Gross Anatomy of the Respiratory System Dr. Sta. Ana September 15, 2011 Competencies: 1.

Demonstrate knowledge & understanding of the gross anatomy of the respiratory system by: 1a. Describing the gross features of the lungs - identifying the surfaces, lobes and fissures - differentiating the right and the left lungs - identifying the impressions made by adjacent structures on the mediastinal surface of either lung - enumerating the composition of the root of the lung and describing the relative positions of the pulmonary arteries and veins and bronchi. 1b. Describing the gross features of the tracheobronchial tree, specifically by: identifying the important structures related to the trachea and the primary bronchi and their position in the mediatinum tracing the ramifications of the bronchial tree as they eventually lead to the broncopulmonary segments describing the orientation of the primary bronchi and the anatomical basis of the location of aspirated foreign bodies describing features of the bronchopulmonary segments and their clinical significance 1c. Mapping out the surface projection of the borders and fissures of the lungs on the chest wall 1d. Describing the blood supply, innervation and lymphatic drainage of the component parts of the respiratory system 1e. Describing the normal radiologic features of the normal lung, noting its translucency and identifying the lobes and fissures.

Alveoli Topography of the Lungs

LUNGS: GENERAL DESRIPTION vital organs of respiration main function: to oxygenate the blood by bringing inspired air into close relation with the venous blood in the pulmonary capillaries a. In RIGHT LUNG: Larger and heavier Shorter because right dome of the diaphragm is higher than the left dome due to the liver occupying the right side Right lung is broader than the left lung due to the heart being located more on the left side of the thoracic cavity Dome of the diaphragm: IV disc level- T8 azygus arch- the briding vessels which define the root b. In LEFT LUNG: Dome of the diaphragm: IV disc level- T8/T9 Aortic arch Respiratory System Anatomic Division Upper Respiratory System: Nose Pharynx Larynx Lower Respiratory System: Trachea Bronchi Lungs

Lungs in Situ

Functional Division Conducting Division: Nasal cavities, pharynx, larynx Bronchi - extrapulmonary (main bronchi) - intrapulmonary (lobar and its branchings) Respiratory Division respiratory bronchioles Alveolar ducts Alveolar sacs

Main function: oxygenate the blood by bringing inspired air into close relation with the venous blood in the pulmonary capillaries

They are elastic and recoil to approximately one third

Each lung has: o Apex o Base o Root o Hilum Different surfaces of the lungs o Costal o Mediastinal o diaphragmatic Borders of the lungs o Anterior o Posterior o Inferior

Lobes of the Lungs

BORDERS 1. Anterior costal and mediastinal surfaces meet anteriorly and overlap the heart a. of 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 b. of 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 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 2. Posterior extends downward from the spinous process of C7 to the level of T10 and lies 1.5 (4 cm) from the midline thick and lies beside the vertebral column 3. Inferior b. Right Lung Fissures: Oblique Horizontal 3 lobes: superior middle inferior a. Left Lung Fissure: Oblique 2 lobes: superior inferior

RIGHT LUNG 3 lobes divided by: 1. Oblique Fissure Runs back to the 2 from apex obliquely downward, laterally and anteriorly following the course of the 6th rib to the inferior border Below the posterior to this lies the lower lobe 2. Horizontal Fissure Line drawn horizontally along the 4th costal cartilage to meet the oblique fissure in the midaxillary line Above lies the upper lobe Below lies the middle lobe, a small triangular lobe bounded by both fissures LEFT LUNG 2 lobes divided by: 1. Oblique Fissure Separates upper lobe (superior) from the lower lobe (inferior posterior) There is NO Horizontal Fissure, therefore NO middle lobe LINGULA tongue-like projection analogous to the middle lobe of the right lung

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 Level of this border changes during inspiration and expiration

Lower

Lateral Medial Superior Anterior basal Medial basal Lateral basal Posterior basal

Bronchopulmonary Segments: Right Lung (10) Bronchopulmonary Segments: Left Lung (8)

RIGHT LUNG 3 lobes divided by: 3. Oblique Fissure Runs back to the 2 from apex obliquely downward, laterally and anteriorly following the course of the 6th rib to the inferior border Below the posterior to this lies the lower lobe 4. Horizontal Fissure Line drawn horizontally along the 4th costal cartilage to meet the oblique fissure in the midaxillary line Above lies the upper lobe Below lies the middle lobe, a small triangular lobe bounded by both fissures 10 segments o Upper Apical Posterior Anterior o Middle

LEFT LUNG 2 lobes divided by: 2. Oblique Fissure Separates upper lobe (superior) from the lower lobe (inferior posterior) There is NO Horizontal Fissure, therefore NO middle lobe LINGULA tongue-like projection analogous to the middle lobe of the right lung

Left lung (8) o Upper o Lower

Apicoposterior Anterior Superior (lingular) Inferior (lingular) Superior Anteromedial

