Mechanics of the pleural space: fundamental concepts.

The transmission of forces from the respiratory muscles to the lung across the extremely thin pleural space has been poorly understood because of the difficulty of accurately measuring pleural liquid and pleural surface pressure (lung static recoil or transpulmonary pressure). Recent results using relatively noninvasive techniques have indicated that the vertical gradient in pleural liquid pressure is not hydrostatic, that pleural liquid pressure is closely related to lung recoil, and that there exists a very thin but continuous pleural liquid layer. These findings contradict concepts based on hydrostatic equilibrium and on the distinction between pleural liquid and pleural surface pressure due to pleural contact. Pleural liquid pressure is not in hydrostatic equilibrium because the difference between the vertical gradient in pleural liquid pressure and the effect of gravity is always balanced by a pressure loss due to a viscous flow within the pleural space. Fluid lubrication of the pleural surfaces is the primary function of the pleural space. The mechanical interaction between the lung and the chest wall is coupled to the dynamics of liquid within the pleural space, which is viewed as a flow-through system. Homeostasis is achieved in such a system by the adjustment of the viscous flow within the pleural space and the outflow absorption rate by lymphatics to the microvascular filtration rate across pleural capillaries.