Full text of "thorax_notes"

Pleura Definition: The pleura is a closed serous sac, which is invaginated by the lung from its medial aspect. Layers of the pleura: The pleura is composed of two layers: 1 ) The outer layer (which lines the thoracic wall from inside) is known as the parietal pleura. 2) The inner layer (which covers the lung) is called the visceral pleura. The visceral and parietal pleurae are continuous together around the root of the lung and the pleura extends downwards as a fold below the root called the pulmonary ligament. The closed cavity between the visceral and parietal pleurae is called the pleural cavity. Visceral pleura The inner layer of the pleura that Covers the surfaces of the lung and lines its fissures. It is absent in the hilum of the lung and between the two layers of the pulmonary ligament. Parietal pleura Is the layer of the pleura that lines the chest wall and covers the mediastinum. Parts of the parietal pleura: The parietal pleura is divided into four parts: costal, cervical, mediastinal and diaphragmatic. 1) Costal pleura: It is the part of the parietal pleura lining the sternum, ribs, costal cartilages, intercostal spaces and sides of the vertebral column. It is continuous with the mediastinal pleura at the costomediastinal reflection and with the diaphragmatic pleura at the costodiaphragmatic reflection. 2) Cervical pleura: It is the part of the parietal pleura, which covers the apex of the lung. It is attached above by the suprapleural membrane. Relations of the cervical pleura: The summit: is related to: 1 ) The costo-cervical trunk. 2) The suprapleural membrane. Anteriorly: 1 ) The subclavian artery: arched in front of it. 2) The scalenus anterior muscle. 3) The internal mammary artery. Posteriorly ( structures in front of the neck of the 1 st rib): 1 ) The stellate ganglion of the sympathetic trunk. 2) The superior intercostal artery. 3) The first thoracic nerve. Laterally: 1 ) The scalenus medius. 2) The scalenus posterior muscle. Medially: 1 ) The trachea and the esophagus. 2) On the right side: the brachiocephalic artery and the right brachiocephalic vein. 3) On the left side: the left subclavian and left brachiocephalic vein. 3) Diaphragmatic pleura: Is the part of the parietal

pleura covering the upper surface of the diaphragm. 4) Mediastinal pleura: Is the part of the parietal pleura, which covers the sides of the mediastinum. Relations: it is related to: On the right side (right side of mediastinum): 1 ) The right brachiocephalic vein. 2) The upper half of the superior vena cava. 3) The terminal part of the azygos vein. 4) The right phrenic nerve. 5) The right vagus nerve. 6) The trachea. 7) The esophagus. 8) The pericardium and right atrium. On the left side (left side of mediastinum): 1 ) The left brachiocephalic vein. 2) The left superior intercostal vein. 3) The left common carotid and left subclavian arteries. 4) The left phrenic nerve. 5) The left vagus nerve. 6) The thoracic duct. 7) The arch of the aorta. 8) The pericardium and the left ventricle. 9) The esophagus. *** Pleura I recesses: d Definition: Narrow extensions of the pleural cavity. d Function: Allows the lungs to expand during deep inspiration. d Site: 1 ) Costomediastinal recess: lies between the costal and mediastinal pleura along the anterior margin of the pleura. 2) Costodiaphragmatic recess: lies between the costal and diaphragmatic pleura along the inferior margin of the pleura. 3 M"Nerve supply: A. Visceral pleura: the sympathetic nerves (pain insensitive). B. Parietal pleura: the intercostal and phrenic nerves (pain sensitive). Arterial supply: A. Visceral pleura: the bronchial artery. B. Parietal layer: a. The intercostal arteries. b. The musculophrenic artery. c. The internal thoracic artery. Venous drainage: A. Visceral layer: the bronchial vein. B. Parietal layer: a. The intercostal veins. b. The musculophrenic vein. c. The internal thoracic vein. Lymph drainage: A. Visceral layer: drains into the bronchopulmonary lymph nodes. B. Parietal layer: drains into: a. The intercostal lymph nodes. b. The internal thoracic lymph nodes. c. The posterior mediastinal lymph nodes. d. The diaphragmatic lymph nodes. 44*Surface anatomy of the pleura. A. The cervical pleura: it is represented by a curved line, one inch above the medial third of the clavicle. B. The anterior border of the pleura : Begins as a straight line extending downwards and medially from the summit and passing to the sternoclavicular joint then to the

