Marco S.

Duque, MD

MEDIASTINUM region between the pleural cavities Boundaries:

Superior - thoracic outlet and the root of the neck Inferior - diaphragm Anterior - sternum Posterior -12 thoracic vertebrae

MEDIASTINUM
divided into SUPERIOR & INFERIOR MEDIASTINA

by imaginary plane passing from sternal angle to the IV disc between T4 & T5 inferior mediastinum is further subdivided into the ANTERIOR, MIDDLE, POSTERIOR MEDIASTINA

SUPERIOR MEDIASTINUM
Boundaries: Anterior - manubrium Posterior - T1-4

SUPERIOR MEDIASTINUM
Contents Thymus SVC Arch of the Aorta Vagus Nerves Trachea Esophagus Thoracic Duct Sympathetic Trunk

INFERIOR MEDIASTINUM Boundaries:

Anterior - sternal body
Posterior - T5-12

Divisions:
Anterior Middle

Posterior

INFERIOR MEDIASTINUM ANTERIOR

Fat and areolar tissue Inferior part of thymus

MIDDLE
Pericardium Heart Phrenic nerves

POSTERIOR MEDIASTINUM
Descending Thoracic Aorta

Esophagus
Thoracic Duct

Azygos System of Veins

Sympathetic Trunks

TRACHEA
o 4-5 inches long in adult, 1 inch in diameter o Fibroelastic wall with a series of C-shaped rings of

hyaline cartilage o Extends from below the cricoid cartilage of the larynx o Bifurcates into the RIGHT & LEFT PRINCIPAL / MAIN BRONCHI

TRACHEA
o Surface anatomy o Begins in the neck below the cricoid cartilage (C6) o Bifurcates behind the sternal angle (T4)
o Starts in the midline, ends to the right of the midline
o Palpable at the root of the neck at the suprasternal notch

o TRACHEALIS muscle- smooth muscle connecting

the posterior free ends of the C-shaped rings of hyaline cartilage

TRACHEA
o CARINA o ridge at the bifurcation o mucosa is very sensitive to external stimuli o Nerve supply to the trachealis muscle and mucosal

lining of the trachea:

Recurrent Laryngeal nerve Pulmonary plexus at the bifurcation

 TRACHEOSTOMY
The operative placement of an artificial airway through the anterior portion of the 2nd or 3rd tracheal ring To re-establish airflow following airway obstruction above the larynx

 ENDOTRACHEAL INTUBATION
A tracheal tube is inserted into the mouth or nose and passed inferiorly through the larynx and trachea Uses include: To re-establish airflow following airway obstruction below the larynx Suctioning mucus that is clogging the trachea To establish an airway in general anesthesia

 PRINCIPAL / MAIN BRONCHUS

RIGHT PRINCIPAL / MAIN BRONCHUS

o Wider, shorter, more vertical than the left o 1 inch long o Just before entering the right lung hilum, it gives

off the SUPERIOR LOBAR BRONCHUS o Upon entering the hilum, it divides into a MIDDLE and an INFERIOR LOBAR BRONCHUS

 PRINCIPAL / MAIN BRONCHUS

LEFT PRINCIPAL / MAIN BRONCHUS

o More narrow, longer, more horizontal than right o 2 inches long o Upon entering the left lung hilum, it divides into a

SUPERIOR and an INFERIOR LOBAR BRONCHUS

Foreign Body Aspiration

More likely to enter the right main bronchus

Right main bronchus is shorter, wider, and more

vertical than left main bronchus

 PRINCIPAL / MAIN BRONCHUS

Bronchoscopy
Allows for the examination of the ff:
Carina and the main bronchi Possibly the interior of the lobar bronchi and the beginning of the 1st segmental bronchi

Allows for the biopsy of the mucous membrane and removal of inhaled foreign bodies

LOBAR / SECONDARY BRONCHUS

o Each supplies a lung lobe

SEGMENTAL / TERTIARY BRONCHUS

o Each supplies a bronchopulmonary segment

TERMINAL BRONCHIOLE
o The smallest set of bronchioles in the conducting zone o Each accompanies a lung lobule

