
leave it there until a thoracotomy tube is
inserted.

PNEUMOTHORAX

In sucking
pneumothorax air
enters and leaves.
But in tension
pneumothorax air
enters but does not
leave. What will be the
fate of this patient?

PRACTICE QUESTIONS
A tumor seen in a radiograph at the level of sternal angle
would likely affect which structures in the thoracic cavity?
A tumor in posterior mediastinum may involve which
structures?
A tumor located just superior to the root of right lung is
likely to obstruct which vein?
Insertion of a needle for pericardiocentesis is best
performed through which route?
What is Pancost tumor, and what are its effects?
Where is pleural effusion located, and how do posture and
gravity affect it?
A Marfans patient with aneurysm of the arch of aorta is
likely to experience compression of which structure (s)?
A thoracocentesis for pleural effusion at the midaxillary
line is best performed in which intercostal spaces? Would
you drain a pneumothorax at same site?
Which structure transit the thoracic diaphragm through
the esophageal hiatus?

EMBRYOLOGIC ORIGIN OF
SEROUS MEMBRANES
SEROUS MEMBRANES :
serous pericardium, serous
pleura, serous peritoneum,
- parietal layer from
somatopleuric (somatic) part
of lateral plate mesoderm,
- visceral layer from the
splanchnopleuric (visceral)
part of lateral plate
mesoderm
FIBROUS PERICARDIUM:
from pleuropericardial
folds/membranes

FORMATION OF A PLEURAL RECESS

PLEURA & INTERPLEURAL

SPACE

IT IS A SEROUS MEMBRANE WHICH IS LINED BY MESOTHELIUM

THERE ARE TWO PLEURAL SACS ON EITHER SIDE OF THE MEDIASTINUM
EACH PLEURAL SAC IS INVAGINATED FROM MEDIAL SIDE BY THE LUNG
SO EACH PLEURAL SAC HAS

AN OUTER LAYER OR PARIETAL PLEURA &,

AN INNER LAYER = VISCERAL OR PULMONARY PLEURA

THE TWO LAYERS ARE CONTINUOUS AT THE HILUM

A POTENTIAL SPACE LIES BETWEEN PARIETAL AND VISCERAL PLEURA
WITH A NEGATIVE PRESSURE
THE CAVITY WILL BECOME A REAL SPACE IN CONDITIONS LIKE
PNEUMOTHORAX, HYDROTHORAX
VISCERAL (PULMONARY) : COVERS THE SURFACE AND FISSURES OF THE
LUNG EXCEPT AT THE HILUM AND ALONG THE ATTACHMENT OF THE
PULMONARY LIG. WHERE THE 2 LAYERS ARE CONTINUOUS ; IT IS SHINY
LAYER FIRMLY ADHERENT TO THE LUNG AND CAN NOT BE SEPARATED,
PARIETAL : IT IS THICKER THAN PULMONARY PLEURA AND IS DIVIDED
INTO 4 PARTS ; COSTAL, DIAPHRAGMATIC, MEDIASTINAL, CERVICAL

LINES OF PLEURAL
REFLECTION

Where the costal part of parietal pleura abruptly

changes direction from one wall to another
Sternal line

Vertebral line

RECESSES OF
PLEURA

THESE ARE RESERVE SPACES : for the expansion of the lungs during deep
inspiration,
COSTOMEDIASTINAL RECESS : Lies anteriorly behind the sternum /costal cartilages,
and between costal and mediastinal pleura,
COSTODIAPHRAGMATIC RECESS : Lies inferiorly between costal and diaphragmatic pleurae,

Bare area

Costal pleura

CLINICAL CORRELATES OF
PERICARDIUM
OTHERS

CARDIAC TAMPONADE

The fibrous pericardium is

unyielding,
And so if fluid accumulates in the
pericardial sac, it is the heart that
suffers no full expansion of the
heart,
Venous return & cardiac output
may decrease to fatal levels,
Heart rate increases to
compensate for the shortfall,
( VR, CO, & HR)
The veins of the neck & face
become very engorged because
of backup of the circulation,
Slow accumulation is amenable to
pericardiocentesis, but the acute
form is a dire emergency that
requires emergency thoracotomy.

IN BYPASS SURGERY THE ARTERIES

ARE CLAMPED THROUGH
TRANSVERSE SINUS
PERICARDITIS LEADS MOSTLY TO
EFFUSION AND THUS CONSTRICTS
HEART CALLED CONSTRICTIVE
PERICARDITIS CARDIAC
TAMPONADE
INFLAMMATION LEADS TO
PERICARDIAL RUB
STAB WOUND
HAEMOPERICARDIUM
MI- CAN LEAD TO PERFORATION OF
HEART HAEMOPERICARDIUM
PERICARDIOCENTASIS IS DONE
IN LEFT 5TH OR 6TH SPACE NEAR
THE STERNUM
( BARE AREA
OF HEART)
OR THROUGH THE LEFT
INFRASTERNAL ANGLE

At the level of aortic arch showing

the superior intercostal vein.