trachea and lungs

Trachea and lungsTrachea and lungs

Trachea Trachea The The tracheatrachea is a flexible tube that extends is a flexible tube that extends

from vertebral level CVI (cricoid cartilage ) from vertebral level CVI (cricoid cartilage ) in the lower neck to vertebral level TIV/V in the lower neck to vertebral level TIV/V

it bifurcates into a right and a left main it bifurcates into a right and a left main

bronchus (carina)bronchus (carina) at the level of sternal at the level of sternal angleangle

The trachea is held open by 'C-shaped' The trachea is held open by 'C-shaped' cartilage rings (16-20) embedded in its wall-cartilage rings (16-20) embedded in its wall-

the open part of the 'C' facing The posterior the open part of the 'C' facing The posterior wall of the trachea is composed mainly of wall of the trachea is composed mainly of smooth muscle (trachealis) and connective smooth muscle (trachealis) and connective tissue.tissue.

In adults the trachea is about 4½ in. (11.25 In adults the trachea is about 4½ in. (11.25 cm) long and 1 in. (2.5 cm) in diameter cm) long and 1 in. (2.5 cm) in diameter

- The trachea widens and lengthens slightly The trachea widens and lengthens slightly with each inspiration, returning to its resting with each inspiration, returning to its resting size with each expiration.size with each expiration.

Relations of TracheaRelations of Trachea

AnteriorllyAnteriorlly Aortic archAortic arch ThymusThymus thyroidthyroid Origin of brachiocephalic arteryOrigin of brachiocephalic artery Manubrium sterniManubrium sterniLeftLeft Arch of aortaArch of aorta Lt. subclavian art.Lt. subclavian art. LT. common carotid art.LT. common carotid art. Lt.Phrenic n.Lt.Phrenic n. Lt. Vagus n.Lt. Vagus n. Lt. main bronchusLt. main bronchusRightRight- Azygous archAzygous arch- Brachiocephalic arteryBrachiocephalic artery- Rt. VagusRt. Vagus- Rt. PhrenicRt. Phrenic- Rt.main bronchusRt.main bronchusPost.Post.- - Esophagus Esophagus- Thoracic ductThoracic duct- left recurrent laryngeal nerveleft recurrent laryngeal nerve

TracheaTrachea carinacarina is a cartilaginous ridge within is a cartilaginous ridge within

the the tracheatrachea that runs anteroposteriorly that runs anteroposteriorly between the two primary between the two primary bronchibronchi at the at the site of the tracheal bifurcation (T4-T5).site of the tracheal bifurcation (T4-T5).

The mucous membrane of the carina The mucous membrane of the carina is the most sensitive area of the is the most sensitive area of the trachea and larynx for triggering a trachea and larynx for triggering a cough reflex.cough reflex.

In deep inspiration it descends to In deep inspiration it descends to the level of 6the level of 6thth thoracic vertebra thoracic vertebra

Tracheotomy and intubationsTracheotomy and intubations Used to reestablish airflow past a tracheal Used to reestablish airflow past a tracheal

obstruction.obstruction.

If the obstruction is superior to the larynx a If the obstruction is superior to the larynx a tracheotomy may be performed tracheotomy may be performed

A longitudinal incision below the cricoid A longitudinal incision below the cricoid cartilagecartilage

The patient can the breath through a metal The patient can the breath through a metal or plastic tube.or plastic tube.

in intubation the tube is inserted through the in intubation the tube is inserted through the mouth or nose and push aside any flexible mouth or nose and push aside any flexible obstructionobstruction

Any mucous clogging can be suctioned Any mucous clogging can be suctioned through the tubethrough the tube

Bronchi Bronchi

Each main bronchus enters the root of a Each main bronchus enters the root of a lung and passes through the hilum into the lung and passes through the hilum into the lung itself.lung itself.

The The right main bronchusright main bronchus is wider and is wider and takes a more vertical course and is about 1 takes a more vertical course and is about 1 in. (2.5 cm) in. (2.5 cm)

principal bronchus gives off the superior principal bronchus gives off the superior lobar bronchus. On entering the hilum, it lobar bronchus. On entering the hilum, it divides into a middle and an inferior lobar divides into a middle and an inferior lobar bronchus. bronchus.

the the left main bronchus is narrower, left main bronchus is narrower, longer, and more horizontal than the longer, and more horizontal than the right and is about 2 in. (5 cm) longright and is about 2 in. (5 cm) long

passes to the left below the arch of the passes to the left below the arch of the aorta and in front of the esophagus aorta and in front of the esophagus

the principal bronchus divides into a the principal bronchus divides into a superior and an inferior lobar bronchus. superior and an inferior lobar bronchus.

