ANATOMY OF LARYNX & TRACHEOBRONCHIAL TREE AND CONTROL OF BREATHING

-Dr Ashish Pareek 1st year resident Dept of Anaesthesiology

Respiratory System

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Lower Airway
Larynx Tracheobronchial Tree (TB Tree)
Trachea Bronchi Bronchioles
Respiratory Terminal

Larynx
Voice Box Function Prevents aspiration Generates sound for speech Conducts air between the pharynx and trachea Creates pressure changes

Cartilages of the Larynx

Composed of nine cartilages Three unpaired cartilage Thyroid Cricoid Epiglottitis Three paired cartilages (six total) Arytenoid Corniculates Cuneiforms

Thyroid Cartilage
The largest laryngeal cartilage is the thyroid cartilage Adam s Apple Superior border has a V-shaped notch. Suspended from hyoid bone. Posterior wall is open. The true and false vocal cords are found on the interior of the larynx.

Cricoid Cartilage
Resembles signet (class) ring. Inferior to Thyroid. Only complete ring of laryngeal structures. Inferior border is attached to the first Cshaped tracheal ring. The narrowest portion of the airway in an infant. We use this fact when ventilating infants as infant ET tubes do not have cuffs to seal the trachea.

Epiglottis
Spoon-shaped cartilage which prevents aspiration by covering the opening of the larynx during swallowing. The tongue and the epiglottis are connected by folds of mucous membranes which form a small space called the vallecula.

Paired Cartilages
The Arytenoids, Cuneiforms, and Corniculates are all associated with movement of the vocal cords and are used in phonation.

Vocal Cords
Two pairs of folds that protrude inward: Upper pair False cords Lower pair True cords The space between the vocal cords is called the rima glottidis or glottis Narrowest portion of the adult airway

Vocal Cords

Vocal Cords
Vocal Cord Abduction Cords are opening or moving away from the midline This occurs during inspiration Vocal Cord Adduction Cords are moving toward the midline or coming together This occurs during expiration

Histology of the Larynx

Above the vocal cords stratified squamous epithelium Below the vocal cords pseudostratified columnar epithelium Trachea to respiratory bronchioles

Muscles of larynx
Cricothyroid Posterior cricoarytenoid Lateral cricoarytenoid Transverse arytenoid Oblique arytenoid Aryepiglotticus Thyroarytenoid Thyroepiglotticus Vocalis

Nerve supply of larynx

Motor nerves All the muscles of larynx are supplied by the recurrent laryngeal nerve except cricothyroid which is supplied by external laryngeal nerve Sensory nerves Internal laryngeal nerve- upto level of vocal fold Reccurent laryngeal nerve- below vocal fold

Blood supply & lymphatic drainage of larynx

Upto vocal folds - sup laryngeal artery & vein - anterosuperior group of deep cervical lymph nodes Below vocal fold - inf laryngeal artery & vein - posteroinferior group of deep cervical lymph nodes

Applied anatomy
Laryngospasm
A laryngeal reflex which will close the vocal cords inside the larynx Laryngospasm results from Extubations Near drowning Inhalation of noxious substances Smoke inhalation

Tracheobronchial Tree
Two Divisions Cartilaginous Airways Primarily conducting airways; no gas exchange. Trachea to terminal bronchioles which is ciliated for removal of debris, mucus lined Noncartilaginous Airways Both conducting airways and sites of gas exchange.

Cartilaginous Airways

Trachea Main Stem Bronchi Lobar Bronchi Segmental Bronchi Subsegmental Bronchi

Lobar Bronchi

Trachea
Generation 0 11 13 cm long and 1.5 2.5 cm wide. th Extends from Cricoid cartilage (6 cervical vertebrae) to the 2nd costal cartilage (5th thoracic vertebrae). 15 - 20 C-shaped cartilages supports the trachea. Posterior wall is contiguous with esophagus.

 The end of the trachea is called the carina. This is the division of the trachea into the right and left mainstem bronchi. The carina is located at approximately T5 or the Angle of Louis. The surgical opening into the trachea is called a tracheostomy. 2nd or 3rd tracheal ring.

