Gross Respiratory Dr.

Esguerra

September 8, 2009 intrapulmonary(secondary/lobar)], bronchiole-terminal 2. Respiratory portion Respiratory bronchiole, alveolar ducts, alveolar sacs, alveoli

RESPIRATORY SYSTEM (Gross)

Objectives: Describe the gross features of the tracheobronchial tree o Identify important structures related to the trachea and primary bronchi o Ramifications of the bronchial tree o Orientation of the primary bronchi and anatomical basis of the location of aspirated foreign bodies o Features of bronchopulmonary segments and their clinical sig. Describe gross features of the lungs o Surfaces, lobes and fissures o Differentiate right and left lungs o Impressions made on the mediastinal surface o Composition of the root of the lung Surface projection of the borders and fissures of the lungs on the chest wall Blood supply, innervations, lymphatics Embryologic development of the tracheobronchial tree (?!?!?!) Describe normal radiologic features

GROSS ANATOMY OF THE LUNGS

THE RESPIRATORY SYSTEM (RS)

Collapsed Lung
Pleural cavity

Inflated Lung
Cervical part

Visceral pleura

Costal part

Mediastinal Part

Component parts: A. Anatomic divisions 1. Upper RS- nose, pharynx and larynx 2. Lower RS- trachea, bronchi, lungs B. Functional divisions 1. Conducting portion Nasal cavities, pharynx, larynx, trachea, bronchi [can be extrapulmonary (primary/main bronchus) or

Parietal Pleura

Diaphragmatic part

conical in shape; reflect space of pleural cavity (except for costodiaphragmatic and costomediastinal recesses) each has an apex, root and base apex aka cupula o blunt superior end of the lung ascending above the level of the 1st rib into the root of the neck for

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about 1 in. (2.5 cm) above the clavicle covered by cervical pleura separated from the neck by suprapleural membrane or Sibsons fascia can be mapped out on the anterior surface of the body by drawing a curved line, convex upward, from the sternoclavicular joint to a point 1 above the junction of the medial and intermediate thirds of the clavicle.

Oblique fissure o At the posterior surface, about 2.5 inches from the apex, it follows the course of 6th rib down to inferior border of the lung o Divides lower lobe of right lung from the upper and middle lobes Horizontal fissure o Divides the middle and upper lobe of the right lung o 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 recess o Slit-like spaces between the costal and diaphragmatic parietal pleurae that are separated only by a capillary layer of pleural fluid o Lower area of the pleural cavity into which the lung expands on inspiration o During expiration, the lower margins of the lungs ascend so that the costal and diaphragmatic pleurae come together again. o 2 (5 cm) deep in the scapular line posteriorly o 3 to 3.5 (8-9 cm) in the midaxillary line o 1 to 1.5 (2.5 to 4 cm) in the midclavicular line

root o aka hilum/hilus o point of entry of lymph nodes, bronchi and pulmonary vessels o structures pass from the neck to abdomen (esophagus, blood vessels, vagus nerve, thoracic anterior to the root: phrenic nerve (found within the pericardial lning) base o concave in shape; conforms to diaphragm diaphragm on right T8 level diaphragm on left IV disc level of T8/T9 o right is higher than the left, because of the liver o it then follows that the right lung is shorter o the heart pushes the left lung, therefore right lung is broader each has 3 surfaces: costal( related to the ribs), mediastinal (beside the heart) and diaphragmatic (inferior) each also has anterior and inferior borders (no posterior border because at the back, the mediastinal surface is continuous to costal surface without any edge) Fissures:

 Costomediastinal recess (left) o potential space in the pleural cavity between the costal pleura and mediastinal pleura at the level of the 5th intercostal space on the left side in which the lingula expands into during inspiration o 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
Right Lung # of Lobes At the root of the lung 3 Azygos arch impression Left Lung 2 Aortic arch impression

Cardiac Notch notch produced by the heart displacing the lung to the left, creating a thin, tongue-like process of the superior lobe, LINGULA, which extends below the cardiac notch and slides in and out of the costomediastinal recess during inspiration and expiration Posterior o extends downward from the spinous process of C7 to the level of T10 and lies 1.5 (4 cm) from the midline o thick and lies beside the vertebral column Inferior o In the midinspiration, follows a curving line, which crosses the 6th rib in the midlavicular line; 8th rib in the midaxillary line and 10th rib adjacent to the vertebral column posteriorly o Level of this border changes during inspiration and expiration

Pulmonary ligament (mesopneumonium) double layer of pleura below the root covers the root and attaches the lung to the mediastinum Pulmonary vein posteriorly and inferiorly located Lobar bronchi posterior and central Pulmonary arteries anterior to bronchi Pulmonary arteries always the most superior structure in some cases, eparterial bronchus Lingula* appears above the artery Oblique, Horizontal Oblique 10 8