Therefore, inhaled foreign bodies tend to Therefore, inhaled foreign bodies tend to lodge more frequently on the right side than lodge more frequently on the right side than on the lefton the left. .

Bronchial treeBronchial tree The main bronchus divides within the The main bronchus divides within the

lung into lung into lobar bronchilobar bronchi (secondary (secondary bronchi),bronchi),

each of which supplies a lobe. each of which supplies a lobe.

On the right side, the lobar bronchus to On the right side, the lobar bronchus to the superior lobe originates within the the superior lobe originates within the root of the lung. root of the lung.

The lobar bronchi further divide into The lobar bronchi further divide into segmental bronchisegmental bronchi (tertiary bronchi), (tertiary bronchi), which supply which supply bronchopulmonary bronchopulmonary segmentssegments

Bronchial treeBronchial tree bronchopulmonary segmentbronchopulmonary segment

further divide into terminal further divide into terminal bronchioles & these into bronchioles & these into respiratory bronchioles which respiratory bronchioles which end in the pulmonary unit . end in the pulmonary unit .

- Pulmonary unit consist of Pulmonary unit consist of alveolar ducts,atriaalveolar ducts,atria

air sacsair sacspulmonary alveolipulmonary alveoli.. The walls of the bronchi are held The walls of the bronchi are held

open by discontinuous elongated open by discontinuous elongated plates of cartilage, but these are plates of cartilage, but these are not present in bronchioles. not present in bronchioles.

Bronchial treeBronchial tree

Bronchopulmonary segments Bronchopulmonary segments A A bronchopulmonary segmentbronchopulmonary segment is the is the

area of lung supplied by a segmental area of lung supplied by a segmental bronchus and its accompanying bronchus and its accompanying pulmonary artery branch pulmonary artery branch

It is a subdivision of a lung lobe.It is a subdivision of a lung lobe.

It is pyramid shaped, with its apex It is pyramid shaped, with its apex toward the lung root.toward the lung root.

It is surrounded by connective tissue.It is surrounded by connective tissue.

It has a segmental bronchus, a It has a segmental bronchus, a segmental artery, lymph vessels, and segmental artery, lymph vessels, and autonomic nerves.autonomic nerves.

The segmental vein lies in the The segmental vein lies in the connective tissue between adjacent connective tissue between adjacent bronchopulmonary segments.bronchopulmonary segments.

Because it is a structural unit, a Because it is a structural unit, a diseased segment can be removed diseased segment can be removed surgically.surgically.

Bronchopulmonary segmentsBronchopulmonary segments

Rt. Lung 10 segmentsRt. Lung 10 segmentsUpper lobeUpper lobe ApicalApical posteriorposterior AntAnt

Middle lobeMiddle lobe MedialMedial LateralLateral

Basal lobeBasal lobe Apical ( apico basal)Apical ( apico basal) AntAnt MedMed LatLatPostPost


Lt. lung 10 segmentsLt. lung 10 segments

Upper lobeUpper lobe ApicalApical posteriorposterior AntAnt sup. Lingualsup. Lingual inf.lingualinf.lingual

Basal lobeBasal lobe Apical( apico basal)Apical( apico basal) AntAnt MedMed LatLat PostPost


Before birth:Before birth:- Rt. Lung 10 segmentsRt. Lung 10 segments

- Lt .lung 8 segments - Lt .lung 8 segments

Apicpo posteriorApicpo posterior

Antero medialAntero medial

Clinical importance of pulmonary Clinical importance of pulmonary segmentssegments

InfectionsInfections No barrierNo barrier SurgerySurgery Postural drainagePostural drainage BronchoscopyBronchoscopy

LungsLungs

Lungs Lungs organs of respiration and lie on either side of organs of respiration and lie on either side of

the mediastinum the mediastinum

surrounded by the right and left pleural cavitiessurrounded by the right and left pleural cavities

Spongy, grey, dark later on.Spongy, grey, dark later on.

600-800gm , 90% air & 10% tissue600-800gm , 90% air & 10% tissue

The pulmonary arteries deliver deoxygenated The pulmonary arteries deliver deoxygenated blood to the lungs from the right ventricle of the blood to the lungs from the right ventricle of the heart. heart.

Oxygenated blood returns to the left atrium via Oxygenated blood returns to the left atrium via the pulmonary veins.the pulmonary veins.

The right lung is normally a little larger than the The right lung is normally a little larger than the left lung because the middle mediastinum, left lung because the middle mediastinum, containing the heart, bulges more to the left containing the heart, bulges more to the left than to the right.than to the right.

