Tracheaandlungs

Trachea• Thetrachea isaflexibletubethatextendsfrom

vertebrallevelCVI(cricoidcartilage)inthelowernecktovertebrallevelTIV/V

• itbifurcatesintoarightandaleftmainbronchus(carina) atthelevelofsternalangle

• Thetracheaisheldopenby'C-shaped'cartilagerings(16-20)embeddedinitswall-

• theopenpartofthe'C'facingTheposteriorwallofthetracheaiscomposedmainlyofsmoothmuscle(trachealis)andconnectivetissue.

• Inadultsthetracheaisabout4½in.(11.25cm)longand1in.(2.5cm)indiameter

- Thetracheawidensandlengthensslightlywitheachinspiration,returningtoitsrestingsizewitheachexpiration.

RelationsofTracheaAnteriorlly• Aorticarch• Thymus• thyroid• Originofbrachiocephalicartery• ManubriumsterniLeft• Archofaorta• Lt.subclavianart.• LT.commoncarotidart.• Lt.Phrenicn.• Lt.Vagusn.• Lt.mainbronchusRight- Azygousarch- Brachiocephalicartery- Rt.Vagus- Rt.Phrenic- Rt.mainbronchusPost.- Esophagus- Thoracicduct- leftrecurrentlaryngealnerve

Trachea• carina isacartilaginousridgewithinthe

trachea thatrunsanteroposteriorlybetweenthetwoprimarybronchi atthesiteofthetrachealbifurcation(T4-T5).

• Themucousmembraneofthecarinaisthemostsensitiveareaofthetracheaandlarynxfortriggeringacoughreflex.

• Indeepinspirationitdescendstothelevelof6th thoracicvertebra

Tracheotomyandintubations• Usedtoreestablishairflowpastatrachealobstruction.

• Iftheobstructionissuperiortothelarynxatracheotomymaybeperformed

• Alongitudinalincisionbelowthecricoidcartilage

• Thepatientcanthebreaththroughametalorplastictube.

• inintubationthetubeisinsertedthroughthemouthornoseandpushasideanyflexibleobstruction

• Anymucouscloggingcanbesuctionedthroughthetube

Bronchi

• Eachmainbronchusenterstherootofalungandpassesthroughthehilumintothelungitself.

• Therightmainbronchus iswiderandtakesamoreverticalcourseandisabout1in.(2.5cm)

• principalbronchusgivesoffthesuperiorlobarbronchus.Onenteringthehilum,itdividesintoamiddleandaninferiorlobarbronchus.

• theleftmainbronchusisnarrower,longer,andmorehorizontalthantherightandisabout2in.(5cm)long

• passestotheleftbelowthearchoftheaortaandinfrontoftheesophagus

• theprincipalbronchusdividesintoasuperiorandaninferiorlobarbronchus.

• Therefore,inhaledforeignbodiestendtolodgemorefrequentlyontherightsidethanontheleft.

Bronchialtree• Themainbronchusdivideswithinthelung

intolobarbronchi (secondarybronchi),

• eachofwhichsuppliesalobe.

• Ontherightside,thelobarbronchustothesuperiorlobeoriginateswithintherootofthelung.

• Thelobarbronchifurtherdivideintosegmentalbronchi (tertiarybronchi),whichsupplybronchopulmonarysegments

Bronchialtree• bronchopulmonarysegment furtherdivideintoterminalbronchioles&theseintorespiratorybronchioleswhichendinthepulmonaryunit.

- Pulmonaryunitconsistofalveolarducts,atria

airsacspulmonaryalveoli.

• Thewallsofthebronchiareheldopenbydiscontinuouselongatedplatesofcartilage,butthesearenotpresentinbronchioles.

Bronchialtree

Bronchialtree

Bronchopulmonarysegments• Abronchopulmonarysegment isthearea

oflungsuppliedbyasegmentalbronchusanditsaccompanyingpulmonaryarterybranch

• Itisasubdivisionofalunglobe.

• Itispyramidshaped,withitsapextowardthelungroot.

• Itissurroundedbyconnectivetissue.

• Ithasasegmentalbronchus,asegmentalartery,lymphvessels,andautonomicnerves.

• Thesegmentalveinliesintheconnectivetissuebetweenadjacentbronchopulmonarysegments.

• Becauseitisastructuralunit,adiseasedsegmentcanberemovedsurgically.

