Chest Wall and Lung

Anatomy and
Physiology
Zeyad S Alharbi, M.D.
Anatomy and Physiology of the Thorax
Thoracic Skeleton
12 Pair of C-shaped Ribs
Ribs 1-7: Join at sternum with cartilage end-points
Ribs 8-10: Join sternum with combined cartilage at 7
th
rib
Ribs 11-12: No anterior attachment
Sternum
Manubrium
Joins to clavicle and 1
st
rib
Jugular Notch
Body
Sternal angle (Angle of Louis)
Junction of the manubrium with the sternal body
Attachment of 2
nd
rib
Xiphoid Process
Distal portion of sternum
Anatomy and Physiology of the Thorax
Thoracic Skeleton
Topographical Thoracic Reference Lines
Midclavicular line
Anterior axillary line
Mid-axillary line
Posterior axillary line
Intercostal Space
Artery, Vein and Nerve on inferior margin of each rib
Thoracic Inlet
Superior opening of the thorax
Curvature of 1
st
rib with associated structures
Thoracic Outlet
Inferior opening of the thorax
12
th
rib and associated structures & Xiphisternal joint
Blood Supply and Innervation
Anterior Chest Wall Deformities
1. Pectus excavatum
2. Pectus carinatum
3. Polands syndrome
4. Sternal defects
5. Miscellaneous
Etiology and Incidence of Pectus Excavatum
It is reported 1/700 of lives birth
M:F=3.4:1
37% occur in Families with Chest wall
deformities
It is a posterior depression of the sternum and
costal cartilage due to over grow of costal
cartilage
The 1
st
and 2
nd
ribs, manubrium are in normal
position


M-S Abnormalities with Pectus Excavatum
Scoliosis
Kyphosis
Myopathy
Marfans syndrome
Cerebral palsy
Prune-belly syndrome
Tuberous sclerosis
Symptoms of Pectus Excavatum
Decreased exercise tolerance
Fatigability
Dyspnea on exertion, and sternal pain
Palpitations and multiple respiratory tract
infections are reported
MOST complaint : cosmetic deformity
rather than symptomatology
Pectus Carinatum
( Pigeon Chest )
It refers to anterior protrusion of the sternum

It is less common than pectus excavatum


Categories of Pectus Carinatum
1. Chondrogladiolar

(I) It is the most common pectus carinatum

(II) It consists of anterior protrusion of
the body of sternum and lower costal
cartilages
(2) Lateral Pectus Carinatum :
a unilateral protrusion of the costal cartilages and
is usually accompanied by sternal rotation to the
opposite side

(3) Chondromanubrial:
(I) Uncommon
(II) Protrusion of Manubrium,
2
nd
and 3
rd
costal cartilages with
relative depression of the body and
sternum

Polands Syndrome
1841
It refers to a congenital absence of the
pectoralis major and minor muscles, ribs,
breast abnormality, chest wall depression
and syndactyly, brachydactyly or absence
of phalanges
It is present in 1/30000
The etiology is unknown

Thoracic Outlet:
The space through which the
subclavian artery, vein and
brachial plexus pass to the upper
limb

Symptoms develop when these
structures are compressed at the
outlet

Boundaries:
First rib, clavicle and Scalene
muscles
Clavicle
1
st
Rib
Scalenus Anterior Muscle
Patients arm is elevated
Thoracic Outlet Syndrome TOS
Cervical Rib:
0.5-1% population (not all
are symptomatic)

Neurogenic symptoms
95%
Ulnar nerve C8-T1 is usually
affected

Vascular Symptoms 5%
Subclavian artery
Subclavian vein


{cervical rib between the transverse
process of C7 & the 1
st
rib. You can
see the cervical rib in the other side
elevating the brachial plexus.}
{Definition of cervical rib: an accessory rib
which is not normally present. If present it
may cause compression of important
structures in the thoracic outlet. }
Vascular Symptoms of TOS
Subclavian Artery:
Prolonged compression & trauma

