OVERVIEW OF THE

RESPIRATORY SYSTEM
Prof. Dr. Farihah Hj. Suhaimi
Prof. Dr. Srijit Das

Anatomy Department, Faculty of

Medicine, UKMMC

Thoracic Wall
Sternum
12 pairs of ribs and
costal cartilages
12 thoracic
vertebrae and
intervertebral discs

Sternum
Manubrium (Aortic arch)

Suprasternal/jugular notch - level

T2/T3
Sternal angle of Louis level T4/T5
Xiphoid process (X) - xiphisternal
joint - level T9-T10
(cardiopulmonary resuscitation)

Sternum preferred site

for bone marrow
aspiration/biopsy in adults
It is subcutaneous
Readily accessible

Needle is inserted in the

anterior aspect of the
manubrium in the midline

In children,
bone marrow aspiration is done from
the upper end of tibia (infants)
and iliac crest
Mediastinal injury
Lower half of the posterior surface of
the manubrium arch of aorta
(Sternal angle)
Upper half left brachiocephalic
vein, brachiocephalic artery, left
common carotid artery, left
subclavian artery

Sternal Angle of Louis

sternal angle of Louis
- level T4/T5

Ribs
12 pairs
True ribs (1-7)
False ribs (8-12)
"Floating" ribs
(11-12)

True Ribs
The First Seven Ribs
The first seven bones are called
true ribs.

Anteriorly - connected directly

to the sternum by a strip of
cartilage called the costal
cartilage.
Posteriorly - connected to the
vertebrae.

False Ribs
The 8th, 9th,
and 10th Ribs
Anteriorly - attach to the
sternum by way of
costal cartilage above it.
Posteriorly - connected
to the vertebrae.

Floating Ribs
The Last Two Ribs

Floating ribs have no

anterior attachment

Ribs which
are least commonly injured in
crushing injury of the chest
Upper two ribs protected by the clavicle

Lower two ribs floating ribs ( unattached

anteriorly hence free to swing)

A Typical Rib:
characteristics

head 2 facets which

articulates with bodies of
vertebrae
neck
tubercle -- articulates with
transverse processes
(vertebrae)
angle -- a point just lateral to
the
tubercle where the shaft bends
forward;
costal groove -- lodges
intercostal vessels and nerves
(neurovascular bundle)

A Typical Rib:
characteristics

head 2 facets divided by a

horizontal crest
tubercle -- it consists of an
articular and a non-articular
portion.
The articular portion, presents
a small, oval surface for
articulation with the end of the
transverse process of the lower
of the two vertebr to which
the head is connected.
The non-articular portion is a
rough elevation, and point of
attachment to the ligament of
the tubercle.

Angle of the Rib

Sternum
Ribs
Thoracic
vertebrae
Weakest point of a rib site of greatest
curvature: costal angle

Atypical Ribs 1,2,10,11 & 12

Atypical rib 1st rib

short, flat and more
sharply curved
It has upper and
lower surfaces
outer and inner
borders
head - one articular
facet only

Thoracic Vertebrae (T1-T12)

C7 - vertebra prominens

TYPICAL THORACIC VERTEBRA

Costal facets for articulation with ribs

bodies are heart-shaped

Articulation between the rib and

thoracic vertebra
T6

T7
Rib 7

Ribs 2-9 attached to the

transverse process and body
of
the
same
numbered
vertebra and that of the body
of the vertebra above it.

Thoracic Apertures
thoracic inlet
(superior
aperture)
manubrium, first rib, and T1
vertebra.
thoracic outlet
(inferior aperture) - xiphoid
process, costal arch, the rib 12.
- this aperture is closed off by
the diaphragm.

Layers of the intercostal space

2 Neurovascular
bundles

A cardiothoracic surgeon is able

to separate the pleura from the
thoracic wall.

Natural cleavage plane

Intercostal nerves
12 pairs of intercostal nerves

Twelfth pairs of intercostal

nerves are the subcostal
nerve

The intercostal nerves are the

anterior/ventral primary rami of
thoracic spinal nerves.

Intercostal space Intercostal nerve

Lateral to erector spinae

Midaxillary
line

Lateral to the sternum

Pus from tuberculous vertebra

(cold abscess) points
on the surface of the thoracic wall
Tracks down along the course of the neurovascular
bundle
Points at the three sites of exit of the cutaneous
branches of the intercostal nerves:
Lateral to erector spinae muscle
In the midaxillary line
Just lateral to the sternum

Neurovascular bundle

Particularly
vulnerable to injury
from fractured ribs

VAN vein - artery nerve (intercostal)

Intercostal space

Thoracocentesis

Needles would always be inserted near the upper border

(superior margin) of a rib (in the intercostal space)

In order to avoid damage to the neurovascular bundles found

below the ribs.