BronchopulmonarysegmentsRt.Lung10segmentsUpperlobeApicalposteriorAnt

MiddlelobeMedialLateral

BasallobeApical(apicobasal)AntMedLatPost

BronchopulmonarysegmentsLt.lung10segments

UpperlobeApicalposteriorAntsup.Lingualinf.lingual

BasallobeApical(apicobasal)AntMedLatPost

Bronchopulmonarysegments

Bronchopulmonarysegments

Beforebirth:- Rt.Lung10segments

- Lt.lung8segmentsApicpoposteriorAnteromedial

Clinicalimportanceofpulmonarysegments• Infections• Nobarrier• Surgery• Posturaldrainage• Bronchoscopy

Lungs

Lungs• organsofrespirationandlieoneithersideofthe

mediastinum

• surroundedbytherightandleftpleuralcavities

Spongy,grey,darklateron.

• 600-800gm,90%air&10%tissue

• Thepulmonaryarteriesdeliverdeoxygenatedbloodtothelungsfromtherightventricleoftheheart.

• Oxygenatedbloodreturnstotheleftatriumviathepulmonaryveins.

• Therightlungisnormallyalittlelargerthantheleftlungbecausethemiddlemediastinum,containingtheheart,bulgesmoretotheleftthantotheright.

Leftlungisnarrower-Rightlungisshorter,morevertical

Lungs• Eachlunghasahalf-coneshape

• base,apex,twosurfacesandthreeborders

• Thebase sitsonthediaphragm.

• Theapex projectsaboveribIandintotherootoftheneck.

1inchabovethemedial1/3rd oftheclavicleandisCoveredbysuprapleuralmembran.

• costalsurface liesimmediatelyadjacenttotheribsandintercostalspaces.

• Themediastinalsurface liesagainstthemediastinumanteriorlyandthevertebralcolumnposteriorly

• containsthecomma-shapedhilumofthelungthroughwhichstructuresenterandleave.

Lungs• inferiorborder ofthelungissharpandseparatesthebasefromthecostalsurface.

• Theanterior andposteriorborders separatethecostalsurfacefromthemedialsurface.

• theanteriorandinferiorborders,aresharp,

• theposteriorborderissmoothandrounded

Surfaceanatomyofthelung

• Atend-expiration• 6th rib– midclavicular• 8th rib– midaxillary• 10th T.vertebra_

Posteriorly- apexisat1stTh vertebra

• PosteriorborderExtendfrom7th Cvert.tothe10th Tvert.- lies4cmfromthemidline

Inferiorborder• Ascendanddescendbetween9th &12th rib

Rootandhilum• Theroot ofeachlungisashorttubularcollection

ofstructuresthattogetherattachthelungtostructuresinthemediastinum

• coveredbyasleeveofmediastinalpleurathatreflectsontothesurfaceofthelungasvisceralpleura

• Athinblade-likefoldofpleuraprojectsinferiorlyfromtherootofthelung.Thisstructureisthepulmonaryligament

• pulmonaryligament stabilizethepositionoftheinferiorlobeandmayalsoaccommodatethedown-and-uptranslocationofstructuresintherootduringbreathing

• thevagusnervespassimmediatelyposteriortotherootsofthelungs,whilethephrenicnervespassimmediatelyanteriortothem.

Rootandhilum

• Withineachrootandlocatedinthehilumare:• pulmonaryartery;• twopulmonaryveins;• amainbronchus;• bronchialvessels;• nerves;• lymphatics.

Rootandhilum• thepulmonaryarteryissuperioratthehilum,

• thepulmonaryveinsareinferior,andthebronchiaresomewhatposteriorinposition.

• Ontherightside,thelobarbronchustothesuperiorlobebranchesfromthemainbronchusintheroot,

• ontheleftitbrancheswithinthelungitself,andissuperiortothepulmonaryartery

Rightlung• Therightlung hasthreelobesandtwofissures

• Normally,thelobesarefreelymovableagainsteachotherbecausetheyareseparated,almosttothehilum,byinvaginationsofvisceralpleura.

• Theseinvaginationsformthefissures:• theobliquefissure separatestheinferiorlobe (lowerlobe) fromthesuperiorlobeandthemiddlelobeoftherightlung;

• thehorizontalfissure separatesthesuperiorlobe(upperlobe) fromthemiddlelobe.

Rightlung• Theapproximatepositionoftheobliquefissureonapatient,inquietrespiration,

• beginsroughlyatthespinousprocessofvertebraT4 levelofthespine,crossesthefifthinterspacelaterally,andthenfollowsthecontourofribVI anteriorly

Rightlung• Thehorizontalfissurefollowsthefourthintercostal spacefromthesternumuntilitmeetstheobliquefissureasitcrossesribV.

• Theorientationsoftheobliqueandhorizontalfissuresdeterminewherecliniciansshouldlistenforlungsoundsfromeachlobe.

