Thoracic wall

Skeleteon of thoracic wall

Ribs, costal cartilages and interocstal spaces
Thoracic vertebre
Sternum

Thoracic apertures
Superior thoracic aperture
Inferior thoracic aperture

Joints of thoraic wall

Costovertebral joints
Sternocostal joints

Movements of thoracic wall

Muscles of thoracic wall
Fascia of thoracic wall
Nerves of thoracic wall
Typical intercostal nerves
Atypical intercostal nerves

Vasculature of thoracic wall

Arteries of thoracic wall
Veins of thoracic wall

Breasts
Vasculator
Nerves of breast

Surface anatomy

Viscera of thoracic cavity

Pleurae, lungs and trahcobronchial tree

Pleurae
Lungs
Trachobronchial tree
Vasculator of lungs and pleura
Nerves of lungs and plearua

Mediastinum
Superior mediastnum
Inferior mediastnum
Posteiror mediastinum
Anteiror mediastnum

Thoracic wall
Structural function of thoracic cage. Because of its
shape it allows us to: (protect, pressure, attachment)
Protect vital thoracic and abdominal organs form ext forces
Resist the negative sub atmospheric internal pressure
generated by elastic recoil of lungs and inspiratory
movements
Provide attachment for and support weight of upper limbs
Provide anchoring attachment of many of muscles for
upper limb, muscles of abdomen, neck back and respiration

Flexibility of its joint + flexibility allow:

Absorb external blows and compression without fracture
Change shape for repsiraiton

Skeleton of thoracic walls

12 pairs of ribs + associated
cartilages
12 thoracic vertebra + intervertebral
disks in between
Sternum

Ribs, costal cartilages, intercostal

spaces
Ribs:
Each rib has
hematopoetic tissue. 3
types of ribs:
1-7 = true
vertebrocostal ribs. Attach
to sternum
8-10 = false
vertebrochandral ribs.
Connected to cartilage of
rib above them.
Connection to sternum is
indirect
11,12 free verebral ribs
End in posterior abdominal
musculature

Ribs:
Typical 3rd-9th
Atypical

Typical 3rd-9th

Head
Wedge shaped
2 facets sep by crest of head
1 facet for articulation
with corrposneidng verbra
1 facet for vertebra
superior to it
Neck
Connects the head of rib with
body at level of tubercle
Tubercle
Located at junciton of neck and
body.
2 articular parts:
Smooth articular
part articulates
with corresponding
transverse process
of vertebre
Rough non articular
provides
attachment for
costotransevrse
ligament
Body
Flat, curved, mostly markedly at
costal angle
Demarcates the lateral limit of
attachment for deep back mucles
of ribs
Has the costal groove

Weakest part of rib is just anterior to its angle

Fractures of lower ribs may tear the
diaphgram and reuslt in diaphragmatic hernia

Atypical ribs:
1st rib
a) broadest, shortest, most
sharply curved of the seven
true ribs
b) Single facet on head to
articulate with T1 vertebra
only
c) Two transversely directed
grooves crossing its superior
surface from subclavian
vessels
d) Groovezs seperated by
scalene tuercle and ridge, to
which anterior scale muscles
attach
Clinical:
Posterior inferior to clavicles
Rarely fracture because of
protected position
You cannot palpate Rib 1
When broken structures
crossting its superior aspect
may be injured:
Brachial plexus of
nerves
Subclavian vessels that
serve uppe rlimb

 Atypical ribs:
2nd rib
a)Thinner
b)less curved body
c)substantially
longer than 1st rib
d)Head has two
facets for
articulation with
bodies of T1 and T2
veretbrae
e)main atypical
feature is a rought
area on upper
sraface, the
tuberosity for
serratus anterior,
from which part the
muscle originates

 Atypical ribs:
10-12th ribs, like
1st rib, one fate on
head. Articulate
with single vertebra
11-12th ribs, short
and have no neck
or tubercle

Flail rib

Costal cartilages:

Function

Costal cartilages 1-7:

Articulate with costal cartilages superior to

them- form a continuous articulate cartilaginous
costal margin.