Left lung is narrowerLeft lung is narrower-Right lung is shorter, more vertical -Right lung is shorter, more vertical

LungsLungs Each lung has a half-cone shape Each lung has a half-cone shape

base, apex, two surfaces and three borders base, apex, two surfaces and three borders

The The basebase sits on the diaphragm. sits on the diaphragm.

The The apexapex projects above rib I and into the projects above rib I and into the root of the neck. root of the neck.

1 inch above the medial 1/31 inch above the medial 1/3rdrd of the clavicle of the clavicle and is Covered by suprapleural membran.and is Covered by suprapleural membran.

costal surfacecostal surface lies immediately adjacent to lies immediately adjacent to the ribs and intercostal spaces. the ribs and intercostal spaces.

The The mediastinal surfacemediastinal surface lies against the lies against the mediastinum anteriorly and the vertebral mediastinum anteriorly and the vertebral column posteriorly column posteriorly

contains the comma-shaped hilum of the contains the comma-shaped hilum of the lung through which structures enter and lung through which structures enter and leave. leave.

LungsLungs inferior borderinferior border of the lung is of the lung is

sharp and separates the base sharp and separates the base from the costal surface. from the costal surface.

The The anterioranterior and and posterior posterior bordersborders separate the costal separate the costal surface from the medial surface from the medial surface. surface.

the anterior and inferior the anterior and inferior borders, are sharp, borders, are sharp,

the posterior border is smooth the posterior border is smooth and rounded and rounded

Surface anatomy of the lungSurface anatomy of the lung At end-expirationAt end-expiration

66thth rib – midclavicular rib – midclavicular 88thth rib – midaxillary rib – midaxillary 1010thth T.vertebra_ T.vertebra_

PosteriorlyPosteriorly- apex is at 1apex is at 1st Thst Th vertebra vertebra

Posterior border Extend from 7Posterior border Extend from 7thth C vert. to the 10C vert. to the 10thth T vert. T vert.

- lies 4cm from the midline- lies 4cm from the midline

Inferior borderInferior border Ascend and descend between 9Ascend and descend between 9thth

& 12& 12thth rib rib

Root and hilum Root and hilum The The rootroot of each lung is a short tubular of each lung is a short tubular

collection of structures that together attach collection of structures that together attach the lung to structures in the mediastinum the lung to structures in the mediastinum

covered by a sleeve of mediastinal pleura covered by a sleeve of mediastinal pleura that reflects onto the surface of the lung as that reflects onto the surface of the lung as visceral pleura visceral pleura

A thin blade-like fold of pleura projects A thin blade-like fold of pleura projects inferiorly from the root of the lung. This inferiorly from the root of the lung. This structure is the structure is the pulmonary ligamentpulmonary ligament

pulmonary ligamentpulmonary ligament stabilize the position of stabilize the position of the inferior lobe and may also accommodate the inferior lobe and may also accommodate the down-and-up translocation of structures the down-and-up translocation of structures in the root during breathing in the root during breathing

the vagus nerves pass immediately posterior the vagus nerves pass immediately posterior to the roots of the lungs, while the phrenic to the roots of the lungs, while the phrenic nerves pass immediately anterior to them. nerves pass immediately anterior to them.

Root and hilumRoot and hilum

Within each root and Within each root and located in the hilum located in the hilum are: are:

pulmonary artery; pulmonary artery; two pulmonary two pulmonary

veins; veins; a main bronchus; a main bronchus; bronchial vessels; bronchial vessels; nerves; nerves; lymphatics. lymphatics.

Root and hilumRoot and hilum the pulmonary artery is the pulmonary artery is

superior at the hilum, superior at the hilum,

the pulmonary veins are the pulmonary veins are inferior, and the bronchi are inferior, and the bronchi are somewhat posterior in position. somewhat posterior in position.

On the right side, the lobar On the right side, the lobar bronchus to the superior lobe bronchus to the superior lobe branches from the main branches from the main bronchus in the root, bronchus in the root,

on the left it branches within on the left it branches within the lung itself, and is superior the lung itself, and is superior to the pulmonary artery to the pulmonary artery

Right lung Right lung The The right lungright lung has three lobes has three lobes

and two fissures and two fissures

Normally, the lobes are freely Normally, the lobes are freely movable against each other movable against each other because they are separated, because they are separated, almost to the hilum, by almost to the hilum, by invaginations of visceral pleura. invaginations of visceral pleura.