RESPIRATORY BRONCHIOLE
o Will divide into 2-3 ALVEOLAR DUCTS o Alveolar ducts terminate in the ALVEOLAR SACS
ALVEOLAR SACS - spaces formed by 2 or more conjoined alveoli Many alveoli and alveolar sacs surround each alveolar duct

ENDOTHORACIC FASCIA
o Thin layer of loose connective tissue separating

the parietal pleura from the thoracic wall

SUPRAPLEURAL MEMBRANE (Sibsons Fascia)

o Dense fascial layer o A thickening of the ENDOTHORACIC FASCIA o Closes off the thoracic inlet o Functions:
o Serves to strengthen and protects the underlying cervical pleura o Resists changes in intrathoracic pressure during respiration

PLEURA
o 2 layers PARIETAL PLEURA VISCERAL PLEURA

 PARIETAL PLEURA
Lines the ff structures:
thoracic wall thoracic surface of the diaphragm lateral aspect of the mediastinum undersurface of the suprapleural membrane

Attached to the above structures by connective tissue (endothoracic fascia) and therefore moves along with the structures during respiration

 VISCERAL PLEURA
Completely covers the outer surfaces of the lungs Extends into the depths of the interlobar fissures The parietal and visceral layers become continuous via a cuff of pleura surrounding the lung root

o Pleural cavity A slit-like space separating the parietal and visceral layers Sealed, blind, potential space On inspiration, the visceral pleura comes into contact with the parietal pleura causing a reduction in the size of the pleural cavity Normally contains as small amount of PLEURAL FLUID

PLEURAL FLUID
A layer of serous fluid secreted by the pleura Covers the surfaces of the pleura as a thin film Lubricates the pleural surfaces and permits the 2 layers to move on each other with minimum friction during respiration

Divisions of the Pleura Cervical pleura (cupola) Costal pleura Diaphragmatic pleura Mediastinal pleura

 CERVICAL PLEURA (CUPOLA)

Covers the lung apex Lines the undersurface of the suprapleural membrane Surface anatomy follows a curved line:
convex upward from sternoclavicular joint to a point 1 inch above the clavicle at junction of its medial and intermediate thirds

 COSTAL PLEURA
Lines the ff structures: o inner surfaces of the ribs, costal cartilages, intercostals spaces o sides of vertebral bodies o back of the sternum

 DIAPHRAGMATIC PLEURA
Covers the thoracic surface of the diaphragm

Surface anatomy of INFERIOR BORDER

At midinspiration - a curving line crosses the ff: 8th rib midclavicular line 10th rib midaxillary line 12th rib adjacent paravertebral line Distance between the inferior borders of the lungs and the pleura corresponds to the COSTODIAPHRAGMATIC RECESS

 MEDIASTINAL PLEURA
Covers and forms the lateral boundary of the mediastinum At the lung hilum:
oit is reflected as a cuff around the vessels and bronchi (lung root) obecomes continuous with the visceral pleura

 MEDIASTINAL PLEURA
Below the lung root, it forms the PULMONARY LIGAMENT o Continuous superiorly with the pleural cuff enclosing the lung root and ends inferiorly as a free border o Allows movement of the pulmonary vessels and the large bronchi during respiration

o PLEURAL REFLECTIONS
Relatively abrupt lines along which the parietal pleura folds back or changes direction from one wall of the pleural cavity to another Boundaries of the pleural sac Important clinical landmarks

1. STERNAL LINE

2. COSTAL LINE

o PLEURAL REFLECTIONS
STERNAL LINE / ANTERIOR COSTOMEDIASTINAL REFLECTION (R&L)
Where the costal pleura is continuous with the mediastinal pleura posterior to the sternum Indicated by lines that pass inferomedially
from the sternoclavicular joints to the anterior median line at the level of the sternal angle (2nd costal cartilage)

o PLEURAL REFLECTIONS
STERNAL LINE / ANTERIOR COSTOMEDIASTINAL REFLECTION
RIGHT:
passes inferiorly in the median plane to the posterior aspect of the xiphoid process then turns laterally

LEFT:
passes inferiorly in the median plane to the level of the 4th costal cartilage then to the left margin of the sternum and continues inferiorly to the 6th costal cartilage

o PLEURAL REFLECTIONS
COSTAL LINE
Where the costal pleura is continuous with the diaphragmatic pleura Passes obliquely across the ff:
8th rib at the midclavicular line
10th rib at the midaxillary line 12th rib at the paravertebral line

o PLEURAL RECESSES Potential spaces not occupied by lung tissue except during deep inspiration
1. COSTODIAPHRAGMATIC RECESSES 2. COSTOMEDIASTINAL RECESSES