sternal angle (2 nd costal cartilage) where it meets the anterior margin of the opposite side. Then, it extends in the middle line from the sternal angle to the fourth costal cartilage where it. differs in both sides: 1. On the right side: Descends vertically in the median plane to the xiphisternal junction where it is continuous with the inferior border. 2. On the left side: Deviates laterally to the margin of the sternum down to the sixth costal cartilage. C. The inferior border of the pleura: The inferior border begins at the sixth costal cartilage (on the right side) or the xiphisternal joint (on the left side). It, then, passes laterally, to cut the eighth rib in the midclavicular line and the tenth rib in the mid-axillary line and twelfth ribs close to the vertebral column. D. The posterior border of the pleura: It extends upwards along the vertebral column from the medial end of the inferior border to the summit of the pleura. Lungs Definition: The main respiratory organ for the exchange of the C0 2 and 2 between the air and the blood. Site: Situated in the pleural cavity and is separated by the mediastinum from the lung of the opposite side. Shape: Each lung is conical in shape. It has an apex, base, two surfaces (costal and medial) and three borders (anterior, posterior and inferior). How to identify the lung right or left: 1. Superiorly: the apex is directed upwards. 2. Inferiorly: the base is broad and concave and is directed downwards. 3. Anteriorly: the anterior border is thin and sharp. 4. Posteriorly: the posterior border is thick and rounded. 5. Medially: the medial surface contains the hilum. 6. Laterally: the lateral (costal) surface is convex. I. Apex: It is the rounded upper end of the lung. It projects upwards through the thoracic inlet into the root of the neck. The apex lies at the level of the neck of the 1 st rib (posteriorly) and at about one inch above the medial third of the clavicle (anteriorly). The apex is covered by the cervical pleura and the suprapleural membrane. It is grooved anteriorly by the subclavian artery. The relations of the apex of the lung are the same as the cervical pleura. Base: - Is the concave lower surface. - Rests on the convex upper surface of the diaphragm. - The diaphragm separates the base of the lung from: 1 ) The right lobe of the liver

(right lung). 2) The left lobe of the liver, fundus of the stomach and spleen (left lung). - The concavity of the base is deep on the right lung as the right cupula of the diaphragm bulges more upwards than the left lung because the presence of the liver. - The sharp margin of the base expands downwards into the costodiaphragmatic recess. III. Surfaces of the lung: A. Costal surface: This surface is related to the sternum, costal cartilages, ribs, intercostal muscles and sternocostalis muscle. B. M>*Medial surface: It is divided into: 1. The vertebral part: Lies behind the hilum and related to the sides of the vertebral bodies, intervertebral disc, posterior intercostal vessels, sympathetic trunk and splanchnic nerves. 2. The mediastinal part: is the anterior part and it differs between the right and left lungs. Mediastinal surface of the right lung: It shows the following features: 1) Hilum of the lung: - Is the part of the medial surface of the lung, which gives passage to the structures forming the root of the right lung. - It shows a cut section of the principle bronchus, the pulmonary artery and the two pulmonary veins. 2) Pericardial impression: - Is the wide depression in front of the hilum and the pulmonary ligament. Related to the pericardium and the right atrium. 3) Impression for the inferior vena cava: - Is the small area posterior to the pericardial impression. - Related to the inferior vena cava. 4) Impression for the superior vena cava, right brachiocephalic vein and the vagus nerve: - Is a shallow vertical groove, in front of the upper part of the hilum. Is continuous upwards with the groove for the right brachiocephalic vein. 5) Groove for the arch of the azygos vein: Is a distinct groove above the hilum. 6) Groove for the azygos vein: It is a shallow groove behind the impression for the esophagus. 7) Impression for the trachea and the right vagus nerve: - Lies behind the groove for the superior vena cava and above the arch of the azygos vein. 8) Impression for the esophagus: Is a vertical groove present on the most posterior part of the mediastinal surface. N.B. The esophagus is related to the right lung in the following sites: 1. Behind the hilum. 2. Behind the pulmonary ligament. 3. Behind the groove of the trachea above the arch of the azygos vein Mediastinal surface of the left lung: 1)