These invaginations form the These invaginations form the fissuresfissures::

the the oblique fissureoblique fissure separates the separates the inferior lobeinferior lobe (lower lobe)(lower lobe) from from the superior lobe and the the superior lobe and the middle middle lobe of the right lunglobe of the right lung; ;

the the horizontal fissurehorizontal fissure separates separates the the superior lobe (upper lobe)superior lobe (upper lobe) from the middle lobe. from the middle lobe.

Right lungRight lung

The approximate The approximate position of the oblique position of the oblique fissure on a patient, in fissure on a patient, in quiet respiration, quiet respiration,

begins roughly at the begins roughly at the spinous process of spinous process of vertebra vertebra T4T4 level of the level of the spine, crosses the spine, crosses the fifthfifth interspace laterally, interspace laterally, and then follows the and then follows the contour of contour of rib VIrib VI anteriorlyanteriorly

Right lungRight lung The horizontal fissure follows the The horizontal fissure follows the

fourth intercostalfourth intercostal space from the space from the sternum until it meets the oblique sternum until it meets the oblique fissure as it crosses rib V. fissure as it crosses rib V.

The orientations of the oblique The orientations of the oblique and horizontal fissures determine and horizontal fissures determine where clinicians should listen for where clinicians should listen for lung sounds from each lobelung sounds from each lobe. .

When listening to lung sounds When listening to lung sounds from each of the lobes, it is from each of the lobes, it is important to position the important to position the stethoscope on those areas of the stethoscope on those areas of the thoracic wall related to the thoracic wall related to the underlying positions of the lobesunderlying positions of the lobes


The medial surface of The medial surface of the right lung lies the right lung lies adjacent to a number adjacent to a number of important of important structures the heart, structures the heart,

inferior vena cava, inferior vena cava, superior vena cava, superior vena cava, azygos vein, azygos vein, esophagus. esophagus.


The right subclavian The right subclavian artery and vein arch artery and vein arch over and are related over and are related to the superior lobe of to the superior lobe of the right lung as they the right lung as they pass over the dome pass over the dome of cervical pleura and of cervical pleura and into the axilla. into the axilla.

Left lung Left lung The The left lungleft lung is smaller than the right is smaller than the right

lung and has two lobes separated by lung and has two lobes separated by an oblique fissure an oblique fissure

oblique fissureoblique fissure of the left lung is of the left lung is slightly more oblique than the slightly more oblique than the corresponding fissure of the right lung corresponding fissure of the right lung

During quiet respiration, the During quiet respiration, the approximate position of the left oblique approximate position of the left oblique fissure can be marked by line on the fissure can be marked by line on the thoracic wall thoracic wall

begins between the spinous processes begins between the spinous processes of vertebrae T3 and T4, crosses the of vertebrae T3 and T4, crosses the fifth interspacefifth interspace laterally, and follows laterally, and follows the contour of the contour of rib VIrib VI anteriorly anteriorly

As with the right lung, the orientation of As with the right lung, the orientation of the oblique fissure determines where the oblique fissure determines where to listen for lung sounds from each to listen for lung sounds from each lobelobe. .

Left lungLeft lung The inferior portion of the The inferior portion of the

medial surface of the left medial surface of the left lung, is notched because lung, is notched because of the of the heart's projectionheart's projection into the left pleural cavity into the left pleural cavity from the middle from the middle mediastinum mediastinum

On the anterior surface of On the anterior surface of the lower part of the the lower part of the superior lobe a tongue-superior lobe a tongue-like extension (the like extension (the lingula of left lunglingula of left lung) ) projects over the heart projects over the heart bulge. bulge.

Left lungLeft lung

The medial surface of The medial surface of the left lung lies the left lung lies adjacent to a number adjacent to a number of important of important structures the structures the

heart, heart, aortic arch, aortic arch, thoracic aorta, thoracic aorta, esophagusesophagus

Right sideRight side

Left sideLeft side

Pulmonary arteries Pulmonary arteries The right and left pulmonary arteries The right and left pulmonary arteries

originate from the originate from the pulmonary trunkpulmonary trunk and carry deoxygenated blood to the and carry deoxygenated blood to the lungs from the right ventricle of the lungs from the right ventricle of the heart heart

The bifurcation of the pulmonary trunk The bifurcation of the pulmonary trunk occurs to the left of the midline just occurs to the left of the midline just inferior to vertebral level T4, and inferior to vertebral level T4, and anteroinferiorly to the left of the anteroinferiorly to the left of the bifurcation of the trachea. bifurcation of the trachea.