 COSTODIAPHRAGMATIC RECESSES (R & L)

Slit-like spaces between the costal and diaphragmatic pleura separated only by a layer of parietal fluid In quiet respiration the costal and diaphragmatic pleura are in apposition to each other below the lower border of the lungs

In full inspiration
the lower margins of the lungs descend into the recess, causing the costal and diaphragmatic pleura to separate During expiration the lower margins of the lungs ascend, causing the costal and diaphragmatic pleura to come together again

 COSTOMEDIASTINAL RECESSES (R & L)

Slit-like spaces between the costal and mediastinal pleura separated only by a layer of parietal fluid Along the anterior margins of the pleura Lie at the anterior ends of the 4th and 5th intercostal spaces During inspiration and expiration, the anterior borders of the lungs slide in and out of the recesses LEFT RECESS
o Larger than the right due to the cardiac notch in the left lung o During full inspiration, recess is occupied by the lingula

o BLOOD SUPPLY OF THE PLEURA PARIETAL

Arterial supply
Intercostal arteries Internal thoracic arteries Musculophrenic arteries

Veins in the adjacent parts of the thoracic wall

VISCERAL
Bronchial arteries Pulmonary veins

o LYMPHATIC DRAINAGE OF THE PLEURA PARIETAL

Drain into ff lymph nodes on the thoracic wall:
Intercostal nodes Parasternal nodes Posterior mediastinal nodes Diaphragamatic nodes

Above nodes drain into the axillary nodes

VISCERAL
Into nodes at the hila of the lungs

o NERVE SUPPLY OF THE PLEURA Parietal pleura

Sensitive to pain, temperature, touch, and pressure Costal pleura Intercostal nerves Mediastinal pleura Phrenic nerve Diaphragmatic pleura o Domes - Phrenic nerve o Periphery - lower 6 Intercostal nerves

o NERVE SUPPLY OF THE PLEURA Visceral pleura

Sensitive to stretch Insensitive to common sensations, e.g. pain and touch Autonomic supply from the Pulmonary Plexus

CLINICAL CORRELATION PLEURITIS / PLEURISY HYDROTHORAX PNEUMOTHORAX Instrumentation

 PLEURITIS / PLEURISY
Inflammation of the pleura Secondary to inflammation of the lung PLEURAL EXUDATE coats the pleural surfaces, causing them to roughen PLEURAL RUB Sound made by the friction between the roughened pleura during respiration PLEURAL ADHESIONS fibroblasts invade the exudate and lay down collagen, thereby binding together the visceral and parietal pleura

 PLEURITIS / PLEURISY
REFERRED PAIN Pain is referred to the cutaneous distribution of the nerves supplying the pleura o Intercostal nerves
o pain referred the thoracic and abdominal wall

o Phrenic nerve (C3,4,5)

o pain referred to the shoulder (C5 dermatome)

 HYDROTHORAX

Accumulation of fluid in the pleural cavity Many possible causes: o PLEURAL EFFUSION
o Accumulation of serous fluid in the pleural cavity o May be caused by obstruction of veins or lymphatic vessels that drain the thorax or by inflammation of structures near the pleura

o HEMOTHORAX Accumulation of blood in the pleural cavity e.g. chest wound o CHYLOTHORAX Lymph and emulsified fat may pass into the pleural cavity from a RUPTURED THORACIC DUCT o EMPYEMA collection of pus in the pleural cavity

 PNEUMOTHORAX
Entry of air from the lungs or through the chest wall into the pleural cavity Causes include: o Chest trauma penetrating wound to the chest wall (e.g. stab or gunshot wound) rib fracture o rupture of a lung or rupture of bullae / blebs in EMPHYSEMA o may also occur in neck wounds d/t the projection of the lung apices and cervical pleura into root of the neck o iatrogenic d/t instrumentation o idiopathic

INSTRUMENTATION Instrumentation of the intercostal space to enter the pleural cavity will penetrate the ff structures:
Skin Superficial fascia Digitations of serratus anterior External intercostal Internal intercostal Transverses thoracis Parietal pleura