Intercostal nerve block

The needle would be inserted along the inferior

margin (border) in order to deliver the anaesthetic
agent to the intercostal nerve lying there.

The thoracic wall is

supplied by three
sources of blood supply
Axillary artery
Supreme/highest thoracic (2)
lateral thoracic (3)

Subclavian artery
internal thoracic (or mammary)
artery (1)
- anterior intercostal branches

Aorta
- posterior intercostal arteries (4)

Arterial supply of the

intercostal spaces
Posterior intercostal arteries
arises from:
- highest intercostal artery (2) - thoracic aorta (9)

Anterior intercostal arteries

arises from:
- internal thoracic artery (5/6)
- musculophrenic artery

Venous drainage
Anterior intercostal veins drain
into the internal thoracic vein

Then
drain
into
brachiocephalic vein
Finally into the SVC

the

Venous drainage
Posterior intercostal veins drain
into the:
azygos, hemiazygos or accessory
hemiazygos veins
Then drain into either the
superior intercostal vein or the
arch of azygos
Finally into the SVC

Innervation of
the thorax
Somatic for the body wall
- twelve thoracic spinal
nerves (intercostal nerves)
- phrenic nerve

Autonomic for the viscera

- sympathetic chain
- vagus nerve.

Diaphragm
The diaphragm is
a thin domeshaped muscle
Separates the
thoracic cavity
from the
abdominal cavity.

Structures passing through or

between the diaphragm
Inferior vena cava through the central
tendon (T8)
Oesophagus - through the muscular
part (T10)
Aorta passes behind the post.
attachment of the diaphragm (T12)
VOA (Vein, Oesophagus, Artery,)
(8,10,12)
(Voice Of Anatomy)

Inferior vena cava T8

The inferior vena
cava passes through
the central tendon

It is accompanied by
branches of the right
phrenic nerve.

Oesophagus T10
Oesophagus
passes
through the muscular
part
The Rt & Lt vagus
nerves,
left
gastric
vessels and lymphatics
also pass through here.

Aorta T12

Aorta lies behind the

median arcuate
ligament
The thoracic duct
accompanies the
aorta.

Arterial supply
Pericardiacophrenic
artery
Musculophrenic artery

Superior phrenic artery

Inferior phrenic artery

Venous drainage
Venous drainage is
via right and left
phrenic veins to
the inferior vena
cava
some drainage
into the left renal
vein

Motor Innervation

Phrenic nerve (C3, C4, C5)

Phrenic nerve

arises in the neck from C3,4,5 roots

lies on the scalenus anterior muscle and
enters the thorax between the
subclavian artery and the subclavian
vein

courses down the mediastinum lying

anterior to the hilum of the lung, and
squeezed between the pleura and the
pericardium.
the phrenic nerve is the only motor
supply to the diaphragm.

each phrenic nerve innervates the

corresponding half of the diaphragm

Effects of Phrenic nerve

damage
Corresponding half of the diaphragm will be
paralysed
The diaphragm will be relaxed and pushed up into
the thorax by positive abdominl pressure
Hence, the lower lobe of the lung on the ipsilateral
side may collapse

Sensory innervation
phrenic
intercostal (6-12)
upper two lumbar nerve roots

Phrenic nerve

Right and left phrenic nerves supply both

sensory and motor innervation

Respiratory Tree

Trachea
The trachea is
beginning
of
respiratory tree.

the
the

Extends from C6 in the

lower
neck
(lower
border
of
cricoid
cartilage).
to T4/5 (sternal angle)
in the mediastinum

Trachea (11cm)
At the level of T4/5,
It bifurcates into a right
and left main/primary
bronchus (carina)

In the erect position, in

deep inspiration, the
carina descends to the
level of T6

Bronchogenic carcinomas
usually occur on the right side
Affects the right bronchial tree
The right bronchus is wider and in
line with the trachea
More exposed to carcinogenic
agents
eg.
Cigarette
and
sulphurous
smokes,
arsenic
vapours, radioactive substances,
tarry particles from roads

Eparterial bronchus Right side

The
secondary
(lobar)
bronchus to the superior lobe
branches from the main
bronchus in the root of the
lung unlike on the left
Superior to the pulmonary
artery eparterial bronchus

Lung abscess mostly occurs in

the right lower lobe
Aspirated foreign bodies
may block the airway
leading to atelectasis (lung
collapse) and inflammation
that may subsequesntly
cause lung abscess

Superior bronchopulmonary segments of

both the right and left lower lobes
of the lungs

Involved in aspiration pneumonia

Located most posterior
Most dependent in position (supine)
Inhaled material would enter these lobes

Tracheal-tug
Intimate relationship
between the arch of
aorta, trachea and left
bronchus
Physical
sign
tracheal-tug

Characteristic
aneurysms
of
aortic arch

of
the

Bronchoscopy

Secondary bronchi
(lobar bronchi)

Within the lungs, the

primary bronchi divide
into
the
secondary
bronchi.

