FOM STUDY GUIDE

ANATOMY 4. Discuss lung volumes and how they are affected by accumulation of
1. Describe the pleural cavity pleural fluid or air
2. Discuss the formation of the lines of pleural reflection
BIOCHEMISTRY
3. Describe the costophrenic angle and its clinical significance
1. Discuss the composition of transudate and exudate. Differentiate one the
4. Describe the anatomy of the chest wall
other
PHYSIOLOGY 2. What is the clinical significance of knowing whether a pleural fluid is a
1. Discuss the production and absorption of pleural fluid transudate or exudate?
2. Discuss the mechanisms that would lead to the accumulation of the pleural
SURGERY
fluid or air
1. What is thoracentesis/thoracostomy?
3. Discuss the physiologic disturbances resulting from the accumulation of
2. What are the anatomic considerations in doing these surgical procedures?
pleural fluid or air

ANSWERS
ANATOMY
Pleural cavity - On chest x-ray: [1] Sharply pointed [2] Downward indentation (dark) between
- Lined by serous membrane called pleura (pulmonary cavity) each hemi-diaphragm (white) and the adjacent chest wall (white) [3] Small
 Single layer of mesothelial cells with secretes or absorb fluid portion of each lung normally reaches into the costophrenic angle [4] Normal
- Located in the peripheral side of the chest wall bilaterally angle usually measures thirty degrees (30O)
 Separated and do not communicate with each other which are joined
by trachea or bronchi
 Also separated from the environment, wherein only the lungs
communicate to the environment
 Provides a vacuum environment via trachea and bronchi

Lines of pleural reflection

- The relatively abrupt lines along which the parietal pleura folds back or
changes direction from one wall of the pleural cavity to another

Figure 2. Important radiographic structures of the thorax

- Clinical significance:
 Pleural effusions collect in the costodiaphragmatic recess when in
Figure 1. Lines of Pleural reflection (a) Sternal line (b) Costal line (c) Vertebral line standing position
 PLEURAL EFFUSION
Sternal line - Have asymmetrical sides due to the deviation of the heart
o Accumulation of fluid in the pleural space caused by
of pleural to the left side
inflammation or recent surgery
reflection - Right side
o Radiographic appearance shows blunting of the costophrenic
 Starts 1 ½ inches above 1st rib
angle and fluid accumulation (typical-300 mL/atypical-1500 mL)
 Ends at 6th rib beside the start of xiphoid process
o One of most important pleural abnormalities observed in
 Passes inferiorly in the anterior median line (AML) thoracic diseases
to the posterior of xiphoid process o Fluid accumulation will separate visceral from parietal pleura
- Left side and compress the lungs
 Starts 1 ½ above 1st rib o Compression will cause lungs to collapse (atelectasis)
 Ends at 4th costal rib, goes laterally then down to o Produces a restrictive lung disorder
the 6th rib  EMPHYSEMA
o This forms a shallow notch which is important o Blunt edges of the costophrenic angle on lateral view
for pericardiocentesis along the “bare area” o A form of COPD which involves destruction of the lungs over
of pericardial contact with anterior thoracic time characterized by permanent enlargement of the air spaces
wall [Moore beyond the terminal bronchioles
Costal line - Left and right lines are the same
of pleural - Start: 6th rib beside the start of xiphoid process Chest wall
reflection - Ends at: Bones: 12 pairs of ribs connected to the sternum (1-7) by costal cartilages | 12
 8th rib along mid-clavicular line thoracic vertebrae
 10th rib lateral along mid-axillary line Intercostal spaces: 11 ICS named after the superior rib with 11 IC Nerves
 12th rib posteriorly at mid-scapular line Subcostal space: Below the 12th rib
Vertebral - Located between mediastinum and costal line Thoracic aperture:
line of - Parallel to vertebral column Superior thoracic aperture Inferior thoracic aperture
pleural - Starts at T1 up to T12 Posterior: T1 vertebra Posterior: T12 vertebra
reflection Lateral: 1st pair of ribs and costal Posterolateral: 11th and 12th pairs of
cartilages ribs
Costophrenic angle Anterior: Superior border of Anterolateral: Costal cartilages of 7th
- Costophrenic angles are the places where the diaphragm (-phrenic) meets the manubrium to 10th ribs forming the costal margin
ribs (costo-). Anterior: Xiphisternal joint
Muscles:  Posterior IC arteries:
- External intercostals: Elevates ribs during forced inspiration o Superior intercostal artery (1-2)
- Internal intercostals: o Thoracic aorta (3-11 & subcostal)
 Interosseus: Depresses ribs during forced respiration - Venous drainage:
 Interchondral: Elevates ribs during forced respiration  Anterior intercostal veins: Internal thoracic vein
- Innermost intercostal muscles  Posterior intercostal veins:
- Subcostal muscles: Lower thoracic wall spanning 1-2 ICS o 1: Brachiocephalic vein
- Transversus thoracis: 4-5 slips radiating from the posterior-inferior sternum o 2-3: Azygos & Brachiocephalic veins
Blood supply: (VAN) o 4-11: Azygos & Hemiazygos veins
- Arterial supply: Thoracic aorta—Subclavian artery—Axillary artery Nerve supply:
 Anterior IC arteries: - Anterior rami of thoracic spinal nerves (T1-T11)
o Internal thoracic artery (1-6) - Subcostal nerve (Anterior ramus of T12)
o Musculophrenic branch of ITA (7-9)