• Whenlisteningtolungsoundsfromeachofthelobes,itisimportanttopositionthestethoscopeonthoseareasofthethoracicwallrelatedtotheunderlyingpositionsofthelobes

Rightlung

• Themedialsurfaceoftherightlungliesadjacenttoanumberofimportantstructurestheheart,• inferiorvenacava,• superiorvenacava,• azygosvein,• esophagus.

Rightlung

• Therightsubclavianarteryandveinarchoverandarerelatedtothesuperiorlobeoftherightlungastheypassoverthedomeofcervicalpleuraandintotheaxilla.

Leftlung• Theleftlung issmallerthantherightlung

andhastwolobesseparatedbyanobliquefissure

• obliquefissure oftheleftlungisslightlymoreobliquethanthecorrespondingfissureoftherightlung

• Duringquietrespiration,theapproximatepositionoftheleftobliquefissurecanbemarkedbylineonthethoracicwall

• beginsbetweenthespinousprocessesofvertebraeT3andT4,crossesthefifthinterspace laterally,andfollowsthecontourofribVI anteriorly

• Aswiththerightlung,theorientationoftheobliquefissuredetermineswheretolistenforlungsoundsfromeachlobe.

Leftlung

• Theinferiorportionofthemedialsurfaceoftheleftlung,isnotchedbecauseoftheheart'sprojection intotheleftpleuralcavityfromthemiddlemediastinum

• Ontheanteriorsurfaceofthelowerpartofthesuperiorlobeatongue-likeextension(thelingulaofleftlung)projectsovertheheartbulge.

Leftlung

• Themedialsurfaceoftheleftlungliesadjacenttoanumberofimportantstructuresthe

• heart,• aorticarch,• thoracicaorta,• esophagus

RIGHT LUNG

3 LobesUpper Middle and Lower

2 FissuresOblique & Horizontal

Segments

Secondary Lobules

LEFT LUNG

2 LobesUpper and Lower

1 FissureOblique

Segments

Secondary Lobules

Rightside

Leftside

Pulmonaryarteries• Therightandleftpulmonaryarteries

originatefromthepulmonarytrunk andcarrydeoxygenatedbloodtothelungsfromtherightventricleoftheheart

• ThebifurcationofthepulmonarytrunkoccurstotheleftofthemidlinejustinferiortovertebrallevelT4,andanteroinferiorlytotheleftofthebifurcationofthetrachea.

• Therightpulmonaryartery islongerthantheleftandpasseshorizontallyacrossthemediastinumItpasses:

• anteriorlyandslightlyinferiorlytothetrachealbifurcationandanteriorlytotherightmainbronchus;

• posteriorlytotheascendingaorta,superiorvenacava,andupperrightpulmonaryvein.

Pulmonaryarteries• Therightpulmonaryarteryenterstherootofthelungandgivesoffalargebranchtothesuperiorlobeofthelung.

• Themainvesselcontinuesthroughthehilumofthelung,givesoffasecond(recurrent)branchtothesuperiorlobe,andthendividestosupplythemiddleandinferiorlobes

• Theleftpulmonaryartery isshorterthantherightandliesanteriortothedescendingaortaandposteriortothesuperiorpulmonaryvein

• Itpassesthroughtherootandhilumandbrancheswithinthelung.

Pulmonaryveins

• Oneachsideasuperiorpulmonaryvein andaninferiorpulmonaryvein carryoxygenatedbloodfromthelungsbacktotheheart

• Theveinsbeginatthehilumofthelung,passthroughtherootofthelung,andimmediatelydrainintotheleftatrium.

Bronchialarteriesandveins• constitutethe'nutritive'vascularsystemofthe

pulmonarytissues(bronchialwallsandglands,wallsoflargevessels,andvisceralpleura).

• Theyinterconnectwithinthelungwithbranchesofthepulmonaryarteriesandveins.

• Thebronchialarteriesoriginatefromthethoracicaortaoroneofitsbranches:

• asinglerightbronchialartery normallyarisesfromthethirdposteriorintercostalartery

• twoleftbronchialarteries arisedirectlyfromtheanteriorsurfaceofthethoracicaorta

• thesuperiorleftbronchialartery arisesatvertebrallevelT5,andtheinferioroneinferiortotheleftbronchus.

• Thebronchialarteriesrunontheposteriorsurfacesofthebronchiandramifyinthelungstosupplypulmonarytissues.

bronchialveins• bronchialveins draininto:

• eitherthepulmonaryveinsortheleftatrium;

• intotheazygosveinontherightorintothesuperiorintercostalveinorhemiazygosveinontheleft.

