Intended for healthcare professionals

Clinical Review Regular review

The pleural cavity

BMJ 2000; 320 doi: (Published 13 May 2000) Cite this as: BMJ 2000;320:1318
  1. Giles J Peek, specialist registrar (,
  2. Sameh Morcos, consultantb,
  3. Graham Cooper, consultanta
  1. a Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield S5 7AN
  2. b Department of Radiology, Northern General Hospital
  1. Correspondence to: G J Peek, Division of Cardiac Surgery, University of Leicester, Glenfield Hospital, Leicester LE3 9QP

    Diseases of the pleural space are common. In this review we discuss the pathophysiology, diagnosis, and treatment of pneumothorax, pleural effusion, and empyema.

    Summary points

    After a second spontaneous pneumothorax there is a 40% chance of recurrence; video assisted thoracoscopic bullectomy and pleurodesis is the treatment of choice.

    Needle decompression (second interspace, mid-clavicular line) is the best treatment for suspected tension pneumothorax.

    Ultrasonography is helpful in cases of pleural effusion.

    A chest drain should be inserted in cases of exudative (protein content greater than 3 g/l) pleural effusion that recur after aspiration, or in parapneumonic effusions when the pH is less than 7.2 or the glucose concentration is less than 3.33 mmol/l.

    A chest drain should be inserted for early empyema.

    Late presenting empyema should be treated by decortication if the patient is fit, but patients who are unfit for major surgery should receive thrombolytic instillation or thoracostomy.


    We searched Medline (1966 to 1999), standard textbooks of thoracic surgery, and life support manuals for articles that answered questions that in our experience non-specialists commonly ask of specialists in the diagnosis and management of pneumothorax, pleural effusion, and empyema.

    The pleural space

    The pleura is a thin serous layer, which covers the lungs (visceral pleura) and is reflected, by way of the lung hila, on to the chest wall and pericardium (parietal pleura). The pleural space thus created extends from the root of the neck, 3 cm above the mid-point of the clavicle, down behind the abdominal cavity, in the costodiaphragmatic recess, to the 12th rib overlying the kidney.1 Only a thin layer of pleural fluid separates the parietal and visceral pleura. The parietal layer secretes 2400 ml of fluid daily, which is resorbed by the visceral layer.2 Maintenance of negative intrapleural pressure is necessary for respiration.


    Pneumothorax describes air within the pleural cavity. …

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