Costal cartilges 11,12:

Attach direct and independently to sternum

Costal cartilages 8,9,10th:

1) length the ribs anteriorly

2) contribute to elasticity of thoracic walls

Caps on anterior ends of corresponding ribs and

do not reach or attach any other bone or
cartialge

Clinical pearls:

The very young

Very elastic injury to thorax can be prsesent even in asbence of rib

fracture

The eldelry:

Costal cartilges lose elastaicity under go calcification making them

radiopaque

Intercostal spaces

11 intercostal spaces
11 intercostal nerves
Intercostal spaces occoupied by
inctercostal muscles and membranes
and two sets (main and ocllateral) of
intercostal blood vessels and nerves
Space below 12th rib = rubcostal sapce
= anterior ramus branch of spinal
nerve T12
ICS is widest anterolaterlaly and widen
further with inspiration
Can also be widd by extension/and or
lateral flexion of thoracic verebtral
column of contra lateral side.

Thoracic Vertebrae
Typical vertebra:
Independent
Have bodies, vertebral arches and seven processes
for muscles and articular connections
Characteristics:
Bilateral costal facets (demifacets) on vertebral bodies
for articulation with heads of ribs
Can be divided into superior and inferior costal facets
small demifacets. Will be covere din more detail next slide

Costal facets on trasverse processes for articulation with

tubercles of ribs
Exception: inferior 2 or 3 thoracic vertebrae

Long inferiorly slating spinous processes

Facets of typical ribs

Superior and inferior costal

facets:
Occur as bilaterally paired,
planar surfaces on superior
and inferior posterolateral
margins of bodies of typical
thoracic vertebrae (T2-T9)
Arranged in pairs on adjacent
vertebra, flanking an
interposed IV disc:
Typically two demifacets
paired in this manner and the
posterolateral marign of IV
disc between them form a
single psocket to receive head
of rib of the same number as
superior rib

e.g Head of rib 6 with superior

costal facet of vertebra T6

Exceptions to facets
Vertebra T1
Superior costal facets of T 1
are not demifacet because
there are no demifacets on C7
vertebra above
Rib 1 only articulates with
vertebre T1
T1 has a typical inerior costal
demi facet

T10
Only one bilateral pair of
costal facets located parlty on
its body and partily on pedicle

T11,T12:
Only a single pair of costal
facets located on pedicles

Manubrium:
Thickest, widest
Easily palpated concave center of superior border of
manubrium - jugular nothc
Inferolateral to calvicular notch, there is the
synchondrosis of first rib
Manibrium and body of sternum not in same plane.
Sternal angle

Sternum:

Body:
Longer, narrower
Located level of T5-T9
Younger people: 4 sternebrae are obvious. Articulat with
each other at primary cartiligouns joints (sternal
synchondrosis)
These joints fuse and form from inferior end between
buperty and age 25.
Nearly flat anterior surface of body of stenrum is marked
in adults by 3 veriable transverse reiddgs.
Xyhpoid process
Inferior end lies at level of T10 vertebre
Can be blunt
Can be biifid
Can be cuved
can be deflected to onside or other
Impt landmark:
a) junction with sternal body indicates inferior limit of
central part of thoracic cavity
b) midle marker for the superior limit of liver, the central
tendon of diaphgragm, infeiror border of heart

 Describing costoverebtral joint

i.e ribs to thoracic spine. 2 parts:
Joints of head and ribs:
Head of rib articulates with the
following:
superior costal facet of
corrosponding vertebre
Infeiror costal facet of vertebre
superior to it
Adjacent iv disc uniting the two
vertebrae
Head of ribs crest attached
to IV disc by an
intraarticular ligameent of
head of rib wihtin joint, this
divides the enclosed space
into two synovical caivities

Fibrous layer of joint capsule:

Strongest anteriorly where it
forms the radiate ligament of
head of rib that found out form
anterior marign of head of rib to
sides of bodies of two vertebre
and IV disc between them.
Very tight connection
Almost no movement

Costotransverse joint

Describing costoverebtral joint

i.e ribs to thoracic spine. 2 parts:
Joints of head and ribs:

Costotransverse joint
Tubercle of rib with transverse
process of vertebre of same
number
Very little movement at these
joints and only have thin
capsules
Few ligmaents:
Strengthening the anterior part:
Costotransvgerse ligament
passing from neck of rib to
transverse process
Strengethinging the posterior part
Lateral costotransverse liagment
passing form tubercle of rib to tip
of transverse process.
Superior costcotransverse
ligaement is a broad band that
joins the crest of neck to rib to
transverse process supieror to it:
Apertur ebetweeh this
ligament and vrebtre
permits passage of spinal
nerve and posteiror branch
of intercostal artery

Movement of thoracic wall

Changes from ribs 1-7 vs 8-10th

 Upper ribs
move in a
pump
handle
movement
Lower ribs
move in a
buck
handle
movement

 Pump handle:
Ribs 1-6
Very storng costcotransverse
ligametns binding these joints and
limiting their mogvements to slight
gliding.
However, articualr surfaces on
tubercles of superior 6 ribs are
convex and fit into concatvities of
the transverse process.
So rotaiton mostly at the
transverse axis that transverses
intrarticular ligamenet and head
and neck of rib.
This results in elevation and
depression movements of sternal
ends of ribs and sternum in
saggital plane

Bucket handle:
Ribs 7-10
Flat articular surfaces
of tubercles and
transverse processes
of 7-10th ribs allow
gliding allowing in
elevation and
dperssion of lateral
most portions of
these ribs

Sternal fractures

Not common any more thanks to airbags

Fracture of sternal body is usually a comminuted fracture
(several pieces)
Displacement uncommon because :
Sternum invested by deep fascia (fibrous continuities of radiate
sternocostal ligaments)
Sternal attachement of pectoralis major muscles.

Most common site of sternal fracture in eldelry people is at

sternal angle i.e fusion of manubriosternal joint which
results in dislocaiton of joint
Mortality 25-45% due to high likelhood of myocardial
contusion, cardiac rupture, tamponade or lung injyr.
Even in cases of soft tissue sternal injjruy they should be
eval for visceral injury.

Muscles of thoracic wall:

Axioappendicular muscles:
Pec major
Pec minor
Inferior part of serratus anterior
Scalene muscle

True muscles of thoracic wall:

Serratus posterior
Levatores costarum
Intercostal muscles
Subcostal muscles
Transverse muscles

Controversial role of serratous

posterior
Perviously described as inspiratory muscles;
Serratous post sup was supposed to elevate the
superior 4 ribs - thus increasing AP diamter of
thorax and raising sternum
Serratous post inferior was supposed to depress
the ifnerior irbs preventing from being pulled
superiroly by diaphgram.
Recent studies show they do not have a primary
motor function - important for prioperceptive
fucniton -particualry serratus posterior sup has
been implicated in chornic pain im yofascial pain
syndrome

Some random points

External intecostal membranes are
continous inferiorly with external oblique
muscles in the anterolateral abdominal
wall. More active during inspiration
Internal intercostal muscles most
active during expiration
Innermost intercostal musces
Seperated from internal intercostals by
intercostal nerves and vessel

External and internal

intercostals

External active during inspiratoin

Internal expiration
Most activity is isometric increases tonus without
producing movement mainly during forced respiration.
Main role is to support rigidity of intercostal space, resistent
paradoxical movement espically during inspiration when
intercostal thoracic pressures are lowst most negative
Clinical example:
High spinal cord injury initial flaccid paralysis of entire trunk but
diaphgram remains active.
Here teh vatial capicty is markedly redcued by paraoxical incursion of
thoracic wall during inspiration
When paralysis spastic thoracic wall stiffens and vital capicty rises

Nerves of thoracic wall

12 pairs of thoraic spinal nerves supply thoracic
wal
Typical vs atypical intercostal nerves

As soon as they leave IV formina divided itno

anterior and posterior rami or branches
Anterior
T1-T11 anterior rami forms the intercostal nerves which rund
along extent of intercostal spaces
Anterior rami of Nerve T12 is the sucbostal nerve and is nefrior
to 12th rib

Posterior:
Go lateral to the articular process of vertebre, to supply joints,
deep back muscles and skin of back in thoracic region

Typical intercostal nerves:

Atypical intercostal nerves

Blood supply

 Vertebre T6
gets tubercle of which rib?
Gets head of which rib

 Head of 6th rib articulates with?