RADIOGRAPHY

Special feature

Fissures # of Bronchopulmonary segments

*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 meet anteriorly and overlap the heart o RIGHT LUNG Relatively straight Begins behind the sternoclavicular joint and runs downward, almost reaching the midline behind the sterna angle, then continues downward reaching the xiphisternal joint Thin and overlaps the heart o LEFT LUNG Similar course as the right lung, but deviates laterally at the level of the 4th costal cartilage to extend for a variable distance beyond the lateral margin of the sternum to form the cardiac notch

Chest X-ray: PA Projection (Posteroanterior View) For babies: AP Pojection (Anteropsterior) To obtain a posteroanterior radiograph, the Xray are projected from behind the patient to a plate that is touching the patients chest; structures close to the plate appear very close to the actual size, and the structures further away appear larger Heart o In anteroposterior view, it appears much larger (and less distinct) than in posteroanterior view

Lungs o dense shadows caused by the presence of the blood-filled pulmonary and bronchial vessels, the large bronchi, and the lymph nodes o lungs are more translucent on full inspiration than on expiration o pulmonary blood vessels are seen as a series of shadows radiating from the lung root. They appear as small, round, white shadows o large bronchi also cast round shadows o smaller bronchi are not seen Bones o thoracic vertebrae are imperfectly seen o costal cartilages are not usually seen, but if calcified, they will be visible o clavicles are clearly seen crossing the upper part of each lung field o medial borders of the scapulae may overlap the periphery of each lung field Diaphragm o diaphragm casts dome-shaped shadows on each side; the one on the right is slightly higher than the one on the left o costophrenic angle,- area where the diaphragm meets the thoracic wall o beneath the right dome is the homogeneous, dense shadow of the liver o beneath the left dome a gas bubble may be seen in the fundus of the stomach

Trachea starts from larynx (C6 level-lower border of cricocartilage) up to its bifurcation (carina*) 5 in. long, 1 in. diameter From the lower border of the cricoids cartilage until the level of the 6th cervical vertebra (C6) Bifurcates into right and left main stem bronchi (extrapulmonary) at T4 and T5 Carina: bifurcation. It is the keel-like ridge between the two openings of the main stem bronchi Main bronchi branch will form the bronchial tree (secondary intrapulmonary lobar bronchi) has fibroelastic wall in which are embedded a series of U-shaped bars of hyaline cartilage that keep the lumen patent posterior free ends are connected by the trachealis muscle (regulated by the recurrent 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

Bronchus
Right Main Bronchus Wider shorter More vertical Branches: superior and intermediate lobar bronchus Latter divides into: middle and inferior lobar bronchus Left Main Bronchus Narrower longer More horizontal/lateral Superior and inferior lobar bronchus

*on x-rays, black-color signifies presence of air. More dense structures

appear as white (bones). Radiopaque materials (coins, pins, wire, etc.) also appear white.

*Primary or main stem bronchus divides into*

GROSS ANATOMY OF the TRACHEOBRONCHIAL TREE

Lobar Bronchi (secondary bronchi)

*Each lobar bronchus divides into*

Segmental Bronchi (tertiary bronchi) Supply the bronchopulmonary segments Name would correspond to the segment it supplies

THE BRONCHOPULMONARY SEGMENT pyramidal shaped segment of the lungs with the apex facing the lung root and the base at the pleural surface largest subdivision of a lobe anatomic, functional, and surgical unit of the lungs separated from adjacent segments by connective tissue septa

 supplied independently by a segmental or tertiary bronchus and a tertiary branch of a pulmonary artery named according to the segmental bronchus that supplies it drained by pulmonary veins along the connective tissue 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 to the 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 to further to posterior or middle lobe) particles aspirated by an adult lying on his left side will most likely fall to the left main bronchus (may go further to lingular segments) particles aspirated by an adult lying on his back will most likely fall to the right main bronchus (may go further to superior bronchopulmonary segment of the right lower lobe) particles aspirated by a baby goes to right upper lobe (more often)
Segmental bronchus Autonomic nerves Lymphatic vessel Pulmonary vein Terminal bronchiole s Respiratory bronchiole Alveolar sac Pulmonary artery
Pulmonary vein in intersegmental connective tissue

Bronchioles Where cartilage disappearsbronchioles possess no cartilage in their walls and are lined with columnar ciliated epithelium Arise from the division of the smallest bronchi Are less than 1mm in diameter Terminal bronchioles The bronchioles divide and give rise to terminal bronchioles which 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 alveolar

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 rich network 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

alveolus

Deoxygenated blood form the terminal branches of the pulmonary arteries is received by the alveoli. The oxygenated blood leaving the alveolar capillaries drains into the tributaries of the pulmonary veins, which follow the intersegmental connective tissue septal to the lung root. Two pulmonary veins leave each lung root to empty into the left atrium of the heart.
Tracheopulmonary segment