The The right pulmonary arteryright pulmonary artery is longer is longer than the left and passes horizontally than the left and passes horizontally across the mediastinum It passes: across the mediastinum It passes:

anteriorly and slightly inferiorly to the anteriorly and slightly inferiorly to the tracheal bifurcation and anteriorly to tracheal bifurcation and anteriorly to the right main bronchus; the right main bronchus;

posteriorly to the ascending aorta, posteriorly to the ascending aorta, superior vena cava, and upper right superior vena cava, and upper right pulmonary vein. pulmonary vein.

Pulmonary arteriesPulmonary arteries The right pulmonary artery enters The right pulmonary artery enters

the root of the lung and gives off a the root of the lung and gives off a large branch to the superior lobe large branch to the superior lobe of the lung. of the lung.

The main vessel continues The main vessel continues through the hilum of the lung, through the hilum of the lung, gives off a second (recurrent) gives off a second (recurrent) branch to the superior lobe, and branch to the superior lobe, and then divides to supply the middle then divides to supply the middle and inferior lobes and inferior lobes

The The left pulmonary arteryleft pulmonary artery is is shorter than the right and lies shorter than the right and lies anterior to the descending aorta anterior to the descending aorta and posterior to the superior and posterior to the superior pulmonary vein pulmonary vein

It passes through the root and It passes through the root and hilum and branches within the hilum and branches within the lung. lung.

Pulmonary veins Pulmonary veins

On each side a On each side a superior pulmonary veinsuperior pulmonary vein and an and an inferior pulmonary veininferior pulmonary vein carry carry oxygenated blood from the lungs back to oxygenated blood from the lungs back to the heart the heart

The veins begin at the hilum of the lung, The veins begin at the hilum of the lung, pass through the root of the lung, and pass through the root of the lung, and immediately drain into the left atrium. immediately drain into the left atrium.

Bronchial arteries and veins Bronchial arteries and veins constitute the 'nutritive' vascular system of the constitute the 'nutritive' vascular system of the

pulmonary tissues (bronchial walls and glands, pulmonary tissues (bronchial walls and glands, walls of large vessels, and visceral pleura). walls of large vessels, and visceral pleura).

They interconnect within the lung with branches of They interconnect within the lung with branches of the pulmonary arteries and veins. the pulmonary arteries and veins.

The bronchial arteries originate from the thoracic The bronchial arteries originate from the thoracic aorta or one of its branches: aorta or one of its branches:

a single a single right bronchial arteryright bronchial artery normally arises normally arises from the third posterior intercostal arteryfrom the third posterior intercostal artery

two two left bronchial arteriesleft bronchial arteries arise directly from the arise directly from the anterior surface of the thoracic aortaanterior surface of the thoracic aorta

the the superior left bronchial arterysuperior left bronchial artery arises at arises at vertebral level T5, and the inferior one inferior to vertebral level T5, and the inferior one inferior to the left bronchus. the left bronchus.

The bronchial arteries run on the posterior The bronchial arteries run on the posterior surfaces of the bronchi and ramify in the lungs to surfaces of the bronchi and ramify in the lungs to supply pulmonary tissues.supply pulmonary tissues.

bronchial veinsbronchial veins

bronchial veinsbronchial veins drain into: drain into:

either the pulmonary either the pulmonary veins or the left veins or the left atrium; atrium;

into the azygos vein into the azygos vein on the right or into on the right or into the superior the superior intercostal vein or intercostal vein or hemiazygos vein on hemiazygos vein on the left. the left.

Innervation Innervation The visceral pleura and other structures of The visceral pleura and other structures of

the lung are supplied by the lung are supplied by visceral afferents visceral afferents and efferentsand efferents distributed through the distributed through the anterior pulmonary plexus and posterior anterior pulmonary plexus and posterior pulmonary plexus pulmonary plexus

These interconnected plexuses lie anteriorly These interconnected plexuses lie anteriorly and posteriorly to the and posteriorly to the tracheal bifurcationtracheal bifurcation and main bronchi.and main bronchi.

The anterior plexus is much smaller than The anterior plexus is much smaller than the posterior plexus. the posterior plexus.

Branches of these plexuses, which Branches of these plexuses, which ultimately originate from the ultimately originate from the sympathetic sympathetic trunks and vagus nervestrunks and vagus nerves, are distributed , are distributed along branches of the airway and vessels along branches of the airway and vessels

Visceral efferentsVisceral efferents from: from: the vagus nerves constrict the bronchioles; the vagus nerves constrict the bronchioles;

the sympathetic system dilate the the sympathetic system dilate the bronchioles. bronchioles.