Secondary bronchi
(lobar bronchi)
Each secondary
bronchus supplies one
lobe of the lung.

Since there are 2 lobes

on the left and 3 on
the right, there are 3
secondary bronchi on
the right and 2 on the
left.
right lower lobe lung abscess
Right lower lobar bronchus is vertically in line with the trachea.

Secondary bronchi (lobar bronchi)

The secondary bronchi
will divide into tertiary
(segmental) bronchi
and then quaternary
bronchi and so on until
about 23 branchings
have occurred.

Branching pattern of
bronchial tree
It determines the appropriate
posture of the patient for draining
the infected area of the lung
Interpretation of the bronchogram

Interpretation of bronchoscopy
Surgical
resection
bronchopulmonary segments

of

Bronchopulmonary segments

A subdivision of one lobe of a lung based on the

connection to the segmental bronchus.

Bronchopulmonary segments
- smallest, functionally
independent region of a
lung.
- smallest area of lung
that can be isolated and
removed
without
affecting
adjacent
regions

Bronchopulmonary segments
pulmonary artery branch
(centrally
located)
accompanying it
Pulmonary
vein
is
peripherally located in
the connective tissue in
between the segments
(intersegmentally)

Intersegmental Veins

Segments are demarcated

by intersegmental veins
Forms a landmark during
the surgical resection of a
segment

Bronchopulmonary segments
Shape - irregular cone:
- apex which is directed
towards the hilum of the lung
- base projected peripherally
onto the surface of the lung
- surrounded by connective
tissue

Pleura of the lungs

The inner layer (visceral) wraps around the

lungs.
The outer layer (parietal) lines the body wall
and mediastinum.

Cervical Pleura & Apex of the lungs

Vulnerable
to
stab
wounds in the root of
the neck
Or to damage by an
anaesthetics
needle
when carrying a nerve
block of the lower trunk
of the brachial plexus

Cervical Pleura

Visceral Pleura
The moist and shiny visceral
(pulmonary) pleura closely
covers the lung and is
adherent to all its surfaces.
The visceral pleura dips into
the fissures of the lungs so
that the lobes are covered by
it.
It provides the lung with a
smooth, slippery surface for
free movement in the parietal
pleura

Hilum of the Lung

The visceral pleura is
continuous with the
parietal pleura at the
root of the lung
(where
structures
enter and leave it).
The
layers
are
continuous at the
hilum (depression) of
the lung.

Pulmonary ligament

Below the root of the lung, identify the

pulmonary ligament
It is a reflection of the pleura

Functions of the
Pulmonary ligament
Allows the apex of the
lung to expand
To provide deadspace for
pulmonary veins to expand
during increased blood
return from the lungs

Pleural Cavity
The pleural cavity is a
separate and closed
potential space.
A thin film of
pleural
fluid
between these two
layers keeps them
together.
This
pleural
fluid
lubricates the two
layers of pleura and
reduces friction.

Pleural & Lung Reflection

(Surface anatomy)

At mid-inspiration, generally:
visceral pleura (lungs) are
2 ribs more superior
than the parietal pleura

Anteriorly
(1) the pleurae reach the
midline at rib 2
(2) the pleurae deviate to
the left at rib 4 (cardiac
notch)
(3) the pleurae deviate to
the right at rib 6
Both the parietal and visceral pleurae

Anteriorly - midclavicular line

(4) the visceral pleura
reaches rib 6 at the midclavicular line (vertical
bar)
(4) the parietal pleura
reaches rib 8 at the midclavicular line (arrow)

midclavicular line

Laterally midaxillary line

the visceral pleura
reaches rib 8 at the
midaxillary
line
(vertical bar)
the parietal pleura
reaches rib 10 at
the midaxillary line

midaxillary line

Posteriorly
the
visceral
pleura reaches
rib 10
the
parietal
pleura reaches
rib 12
Lateral border of erector spinae muscle

Pleural (parietal pleura)

reflections
The lower margins of
the parietal pleura
cross the:
8th
line

midclavicular

10th midaxillary line

12th lateral border of
the erector spinae
muscle respectively

Lung (visceral pleura)

reflections
The lower margins of
the lungs cross the:
6th
line

midclavicular

8th midaxillary line

10th lateral border
of the erector spinae
muscle respectively

Pleural reflections & recesses

Costodiaphragmatic
recesses
Costomediastinal
recesses

Costodiaphragmatic recess
The distance between the
two borders corresponds
to the costodiaphragmatic
recess.

