External Morphology

Define lungs and their components

- Lungs held in close apposition to the thoracic walls by: 1) Intrapleural fluid cohesiveness( surface tension) 2) Slightly negative pressure in the pleural cavity compared to the external pressure.

Cadaveric lungs with impressions

Groove for lt. subclavian a.
Groove for arch of aorta

Groove for rt. brachiocephalic v

Groove for esophagus Groove for Arch of azygos v.

Groove for
Groove for Thoracic aorta

Phrenic superior vena cava nerve

Groove for esophagus

Vagus nerve

Cardiac impression

Arch of azygos
Rt. brachiocephalic Aortic arch Superior vena cava

Esophagus
Azygos vein Thoracic aorta

Inferior vena cava

Horizontal fissure also known as transverse fissure

List and define the relationship of structures that make up the root of the lung (hilum of lung)
Wedge shaped area on the mediastinal surface of each lung through which structures form the root of the lung, passes to enter or exit the lung. Because of the angled portion of the left principal bronchial the left pulmonary artery will be higher than the left main bronchus. The left pulmonary artery must arch over the left main bronchus to get to the lungs. On the right side, due to the more vertical nature of the right principal bronchial, the right pulmonary artery will be at the same level as the right main bronchus.

Eparterial bronchus

Hilum of Lung

Right Lung hilum Main difference: The relationship between Pulmonary artery and Main bronchus

Left Lung hilum

Compare right and left lung

Right Lung Two fissures (oblique and transverse) 3 lobes (superior, middle and inferior) (3 secondary bronchi) Shorter and wider(dome placed higher due to liver) Presence of middle lobe Heavier and larger Left Lung One fissure (oblique) 2 Lobes(Superior and Inferior) (2 Secondary Bronchi) Long and Narrow Cardiac Notch Lingua Smaller and lighter

Relate lungs to the thoracic and pleural cavities

Surface Landmarks
Horizontal fissure

T2

Oblique fissure

4 5 6
Oblique fissures

th Oblique fissures on both lungs extend from T2 vertebrae Oblique fissures on both lungs extend from T2 vert. to to 6 6th costal costal cartilage cartilage.

Horizontal fissure on right lung extends along the 4th rib & costal cartilage.

Horizontal fissure on the right lung extends along the 4 rib and costal cartilage.
Clinical Significance: -Vulnerability of lobes to injuries (e.g. of stab wounds)

Areas to know because of-Radiological potential injuries associated with each section. studies of lungs Prominent : radiological scan Plus better idealobes during
Posteriorly: the inferior lobe Anteriorly: the superior lobe Prominent lobes: Left lung: Right lung: the superior and middle lobe Posteriorly: the inferior lobe Anteriorly: Left Lung: superior lobe Right Lung: Superior and middle lobe.

Define and differentiate between auscultation and percussion

Auscultation: Listen to lung sounds by stethoscope. Assesses air flow through tracheobronchial tree into the lobes. Percussion: Tapping the thorax to listen to lungs sounds Detects air filled spaces. Fluid filled -> dull sound Solid -> flat sound Yellow = area of flatness Unshaded = area of resonance(air filled)

en to lungs

ound).

Explain the anatomical and clinical presentation of pneumothorax Internal Morphology

Open Pneumothorax: Pleural Cavity has contact with the atmosphere. Air is sucked in and out (while inhalation and exhalation). Collapsed Lung. (Atelectasis: alveoli deflate and looses their air due to loss of elasticity or air blockage) mothorax (air in the pleural cavity) Mediastinal and tracheal shifts TOWARDS THE AFFECTED SIDE.
Open wound

with the outside.

wards the

h a thoracic th valvelike

One way valve

owards the

Tension Pneumothorax: Injury to the lung and the thoracic wall. Air enters one way through a thoracic wall wound (Valvelkie opening) Medialstinal and tracheal shift TOWARDS THE UNEFFECTED SIDE Every breath in causes more air to enter into the damage side. Thus it increases the pressure and pushes out on the other structure ie. Medistinum and diaphragm. Widening of intercostal space

. (affected side).

n-existing lung diseases associated with existing lung diseases

with the outside.

is

owards the

Diaphram displaced inferiorly on the affected side

One way valve

gh a thoracic with valvelike towards the

es.

y (affected side).