Thoracentesis
A needle is used to sample fluid from a

costodiaphragmatic recess Needle may be inserted into the pleural cavity at the midaxillary line, 9th ICS to AVOID the intercostal nerves, needle is inserted into inferior part of interspace to ANESTHETIZE the intercostal nerve, needle is inserted into superior part of interspace

LUNGS
o Soft & spongy o Very elastic o Color:

o o o o

Child pink With age dark and mottled due to inhaled dust particles (especially in city dwellers and coal miners) Each lung occupies one side of the mediastinum Conical in shape Covered with visceral pleura Suspended freely in its own pleural cavity, attached to the mediastinum only at its root

LUNGS
o APEX / CUPOLA Dome-shaped Surface anatomy - projects upward into the neck following a curved line:
Convex upward Starting at the sternoclavicular joint To a point about 1 inch above the clavicle at junction of its medial and intermediate thirds

Crossed by the SUBCLAVIAN artery & vein anteriorly

LUNGS
o BASE / DIAPHRAGMATIC SURFACE
Concave; more concave on the right d/t liver Sits on the diaphragm
Surface anatomy of INFERIOR BORDER
At midinspiration - a curving line crosses the ff:
6th rib midclavicular line 8th rib midaxillary line 10th rib paravertebral line

Level will vary with phase of respiration

LUNGS
o COSTAL SURFACE Convex Corresponds to the concave chest wall

LUNGS
o MEDIASTINAL SURFACE Concave Molded to the pericardium and other mediastinal structures Left lung has a deep cardiac impression

LUNGS
o MEDIASTINAL SURFACE HILUM
At the middle of the mediastinal surface A depression for the entry and exit of the structures forming the ROOT of the lung

 ROOT of the LUNG o Formed by structures that enter or leave the lung:
Bronchi Pulmonary artery Pulmonary veins Lymph vessels Bronchial vessels Nerves

o Surrounded by a tubular sheath (cuff) of pleura

which joins the parietal and visceral layers

LUNGS
o ANTERIOR BORDER Thin and overlaps the heart CARDIAC NOTCH on the left accommodates the heart Surface Anatomy
Right lung
Begins behind sternoclavicular joint Runs downward almost to the midline behind the sternal angle Continues downward until the xiphisternal joint

LUNGS
o ANTERIOR BORDER Surface Anatomy
Left lung
Begins behind sternoclavicular joint Runs downward almost to the midline behind the sternal angle At the level of 4th costal cartilage, it deviates laterally to form the cardiac notch

Continues sharply downward until the xiphisternal joint

LUNGS
o POSTERIOR BORDER Thick Beside the vertebral column
Surface Anatomy
From spinous process of C7 T10 1 inches from the midline

Lobes & Fissures

o LOBES
o 3 on the right
o 2 on the left

o FISSURES
o Oblique fissure right & left o Horizontal fissure right only

o Each LOBAR / SECONDARY BRONCHUS supplies a lobe

RIGHT LUNG
o Slightly larger than the left

o 2 fissures OBLIQUE FISSURE HORIZONTAL FISSURE

 OBLIQUE FISSURE
Runs from the inferior border at the level of the 5th intercostal space Proceeds upward and backward across the medial and costal surfaces Until it cuts the posterior border about 2 inches below the apex

 HORIZONTAL FISSURE
Runs horizontally across the costal surface at the level of the 4th costal cartilage To meet the oblique fissure at the midaxillary line

RIGHT LUNG
o 3 lobes UPPER LOBE MIDDLE LOBE
small triangular lobe bound by the horizontal and oblique fissures

LOWER LOBE

LEFT LUNG
o OBLIQUE FISSURE

o 2 lobes UPPER LOBE above oblique fissure LOWER LOBE below oblique fissure

 BRONCHOPULMONARY SEGMENTS
o Each lobe is partitioned into bronchopulmonary

segments o Anatomical, functional, and surgical unit of the lungs

 BRONCHOPULMONARY SEGMENTS
o Each bronchopulmonary segment has the ff

characteristics:
It is a subdivision of a lung lobe It is pyramidal in shape with its apex directed toward the lung root It is surrounded by connective tissue