Lymphatic drainage Lymphatic drainage Superficial, or subpleural, and deep Superficial, or subpleural, and deep

lymphatics of the lung drain into lymph lymphatics of the lung drain into lymph nodes called nodes called tracheobronchial nodestracheobronchial nodes around the roots of lobar and main around the roots of lobar and main bronchi and along the sides of the bronchi and along the sides of the trachea trachea

As a group, these lymph nodes extend As a group, these lymph nodes extend from within the lung, through the hilum from within the lung, through the hilum and root, and into the posterior and root, and into the posterior mediastinum mediastinum

Efferent vessels from these nodes Efferent vessels from these nodes pass superiorly along the trachea to pass superiorly along the trachea to unite with similar vessels from unite with similar vessels from parasternalparasternal nodes and nodes and brachiocephalicbrachiocephalic nodes, to form the nodes, to form the rightright and and left bronchomediastinal left bronchomediastinal trunkstrunks

These trunks drain directly into deep These trunks drain directly into deep veins at the base of the neck, or may veins at the base of the neck, or may drain into the right lymphatic trunk or drain into the right lymphatic trunk or thoracic duct. thoracic duct.

PleuraPleura

Pleura Pleura Each pleural cavity is lined by a single layer of Each pleural cavity is lined by a single layer of

flat cells, mesothelium, and an associated layer flat cells, mesothelium, and an associated layer of supporting connective tissue; together, they of supporting connective tissue; together, they form the pleuraform the pleura

The The pleurapleura is divided into two major types, is divided into two major types, based on location: based on location:

pleura associated with the walls of a pleural pleura associated with the walls of a pleural cavity is cavity is parietal pleuraparietal pleura; ;

visceral pleuravisceral pleura which adheres to and covers which adheres to and covers the lung. the lung.

Each pleural cavity is the potential space Each pleural cavity is the potential space enclosed between the visceral and parietal enclosed between the visceral and parietal pleurae. They normally contain only a very thin pleurae. They normally contain only a very thin layer of serous fluid layer of serous fluid

As a result, the surface of the lung, which is As a result, the surface of the lung, which is covered by visceral pleura, directly opposes and covered by visceral pleura, directly opposes and freely slides over the parietal pleura attached to freely slides over the parietal pleura attached to the wall. the wall.

PleuraPleura

Function:Function: 1- protection1- protection 2- Produces fluid that allows for lubrication2- Produces fluid that allows for lubrication

- Failure to function results in difficult painful Failure to function results in difficult painful breathingbreathing

- The pleural cavity is a site for—pneumothorax, The pleural cavity is a site for—pneumothorax, pleural effusion, Empyema & haemothorax. pleural effusion, Empyema & haemothorax.

PleuraPleura The names given to the parietal pleura The names given to the parietal pleura

correspond to the parts of the wall with correspond to the parts of the wall with which they are associated which they are associated

pleura related to the ribs and intercostal pleura related to the ribs and intercostal spaces is termed the spaces is termed the costal partcostal part; ;

pleura covering the diaphragm is the pleura covering the diaphragm is the diaphragmatic partdiaphragmatic part; ;

pleura covering the mediastinum is the pleura covering the mediastinum is the mediastinal partmediastinal part; ;

the dome-shaped layer of parietal pleura the dome-shaped layer of parietal pleura lining the cervical extension is lining the cervical extension is cervical cervical pleurapleura ( (dome of pleuradome of pleura or or pleural cupola) pleural cupola) and is covered by and is covered by suprapleuralsuprapleural membrane membrane (sibson’s fascia).(sibson’s fascia).

PleuraPleura

in the region of vertebrae in the region of vertebrae TV to TVII, the TV to TVII, the mediastinal pleura mediastinal pleura reflects, forms the reflects, forms the root root of the lungof the lung

The root joins the medial The root joins the medial surface of the lung at the surface of the lung at the hilumhilum, and the , and the mediastinal pleura mediastinal pleura becomes continuous with becomes continuous with the visceral pleura. the visceral pleura.

Peripheral reflectionsPeripheral reflections The peripheral reflections of parietal The peripheral reflections of parietal

pleura pleura mark the extent of the pleural mark the extent of the pleural cavitiescavities

Superiorly, the pleural cavity can Superiorly, the pleural cavity can project as much as 3-4 cm above the project as much as 3-4 cm above the first costal cartilage, but does not first costal cartilage, but does not extend above the neck of rib I.extend above the neck of rib I.

This limitation is caused by the inferior This limitation is caused by the inferior slope of rib I to its articulation with the slope of rib I to its articulation with the manubrium. manubrium.