Very basic physiology

In healthy individuals, GFR remains stable despite changes in
volume and blood pressure.
Overload
When overload of sodium and volume -> rise in atrial pressure ->
release of natruietic peptides -> renal sodium secretion via direct
ubular effects -> rise in GFR
RAAS is suppressed -> systemic vasodilatation and renal sodium
excretion by inhibiting tubular effects of AGII and aldosterone

Volume depletion:
Increased RAAs -> systemic vasoconstrict and renal sodium absorption.
Angiotensin II induced renal effecert vasoconstriction, helping to
maintain renal filling pressure and GFR despite decreased arterial
pressure.

Interaction of cardiorenal system + osmoregulation

Normal physiological conditions High plasma osmolarity -> Release of arginine
vasopresion (ADH) -> renal water retention ->
Normal osmolarity

During pronounced water volume disturbances:

responses to volume depletion or overload can
overcome osmotic triggers, contribute to restoration
of volume status at expense of osmoregulation.

Basic mechanisms in play during

AHF
Acute heart failure:
Decreased cardiac function -> Reduced CO + arterial
underfilling -> decreased activation of arterial strech R ->
compensatory systemic and intrarenal vasocnstriction
Decreased strech of glomeural afferent arteriole -> renin -> AGII

AGII -> afferent and efferent vasconstricion -> sodium retenion

in proximal tuble + rls of aldosterone
Aldosterone -> increased sodium reabsorpiton in collecting duct
-> ECF expansion and systemic congestion

Aldosterone escape
mechanism

Protective effect of natruiretic

peptides in AHF pt
Protective effect of natriuretic
peptides is diminished in patients
with AHF due to:
renal vasocontriction,
reduced sodium delivery,
fewer active formsof natriuretic peptides
and down reuglation of their receptors.

Decreased protective effect of

natreretic peptides + adenisone
In addition, adenosine (which is
released in reposnse to increased
renal work load and high sodium
concentration in distal tubule):
further reducedsrenal blood flow,
stimulates proximal sodium
reabsorpaiton and through
tubuloglomeural feedback futher
decreased GFR via adenosine Areceptor.

In a typical heart failure patient

kidneys get smashed
Pump failure
Neurohorminal activation
Usually on Ace I and ARB which overcome kideny`s
capacity to comepnsate for reduced perfusion
Increased renal interstitium pressure + reduced
transrenal perfusion
ANother hit to kindey:
increased vnous filling + abdo pressure ->
ascities -> increased renal afterload and intranreal pressure
reduce transrenal perfusion gardient
increased renal insteritum pressure (directly opposing
pressure)
futher contirpute to renal insuff

Tx them with diuretics

Mechanisms of resistance
1) orally admin diuretics must be absorbed in gut - in presence of GI oedema or gut hypoperfusion,
absorpiton of orally admin diuretics is impaired. IV admin can overcome impaired absorption.
2) Hypoalbuminemia:
Most diuretics are bound to plasma albumin:
thiazide diuretics
metolazone
acetazolamide
LOOP DIURETICS.
Hypoaluminemia common in ahf
Impairs uptake and secretionof active fursemide and enhances conversion to active form.
Coadmin of albumin and frusomide improved diuretic repsonse in patients with cirrhosis, nephrtic
syndrome or chornic kindey disease but no date on hf.

3) Elevated BUN
reduces diuretic availaibility by competitively inhibiting the organic anion transporter
Furthermore, there is increased urea actively retains sodium itself.
This happens because RAAS and SNS lead to follow dependent passive resporation of urea in distal
tubule; a concen trationg raident created by increasd sodium adn water resport in proximal tubule
results in diminished distal aflow and increased reabsopriton.