Spontaneous Pneumothorax:

Lungs open up on-existing lung diseases associated with existing lung diseases -> non-existing lung diseases Primary Spontaneous Secondary Spontaneous -> associated with existing lung disease

Tracheal Deviation Technique

Mediastinal structures and trachea shifts to the side with lower pressure

Youtube Video: http://www.youtube. com/watch?v=DKRj4 k7thEY

Deviates to the affected side Open pneumothorax or Atelectasis Lung agenesis (failure to develop) Pneumonectomy

Deviates to the unaffected side Tension pneumothorax Pleural effusion Masses

Describe a tracheobronchial tree and the associated branches

Trachea divides into two Main (primary) Bronchi Each main bronchus divides into Secondary (lobar) bronchi Right lobe = 3 Left lobe = 2 Each lobar bronchus divides into Tertiary Bronchi. They supply the bronchopulmonary segments.

Lungs Internal Morphology & Str

I) Tracheobronchial Tree (trachea and bronchial s

Rt main Lt main bronchus

Lungs Internal Morphology & Structures Lt superior I) Tracheobronchial Tree (trachea and bronchial system) lobar bronchus
Rt superior lobar bronchus bronchus Eparterial

Rt superior lobar bronchus bronchus Eparterial

Trachea divid (primary) br

Rt main

Lt main bronchus

Each main b secondary ( Trachea divides into two main 3 = righ (primary) bronchi 2 = left

Lt superior lobar bronchus

Each main bronchus divides into Lt inferior secondary (lobar) bronchi Each lobar b 3lobar = right side into tertiary 2bronchus = left side

Lt inferior lobar bronchus

supplies the Each lobar bronchus divides segments into tertiary bronchi which
supplies the bronchopulmonary segments

Rt inferior lobar bronchus Rt inferior lobar

bronchus

Rt middle lobar bronchus Rt middle lobar

bronchus

Main bronchus primary; Lobar = secondary; Main bronchus = primary; = Lobar = secondary; Segmental = tertiary
The right Main Bronchus is wider, shorter and runs more vertically. The left Main Bronchus passes inferolaterally, inferior to the arch of the aorta and anterior to the oesophagus and thoracic aorta to reach the hilum of the lung. That is why on the left side of the hilum the pulmonary artery is above the main bronchus

Segm

Right main bronchus = wider, shorter and runs more vertically

Carina Trachea bronchi are supported From the Larynx downward, the trachea and primaryand bronchus have walls that are by C-shaped cartilaginous rings. supported by a C shaped ring of hyaline cartilage. Secondary & tertiary bronchi: the them. The Secondary and Tertiary cartilage no longer have rings of cartilage to support cartilaginous rings becomes They now have cartilaginous plates that line them cartilaginous plates. The Bronchioles have NO cartilage supporting them. Bronchioles have no cartilaginous The Bronchioles have three subgroups: covered walls. Conducting bronchiole 1. Conducting bronchioles Three types 2. Terminal bronchioles i) Conducting bronchioles Emphysema3. Respiratory bronchioles (aveoli resides and has respiration) ii) Terminal bronchioles (COPD) iii) Respiratory bronchioles Right main bronchus = wider, shorter
and runs more vertically

Carina Trachea and bronchi are supported by C-shaped cartilaginous rings. Secondary & tertiary bronchi: the cartilaginous rings becomes cartilaginous plates.
Conducting bronchiole

Bronchioles have no cartilaginous covered walls. Three types i) Conducting bronchioles ii) Terminal bronchioles iii) Respiratory bronchioles

Emphysema (COPD)

II) Bronchopulmonary segments segment Explain the clinical significance of bronchopulmonary

Rt. lung

ML=ML Lateral view Medial view Lt. lung

**Can combine into apicoposterior segment * Can combined into anteriomedial basal segment
10 segments 8-10 segments Medial view Lateral view

Knowing each segment is necessary for surgical ofcan a specific section Tumors, abscesses and atelectasis localize in a single segment

Discrete units that can be surgically resected = segmentectomy (CR )Aspiration of Foreign Bodies Mostly in the right main bronchus because it is straight, short and wide.