Anteriorly, the pleural cavities Anteriorly, the pleural cavities approach each other posterior to the approach each other posterior to the upper part of the sternum. upper part of the sternum.

posterior to the lower part of the posterior to the lower part of the sternum, the parietal pleura does not sternum, the parietal pleura does not come as close to the midline on the left come as close to the midline on the left side as it does on the right because side as it does on the right because the heart bulges to the left. the heart bulges to the left.

Peripheral reflectionsPeripheral reflections Inferiorly, the costal pleura reflects Inferiorly, the costal pleura reflects

onto the diaphragm above the costal onto the diaphragm above the costal margin. In the midclavicular line, the margin. In the midclavicular line, the pleural cavity extends inferiorly to pleural cavity extends inferiorly to approximately rib VIII. approximately rib VIII.

In the midaxillary line, it extends to rib In the midaxillary line, it extends to rib X.X.

From this point, the inferior margin From this point, the inferior margin courses somewhat horizontally, courses somewhat horizontally, crossing ribs XI and XII to reach crossing ribs XI and XII to reach vertebra TXII. vertebra TXII.

From the midclavicular line to the From the midclavicular line to the vertebral column, the inferior boundary vertebral column, the inferior boundary of the pleura can be approximated by of the pleura can be approximated by a line that runs between the rib VIII, rib a line that runs between the rib VIII, rib X, and vertebra TXII. X, and vertebra TXII.

Suprapleural membraneSuprapleural membrane A fibrous sheath attached to :A fibrous sheath attached to : Laterally: medial border of 1Laterally: medial border of 1stst rib rib

and costal cartilageand costal cartilage

Medially : blend with fascia Medially : blend with fascia investing the structure that pass investing the structure that pass from thorax to neckfrom thorax to neck

Apex : to the tip of the transverse Apex : to the tip of the transverse process of the 7process of the 7thth cervical vertebra cervical vertebra

Action : protect the cervical pleura Action : protect the cervical pleura and lung aand lung a

Also resist changes in the Also resist changes in the intrathoracic pressure during intrathoracic pressure during respiratory movementsrespiratory movements

Visceral pleura Visceral pleura

Visceral pleura is continuous with parietal Visceral pleura is continuous with parietal pleura at the hilum of each lung where pleura at the hilum of each lung where structures enter and leave the organ structures enter and leave the organ

The visceral pleura is firmly attached to The visceral pleura is firmly attached to the surface of the lung, including both the surface of the lung, including both opposed surfaces of the fissures that opposed surfaces of the fissures that divide the lungs into lobes divide the lungs into lobes

Pleural recesses Pleural recesses The lungs do not completely fill The lungs do not completely fill

the anterior or posterior inferior the anterior or posterior inferior regions of the pleural cavities regions of the pleural cavities

This results in recesses in which This results in recesses in which two layers of parietal pleura two layers of parietal pleura become opposed. become opposed.

Expansion of the lungs into Expansion of the lungs into these spaces usually occurs only these spaces usually occurs only during forced inspiration during forced inspiration

the recesses also provide the recesses also provide potential spaces in which fluids potential spaces in which fluids can collect and from which fluids can collect and from which fluids can be aspirated. can be aspirated.

Pleural recessesPleural recesses Costomediastinal recesses occurs Costomediastinal recesses occurs

on each side where costal pleura on each side where costal pleura is opposed to mediastinal pleura. is opposed to mediastinal pleura. The largest is on the left side in The largest is on the left side in the region overlying the heart. the region overlying the heart.

The largest and clinically most The largest and clinically most important recesses are the important recesses are the costodiaphragmatic recessescostodiaphragmatic recesses, ,

which occur in each pleural cavity which occur in each pleural cavity between the costal pleura and between the costal pleura and diaphragmatic pleura diaphragmatic pleura

The costodiaphragmatic recesses The costodiaphragmatic recesses are the regions between the are the regions between the inferior margin of the lungs and inferior margin of the lungs and inferior margin of the pleural inferior margin of the pleural cavities cavities

Pleural recessesPleural recesses They are deepest after forced expiration They are deepest after forced expiration

and shallowest after forced inspiration. and shallowest after forced inspiration.

During quiet respiration, the inferior During quiet respiration, the inferior margin of themargin of the lung lung crosses rib VI in the crosses rib VI in the midclavicular line, rib VIII in the midaxillary midclavicular line, rib VIII in the midaxillary line, and then courses somewhat line, and then courses somewhat horizontally to reach the vertebral column horizontally to reach the vertebral column at vertebral level T10 at vertebral level T10

the inferior margin of thethe inferior margin of the lun lung can be g can be approximated by a line running approximated by a line running between between rib VI, rib VIII, and vertebra T10. rib VI, rib VIII, and vertebra T10.

