2009-09-08 Ana Gross Respiratory 2013

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RESPIRATORY SYSTEM (Gross)

Objectives:

Describe the gross features of the tracheobronchial treeo Identify important structures related to the trachea

and primary bronchi

o Ramifications of the bronchial treeo Orientation of the primary bronchi and anatomical

basis of the location of aspirated foreign bodies

o Features of bronchopulmonary segments and theirclinical sig.

Describe gross features of the lungso Surfaces, lobes and fissureso Differentiate right and left lungso Impressions made on the mediastinal surfaceo Composition of the root of the lung

Surface projection of the borders and fissures of the lungs onthe chest wall

Blood supply, innervations, lymphatics Embryologic development of the tracheobronchial tree (?!?!?!) Describe normal radiologic features

THE RESPIRATORY SYSTEM (RS)

Component parts:

A. Anatomic divisions1. Upper RS- nose, pharynx and larynx2. Lower RS- trachea, bronchi, lungs

B. Functional divisions1. Conducting portion

Nasal cavities, pharynx, larynx, trachea,bronchi [can be extrapulmonary

(primary/main bronchus) or

intrapulmonary(secondary/lobar)],

bronchiole-terminal

2. Respiratory portion Respiratory bronchiole, alveolar ducts,

alveolar sacs, alveoli

GROSS ANATOMY OF THE LUNGS

conical in shape; reflect space of pleural cavity(except for costodiaphragmatic andcostomediastinal recesses)

each has an apex, root and base apex aka cupula

o blunt superior end of the lungascending above the level of the1st rib into the root of the neck for

September 8, 2009

Collapsed Lung Inflated LungCervical part

Costa

part

Pleural cavity

Visceral pleura

Diaphragmaticpart

Parietal Pleura

Mediastinal Part

Gross Respiratory

Dr. Esguerra


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about 1 in. (2.5 cm) above theclavicle

o covered by cervical pleurao separated from the neck by

suprapleural membrane or Sibsons

fasciao can be mapped out on the anterior

surface of the body by drawing a

curved line, convex upward, from

the sternoclavicularjoint to a point1 above the junction of the medialand intermediate thirds of theclavicle.

rooto aka hilum/hiluso point of entry of lymph nodes,

bronchi and pulmonary vesselso structures pass from the neck to

abdomen (esophagus, bloodvessels, vagus nerve, thoracicanterior to the root: phrenic nerve

(found within the pericardial lning) base

o concave in shape; conforms todiaphragm

diaphragm on right T8 level

diaphragm on left IVdisc level of T8/T9

o right is higher than the left,because of the liver

o it then follows that the right lung isshorter

o the heart pushes the left lung,therefore right lung is broader

each has 3 surfaces: costal( related to theribs), mediastinal (beside the heart)anddiaphragmatic (inferior)

each also has anterior and inferior borders(no posterior border because at the back, themediastinal surface is continuous to costal

surface without any edge) Fissures:

Oblique fissureo At the posterior surface, about

2.5 inches from the apex, itfollows the course of 6th ribdown to inferior border of the

lungo Divides lower lobe of right lung

from the upper and middle

lobes

Horizontal fissureo Divides the middle and upper

lobe of the right lungo Follows the plane of 4th rib as it

attaches to the sternum Formation: each lung bud invaginates the wall

of the coelomic cavity and then grows to fill a

greater part of the cavity in life, light, soft, spongy and elastic that it

recoils to about one third their size when the

thoracic cavity is opened in children, they are pink; in adults, dark and

molted due to inhalation of dust particles

(carbon)

Occupy the thoracic cavity except for the ff:Costodiapharagmatic recessoSlit-like spaces between the costal and

diaphragmatic parietal pleurae that areseparated only by a capillary layer of pleural

fluidoLower area of the pleural cavity into which

the lung expands on inspiration

oDuring expiration, the lower margins of thelungs ascend so that the costal anddiaphragmatic pleurae come together again.

o2 (5 cm) deep in the scapular lineposteriorly

o3 to 3.5 (8-9 cm) in the midaxillary lineo1 to 1.5 (2.5 to 4 cm) in the midclavicular

line


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Costomediastinal recess (left)opotential space in the pleural cavity between

the costal pleura and mediastinal pleura atthe level of the 5th intercostal space on theleft side in which the lingula expands into

during inspirationo structures pass the thoracic cavity

posteriorly except the phrenic nerve

which passes anteriorly to the root of the

lung to the pericardium of the heart

*Lingula is a tongue like projection on the left lung analogous to the

middle lobe of the right lung* 3R, 2L number of lobes, lobar bronchi and bronchial arteries.*Segue: Amazingly, same trend in the heart. Right: tricuspid valve,left: bicuspid valve.