Basal Lateral basal Posterior basal

Bronchopulmonary Segments: 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 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 why important? o possible to locate where a foreign body can fall, depending on the position of the person o chichacorn aspirated by an adult in an upright position will most likely fall to the Medial Surface: Root of the Lungs right main bronchus (may go further to the Formed by: posterior basal segment) o Pulmonary arteries o chichacorn aspirated by an adult lying on R: posterior his right side will most likely fall to the right L: superior main bronchus (may go to further to o Lobar bronchi posterior or middle lobe) R: Posterior central o chichacorn aspirated by an adult lying on L: posterior central his left side will most likely fall to the left o Pulmonary veins main bronchus (may go further to lingular segments) R: anterior and inferior o chichacorn aspirated by an adult lying on L: anterior and inferior his back will most likely fall to the right o Pulmonary ligament main bronchus (may go further to superior o ** Broncopulmonary (Hilar) Lymph nodes bronchopulmonary segment of the right **Epaterial bronchus: superior- bronchus located above the lower lobe) pulmonary artery at the root of hilum o

chicacorn aspirated by a baby goes to rightImpressions on the Right Medial Lung Surface upper lobe (more often) Right Lung Left Lung Segmental bronchi and bronchopulmonary segments Azygous vein Arch of aorta Superior vena cave Cardiac impression There are 10 tertiary or segmental bronchi on the Esophageal groove Descending aorta right, and 8 on the left. Note that on the left, the Cardiac depression Left subclavian artery apical and posterior bronchi arise from a single stem, as do the anteriorbasal and medial basal. B to F.

A bronchopulmonary segment consists of: o tertiary bronchus o pulmonary vein and artery o the portion of lung they serve. These structuresare surgically separable to allow segmental resection of the lung

Right lung Higher than the left (at T8) Shorter, heavier Broader/ wider With cardiac impression No cardiac notch Azygos arch Pulmonary vein - anterior and inferior to all other structures within the root Lobar bronchi - posterior Pulmonary arteries - anterior to bronchus in some, the bronchus is superior to the arteries and is called eparterial bronchus Fissures 1. Oblique fissure separates the upper and middle from the inferior lobe 2. Horizontal fissure separates the upper and middle lobe; lies along the median plane meeting the oblique fissure The Trachea and the Bronchi

Left lung Between T8 and T9

With cardiac impression Cardiac notch indicates the heart just beside the lung Aortic arch - anterior and inferior - central - always superior at the root of the lung no eparterial bronchus

10-11 cm C-shaped cartilage (anterolateral wall) flat muscular wall (posterior wall) divides into right & left primary bronchi carina at level between T4 & T5

Primary Bronchus: Structural Differences Right Main Bronchus - shorter (2.5 cm long) - straighter - larger in diameter - gives rise to 3 lobar bronchus Left Main Bronchus - longer (5 cm long) - smaller in diamater - 2 lobar bronchus

1. Oblique fissure course same with right lung; goes along the posterior surface lingula overlies much of the anterior surface of the lung; analogous to middle lobe

Clinical Correlation: The right main stem bronchus is wider and shorter than the left one and descends in a more vertical plane, so aspirated foreign objects are more likely to lodge in it or one of its branches. Because the posterior segmental bronchus of the right lower lobe runs directly posterior, foreign objects that are inhaled when the person is lying down, such as food, may end up in this segmental bronchus. NOTE! ** foreign bodies are more likely to lodge on the right side **sitting upright, standing, lean backwards foreign body will go to right bronchi ** lying on the right side foreign body will go to right posterior or middle segment **lying on the left side foreign body will go to superior and inferior segment of left lung ** supine - foreign body will go to superior bronchopulmonary segment of left lower lobe **lean to left foreign body will go to left bronchi . Intrapulmonary Airways Schema

Trachea

Conducting unit Anatomic Relations: Main Bronchi and Pulmonary Vessels Terminal bronchioles Respiratory unit ACINUS Bronchial Arteries Respiratory bronchioles 2-11 alveolar ducts 56 alveolar sacs lined with alveoli Alveoli basic unit of gas exchange in the lungs Pulmonary Circulation 2 functionally distinct circulatory pathways: 1. Pulmonary vessels convey deoxygenated blood to alveolar walls and drain oxygenated blood back to the left side of the heart. 2. The smaller bronchial vessesl dervided from the systemic circulation provide oxygenated blood for nutrition of structures making up the root of the lungs, supporting tissues of the lungs, and the visceral pleura. Bronchial arteries o Supply oxygenated blood to pulmonary tissues as far distally to respiratory brochioles o Descending aorta left bronchial artery

supply oxygenated blood to pulmonary tissues as far distally to respiratory bronchioles

descending aorta 2 left bronchial aa. 3rd posterior intercostal artery right 3rd posterior intercostal a. right bronchial a. bronchial artery eventually drained from the lung primarily through o eventually drained from the lung primarily the pulmonary venous system through the pulmonary venous system o READ: variations of the R bronchial arteries Bronchial Veins Bronchial veins o Drain blood from the larger bronchi and from hilar structures o R bronchial vein- azygos vein o Left bronchial vein- accessory hemiazygos vein o

Pulmonary Arteries and Veins

drain blood from the larger bronchi and from hilar structures right bronchial v. axygos v. left bronchial v. accessory hemiazygos v. or left superior intercostal v.

