ANATOMY - LUNGS DR.

CINIO September 30, 2013

Lung and its Features Lungs -found on each side of the heart with other mediastinal content Parts: apex, 3 borders- anterior, posterior and inferior, three surfaces- costal, diaphragmatic and mediastinal Blunt apex-projects upward into the root of the neck; covered by cervical pleura Concave base-sits on the diaphragm Convex costal surface-corresponds to chest wall Concave mediastinal surface more pronounced at the left due to concavity of the heart, molded to the pericardium and other mediastinal structures. Hilum-depression in which the bronchi, vessels, and nerves that form the root that enter and leave the lung Anterior border- thin and overlaps the heart Posterior border- lies beside the vertebra Cardiac notch- found in the left lung Right lung -625 grams; Left lung -565 grams Lobes and fissures: Right lung Has upper, middle and lower lobe divided by horizontal and oblique fissure Larger than left Broader, has greater capacity Vertically shorter by 2.5 cm Oblique fissure of right lung corresponds closely to the left oblique fissure, although it is less vertical crosses the inferior border of the lung 7.5 cm behind its anterior end on the posterior border it is either levelled with the spine of T4 or slightly lower th descends across the 5 ICS and follows the 6th rib to the 6th costochondral junction from inferior border, upward and backward across the medial and costal surface until it cuts the posterior border 2.5 in/6.25 cm below the apex Horizontal fissure of right lung passes from the oblique fissure, near the midaxillary line, horizontally forwards to the anterior border of the lung, level with the sternal end of the 4th costal cartilage, then passes backwards to the hilum on the mediastinal surface th runs horizontally at the level of 4 costal cartilage and meets the oblique fissure in the midaxillary line *Middle lobe small, triangular lobe bounded by oblique and transverse fissure Left Lung Oblique fissure of the left lung extends from the costal to the medial surfaces of the lung both above and below the hilum superficially this fissure begins on the medial surface at the posterosuperior part of the hilum ascends obliquely backwards to cross the posterior border of the lung 6 cm below the apex, then descends forwards across the costal surface, to reach the lower border almost at its anterior end finally ascends on the medial surface to the lower part of the hilum at the posterior border of the lung the fissure usually lies opposite a surface point 2 cm to the side of the midline between the spines of T3 and T4 but it may be above or below this level th traced around the chest, the fissure reaches the 5 ICS (at or near the midaxillary line) and follows this to intersect the inferior border of the lung close to, or just below, the th 6 costochondral junction (7.5 cm from the midline) more vertical than the right, and is indicated approximately by the medial border of the scapula when the arm is fully abducted above the shoulder left horizontal fissure is a normal variant found in c.10% of patients. Apex of lungs: protrudes above the thoracic inlet rises 3-4 cm above the level of the costal cartilage, posterior of the neck of the first rib summit is 2.5 cm above the medial third of the clavicle Relations of the apex are as follows: Anterior: subclavian artery, anterior scalene muscle, subclavian vein, phrenic nerve, vagus nerve *Subclavian artery: arches up and laterally over the suprapleural membrane; groups the anterior surface of the apex near its summit Posterior: cervicothoracic or sympathetic ganglia, ventral st ramus of the 1 thoracic nerve, superior intercostal artery Medial: Right lung (bracheocephalic trunk, right bracheocephalic vein, trachea); Left lung (left subclavian artery and left bracheocephalic vein) Lateral: scalenus medius muscle, first rib Base of lungs: Semilunar and concave Rest upon the superior surface of the diaphragm Diaphragm extends higher on the right Concavity is deeper on the right lung Posterolaterally the base has a sharp margin that projects a little into the costodiaphragmatic recess