BORDERS Anterior

o costal and mediastinal surfaces meetanteriorly and overlap the heart

o RIGHT LUNG Relatively straight Begins behind the sternoclavicular

joint and runs downward, almost

reaching the midline behind thesterna angle, then continues

downward reaching the xiphisternaljoint

Thin and overlaps the hearto LEFT LUNG

Similar course as the right lung, butdeviates laterally at the level of the4th costal cartilage to extend for avariable distance beyond the lateral

margin of the sternum to form thecardiac notch

Cardiac Notchnotch produced by the heartdisplacing the lung to the left, creating a thin,

tongue-like process of the superior lobe,LINGULA, which extends below the cardiacnotch and slides in and out of the

costomediastinal recess during inspiration andexpiration

Posterioro extends downward from the spinousprocess of C7 to the level of T10 and lies

1.5 (4 cm) from the midlineo thick and lies beside the vertebral column

Inferioro In the midinspiration, follows a curving

line, which crosses the 6th rib in the

midlavicular line; 8th rib in themidaxillary line and 10th rib adjacent tothe vertebral column posteriorly

o Level of this border changes duringinspiration and expiration

RADIOGRAPHY

Chest X-ray: PA Projection (PosteroanteriorView)

For babies: AP Pojection (Anteropsterior) To obtain a posteroanterior radiograph, the X-

ray are projected from behind the patient to a

plate that is touching the patients chest;structures close to the plate appear very close tothe actual size, and the structures further away

appear larger

Hearto In anteroposterior view, it appears much

larger (and less distinct) than in posteroanteriorview

Right Lung Left Lung

# of Lobes 3 2

At the root of the

lung

Azygos arch

impressionAortic arch impression

Pulmonary ligament (mesopneumonium)

double layer of pleura below theroot

covers the root and attaches thelung to the mediastinum

Pulmonary vein posteriorly and inferiorly

located

Lobar bronchi posterior and central

Pulmonary arteries anterior to bronchiPulmonary arteries always the most

superior structure

Special feature

in some cases,

eparterial bronchus

appears above the

artery

Lingula*

Fissures Oblique, Horizontal Oblique

# of

Bronchopulmonary

segments

10 8


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Lungsodense shadows caused by the presence of the

blood-filled pulmonary and bronchial vessels, thelarge bronchi, and the lymph nodes

olungs are more translucent on full inspirationthan on expiration

opulmonary blood vessels are seen as a series ofshadows radiating from the lung root. They

appear as small, round, white shadows

olarge bronchi also cast round shadowsosmaller bronchi are not seen

Bonesothoracic vertebrae are imperfectly seenocostal cartilages are not usually seen, but if

calcified, they will be visible

oclavicles are clearly seen crossing the upper partof each lung field

omedial borders of the scapulae may overlap theperiphery of each lung field

Diaphragmodiaphragm casts dome-shaped shadows on each

side; the one on the right is slightly higher thanthe one on the left

ocostophrenic angle,- area where the diaphragmmeets the thoracic wall

obeneath the right dome is the homogeneous,dense shadow of the liver

obeneath the left dome a gas bubble may beseen in the fundus of the stomach

*on x-rays, black-color signifies presence of air. More dense structuresappear as white (bones). Radiopaque materials (coins, pins, wire, etc.)

also appear white.

GROSS ANATOMY OF the TRACHEOBRONCHIALTREE

Tracheastarts from larynx (C6 level-lower border of

cricocartilage) up to its bifurcation (carina*)5 in. long, 1 in. diameterFrom the lower border of the cricoids cartilage

until the level of the 6thcervical vertebra (C6)Bifurcates into right and left main stem bronchi

(extrapulmonary) at T4and T5

Carina: bifurcation. It is the keel-like ridgebetween the two openings of the main stembronchi

Main bronchi branch will form the bronchial tree(secondary intrapulmonary lobar bronchi)

has fibroelastic wall in which are embedded aseries of U-shaped bars of hyaline cartilagethat keep the lumen patent

posterior free ends are connected by thetrachealis muscle(regulated by therecurrent laryngeal nerve-branch of vagus)