How does it happen

1) Initially natriuretic effect results in
intended negative sodium balance
2) Resulting decrease in ECF volume
triggers a hoemostatic response (RAAS
and SNS triggereD) increased sodium
reteion at tubular sites
3) After several days, homeostatic
resposne counterbalances diuretic effect
fo drug creating a new steady state with
lower Ecf
4) In patients with hyperaldosteronism,
this phenomenon is pronouced cuasing
rapid and abundand sodium reabsopriotn
5) Aslo you have hypertorphy of distal
tubular cells due to rapid and abundant
sodium reabsroption

Braking
phenomenon
appropriate
homeostatic
repsosne that
prevents excessie
volume depletion
during continued
diuretic therapy

Defn of diuretic resistance

Persistent congestion despite
adequate adn eslcate doses of
diuretics with > 80 mg lasix pre day
Amount of sodium excreted as a
percentage of filtered load <0.2%
Fialure to excrete atleast 90 mmol of
sodium within 72 hours of a 160 mh
frusemide dose given twice daily

Tx of patients with diuretic

resistance
1) rule out non compliance verify mediction intake and sodium
restriction
2) NSAID cease inhibiation of prostagland G syntahse 2 i.e COX
interferes with prostaglandin syntehishs which antognises natruretic
reposse to loop diuretics
3) Alternative loop diuretic bumetanide and torasemide have
higher biological apsoriton than frusemide with chronic heart failure
4)Increases doses of loop duiretics can also help dstablish diuretic
resistance
5) Switch from Oral to IV
6) Continus infusion improves diuresis, renal funciton and leads to
fewer adverse affects rather htan bolus but data is eqvuical
7) Combine diuretic therapy:
Add thaizide longer halflife

 Pleura
Basic lung anatomy no surface
marking
Needs to be done:
Upper airways
Nerve supply of lungs
Vascular supply of lungs

 To visualize the relationship of the

pleurae and lungs, push your fist
into an underinflated balloon (Fig.
1.30C).
The inner part of the balloon wall
(adjacent to your fist, which
represents the lung), is comparable
to the visceral pleura;the remaining
outer wall of the balloon represents
the parietal pleura.
The cavity between the layers of
the balloon, here filled with air, is
analogous to the pleural cavity,
although the pleural cavity contains
only a thin film of fluid.
At your wrist (representing the root
of the lung), the inner and outer
walls of the balloon are continuous,
as are the visceral and parietal
layers of pleura, together forming a
pleural sac.
Note that the lung is outside of but
surrounded by the pleural sac, just
as your fist is surrounded by but
outside of the balloon

Embryology - revisit

Pleura
PLEURAE
Each lung is invested by and enclosed in a serous
pleural sac that consists of two continuous membranes:
the visceral pleura, which invests all surfaces of the
lungs forming their shiny outer surface, and the parietal
pleura, which lines the pulmonary cavities (Fig. 1.30B &
C).

The pleural cavitythe potential space between the layers of pleuracontains a capillary layer of serous
pleural fluid, which lubricates the pleural surfaces and
allows the layers of pleura to slide smoothly over each
other during res- piration.

 The surface tension of the pleural fluid provides the cohesion that keeps the lung
surface in contact with the tho- racic wall;
consequently, the lung expands and fills with air when the thorax expands while
still allowing sliding to occur, much like a film of water between two glass plates.
The visceral pleura (pulmonary pleura) closely covers the lung and adheres to all
its surfaces, including those within the horizontal and oblique fissures (Figs.
1.30B & C and 1.31A).
In cadaver dissection, the visceral pleura cannot usu- ally be dissected from the
surface of the lung.
It provides the lung with a smooth slippery surface, enabling it to move freely on
the parietal pleura.
The visceral pleura is continu- ous with the parietal pleura at the hilum of the
lung, where structures making up the root of the lung (e.g., bronchus and
pulmonary vessels) enter and leave the lung (Fig. 1.30C).
The parietal pleura lines the pulmonary cavities, thereby adhering to the thoracic
wall, mediastinum, and diaphragm.
It is thicker than the visceral pleura, and in surgery and in cadaver dissections, it
may be separated from the surfaces it covers.