(CR)Aspirating Pneumonia Aspirates/vomit liquid that goes down the trachea and down into the lungs Seated Upright -> Right Posterior Basal Portion Lying Supine -> Right Anterior Portion

Clinical Relevance:
When seated upright When lying supine

If a patient aspirates some fluid or vomitus down the trachea into the lungs: (Aspirated pneumonia). Right Posterior basal segment Right Superior segment
Right Main Bronchus Apicoposterior

Apical Posterior of right superior lobe

Anterior

2 2

Lingula

Middle lobe

Posterior basal of right inferior lobe Superior of right inferior lobe

Basal (anterior, posterior, lateral and medial

(CR)Pancoast Tumor Lung Cancer at the apex of the lung Ass. Compression Syndrome Compression of the sympathetic trunk -> Horners Syndrome: Miosis Ptosis Anhidrosis Compression of the Brachial Plexus: Klumpkes Palsy (C8-T1) Compression of Subclavian a & n. Pulselessness Pallor Pain Differential: Thoracic outlet syndrome

Describe the arterial supply and venous drainage of lungs

Pulmonary Circulation: 1) Pulmonary Arteries (deoxy blood to lungs) 1 Lobar artery and 1 secondary bronchus serves each lobe Tertiary Segmental artery and bronchus supplies a single bronchopulmonary segment 2) Pulmonary Veins (carry oxygenated blood to heart) Two pulmonary veins drain the lobes Run independent of arteries and bronchi Receive oxygenated blood from two adjacent bronchopulmonary segments

They run independent of arteries and bronchi.

Receive oxygenated blood from two adjacent bronchopulmonary segm Pulmonary arteries

Pulmonary veins
Segmental Vasculature and Bronchial system: A Tertiary Pulmonary Artery and segmental bronchus supply a single segment A Tertiary Pulmonary Vein drains 2 adjacent segments (CR) Segmentectomy: Surgical resection of a single segment Segmental vasculature & bronchial system Veins at risk of damage since there are 2 segments
(Intrasegmental)

Bronchiole

Pulmonary arteries.

(Intersegmental) Pulmonary veins

gmentectomy

Surgical resection single segments Veins at risk of mage

Adjacent bronchopulmonary segments drained by a single tertiary pulmonary vein

tertiary pulmonary artery & segmental bronchus supply a ngle segment.

Systemic Circulation: tertiary pulmonary vein drain 2 adjacent segments. 1) Bronchial Arteries: Supplies the lung: Right Artery from aorta or 3rd posterior intercostal art.

ystemic CirculationLeft Artery from the thoracic Aorta

ystemic Circulation

rta or 3rd

rta or 3rd . thoracic aorta. thoracic aorta.

2) Bronchial Veins Drains the lungs: Right Veins drain into the Azygos Vein Left Vein drains into the Accessory hemiazygos vein

Azygos vein.

Azygos vein. ccessory

ccessory

ood 5% the ood

l vessels 5% the

al vessels ncer, TB, PE

ncer, TB, PE

(CR)Hemoptysis (spitting blood): If derived from the lungs, 95% of the blood will be from the bronchial vessels Causes: Bronchitis, Cancer, TB, PE

Nerves Explain the innervation of lungs of

Originate from Pulmonary Plexus: 1) Sympathetic Nerve Originates from(via pulmonary plexus 2) Parasympathetic vagus nerve) 3) Visceral Afferent Fibers

the lungs:
1. Sympathetic nerves 2. Parasympathetic (via vagus nerve) 3. Visceral afferent fibers

Compression associated with Horners Syndrome

Sympathetic Nerves: Postsynaptic sympathetic fibers Synapse at paravertebral sympathetic ganglia located -> sympathetic trunk (chain) Parasympathetic Nerves: Presynaptic fibers from vagus Synapse at parasympathetic ganglia at pulmonary plexus + along bronchial trees

Viseral Afferent Fibers: I) Reflex sensation: Fibers accompany Vagus II) Nociceptive (pain) Fibers from Trachea accompany Vagus

Fibers from Visceral Pleura and bronchi accompany Sympathetic

Describe the two main lymphatic drainage pathways of lungs

Two pathways: 1) Superficial Lymphatics Plexus: Drains visceral pleura and lung parenchyma Drains first into the bronchopulmonary (Hilar) nodes 2) Deep Lymphatic Plexus: Drains Bronchi submucosa and peribronchial connective tissue Drains first into the Pulmonary nodes ( The Pulmonary Nodes meet the superficial lymphatic plexus in the Bronchopulmonary (hilar) node)
Group of lymph nodes 1 = Deep
1. Pulmonary 2 = Superficial

Lung Lymphatic Drainage

Right lymphatic duct

2. Bronchopulmonary (Hilar) nodes

3. Tracheobronchial nodes (Superior & Inferior Carinal)

4. Paratracheal nodes

5. Bronchomediastinal lymph trunk

6.