Hilum of the lung: Is the part of the medial surface of the lung, which gives passage to the structures forming the root of the right lung. It shows a cut section of the principle bronchus, the pulmonary artery and the two pulmonary veins. 2) Pericardial impression: Is the wide depression in front of the hilum and the pulmonary ligament. Related to the pericardium, left ventricle, left auricle and part of the right ventricle. 3) Impression for the pulmonary trunk and remains of the thymus gland: It lies above the pericardial impression and in front of the upper part of the hilum. 4) Groove for the arch of the aorta: Welldefined groove above the hilum. Also, related to the structures on the left side of the arch (left vagus and left phrenic nerves and left superior intercostal vein). 5) Groove for the descending aorta: Is a large groove behind the hilum and the pulmonary ligament. 6) Groove for the left subclavian and left common carotid arteries: The groove for the left common carotid artery lies in front of and parallel to the groove for the left subclavian. 7) The left phrenic nerve: Passes between the grooves for the left common carotid and left subclavian. 8) Impressions for the esophagus, thoracic duct and left recurrent laryngeal nerve: The esophagus forms narrow vertical area behind the groove for the left subclavian artery and a groove in front of the descending aorta. Fissures of the lung The left lung has only one fissure (oblique) dividing it into upper and lower lobes. The right lung has two fissures (oblique and horizontal) into three lobes (upper, middle and lower). 1. The oblique fissure: - Begins at the posterior border 2.5 inches below the apex (opposite the third thoracic spine) 1 inch from the median plane. Extends downwards and forwards. - Cuts the inferior border of the lung opposite the sixth costo-chondral junction. - In the left lung, the oblique fissure separates the upper from the lower lobes. - In the right lung, the oblique fissure separates the upper and middle lobes, above from the lower lobe, below. 2. Horizontal fissure: - Extends from the anterior border of the right lung at the level of the fourth costal cartilage to meet the oblique fissure in the midaxillary line. Root of the lung Definition: Is the connection between the medial surface of the

lung and both the heart and the trachea. Site: Lies opposite the bodies of the 5-7 thoracic vertebrae. Relations of the root of the lung: A. Root of the right lung: (see the mediastinal surface of the lung) Above: arch of the azygos vein. Below: the pulmonary ligament. In front: 1) Superior vena cava. 2) Right phrenic nerve and the pericardiacophrenic vessels. 3) Part of the right atrium. 10 Behind: 1) Right vagus nerve. 2) Upper part of the azygos vein. B. Root of the left lung: (see the mediastinal surface of the lung) Above: arch of the aorta. Below: the pulmonary ligament. In front: left phrenic nerve and the pericardiacophrenic vessels. Behind: left vagus nerve and descending aorta. Contents of the root of the lung: 1. Bronchus: Site: Occupies the most posterior position in the hilum. How to identify the bronchus: it is identified by its posterior position and the presence of cartilage rings in its wall. Divisions of the bronchus: 1. The left principle bronchus: usually divides after entering into the lung. 2. The right principle bronchus: usually divides before entering into the lung, giving two branches, which can be identified in the hilum of the right lung: a. The upper branch (eparterial bronchus): It lies above the level of the pulmonary artery. b. The lower branch (hyparterial bronchus): It lies below the level of the pulmonary artery. 2. Pulmonary artery: Origin: Is a branch of pulmonary trunk. Site: - On the left side: it is more anterior and at a higher level in relation to the left bronchus. - On the right side: it lies in front and in between the two branches of the right bronchus. 11 3. Pulmonary veins: Number: Two pulmonary veins in each side: Site: - The superior pulmonary vein: is the most anterior stricture. - The inferior pulmonary vein: is the most inferior structure. 4. Bronchial vessels: On the left side: are two bronchial arteries. - On the right side: is only one bronchial artery. 5. Broncho-pulmonary lymph nodes: 6. Anterior and posterior pulmonary plexuses: Site: - The anterior pulmonary plexus: lies in front of the root. - The posterior pulmonary plexus lies behind the root. 7. Areolar connective tissue: 8. Pleural forming pulmonary ligam. Intrapulmonary branches of the principle bronchi: Trachea gives 2 principle

bronchi (right and left) each principle bronchus lobar bronchus then segmental bronchus. 1. Right principle bronchus: - Before it enters the hilum, the right principle bronchus gives off the superior and inferior lobar bronchi. - After entering the lung the inferior lobar bronchus divides into the middle lobar bronchus and lower lobar bronchus. a Divisions of the right bronchus: - It divides into 3 lobar bronchi to the 3 lobes of the lung (superior, middle and inferior) which then give off 10 segmental bronchi to the bronchopulmonary segments. 12 I. Superior lobar bronchus: - Is the bronchus of the upper lobe. - Divides into 3 segmental bronchi: apical, posterior and anterior. II. Middle lobar bronchus: -Is the bronchus of the middle lobe. Divides into 2 segmental bronchi medial and lateral. III. Inferior lobar bronchus: -Is the bronchus of the lower lobe. -Divides into apical and 4 basal segmental bronchi: anterior basal segmental bronchus, lateral basal segmental bronchus, medial basal segmental bronchus and posterior basal segmental bronchus. 2. Left principle bronchus: - It has no branches outside the lung - Inside the lung it divides into 2 lobar bronchi (superior and inferior) to the 2 lobes of the lung. d Divisions of the left bronchus: It divides into: - 2 lobar bronchi (superior and inferior) which then give off 10 segmental bronchi \o the bronchopulmonary segments. I. Superior lobar bronchus: - Is the bronchus of the upper lobe. - The segmental bronchi of the upper lobe are 5: apical segmental bronchus, anterior segmental bronchus, posterior segmental bronchus, superior lingular bronchus and inferior lingular bronchus. II. Inferior lobar bronchus: - Is the bronchus of the lower lobe. - The segmental bronchi of the lower lobe are 5: an apical segmental bronchus and 4 basal segmental bronchi: anterior basal segmental bronchus, Lateral basal segmental bronchus, Medial basal segmental bronchus and Posterior basal segmental bronchus. 13 Bronchopulmonary Segments Definition: A bronchopulmonary segment is a functionally independent unit of lung tissue it has its own: 1) segmental bronchus. 2) branch of the pulmonary artery, 3) Radicle of the pulmonary vein 4) Lymphatic vessels. Structures: Each segment contains: 1-A segmental bronchus: is the 3 rd order division of the principle bronchus (principle