 BRONCHOPULMONARY SEGMENTS
o Each bronchopulmonary segment has the ff:
SEGMENTAL / TERTIARY BRONCHUS SEGMENTAL ARTERY LYMPH VESSELS AUTONOMIC NERVES

 BRONCHOPULMONARY SEGMENTS
o Each bronchopulmonary segment has the ff

characteristics:
The SEGMENTAL VEIN lies in the connective tissue between adjacent bronchopulmonary segments A diseased segment can be removed surgically as a unit

LUNGS
o LOBULE Each bronchopulmonary segment is further divided into many smaller compartments Surrounded by elastic connective tissue Accompanied by a branch of the TERMINAL BRONCHIOLE

LUNGS
o ALVEOLUS The respiratory bronchiole divides into 2-3 ALVEOLAR DUCTS The alveolar duct terminates in the ALVEOLAR SACS ALVEOLAR SACS
Spaces formed by 2 or more conjoined alveoli Many alveoli and alveolar sacs surround each alveolar duct

 Blood Supply of the Lungs

o Bronchial arteries Supply the ff:
Bronchi Connective tissue of the lung (non-respiratory portions) Visceral pleura

From the descending aorta

o Bronchial veins Communicate with the pulmonary veins Drain into the azygos and hemiazygos veins

 Blood Supply of the Lungs

o Pulmonary arteries Carry deoxygenated blood for the alveoli o Pulmonary veins The tributaries receive oxygenated blood from the alveolar capillaries 2 pulmonary veins leave the each lung root to empty into the left atrium

 Lymphatic Drainage of the Lungs

Lymph vessels originate from 2 plexuses They are not present in the alveolar walls

o SUPERFICIAL / SUBPLEURAL PLEXUS Lies beneath the visceral pleura Drains over the surface of the lung
Empties into the BRONCHOPULMONARY NODES at the hilum

 Lymphatic Drainage of the Lungs

o DEEP PLEXUS Travel along the bronchi and pulmonary vessels toward the hilum Pass through the PULMONARY NODES located within the lung substance Lymph then enters the BRONCHOPULMONARY NODES at the hilum

Lymphatic Drainage of the Lungs

All the lymph from the lung leaves the hilum Drains into the TRACHEOBRONCHAL NODES Then into the BRONCHOMEDIASTINAL LYMPH TRUNKS

 Nerve Supply of the Lungs

o ANTERIOR & POSTERIOR PULMONARY PLEXUS Posterior to each lung root Composed of efferent and afferent autonomic fibers Formed from branches of: Sympathetic trunk Parasympathetic fibers from the Vagus nerve

 Nerve Supply
o ANTERIOR & POSTERIOR PULMONARY PLEXUS
Sympathetic efferent fibers o Bronchodilation o Vasoconstriction Parasympathetic efferent fibers o Bronchoconstriction o Vasodilation o Increased glandular secretion

 Nerve Supply
o ANTERIOR & POSTERIOR PULMONARY PLEXUS
Afferent fibers o Derived from the bronchial mucous membrane and stretch receptors in the alveolar walls o Pass to the CNS in both sympathetic and parasympathetic nerves

o TRAUMA TO THE LUNG

Causes include:
Penetrating injuries (e.g. stab or gunshot wounds) Rib fracture Air escapes the lungs and enters the pleural cavity causing pneumothorax and atelectasis SUBCUTANEOUS EMPHYSEMA Air can also enter the lung connective tissue, move under the visceral pleura until it reaches the lung root, pass into the mediastinum and up the neck Causes the distention of the subcutaneous tissue

Clinical picture:

o PNEUMONIA Inflammation of the lungs LOBAR PNEUMONIA with PLEURISY

Characterized by severe tearing pain that increases with deep inspiration or coughing Pain is referred according to the innervations of the pleura Intercostal nerve distribution thoracic and abdominal wall Phrenic nerve - shoulder

CHRONIC BRONCHITIS
o Characterized by productive cough for at least 3 months during each of 2 consecutive years o Airway obstruction due to thickening of bronchial walls

EMPHYSEMA
o Abnormal enlargement of air spaces with destruction of alveolar walls (formation of bullae / blebs)

o Loss of elasticity results in inadequate elastic recoil

o Resulting in airway collapse on expiration

o ASTHMA Chronic inflammatory disorder of the airways associated with intermittent reversible airway obstruction Characterized by the ff changes in the bronchiole:
Airway hyperresponsiveness