Most
dependent
part of the pleural
sac
In pleurisy fluid
first collects in this
recess

Arterial Supply of the Pleurae

Arteries that supply the
thoracic wall (parietal pleura):intercostal, internal thoracic,
and musculophrenic arteries
Arteries that supply the
visceral pleura: bronchial arteries, (branches
of the thoracic aorta).

Innervation of the Pleurae

Parietal pleura:
- costal: intercostal nerves
(referred pain to the
thoracic and abdominal
walls)
- mediastinal
&
diaphragmatic:
phrenic
nerve (referred pain to
the root of the neck and
over the shoulders)
Visceral pleura:
autonomic nerves from the
pulmonary
plexuses
(insensitive to pain)

LUNGS

Blunt apex of the lung into

the root of the neck

2.5 cm above the medial 1/3 of the clavicle

5 cm above the first costal cartilage

Why is there no puffing

of the root of the neck
during respiration?
Apex of the lung is surrounded by
cervical pleura
Covered on its outer surface by a tough
fascia Sibson fascia/ suprapleural
membrane
Provides rigidity to the thoracic inlet

Prevents its ballooning in

(puffing) during respiration

and

out

Base of the lung

Concave base - sits on the diaphragm

2 Surfaces of the lungs

Convex costal surface
corresponds to the
convex chest wall
Concave mediastinal
surface molded to
the pericardium and
other mediastinal
structures

Mediastinal surfaces

3 Borders of the lungs

Anterior border thin
and overlaps the heart
Left lung cardiac
notch
Posterior border
thick and lies beside
the vertebral column
Inferior
border

sharp and separates

the base from the
costal surface

Root of the Lung

Generally:
pulmonary artery
superior
pulmonary veins
inferior
bronchi - posterior

Root of the Right Lung

bronchi lie posterior
pulmonary arteries are
superior
pulmonary veins are
inferior and anterior
bronchial vessels
lymphatic vessels
nerves

Root of the Left Lung

bronchus lies posterior
pulmonary
artery
is
superior
pulmonary vein is inferior
and anterior
bronchial vessels
lymphatic vessels
nerves

Fissures
Oblique fissure Spine of T3
posteriorly to 6th rib
anteriorly
Horizontal fissure 4th rib/costal
cartilage anteriorly
to the 5th rib in
midaxillary line

Lobes of the Lungs

Lobes of the Right Lung:
Superior, Middle, Inferior
Lobes of the Left lung:
Superior, Lingula, Inferior
- Lingula is part of the
superior lobe of the left lung

Right lung

Major Structures
related to the
mediastinal surface of
the right lung

Heart
Inferior vena cava
Superior vena cava
Azygos veins
Oesophagus
Phrenic/Vagus
nerves

LEFT LUNG

Major Structures
related to the
mediastinal surface of
the left lung

Heart
Aortic arch
Thoracic aorta
Oesophagus
Phrenic/Vagus
nerves

Rt. Lung

Lt. Lung

Lungs
Blood supply
Innervations
Lymphatic drainage

Bronchial arteries and veins

nutritive
vascular system
of the pulmonary
tissues (bronchial
walls and glands,
wall of large
vessels, visceral
pleura)

Bronchial veins
Drains into:

Azygos vein on the right

Left superior intercostal
vein or hemiazygos vein
on the left

Pulmonary arteries
Pulmonary trunk
- carry
deoxygenated
blood to the
lungs from the
right ventricle of
the heart

Pulmonary veins
Superior and
inferior
pulmonary veins
carry oxygenated
blood from the
lungs back to the
left atrium of the
heart

Innervation
Structures of the
lungs are supplied
by visceral
afferents and
efferents
distributed through
the anterior and
posterior
pulmonary plexus

Innervation
These
branches
ultimately originate
from
the
sympathetic trunks
and vagus nerves
(parasympathetic)

Innervation
Vagus nerves
constricts the
bronchioles
Sympathetic
system dilate the
bronchioles

LYMPHATIC
DRAINAGE

Lymphatics originate from

the superficial subpleural
plexus
and
deep
submucosal plexus of the
lung which drains into
tracheobronchial nodes
Form right and left
bronchomediastinal lymph
trunks
Finally they drain into the
deep veins at the base of
the neck or into the right
lymphatic
trunk
or
thoracic duct

Acknowledgement- Prof. Dr.Farihah