The costal part of the parietal pleura (costovertebral or

costal pleura) covers the internal surfaces of the thoracic
wall (Figs. 1.30B & C and 1.32).
It is separated from the internal surface of the thoracic
wall (sternum, ribs and costal cartilages, intercostal
muscles and membranes, and sides of thoracic vertebrae)
by endothoracic fascia.
This thin, extra- pleural layer of loose connective tissue
forms a natural cleav- age plane for surgical separation of
the costal pleura from the thoracic wall (see the blue box
Extrapleural Intrathoracic Surgical Access, p. 96).
The mediastinal part of the parietal pleura (medias- tinal
pleura) covers the lateral aspects of the mediastinum, the
partition of tissues and organs separating the pulmonary
cavities and their pleural sacs.
It continues superiorly into the root of the neck as cervical
pleura.
It is continuous with costal pleura anteriorly and
posteriorly and with the diaphragmatic pleura inferiorly.
Superior to the root of the lung, the medi- astinal pleura is
a continuous sheet passing anteroposteriorly between the
sternum and the vertebral column.
At the hilum of the lung, it is the mediastinal pleura that
reflects laterally onto the root of the lung to become
continuous with the vis- ceral pleura.
The diaphragmatic part of the parietal pleura (diaphragmatic pleura) covers the superior (thoracic) surface
of the diaphragm on each side of the mediastinum,
except along its costal attachments (origins) and where
the diaphragm is fused to the pericardium, the
fibroserous membrane sur- rounding the heart (Figs.
1.30B & C and 1.32).
A thin, more elastic layer of endothoracic fascia, the
phrenicopleural fascia,
connects the diaphragmatic pleura with the muscular
fibers of the diaphragm (Fig. 1.30C).
The cervical pleura covers the apex of the lung (the part
of the lung extending superiorly through the superior thoracic aperture into the root of the neckFigs. 1.30B & C
and 1.31A).
It is a superior continuation of the costal and mediastinal

 The cervical pleura forms a cup-like dome (pleural

cupula) over the apex that reaches its summit 23
cm superior to the level of the medial third of the
clavicle at the level of the neck of the 1st rib.
The cervical pleura is reinforced by a fibrous
extension of the
endothoracic fascia,
the suprapleural membrane (Sibson fascia).
The membrane attaches to the internal border of the 1st rib and
the transverse process of C7 vertebra (Fig. 1.30C the relatively
abrupt lines along which the parietal pleura changes direction as
it passes (reflects) from one wall of the pleural cavity to another
are the lines of pleural reflection (Figs. 1.31 and 1.32).

 The lungs do not fully occupy the

pulmonary cavities during expiration; thus
the peripheral diaphragmatic pleura is in
con- tact with the lowermost parts of the
costal pleura.
The potential pleural spaces here are the
costodiaphragmatic recesses,
pleura-lined gutters, which surround the
upward convexity of the diaphragm inside the
thoracic wall (Figs. 1.30B and 1.32).

Lung basics
Each lung has:
An apex, the blunt superior end of the lung ascending above the level of the
1st rib into the root of the neck that is covered by cervical pleura.
A base, the concave inferior surface of the lung, opposite the apex, resting on
and accommodating the ipsilateral dome of the diaphragm.
Two or three lobes, created by one or two fissures.
Three surfaces (costal, mediastinal, and diaphragmatic).
The costal surface of the lungis large, smooth, and con- vex.
It is related to the costal pleura, which separates it from the ribs, costal cartilages, and
innermost intercostal muscles.
The posterior part of the costal surface is related to the bod- ies of the thoracic vertebrae
and is sometimes referred to as the vertebral part of the costal surface.
The mediastinal surface of the lungis concave because it is related to the middle
mediastinum, which contains the pericardium and heart (Fig. 1.34).
The mediastinal surface includes the hilum, which receives the root of the lung.

Three borders (anterior, inferior, and posterior). The right lung features right
oblique and horizontal fis- sures that divide it into three right lobes: superior,
mid- dle, and inferior.

R vs L
The right lung is larger and heavier than the left, but it is shorter and wider
because the right dome of the diaphragm is higher and the heart and
pericardium bulge more to the left.
The anterior border of the right lung is rel- atively straight.

The left lung has a single left oblique fis- sure dividing it into two left lobes,
superior and inferior.
The anterior border of the left lung has a deep cardiac notch, an indentation
consequent to the deviation of the apex of the heart to the left side.
This notch primarily indents the anteroinferior aspect of the superior lobe. This
indentation often shapes the most inferior and anterior part of the supe- rior lobe into
a thin, tongue-like process, the lingula(L. dim. of lingua, tongue), which extends
below the cardiac notch and slides in and out of the costomediastinal recess
during inspiration and expiration (Figs. 1.30B, 1.31A, and 1.34C).