ANATOMY - LUNGS DR. CINIO September 30, 2013

Surfaces of lung: Costal Surface Smooth and convex Shape is adopted to that of the thoracic wall which is vertically deeper posteriorly At contact with the costal pleura and exhibits in specimens preserved in situ, grooves then corresponds with the overlying ribs Medial Surface Vertebral part Lies in contact with: thoracic vertebrae and intervertebral disc, posterior intercostals vessels, splanchnic nerves Mediastinal part Deeply concave adapted to the cardiac impression, much larger and deeper on the left lung where the heart projects more to the left of the median plane Hilum and pulmonary ligament Other Impression on the Lung Surface: Right Lung Cardiac impression is related to the anterior surface of the right auricle, anterolateral surface of the right atrium and partially to the anterior surface of the right ventricle Impression ascends anterior in the hilum as a wide groove for the superior vena cava and the end of the right bracheocephalic vein Posteriorly the groove is joined by a deep sulcus which arches forwards above the hilum and is occupied by the azygous vein. Groove for right side of the esophagus Shallow vertical groove behind the hilum and pulmonary ligament Towards the diaphragm it inclines left and leaves the right lung Posteroinferiorly the cardiac impression is confluent with a short wide groove adapted to the inferior vena cava Between the apex of the groove for the azygous, the trachea and right vagus are close to the lung Left Lung Cardiac impression is related to the anterior and lateral surface of the left ventricle and auricle The anterior infundibular surface of the right ventricle related to the lung as it ascends in front of the hilum to accommodate the pulmonary trunk A large groove arches over the hilum descends behind it and the pulmonary ligament Summit a narrower groove ascends to the apex for the left subclavian artery Behind and above the aortic groove the lung is in contact with the thoracic duct and esophagus In front of the subclavian groove, faint linear depression for the left brachiocephalic vein Inferiorly the esophagus mould the surface in front of the lower end of the pulmonary ligament Borders of the lung: INFERIOR BORDER thin and sharp where it separates the base from the costal surface and extends into the costodiaphragmatic recess more rounded medially where it divides the base from the mediastinal surface corresponds, in quiet respiration, to a line drawn from the lowest point of the anterior border which passes to the 6th rib at the midclavicular line, then to the 8th rib in the midaxillary line (10 cm above the costal margin), and then continues posteriorly, medially and slightly upwards to a point 2 cm lateral to the tenth thoracic spine POSTERIOR BORDER Separates the costal surface from the mediastinal, and corresponds to the heads of the ribs No recognizable markings and is really a rounded junction of costal and vertebral (medial) surfaces ANTERIOR BORDER Thin, sharp Overlaps the pericardium ON THE RIGHT - Corresponds closely to the costomediastinal line of pleural reflection and is almost vertical ON THE LEFT approaches the same line above; however, th below the 4 costal cartilage, it shows a variable cardiac notch, the end of which passes laterally for 3.5 cm before th curving down and medially to the 6 costal cartilage 4 cm from the midline Bronchopulmonary Segments: Structurally separate, functionally independent, unit of lung tissue Each of the principal bronchi divides into lobar bronchi Each segment is surrounded by connective tissue that is continuous with the visceral pleura, and is a separate respiratory unit The main characteristics of a bronchopulmonary segment may be summarized as follows: It is a subdivision of a lung lobe It is a pyramid shaped, with its apex toward the lung root It is surrounded by connective tissue It has a segmented bronchus, a segmental artery, lymph vessels, and autonomic nerves The segmental vein lies in the connective tissue between adjacent bronchoplmonary segments Because it is a structural unit, a diseased segment can be removed surgically

ANATOMY - LUNGS DR. CINIO September 30, 2013

Table: Major Structures and Corresponding Generations of the Tracheobronchial Tree Structures of Generations the Lungs * Trachea 0 Cartilagenous Main stem 1 Conductin bronchi airways g zone Lobar 2 bronchi Segmental 3 Subsegment 4-9 al bronchi Bronchioles 10-15 Noncartilagenou s airways Terminal 16-19 bronchioles Respiratory 20-23 Respirator bronchioles Sites of gas y zone exchange Alveolar 24-27 ducts Alveolar 28 sacs *Note: The precise number of generations between the subsegmental bronchi and the alveolar sacs is not known. These structures collectively are referred to as a primary lobule (see pages 3639) or lung parenchyma; they are also called terminal respiratory units and functional units Pulmonary Hila Principal bronchus, pulmonoary artery, bronchial vessels, a pulmonary autonomic plexus, bronchopulmonary lymph nodes and loose connective tissue th Pulmonary roots pedicles, lie opposite the bodies of the 5 th to 7 thoracic vertebrae Common anterior relations: Phrenic nerve, pericardiophrenic artery and vein, and anterior pulmonary plexus Common posterior relations: vagus nerve and posterior pulmonary plexus The pulmonary ligament is inferior The major structures in both roots are similarly arranged: Upper of the two pulmonary veins in front The pulmonary artery and principal bronchus are behind Bronchial vessels - most posterior RIGHT HILUM Root is situated behind the superior vena cava and right atrium, and below the terminal part of the azygous vein The sequence from above downwards; Superior lobar bronchus Pulmonary artery Principal bronchus Lower pulmonary vein