Innervation• Thevisceralpleuraandotherstructuresofthe

lungaresuppliedbyvisceralafferentsandefferents distributedthroughtheanteriorpulmonaryplexusandposteriorpulmonaryplexus

• Theseinterconnectedplexuseslieanteriorlyandposteriorlytothetrachealbifurcation andmainbronchi.

• Theanteriorplexusismuchsmallerthantheposteriorplexus.

• Branchesoftheseplexuses,whichultimatelyoriginatefromthesympathetictrunksandvagusnerves,aredistributedalongbranchesoftheairwayandvessels

• Visceralefferents from:

• thevagusnervesconstrictthebronchioles;

• thesympatheticsystemdilatethebronchioles.

Lymphaticdrainage• Superficial,orsubpleural,anddeep

lymphaticsofthelungdrainintolymphnodescalledtracheobronchialnodesaroundtherootsoflobarandmainbronchiandalongthesidesofthetrachea

• Asagroup,theselymphnodesextendfromwithinthelung,throughthehilumandroot,andintotheposteriormediastinum

• Efferentvesselsfromthesenodespasssuperiorlyalongthetracheatounitewithsimilarvesselsfromparasternal nodesandbrachiocephalic nodes,toformtherightandleftbronchomediastinaltrunks

• Thesetrunksdraindirectlyintodeepveinsatthebaseoftheneck,ormaydrainintotherightlymphatictrunkorthoracicduct.

Pleura

Pleura• Eachpleuralcavityislinedbyasinglelayerofflat

cells,mesothelium,andanassociatedlayerofsupportingconnectivetissue;together,theyformthepleura

• Thepleura isdividedintotwomajortypes,basedonlocation:

• pleuraassociatedwiththewallsofapleuralcavityisparietalpleura;

• visceralpleura whichadherestoandcoversthelung.

• Eachpleuralcavityisthepotentialspaceenclosedbetweenthevisceralandparietalpleurae.Theynormallycontainonlyaverythinlayerofserousfluid

• Asaresult,thesurfaceofthelung,whichiscoveredbyvisceralpleura,directlyopposesandfreelyslidesovertheparietalpleuraattachedtothewall.

Pleura

• Function:• 1- protection• 2- Producesfluidthatallowsforlubrication

- Failuretofunctionresultsindifficultpainfulbreathing

- Thepleuralcavityisasitefor—pneumothorax,pleuraleffusion,Empyema&haemothorax.

Pleura• Thenamesgiventotheparietalpleuracorrespondtothepartsofthewallwithwhichtheyareassociated

• pleurarelatedtotheribsandintercostalspacesistermedthecostalpart;

• pleuracoveringthediaphragmisthediaphragmaticpart;

• pleuracoveringthemediastinumisthemediastinalpart;

• thedome-shapedlayerofparietalpleuraliningthecervicalextensioniscervicalpleura (domeofpleura orpleuralcupola)andiscoveredbysuprapleuralmembrane(sibson’sfascia).

Pleura• intheregionofvertebraeTVtoTVII,themediastinalpleurareflects,formstherootofthelung

• Therootjoinsthemedialsurfaceofthelungatthehilum,andthemediastinalpleurabecomescontinuouswiththevisceralpleura.

Peripheralreflections• Theperipheralreflectionsofparietalpleura

marktheextentofthepleuralcavities

• Superiorly,thepleuralcavitycanprojectasmuchas3-4cmabovethefirstcostalcartilage,butdoesnotextendabovetheneckofribI.

• ThislimitationiscausedbytheinferiorslopeofribItoitsarticulationwiththemanubrium.

• Anteriorly,thepleuralcavitiesapproacheachotherposteriortotheupperpartofthesternum.

• posteriortothelowerpartofthesternum,theparietalpleuradoesnotcomeasclosetothemidlineontheleftsideasitdoesontherightbecausetheheartbulgestotheleft.

Peripheralreflections

• Inferiorly,thecostalpleurareflectsontothediaphragmabovethecostalmargin.Inthemidclavicular line,thepleuralcavityextendsinferiorlytoapproximatelyribVIII.

• Inthemidaxillary line,itextendstoribX.

• Fromthispoint,theinferiormargincoursessomewhathorizontally,crossingribsXIandXIItoreachvertebraTXII.

• Fromthemidclavicular linetothevertebralcolumn,theinferiorboundaryofthepleuracanbeapproximatedbyalinethatrunsbetweentheribVIII,ribX,andvertebraTXII.