Intimal injury

Stenosis, Thrombosis
Post-stenotic Dilatation or Aneurysm

Distal Micro-embolisation
Band
Cervical
Rib
{In Unilateral Raynauds always
suspect TOS, because usually
Raynauds phenomenon is
systemic & will cause bilateral
symptoms}
Depending on the surgeons preference, there are 2 approaches
for the surgery:
Supraclavicular Approach:
Scalenectomy
Excision of 1
st
rib & fibrous bands
Repair of subclavian artery if its injured and patient has vascular
problems:
Thrombectomy, patch angioplasty
Excision of aneurysm & bypass graft

{scalenectomy & 1
st
rib excision are enough in those with
neurological symptoms}

Transaxillary Approach:
Excision of 1
st
rib. This causes the brachial to go down a little relieving
the compression

Surgical Treatment of TOS
The Respiratory Muscles
Anatomy and Physiology of the Thorax
Pleura:
appears between the 4th and 7th gestational weeks
Visceral Pleura
Cover lungs
Parietal Pleura
Lines inside of thoracic cavity.
Pleural Space

The relationships of the pleural reflections and
the lobes of the lung to the ribs that at the
midclavicular line, the recess is between rib
spaces 6 and 8, at the midaxillary line between
8 and 10 and at the paravertebral line between
10 and 12.
Lungs Gross Anatomy
Paired, cone-shaped organs in thoracic
cavity
Separated by heart and other
mediastinal structures
Covered by pleura
Extend from diaphragm inferiorly to
just above clavicles superiorly
Lies against thoracic cage (pleura,
muscles, ribs) anteriorly, laterally and
posteriorly


Lungs Gross Anatomy
Hilum
Medial root of the lung
Point at which vessels, airways and lymphatics
enter and exit
Cardiac Notch
Lies in medial part of left lung to
accommodate the heart
Lobes and Fissures
Lung Blood Supply
Dual Supply
Bronchial Supply: arises from superior
thoracic aorta or the aortic arch.
Supply bronchi, airway airway walls and pleura
Pulmonary Supply
Pulmonary arteries enter at hila and branch
with airways

Lymphatics
Lymphatic drainage follows vessels
Parabronchial (peribronchial) lymphatics
and nodes hilar nodes mediastinal
nodes pre- and para-tracheal nodes
supraclavicular nodes
Anatomy and Physiology of the Thorax
Mediastinum
Central space within thoracic cavity
Boundaries
Lateral: Lungs
Inferior: Diaphragm
Superior: Thoracic inlet
Structures
Heart
Great Vessels
Esophagus
Trachea
Nerves
Vagus
Phrenic
Thoracic Duct
Control of Breathing
Respiratory Center in Reticular
Formation of the Brain Stem
Medullary Rhythmicity Center
Controls basic rhythm of respiration
Inspiratory (predominantly active) and
expiratory (usually inactive in quiet
respiration) neurones
Drives muscles of respiration
Pneumotaxic Area
Inhibits inspiratory area
Apneustic Area
Stimulates inspiratory area, prolonging
inspiration
Regulation of Respiratory Center
Chemical Regulation
Most important
Central and peripheral chemoreceptors
Most important factor is CO
2
(and pH)
in arterial CO
2
causes in acidity of
cerebrospinal fluid (CSF)
in CSF acidity is detected by pH sensors
in medulla
Medulla rate and depth of breathing
Regulation of Respiratory Center
Cerebral Cortex
Voluntary regulation of breathing
Inflation Reflex
Stretch receptors in walls of bronchi/bronchioles
Figure 23.27
Respiratory Centers and Reflex Controls
Pulmonary function is affected by lung
resection, extent varies:
pneumonectomy:
FEV
1
: 34~36%
FVC: 36~40%
VO
2
max: 20~28%
lobectomy:
FEV
1
: 9~17%
FVC: 7~11%
VO
2
max: 0~13%
Am J of Med (2005) 118, 578583

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