Main Stem Bronchi

Generation 1 Trachea divides into the right and left mainstem bronchi one for each lung Right Mainstem is wider, shorter and more vertical Branches at a 25 degree angle Left Mainstem Branches at a 40 60 angle Infants Both mainstem bronchi form a 55 angle with the trachea

Newborn

Applied-Complications of Intubation
During intubations, if the tube is advanced to far, the tube will usually go into the right mainstem bronchi. Lung inflation will be absent on the left but present on the right. Withdraw tube until bilateral sounds are heard. Failure to hear lung sounds or visualize chest inflation on either side means the tube is probably in the stomach. Extubate the patient and re-attempt the intubation.

Aspiration
Children who aspirate objects Foreign body usually lodged in right main stem bronchi secondary to the angle being less acute. Wheezing on right or absent lung sounds (breath sounds).

Lobar Bronchi
Generation 2 Lobar Bronchi correlate to the number of lobes of the lung. The right mainstem bronchi will divide into the right upper, right middle and right lower lobe bronchi. The left mainstem bronchi will divide into the left upper and left lower lobe bronchi.

Segmental Bronchi
Generation 3 Correlate with the segments of the lung. There are 10 segmental bronchi on the right. There are 8 segmental bronchi on the left.

Subsegmental Bronchi
4th to 9th Generations 1 to 4 mm in diameter Connective tissue containing: Nerves Lymphatics Bronchial Arteries

Non-Cartilaginous Airways
Bronchioles 10th to 15th Generation. 1 mm in diameter. Simple cuboidal epithelium. No cartilage. Terminal Bronchioles Less than 0.5 mm in diameter. No cartilage (lack of support). Cilia and mucous glands disappear. Clara Cells appear

Blood Supply
Bronchial Blood Supply --Bronchial arteries nourish the tracheobronchial tree --The arteries arise from the aorta and follow the tracheobronchial tree as far as the terminal bronchioles. --Beyond the terminal bronchioles pulmonary arteries & capillaries feed the airways & alveoli. --Normal bronchial blood flow is approximately 1% of the cardiac output.

Respiratory Areas in Brainstem

Medullary respiratory center Dorsal groups stimulate the diaphragm Ventral groups stimulate the intercostal and abdominal muscles Pontine (pneumotaxic) respiratory group Involved with switching between inspiration and expiration
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Respiratory Structures in Brainstem

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Rhythmic Ventilation
Starting inspiration
Medullary respiratory center neurons are continuously active Center receives stimulation from receptors and simulation from parts of brain concerned with voluntary respiratory movements and emotion Combined input from all sources causes action potentials to stimulate respiratory muscles

Increasing inspiration
More and more neurons are activated

Stopping inspiration
Neurons stimulating also responsible for stopping inspiration and receive input from pontine group and stretch receptors in lungs. Inhibitory neurons activated and relaxation of respiratory muscles results in expiration.

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Modification of Ventilation
Chemical control Cerebral and limbic system
Respiration can be voluntarily controlled and modified by emotions Carbon dioxide is major regulator
Increase or decrease in pH can stimulate chemosensitive area, causing a greater rate and depth of respiration

Oxygen levels in blood affect respiration when a 50% or greater decrease from normal levels exists
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Modifying Respiration

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Regulation of Blood pH and Gases

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Herring-Breuer Reflex
Limits the degree of inspiration and prevents overinflation of the lungs
Infants
Reflex plays a role in regulating basic rhythm of breathing and preventing overinflation of lungs

Adults
Reflex important only when tidal volume large as in exercise

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Ventilation in Exercise
Ventilation increases abruptly
At onset of exercise Movement of limbs has strong influence Learned component

Ventilation increases gradually

After immediate increase, gradual increase occurs (4-6 minutes) Anaerobic threshold is highest level of exercise without causing significant change in blood pH
If exceeded, lactic acid produced by skeletal muscles
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Effects of Aging
Vital capacity and maximum minute ventilation decrease Residual volume and dead space increase Ability to remove mucus from respiratory passageways decreases Gas exchange across respiratory membrane is reduced

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