Suprapleuralmembrane

• Afibroussheathattachedto:• Laterally:medialborderof1st ribandcostalcartilage

• Medially:blendwithfasciainvestingthestructurethatpassfromthoraxtoneck

• Apex:tothetipofthetransverseprocessofthe7th cervicalvertebra

• Action:protectthecervicalpleuraandlunga

• Alsoresistchangesintheintrathoracicpressureduringrespiratorymovements

Visceralpleura

• Visceralpleuraiscontinuouswithparietalpleuraatthehilumofeachlungwherestructuresenterandleavetheorgan

• Thevisceralpleuraisfirmlyattachedtothesurfaceofthelung,includingbothopposedsurfacesofthefissuresthatdividethelungsintolobes

Pleuralrecesses• Thelungsdonotcompletelyfilltheanteriororposteriorinferiorregionsofthepleuralcavities

• Thisresultsinrecessesinwhichtwolayersofparietalpleurabecomeopposed.

• Expansionofthelungsintothesespacesusuallyoccursonlyduringforcedinspiration

• therecessesalsoprovidepotentialspacesinwhichfluidscancollectandfromwhichfluidscanbeaspirated.

Pleuralrecesses• Costomediastinalrecessesoccursoneachsidewherecostalpleuraisopposedtomediastinalpleura.Thelargestisontheleftsideintheregionoverlyingtheheart.

• Thelargestandclinicallymostimportantrecessesarethecostodiaphragmaticrecesses,

• whichoccurineachpleuralcavitybetweenthecostalpleuraanddiaphragmaticpleura

• Thecostodiaphragmaticrecessesaretheregionsbetweentheinferiormarginofthelungsandinferiormarginofthepleuralcavities

Pleuralrecesses• Theyaredeepestafterforcedexpirationand

shallowestafterforcedinspiration.

• Duringquietrespiration,theinferiormarginofthe lungcrossesribVIinthemidclavicularline,ribVIIIinthemidaxillaryline,andthencoursessomewhathorizontallytoreachthevertebralcolumnatvertebrallevelT10

• theinferiormarginofthe lungcanbeapproximatedbyalinerunningbetweenribVI,ribVIII,andvertebraT10.

• TheinferiormarginofthepleuralcavityatthesamepointsisribVIII,ribX,andvertebraT12.Thecostodiaphragmaticrecessistheregionbetweenthetwomargins.

Therelationshipsofthepleuralreflectionsandthelobesofthelung

atthemidclavicularline,therecessisbetweenribspaces6and8,• atthemidaxillarylinebetween8and10• attheparavertebrallinebetween10and12.

Costodiaphragmaticrecess

• 1”(1inch) inthemidclavicularline

• 2”inthescapularlinepost

• 3”inthemidaxillaryline

Clinicalnote

• Aspirationoffluid(pneumothorax)fromthepleuralcavitybyputtinganeedlethroughthe7thintercostalspaceinthemidclavicularlineorinanyotherrecesses

• Theneedleisputinthelowerborderofthespace.

Pleuraleffusion

- Pleuralspacenormallycontain5- 10mlofclearfluid

- Absorbednormallybyvisceralpleurabyhydrostaticandosmoticpressure

- Pleuraleffusion:isaccumulationofexcessfluidwithinthepleuralcavity,pleuralfluidincreasemorethan300(ml)incostodiaphragmaticrecess

- Maincauses1- Infection2- Injury

ClinicalManifestations• Decreaseinlungexpansion• Decreasebreathsound• InPercussionà Dullness• Pain• Cough

NervesupplyofthepleuraParietalpleura:- Itissensitiveto

painTempTouch&pressure

1- Intercostalnervesà Costalpleura(segmentaly)

2- PhrenicnerveàMediastinalpleura+diaphragmaticpleura

3- lower6intercostalà peripheralpleuraVisceralpleura- Sensitivetostretch- Insensitivetopain,temportouch- Suppliedbypulmonaryplexus&autonomic.N.S

ArterialSupplyofthePleura

• Thearterialsupplyoftheparietalpleura isfromthearteriesthatsupplythethoracicwall

Intercostalarteries(ant&post)InternalthoracicMusculophrenicarteries.

• Thearterialsupplyofthevisceralpleura isfromthe-Bronchialarteries,whicharebranchesofthethoracicaorta.

Veinsdrainintoazygos &internalthoracicveins.

Lymphaticdrainageofpleura

parietalpleuraMediastinalpleuraby

1- mediastinalnodes2- Tracheobronchialnodes3- Intercostalnodes

Diaphragmaticpleura1- Parasternalnodes2- Post.mediastinalnodes

• Pulmonarypleura(visceral):alongbronchialarteries→bronchopulmonarynodes

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