- Enters the heart via the left atrium carrying oxygenated blood Bronchial Veins - Communicate with the pulmonary veins - Drain into the azygos vein which collects posterior intercostal veins (right) and helmazygos veins (left) RIGHT SIDE Located inferior to the Eparterial Bronchus One (1) Right bronchial artery LEFT SIDE Most superior structure (No bronchus) Two (2) Left Bronchial Arteries: 1. Superior LBA 2. Inferior LBA Both are branches of the descending aorta LBV drains to the left accessory hemiazygos/intercos tal vein

Pulmonary Artery

Bronchial Artery Arteries Pulmonary Artery - follows the lobes (bronchial branching) and carries unoxygenated blood from the heart - Upper and lower pulmonary arteries are drained by one Upper Pulmonary Vein Bronchial Artery -Branch of descending bronchiole -Trachea to bronchi to respiratory bronchiole -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 bronchial arteries) -Left Lung: 2(superior and inferior branches of descending thoracic aorta) -Eventually anastomose with with pulmonary arteries

Bronchial Venous System

RBV drains to the azygos vein

Mixing of Oxygenated and Unoxygenated Blood Occurs in the alveoli, along pleura and intersegmental CT Bronchial artery with pulmonary vein from alveoli Blood supply drained from the visceral pleura and the capillaries LYMPHATIC DRAINAGE AND NERVOUS SUPPLY -Follow veins and arteries -Lymph vessels originate in superficial and deep plexus -Up to terminal bronchioles only (fluid absorbed at this level) not present in alveolar walls

Veins Pulmonary Vein - All drain to posterior aspect (Left Atrium) - Primary drainage of blood from bronchial artery - NOT the bronchial venous system (which drains the proximal part of the lungs 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

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 pulmonary vessels toward the hilum of the lung -passes through pulmonary nodes in the hilum -all the lymph from the lung leaves the hilum and drains into the tracheobronchial nodes (superior and inferior tracheobronchial CARINAL

Nodes paratracheal nodes) and then into the bronchiomedistinal lymph trunks (along venous circulation at the junction of subclavian vein and internal jugular vein RIGHT LUNG RIGHT LYMPHATIC DUCT Lymph from Hilar Nodes Carinal/Tracheobro nchial Trunk Right Lymphatic Trunk Subclavian Vein and Internal Jugular Vein LEFT LUNG THORACIC DUCT (Upper lobe) Hilar Node Superior Tracheobronchial Nodes Left Paratracheal Nodes Thoracic Duct (Lower Lobe) Hilar Node Carinal/Inferior Tracheobrochial Right Lung

DRAINAGE

THORACIC DUCT - Collects all lymphatics from below the right and left 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, the CISTERNA CHYLI - Enters the AORTIC HIATUS (shares the same foramen with the aorta) - 180 turn at C7 - Terminates at the junction of the Left Internal Jugular Vein and the Left Subclavian Vein

Pulmonary Plexus Supplies each lung Formed by branches of the sympathetic trunk and received parasympathetic fibers from the Vagus nerve (CNX): Innervation of the smooth muscle of the brachial tree, pulmonary vessels, and the glands of the bronchial tree via the pulmonary plexuses located anterior and posterior to the lung roots Postganglionic Sympathetic Fibers from the sympathetic trunks (bronchodilators, vasoconstrictors, and inhibit glandular excretion)

Right bronchomediastinal lymph trunk drains into right lymphatic duct Superior tracheobronchial nodes

Left bronchomediastinal lymph trunk drains into thoracic duct Paratracheal nodes

Bronchopulmonary (hillar) nodes Interpulmonary nodes

Inferior tracheobronchial (cardinal) nodes

Subpleural lymphatic plexus Interlobar lymphatic vessels

Preganglionic Parasympathetic Fibers from the Vagus Nerve (CNX) bronchoconstrictors,

vasodilators, and secretomotor to the glands Visceral Afferent Fibers follow sympathetic fibers carry information involved in cough reflexes, stretch reception, blood pressure, chemoreception, and nociception (also pain receptors sympathetic over distention)
Left Vagus Nerve Phrenic Nerve Left

Deep lymphatic drainage follows the bronchial tree

Drainage to mediastinum enough pulmonary ligaments

Right Vagus Nerve Right Phrenic Nerve Left Phrneic nerve Right Recurrent Pharyngeal Nerve

Cervical Cardiac Branches Left Phrneic nerve (Vagosympathetic) Left Recurrent Pharyngeal Nerve Pulmonary Plexus Pulmonary Trunk

Right Vagus Nerve

Left Vagus Nerve

Anterior view

Esophageal plexus

TEST YOURSELF! 1. All of the following commonly occur on inhalation except: a. The diaphragm descends b. The external intercostal muscles contract c. The abdominal muscles contract and push the abdominal viscera cranially d. The ribs are raised e. The visceral dimension of the thoracic cavity increases 2. With a patient in the standing position, fluid in the left increases cavity tends to gravitate down to: a. The oblique fissures b. The cardiac notch c. The costomediastinal recess d. The costodiapragmatic recess e. The horizontal tissue 3. Which of the following statements is (are) correct regarding the bronchopulmonary