Left Right

Thoracic duct & Right lymphatic duct

7. Venous system (rt & lt Venous angles)

There is a major variation in lymphatic drainage that is important. The left lower lobe has contralateral lymph drainage. The LOWER LEFT LOBE -> RIGHT Superior Tracheobronchial node -> RIGHT lymphatic duct Normally lymph follows consecutive group of ipsilatetal nodes In some people, the lymph from the lower left lobe drains into the right superior tracheobronchial nodes.

Variation: Left lower lobe contralateral lymph drainage

Right lymphatic duct

Right Superior tracheobronchial nodes

Lower Left Lobe

Normally lymph follows consecutive group of ipsilaletal nodes. In some people, the lymph from lower left lobe drains into the Right Superior tracheobronchial nodes.

Clinically Relevant Conditions Thoracocentesis: sites and structures likely to be damaged during the procedure
Midclavicular line: 7th intercostal space Midaxillary line: 9th intercostal space Paravertebral line: 10th intercostal space. Target the costodiaphragmatic recesses to avoid injuring the lung and the diaphragm.

Review:

Surface Anatomy of the Lungs and Thoracic cage

6 8th ribs Midclavicular line

8 10th ribs Midaxillary line

10 11th ribs Paravertebral line 10th intercostal space

7th
intercostal space

9th
intercostal space

Recall Thoracentesis: You target the costodiaphragmatic recess to avoid injuring the lungs & the diaphragm.

Lung sounds: locations

Anterior Lung Auscultations: (All Right Lung) Apex of lung: Superior to Medial third of Clavicle Superior lobe: 2nd intercostal space (angle of Louis) Middle lobe of the right lung: 4th intercostal space Inferior lobe: 6/7th intercostal space

Apex of the lung: -superior to medial third of clavicle

Lung Auscultation (Anterior side)

2nd Superior lobe: intercostal space

Middle lobe of the right lung: -4th intercostal space

-6th

Inferior lobe: or 7th intercostal space

Posterior Lung Auscultation: (All Left Lung) Apex of lung: superior to medial third of Clavicle Superior lobe: 2nd intercostal Inferior lobe: Triangle of Auscultation

Pneumothorax: types & presentation

Open Pneumothorax: Lung (Atelectasis) mothorax (air inCollapsed the pleural cavity) Mediastinal and tracheal shifts TOWARDS THE AFFECTED SIDE.
Open wound

with the outside.

wards the

h a thoracic th valvelike

One way valve

owards the

Tension Pneumothorax: Air enters one way (Valvelkie opening) Medialstinal and tracheal shift TOWARDS THE UNEFFECTED SIDE Widening of intercostal space

. (affected side).

n-existing lung diseases

is

owards the

Diaphram displaced inferiorly on the affected side

One way valve

gh a thoracic with valvelike towards the

es.

y (affected side).

Spontaneous Pneumothorax: Lungs open up Primary Spontaneous -> non-existing lung diseases on-existing lung diseases associated withClinical existing lung diseases Secondary Spontaneous associated with existing lung disease lung Relevance : -> Atelectasis = collapsed

or part of a lung

Collapse of previously inflated lung or failure of the lungs to inflate at birth. Atelectasis
Atelectasis: alveoli deflate and looses their air due to loss of elasticity or air blockage. Lung collapses and creates a void. Lung collapses and creates a void.

Normal alveoli

Collapsed alveoli

. Bronchogenic carcinoma: spread and structures at risk of compression

Pulmonary embolisms: Whichand veins are their involved and the Atelectasis: alveoli deflate lose air due to loss of structures at risk elasticity or airway blockage. Obstruction of pulmonary artery by a blood clot (embolus).
Source: Deep veins of the lower limb, ie. External iliac, Femoral, deep femoral and popliteal veins Symptoms: Dyspnea Sharp Chest Pain

Blood Tinged Foamy sputum Associated Conditions: Acute respiratory distress: blockage of pulmonary artery Acute cor pulmonale: dilated right heart ventricle (contrast with chronic right ventricular hypertrophy) Pulmonary Infarct: Death of bronchopulmonary segment

Trace the spread of cancer cells along the series of pulmonary and tracheobronchial lymph nodes
Bronchogenic Carcinoma (lung cancer) Lung Cancer metastasizing to the inferior tracheobronchial (carinal) lymph node Displace carina from its midline position and reduce the sharpness of its edge