Bronchoconstriction
Excess mucus secretion

Difficulty in expiration, with normal inspiration

o Segmental Resection Careful dissection of a particular bronchopulmonary segment for removal, while leaving the surrounding lung intact For localized chronic lesions
e.g. tuberculosis or benign tumor

MUSCLES OF RESPIRATION (QUIET)

o Primary muscle of respiration o Upon contraction, it descends and pulls down its central

DIAPHRAGM

tendon and increases the vertical diameter of the thorax (INSPIRATION) o Relaxation causes it to ascend (EXPIRATION)
o The diaphragm is the most important muscle used in

inspiration

MUSCLES OF RESPIRATION (QUIET) INTERCOSTALS,TRANSVERSUS THORACIS

o Pull the ribs nearer one another o If 1st rib is fixed intercostals will raise ribs 2-12 toward 1st rib (INSPIRATION) o If 12th rib is fixed intercostals will lower ribs 1-11 (EXPIRATION)

EXTERNAL INTERCOSTALS, INTERNAL

MUSCLES OF RESPIRATION (QUIET) LEVATORES COSTARUM

o Raises the rib below (INSPIRATION)

SERRATUS POSTERIOR SUPERIOR

o Elevates ribs (INSPIRATION)

SERRATUS POSTERIOR INFERIOR

o Depresses ribs (EXPIRATION)

MECHANICS OF RESPIRATION
o Respiration is accomplished by alternate increase

and decrease of the capacity of the thoracic cavity o Normal resting RR: 16-20 per minute

o QUIET INSPIRATION The capacity of the thoracic cavity is increased by elongating all its diameters causing air under atmospheric pressure to enter the cavity through the airways 3 Diameters of the thoracic cavity
Vertical diameter Antero-posterior diameter Transverse diameter

QUIET INSPIRATION Vertical diameter

o The suprapleural membrane is fixed but the diaphragm is mobile o When the diaphragm contracts, the domes are flattened and the diaphragm descends

QUIET INSPIRATION Antero-posterior diameter

o Increased when the downward-sloping ribs are raised at their sternal ends and the lower end of the sternum is thrust forward o Accomplished by: fixing the first rib by contraction of the scaleni muscles drawing the lower 11 ribs together and raising them toward the 1st by contraction of the intercostals
PUMP HANDLE ACTION

QUIET INSPIRATION Transverse diameter

o Increased by raising the downward-sloping ribs
o BUCKET HANDLE ACTION

 MUSCLES that elevate the ribs in QUIET INSPIRATION Intercostals Diaphragm also: Levatores costarum Serratus posterior superior

o FORCED INSPIRATION Maximum increase in the capacity of the thoracic cavity Every muscle that can raise the ribs is called into action, including: Scalenus anterior Scalenus medius Sternocleidomastoid

o QUIET EXPIRATION Mostly a passive event Brought about by:

Elastic recoil of the lungs Relaxation of the diaphragm and intercostals Increase in tone of the anterior abdominal wall muscles, which forces the diaphragm to relax

Also assisting:
serratus posterior inferior will pull down lower ribs

o FORCED EXPIRATION An active process Accomplished by:

Forceful contraction of the anterior abdominal wall muscles Quadrates lumborum pulls down the 12 ribs Intercostals pull the ribs together and depress them toward the lowered 12th rib Serratus posterior inferior and lattisimus dorsi may also play a minor role

 TYPES OF RESPIRATION
o ABDOMINAL type o THORACIC type

 TYPES OF RESPIRATION
o ABDOMINAL Seen in infants and young children
Ribs are almost horizontal Rely mainly on the descent of the diaphragm to increase the thoracic capacity for inspiration Marked by the prominent inward and outward excursion of the anterior abdominal wall

Also the main form of respiration in adult males

 TYPES OF RESPIRATION
o THORACIC At >2 y/o the ribs become more oblique, establishing the adult form of respiration Seen in adult females
Rely mainly on the rib movement than the diaphragmatic descent

Adult Males
Use both thoracic and abdominal, but mainly abdominal

Thank you.