LEFT HILUM Root lies below the aortic arch and in front of the descending thoracic aorta The vertical sequence at the left hilum: Pulmonary artery Principal Bronchus Lower pulmonary vein The pulmonary artery is longer in the left lung Secondary Pulmonary Lobules: Each segmental bronchus supplies a bronchopulmonary segment Progressive subdivision of the bronchus occur within each segments All intrapulmonary bronchi are kept patent by cartilaginous plates, which decline in size and number and finally disappear when the tubes are less than 1 mm in diameter (bronchioles) The primary lobule is the lung distal to the respiratory bronchiole (?) The secondary lobule is the smallest subsection of the peripheral lung bounded by connective tissue septa and consists of approximately six terminal bronchioles The connective tissue septa are uneven in both size and shape Vascular Supply and Lymphatic Drainage: Two functionally distinct pathways - Pulmonary vessels: convey deoxygenated blood to the alveolar walls; drain oxygenated blood back to the left side of the heart - Bronchial vessels: from the systemic circulation; provide oxygenated blood to lung tissues which do not have close access to atmospheric Oxygen e.g. those of the bronchi and larger bronchioles Pulmonary artery right and left arteries pass to the hila of the lungs- divide into branches that accompany segmental and subsegmental bronchi and mostly dorsolateral Pulmonary capillaries from plexuses immediately outside the epithelium in the walls and septa of alveoli and alveolar sacs Pulmonary veins two from each lung, drain the pulmonary capillaries Their radicles coalesce into larger branches which traverse the lung independently of the pulmonary arteries and bronchi Communicating freely, they form large vessels that ultimately accompany the arteries and bronchial tubes to the pulmonary hilum, where the bronchi often separate the dorsolateral artery and the ventromedial vein

ANATOMY - LUNGS DR. CINIO September 30, 2013

The pulmonary vein open into the left atrium and convey oxygenated blood for systemic distribution by the left ventricle Pulmonary hepatic vessels originate in a superficial subpleural plexus A deep plexus accompanies the branches of the pulmonary vessels and bronchi Superficial efferents turn normal lung borders and the margins of fissures to converge in the bronchopulmonary nodes There is little anastomosis between the superficial and the deep lymphatics, except in the hilar regions Deep in the fissures, lymphatic vessels of adjoining lobes connect Consequently, although there is a tendency for vessels from the upper lobes to pass to the superior tracheobronchial nodes, and those from lower lobes to the inferior tracheobronchial group, these groups are not exclusive. RIGHT LUNG Superior right pulmonary vein union of apical, anterior and posterior veins (draining the upper lobe) with a middle lobar vein (formed by lateral and medial tributaries) in the hilum Inferior right pulmonary vein hilar union of superior (apical) and common basal veins from the lower lobe The union of superior and inferior basal tributaries forms the common basal vein The right pulmonary artery divides into two large branches as it emerges behind the superior vena cava A lymph node usually occupies the bifurcation Superior branch smaller of two, goes to the superior lobe and usually divides into the further branches, which supply the majority of that lobe Inferior branch descends anterior to the intermediate bronchus and immediately posterior to the superior pulmonary vein Provides a small recurrent branch to the superior lobe Middle lobe anteriorly and the branch to the superior segment of the inferior lobe posteriorly Inferior lobe segments LEFT LUNG Superior left pulmonary vein Drains the upper lobe Union of apicoposterior (draining the apical and posterior segments) anterior and lingular veins Inferior left pulmonary vein Drain the lower lobe Hilar union of the superior apical and common basal (superior and inferior basal vein) Tributaries of pulmonary vein receive smaller tributaries Innervation: Vagal fibers Supply the bronchial muscles and glands Brochoconstrictor and secretomotor Efferent sympathetic fibers Inhibitory Relax the bronchial smooth muscle Vasoconstrictor effects Pulmonary plexuses The pulmonary plexuses are anterior and posterior to the other hilar structures of the lungs The anterior plexus is much smaller and is formed by rami from the vagal and cervical sympathetic cardiac nerves as direct branches from both sources The left plexus also receives branches from the left recurrent laryngeal nerve Blood supply of the lungs is two fold Unoxygenated blood is pumped to the lung from the right ventricle by the way of pulmonary vein After oxygenation in the lung, the blood is returned to the left atrium by the way of pulmonary vein Blood supply to the bronchi is from the systemic circulation by bronchial arteries arising from the superior thoracic aorta or the aortic arch, either as discrete branches or in combination with the intercostal arteries In most individuals, there are 2 left and 1 right main bronchial artery The bronchi, the connective tissue of the lung and the visceral pleura receive their blood supply from the bronchial arteries which are branches of descending aorta. The bronchial vein which communicate with the pulmonary vein drains into the azygus and hemi azygus vein Lymph drainage pathway: Superficial and deep plexus ----- pulmonary nodes ----brochopulmonary nodes ----- tracheobronchial ---tracheomeddiastinal ----- cephalad The lymphatic sump of Borne includes the groups of lymph nodes that receive lymphatic drainage from all pulmonary lobes of the corresponding lung. Lymphatic vessels are present throughout the parenchyma and gradually coalesce toward the hilar area of the lungs. Generally, lymphatic drainage from the lungs affect the ipisilateral lymph nodes, however the flow of lymph from the left lower lobe may drain to the right mediastinal lymph vessels Reference for reading: Gray's Anatomy, 39th Edition.Susan Standring.2008.

ANATOMY - LUNGS DR. CINIO September 30, 2013