Intrapulmonary Blood Circulation -sympathetic efferent fibers a. produce bronchodilatation and vasoconstriction b. from sympathetic trunk - parasympathetic efferent fibers a. produce bronchoconstriction (motor to smooth muscles), vasodilatation (inhibitory to pulmonary vessels), and secremotor (increased glandular secretion) b. from Vagus nerve Afferent impulses derived from the bronchial mucous membrane and from stretch receptors in the alveolar walls pass to the central nervous system in both sympathetic and parasympathetic nerves. Reflexive visceral afferent fibers of CN X are distributed to the: Bronchial mucosa, probably in association with tactile sensation for cough reflexes. Bronchial muscles, possibly involved in stretch reception. Interalveolar connective tissue, in association with Hering-Breuer reflexes (a mechanism that tends to limit respiratory excursions). Pulmonary arteries, serving pressor receptors (receptors sensitive to blood pressure). Pulmonary veins, serving chemoreceptors (receptors sensitive to blood gas levels). Nociceptive visceral afferent fibers

Lymphatic Drainage and Nerve Supply

Lymphatics

- follow the bronchial tree course - only found up to or down to terminal bronchioles beyond alveolar ducts, lymphatic vessels do not occur 1. superficial a. present in visceral pleura Innervation of Tracheobronchial Tree b. drains over the surface of the lung toward the hilum, where the lymph vessels enter the bronchopulmonary nodes 2. deep a. follow bronchi and pulmonary vessels b. then enters the bronchopulmonary nodes in the hilum of the lung All the lymph from the lung leaves the hilum and drains into the tracheobronchial nodes and then into the bronchomediastinal lymph trunks. tracheobronchial lymph nodes a. trachea or paratracheal b. superior tracheobronchial c. inferior tracheobronchial d. bronchopulmonary e. pulmonary lymph from left lower lobe may cross to the right side at the tracheobronchial nodes while the lymph from the lungs generally drain ipsilaterally Thoracic duct - most important lymphatic duct - crosses to the left at T4, T5 - receives all lymphatic drainage of the lower limbs, pelvic cavity, abdominal cavity, left side of the thorax, and left side of the head, neck, and left arm almost all parts of the body Nerve Supply - at the root pulmonary plexus composed of efferent and afferent autonomic nerve fibers - The plexus is formed from branches of the sympathetic trunk and receives parasympathetic fibers from the vagus nerve

Innervation: Pulmonary Plexus Nerve supply is derived from the pulmonary plexuses anterior and (mainly) posterior to the root of the lung. Pulmonary Plexus: parasympathetic preganglionic fibers from vagus nerve sympathetic postganglionic fibers from sympathetic trunk

X-ray of the Lungs

Memory Aids Posterior, Superior) Let's play the violin: L = lung pleura, parietal V = visceral 3 Ps: Parietal Pleura innervated by the nerve Victor has no sensation: Visceral pleura has no sensory innervation Causes of Hilar Lymphadenopathy: Tell Some Lies: Tuberculosis, Sarcoidosis, Bronchopulmonary segments: A Possums Might Light LAMPS: Apical, Anterior, Posterior; Middle lobe: and Lateral; Lower lobe: Lateral,

Prepared by: Kae, Joe Mhel, Miggy M., Leslie, Erika R., Ina, Cai, Albert, Toni, Vince, Louie L. God uses our activities and circumstances to bring us to Himself. When He gives us a God-sized assignment, its sheer impossibility brings us back to Him for enabling. When God allows us to go through crises, it brings us closer to Him. -Blackaby Chest X-ray: PA Projection (Posteroanterior View) 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 1. Heart In anteroposterior view, it appears much larger (and less distinct) than in posteroanterior view 2. Lungs dense shadows caused by the presence of the blood-filled pulmonary and bronchial vessels, the large bronchi, and the lymph nodes lungs are more translucent on full inspiration than on expiration pulmonary blood vessels are seen as a series of shadows radiating from the lung root. They appear as small, round, white shadows large bronchi also cast round shadows smaller bronchi are not seen 3. Bones thoracic vertebrae are imperfectly seen costal cartilages are not usually seen, but if calcified, they will be visible clavicles are clearly seen crossing the upper part of each lung field medial borders of the scapulae may overlap the periphery of each lung field 4. Diaphragm diaphragm casts dome-shaped shadows on each side; the one on the right is slightly higher than the one on the left costophrenic angle,- area where the diaphragm meets the thoracic wall beneath the right dome is the homogeneous, dense shadow of the liver beneath the left dome a gas bubble may be seen in the fundus of the stomach.