The inferior margin of the pleural cavity at The inferior margin of the pleural cavity at the same points is the same points is rib VIII, rib X, and rib VIII, rib X, and vertebra T12vertebra T12. The costodiaphragmatic . The costodiaphragmatic recess is the region between the two recess is the region between the two margins. margins.

The relationships of the pleural The relationships of the pleural reflections and the lobes of the lungreflections and the lobes of the lung

at the midclavicular line, the recess is between at the midclavicular line, the recess is between rib spaces 6 and 8, rib spaces 6 and 8,

at the midaxillary line between 8 and 10at the midaxillary line between 8 and 10 at the paravertebral line between 10 and 12. at the paravertebral line between 10 and 12.

Costodiaphragmatic recessCostodiaphragmatic recess

1”1”(1 (1 inchinch)) in the midclavicular line in the midclavicular line

2 ” in the scapular line post2 ” in the scapular line post

3 ” in the midaxillary line3 ” in the midaxillary line

Clinical noteClinical note

Aspiration of fluid (pneumothorax) from the Aspiration of fluid (pneumothorax) from the pleural cavity by putting a needle through pleural cavity by putting a needle through the 7the 7thth intercostal space in the intercostal space in the midclavicular line or in any other recessesmidclavicular line or in any other recesses

The needle is put in the lower border of The needle is put in the lower border of the space.the space.

Pleural effusionPleural effusion

- Pleural space normally contain 5- Pleural space normally contain 5- 10 ml of clear fluid10 ml of clear fluid

- Absorbed normally by visceral Absorbed normally by visceral pleura by hydrostatic and osmotic pleura by hydrostatic and osmotic pressurepressure

- Pleural effusion: is accumulation of Pleural effusion: is accumulation of excess fluid within the pleural excess fluid within the pleural cavity, pleural fluid increase more cavity, pleural fluid increase more than 300 (ml) in than 300 (ml) in costodiaphragmatic recesscostodiaphragmatic recess

- Main causesMain causes 1- Infection1- Infection 2- Injury2- Injury

Clinical ManifestationsClinical Manifestations

Decrease in lung Decrease in lung expansionexpansion

Decrease breath soundDecrease breath sound In Percussion In Percussion

DullnessDullness PainPain CoughCough

Nerve supply of the pleuraNerve supply of the pleuraParietal pleuraParietal pleura::- It is sensitive to- It is sensitive to painpain TempTemp Touch & pressureTouch & pressure1- Intercostal nerves 1- Intercostal nerves Costal Costal

pleura( segmentaly)pleura( segmentaly)2- Phrenic nerve 2- Phrenic nerve Mediastinal pleura Mediastinal pleura

+ diaphragmatic pleura+ diaphragmatic pleura3- lower 6 intercostal 3- lower 6 intercostal peripheral peripheral

pleurapleuraVisceral pleuraVisceral pleura- Sensitive to stretch- Sensitive to stretch- Insensitive to pain, temp or touch- Insensitive to pain, temp or touch- Supplied by pulmonary plexus & - Supplied by pulmonary plexus &

autonomic.N.Sautonomic.N.S

Arterial Supply of the PleuraArterial Supply of the Pleura The arterial supply of the The arterial supply of the parietal pleuraparietal pleura is from the arteries that is from the arteries that

supply the supply the thoracic wallthoracic wall

Intercostal arteries(ant& post)Intercostal arteries(ant& post) Internal thoracicInternal thoracic Musculophrenic arteriesMusculophrenic arteries. .

The arterial supply of the The arterial supply of the visceral pleuravisceral pleura is from the is from the --Bronchial arteriesBronchial arteries, which are branches of the , which are branches of the

thoracic aortathoracic aorta..

Veins Veins drain into drain into azygosazygos & & internal thoracic veins.internal thoracic veins.

Lymphatic drainage of pleuraLymphatic drainage of pleura

parietal pleura parietal pleura Mediastinal pleura byMediastinal pleura by 1- mediastinal nodes1- mediastinal nodes 2- Tracheobronchial nodes2- Tracheobronchial nodes 3- Intercostal nodes3- Intercostal nodes Diaphragmatic pleuraDiaphragmatic pleura 1- Parasternal nodes1- Parasternal nodes 2- Post.mediastinal nodes2- Post.mediastinal nodes Pulmonary pleura(visceral) :Pulmonary pleura(visceral) :along bronchial along bronchial

arteries →bronchopulmonary nodesarteries →bronchopulmonary nodes

Thank youThank you

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