 The lungs are attached to the mediastinum

by the roots of the lungsthat is,
the bronchi (and associated bronchial vessels),
pulmonary arteries,
superior and inferior pulmonary veins,
the pulmonary plexuses of nerves
(sympathetic, para- sympathetic, and visceral
afferent fibers),
and lymphatic ves- sels (Fig. 1.34).

Not useful: The pulmonary ligament

Medial to the hilum, the lung root is enclosed within the area of continuity between
the parietal and the visceral layers of pleurathe pleural sleeve (mesopneumonium).
Inferior to the root of the lung, this continuity between parietal and visceral pleura
forms the pulmonary ligament,
extending between the lung and the mediastinum, immedi- ately anterior to the
esophagus.
The pulmonary ligament consists of a double layer of pleura separated by a small
amount of connective tissue.
When the root of the lung is severed and the lung is removed, the pulmonary
ligament appears to hang from the root.
To visualize the root of the lung, the pleural sleeve surrounding it, and the pulmonary
ligament hanging from it, put on an extra-large lab coat and abduct your upper limb.
Your forearm is comparable to the root of the lung, and the coat sleeve represents
the pleural sleeve surrounding it.
The pulmonary ligament is compara- ble to the slack of the sleeve as it hangs from
your forearm; and your wrist, hand, and abducted fingers represent the branching
structures of the rootthe bronchi and pul- monary vessels.

 Beginning at the larynx,the walls of the airway are supported by

horseshoe- or C-shaped rings of hyaline cartilage.
The sub- laryngeal airway constitutes the tracheobronchial tree.
The trachea(described with the superior mediastinum,later in this
chapter), located within the superior mediastinum, consti- tutes the
trunk of the tree.
It bifurcates at the level of the transverse thoracic plane (or
sternal angle) into main bronchi, one to each lung, passing
inferolaterally to enter the lungs at the hila (singular = hilum) (Fig.
1.35E).
The right main bronchus is wider, shorter, and runs more vertically
than the left main bronchus as it passes directly to the hilum of the
lung.
The left main bronchuspasses inferolaterally, inferior to the arch of the
aorta and anterior to the esophagus and thoracic aorta, to reach the
hilum of the lung.

 Within the lungs, the bronchi branch in a constant

fashion to form the branches of the tracheobronchial
tree.
Note that the branches of the tracheobronchial tree are
components of the root of each lung (consisting of
branches of the pulmonary artery and veins as well as
the bronchi).
Each main (primary) bronchus divides into secondary
lobar bronchi, two on the left and three on the right,
each of which supplies a lobe of the lung.
Each lobar bronchus divides into several tertiary
segmental bronchi that supply the bronchopulmonary
segments (Figs. 1.35 and 1.36).

The bronchopulmonary segments

are
:
The largest subdivisions of a lobe.
Pyramidal-shaped segments of the lung, with
their apices facing the lung root and their
bases at the pleural surface.
Separated from adjacent segments by
connective tissue septa.
Supplied independently by a segmental
bronchus and a tertiary branch of the
pulmonary artery.
Named according to the segmental bronchi
supplying them.
Drained by intersegmental parts of the
pulmonary veins that lie in the connective
tissue between and drain adja- cent segments.
Usually 1820 in number (10 in the right lung;
810 in the left lung, depending on the
combining of segments).
Surgically resectable.

 A healthy 23-year-old male volunteers for an experiment on pulmonary

function. He is asked to ride a bicycle at maximum effort for 2 minute
intervals while his vital signs as well as other key data are collected.
Measured parameters include VO2, O2saturation, respiratory rate and tidal
volume. At the end of the experiment, the man is asked to stand upright for
some final measurements. At this point, which of the following statements
correctly explains why airway resistance is lowest at the apex of the lung?
ALow alveolar CO2at apex allows bronchodilation
BMagnitude of transmural pressure is greatest at the apex
CLess turbulent flow is found in the apex
DSurfactant levels are greatest at the apex
EHigher density of 2receptors at the apex