*normally located at T4/t5; in deep inspiration, the carina

descends up to the T6 level because the lungs go down

BronchusRight Main Bronchus Left Main Bronchus

Wider Narrower

shorter longer

More vertical More horizontal/lateral

Branches: superior and

intermediate lobar

bronchus

Superior and inferior lobar

bronchus

Latter divides into: middle

and inferior lobar bronchus

*Primary or main stem bronchus divides into*

Lobar Bronchi (secondary bronchi)*Each lobar bronchus divides into*

Segmental Bronchi (tertiary bronchi)Supply the bronchopulmonary segmentsName would correspond to the segment it

supplies

THE BRONCHOPULMONARY SEGMENT

pyramidal shaped segment of the lungs with theapex facing the lung root and the base at the pleura

surface largest subdivision of a lobe anatomic, functional, and surgical unit of the lungs separated from adjacent segments by connective

tissue septa


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supplied independently by a segmental or tertiarybronchus and a tertiary branch of a pulmonary

artery named according to the segmental bronchus that

supplies it

drained by pulmonary veins along the connectivetissue septa (intersegmental drainage)

surgically resectable (Segmentectomy) functionally and independent unit of the lung with its

own segmental bronchus and artery

Aspiration Pneumonia particles aspirated by an adult in an

upright position will most likely fall tothe right main bronchus (may go

further to the posterior basal segment) paricles aspirated by an adult lying on

his right side will most likely fall to the

right main bronchus (may go tofurther to posterior or middle lobe)

particles aspirated by an adult lying onhis left side will most likely fall to theleft main bronchus (may go further tolingular segments)

particles aspirated by an adult lying onhis backwill most likely fall to the rightmain bronchus (may go further to

superior bronchopulmonary segment ofthe right lower lobe)

particles aspirated by a baby goes toright upper lobe (more often)

Bronchioles Where cartilage disappearsbronchioles

possess no cartilage in their walls and

are lined with columnar ciliated

epithelium

Arise from the division of the smallestbronchi

Are less than 1mm in diameter Terminal bronchioles

The bronchioles divide and give rise toterminal bronchioleswhich show

delicate outpouchings from their walls.

Respiratory bronchiole Start of respiratory portion Associated with alveoli on the walls Gaseous exchange between blood and

air takes place in the walls of these

outpouchings

Alveolar duct The respiratory bronchioles end by

branching into alveolar ducts which lead

into tubular passages with numerous

thin-walled out-pouchings called alveola

sacs

Alveolar Sac Consist of several alveoli opening into a

single chamber

Alveolus The alveolar sacs consist of several

alveoli opening into a single chamber.

Each alveolus is surrounded by a richnetwork of blood capillaries. Gaseous

exchange takes place between the air in

the alveolar lumen through the alveolar

wall into the blood within the

surrounding capillaries

PULMONARY CIRCULATION (refer to Appendix A)s

Deoxygenated blood form the terminal branches of thepulmonary arteries is received by the alveoli. The

oxygenated blood leaving the alveolar capillaries drainsinto the tributaries of the pulmonary veins, which followthe intersegmental connective tissue septal to the lungroot. Two pulmonary veins leave each lung root to

empty into the left atrium of the heart.

Segmental bronchus

Pulmonary artery

Pulmonary vein in

intersegmental

connective tissue

Autonomic nerves

Lymphatic vessel

Pulmonary vein

Terminal

bronchiole

Respiratory

bronchiole

Alveolar sac

alveolus

Tracheopulmonary segment


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Arteries Pulmonary Artery

- follows the lobes (bronchial branching)and carries unoxygenated blood fromthe heart

- Upper and lower pulmonary arteriesare drained by one Upper Pulmonary

Vein Bronchial Artery

-Branch of descending bronchiole

-Trachea to bronchi to respiratorybronchiole-Supplies the bronchi, connective tissue

to the lung and the visceral pleura-Carries oxygenated blood-Right Lung: 1(posterior intercostal

artery arises from the left bronchialarteries)-Left Lung: 2(superior and inferior branches of descending thoracic aorta)-Eventually anastomose with withpulmonary arteries

Veins Pulmonary Vein

- All drain to posterior aspect (LeftAtrium)- Primary drainage of blood frombronchial artery- NOT the bronchial venous system

(which drains the proximal part of thelungs bronchi and CT only)- Right Lung: One (1) upper and middle

and one (1) lower- Drain intersegmentally- Left Lung: One (1) upper and one

lower

- Enters the heart via the left atriumcarrying oxygenated blood

Bronchial Veins- Communicate with the pulmonaryveins

- Drain into the azygos vein whichcollects posterior intercostal veins(right) and helmazygos veins (left)

RIGHTSIDE

LEFT SIDE

PulmonaryArtery

Locatedinferior to

theEparterialBronchus

Most superiorstructure (No

bronchus)

BronchialArtery

One (1)Right

bronchialartery

Two (2) LeftBronchial Arteries:

1. SuperiorLBA

2. Inferior LBABoth are branches

of the descendingaorta

BronchialVenousSystem

RBV drainsto theazygos vein

LBV drains to theleft accessoryhemiazygos/intercos

tal vein

Mixing of Oxygenated and Unoxygenated Blood

Occurs in the alveoli, along pleura andintersegmental CT

Bronchial artery with pulmonary vein from alveoliBlood supply drained from the visceral pleura and thecapillaries

LYMPHATIC DRAINAGE AND NERVOUS SUPPLY

-Follow veins and arteries

-Lymph vessels originate in superficial and deepplexus-Up to terminal bronchioles only (fluid absorbed

at this level)not present in alveolar walls

Superficial/ Subpleural Plexus- lies beneath the visceral pleura- drains over the surface of the lung toward the

hilum (lymph vessels enter the bronchopulmonary nodes

Deep Plexus- travels along the bronchi and pulmonaryvessels toward the hilum of the lung-passes through pulmonary nodes in the hilum

-all the lymph from the lung leaves the hilumand drains into the tracheobronchial nodes(superior and inferior tracheobronchial CARINAL


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Nodes paratracheal nodes) and then into thebronchiomedistinal lymph trunks (along venous

circulation at the junction of subclavian vein andinternal jugular vein

RIGHT LUNG LEFT LUNG

DRAINAGE RIGHT LYMPHATICDUCT

THORACIC DUCT

Lymph from Hilar

Nodes Carinal/Tracheobronchial Trunk

Right LymphaticTrunk

Subclavian Veinand Internal

Jugular Vein

(Upper lobe) Hilar

Node SuperiorTracheobronchialNodes Left

Paratracheal Nodes Thoracic Duct

(Lower Lobe) HilarNode

Carinal/InferiorTracheobrochial

Right Lung

THORACIC DUCT

- Collects all lymphatics from below the right andleft diaphragm

- Located at the level of T12- Drains left side of the face and arm and the left

upper lobe of the lung and below the diaphragm

- Begins in the abdomen as a dilated sac, theCISTERNA CHYLI

- Enters the AORTIC HIATUS (shares the sameforamen with the aorta)

- 180 turn at C7- Terminates at the junction of the Left Interna

Jugular Vein and the Left Subclavian Vein

Pulmonary Plexus- Supplies each lung-

Formed by branches of the sympathetic trunkand received parasympathetic fibers from the- Vagus nerve (CNX): Innervation of the smoot

muscle of the brachial tree, pulmonary vessels,and the glands of the bronchial tree via the

pulmonary plexuses located anterior andposterior to the lung roots

- Postganglionic Sympathetic Fibers from thesympathetic trunks (bronchodilatorsvasoconstrictors, and inhibit glandular excretion)

- Preganglionic Parasympathetic Fibers from theVagus Nerve (CNX) bronchoconstrictorsvasodilators, and secretomotor to the glands

- Visceral Afferent Fibers follow sympathetic fibers carry information involved in cough reflexesstretch reception, blood pressurechemoreception, and nociception (also painreceptors sympathetic over distention)

Left bronchomediastinal lymph

trunk drains into thoracic duct

Paratracheal nodes

Inferior tracheobronchial

(cardinal) nodes

Subpleural lymphatic plexus

Interlobar

lymphatic vessels

Drainage to

mediastinum

enough

pulmonary

ligaments

Deep

lymphatic

drainage

follows the

bronchial tree

Right bronchomediastinal lymph

trunk drains into right lymphatic duct

Superior tracheobronchial nodes

Bronchopulmonary

(hillar) nodes

nterpulmonary

nodes

Anterior

viewEsophageal

plexus

Left Vagus Nerve Left

Phrenic Nerve

Cervical Cardiac Branches

(Vagosympathetic)

Left Recurrent

Pharyngeal Nerve

Pulmonary Plexus

Pulmonary Trunk

Left

Vagus

Nerve

Right

Vagus

Nerve

Right Recurrent

Pharyngeal Nerve

Right Vagus Nerve

Right Phrenic Nerve


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TEST YOURSELF!1. All of the following commonly occur on

inhalation except:a. The diaphragm descendsb. The external intercostal muscles

contractc. The abdominal muscles contract and

push the abdominal viscera cranially

d. The ribs are raisede. The visceral dimension of the thoraciccavity increases

2. With a patient in the standing position, fluid inthe left increases cavity tends to gravitate downto:

a. The oblique fissuresb. The cardiac notchc. The costomediastinal recessd. The costodiapragmatic recesse. The horizontal tissue

3. Which of the following statements is (are)correct regarding the bronchopulmonary

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2009-09-08 Ana Gross Respiratory 2013