PHYSIOLOGY
1. Discuss the production and absorption of pleural fluid
2. Discuss the mechanisms that would lead to the accumulation of the pleural fluid or air
3. Discuss the physiologic disturbances resulting from the accumulation of pleural fluid or air
4. Discuss lung volumes and how they are affected by accumulation of pleural fluid or air
EDEMA OF THE PLEURAL CAVITY
-

PUSHER STOPPER Flux = K ([Pc – Pi] – σ [πp – πi])

K Capillary filtration coefficient Increased Infections and toxins
Pc Capillary (intravascular) hydrostatic pressure High Left-sided heart failure and fluid overload
Pi Interstitial hydrostatic pressure Low Re-expansion pulmonary edema from rapid evacuation of fluid
σd Average colloid osmotic reflection coefficient Low Acute respiratory distress syndrome
πp Capillary (intravascular) oncotic pressure Low Hypoalbuminemia
πi Interstitial oncotic pressure Increased solute Increased solute in interstitium

BIOCHEMISTRY
TRANSUDATE EXUDATE
Components: Fluid only Components: Both fluid and proteins
Characteristics: Usually clear, decreased cell count, has low levels of protein, Characteristics: Cloudy, increased cell count, has high levels of protein, albumin
albumin and LDH and LDH
Pathophysiology: Increased capillary hydrostatic p. | Decreased oncotic p. Pathophysiology: Increased capillary permeability (larger spaces between
Common causes: endothelial cells due to inflammation)
- Congestive heart failure Common causes:
- Hepatic cirrhosis - Infections (Pneumonia, TB, pleural empyema)
- Nephrotic syndrome - Malignancy (Lung CA, lymphoma, mesothelioma, metastatic breast CA)
- Protein-losing enteropathy - Pulmonary embolism
- Chronic kidney disease - Autoimmune diseases (vasculitis)
Light’s Criteria:
- If at least one of the following criteria is present, then the fluid is determined to be an exudate:
 Pleural fluid protein to serum protein ratio > 0.5
 Pleural fluid LDH to serum LDH ratio > 0.6
 Pleural fluid LDH > 2/3 the upper limit for normal serum LDH
Clinical significance of knowing the type of fluid:
- Pleural fluid analysis through thoracentesis is required to establish the underlying diagnosis in most pleural effusions
- Treatment should focus on correcting the underlying condition.

SURGERY
THORACENTESIS/THORACOSTOMY
- Aspiration of fluid from the pleural space for diagnostic (e.g., transudate vs. exudate) and/or therapeutic purposes
- Indications
 Any new unilateral effusion > 1 cm on x-ray in an undiagnosed patient (except in patients with obvious typical heart failure)
 History of malignant tumor with effusion > 1 cm on x-ray
 Large effusion with dyspnea and/or cardiac decompensation
- Steps:
[1] Insertion of a 14-gauge needle in the right midclavicular line at the 2nd ICS and air is heard escaping (decreases the pressure in the pleural cavity)
[2] Incision is made within the safety triangle
[3] Insertion of a chest tub/thoracostomy tube at the 5th ICS in the midaxillary line connected to a chest drainage device
- Anatomic considerations:
1. Incision must be made within the safety triangle
 Boundaries:
o Anterior Boundary: Lateral border of pectoralis major
o Posterior Boundary: Midaxillary line by the apex below the axilla
  Also, the anterior aspect of the latissimus dorsi
o Inferior Boundary: Horizontal level of the nipple in between 4th and 5th ICS in males
 Unreliable landmark for females due to breast tissue
 Incision must be around 1.5-2 cm incision is preferably made between the 4th and 5th ICS in the anterior axillary line