bronchus- lobar bronchus- segmental bronchus). It supplies a part of respiratory tissue formed of a number of bronchioles and related alveolar ducts and alveoli. 2-Segmental branches of the pulmonary artery: carry oxygenated blood. 3-Segmental radicles of the pulmonary veins: carry non-oxygenated blood. 4-Lymph vessels: run along the segmental bronchus and the blood vessels. Distribution of the bronchopulmonary segments: Each lung contain 10 segments. Right lung: a. Upper lobe: consists of 3 segments (apical, posterior and anterior). b. Middle lobe: consists of 2 segments (medial and lateral). c. Lower lobe: consists of 5 segments (apical, medial basal, anterior basal, lateral basal and posterior basal). Left lung: a. Upper lobe: consists of 3 segments (apical, posterior and anterior). b. Lingula: consists of 2 segments (superior lingular and inferior lingular). c. Lower lobe: consists of 5 segments (apical, anterior basal, lateral basal, posterior basal and medial basal). However, the medial basal segment is usually absent. 14 Surface Anatomy of the Lung A. Apex: - Is the same in both lungs. (Like cervical pleura). Represented by a curved line convex upwards, one inch above the medial third of the clavicle. B. Borders: 1. Anterior border: a. The right lung: Represented by a line drawn downwards and medially from the apex of the lung, to the right sternoclavicular joint, then to the sternal angle near the midline. - This line then extends vertically downwards to the 6th sternocostal junction near the middle line. b. The left lung: Represented by a line drawn downwards and medially from the apex of the lung, to the left sternoclavicular joint, to the sternal angle near the midline. - This line extends vertically downwards to the 4 th costal cartilage in the midline, where it deviates to the left for 4 cm from the border of the sternum and then descends downwards to the left 6 th costal cartilage 4 cm from the median plane. 2. Inferior border: - Is the same in both lungs. - Runs laterally and backwards round the chest. It cuts the 6 th rib in the midclavicular line, the 8 th rib in the midaxillary line, the 1 th rib 5 cm from the midline of the back. 3-Posterior border: - Is the same in both lungs. - Represented by a vertical line from the

posterior end of the inferior border to the apex of the lung. C. Fissures: 1. Oblique fissure: Presents in both lungs. 15 - Represented by an oblique line 2 cm lateral to the 3rd thoracic spine and runs downwards and laterally to the 6 th costochondral junction 7.5-cm from the median plane. Transverse (horizontal) fissure: - Presents in the right lung only. - Represented by a horizontal line from the right 4 th costal cartilage to the 6 th rib at the midaxillary line. Hilum of the lung: Lies opposite the bodies of the 5 th , 6 th and 7 th thoracic vertebrae. Blood Vessels of the Lung A. The pulmonary vessels: 1. The pulmonary artery: Each lung has one pulmonary artery from the pulmonary trunk It carries venous blood to be oxygenated in the lung. - It, also, supplies the wall of the alveoli and respiratory bronchioles. - In the lung, the artery gives off branches, which accompanies the divisions of the bronchi. 2. The pulmonary vein: - Each lung is drained by two veins. Carry oxygenated blood to the left atrium. The bronchial vessels: 1. The bronchial arteries: d Origin: In the right side: there is only one bronchial artery, which arises from the upper left bronchial artery or from the right third posterior intercostal artery. In the left side: there are two left bronchial arteries from the descending thoracic aorta. d Distribution: The bronchial arteries supply the visceral pleura and the lung except the alveoli and the respiratory bronchioles. 2. The bronchial vein: They end either in the azygos vein or the hemiazygos veins. 16 Nerves of the Lung Distribution: a. Parasympathetic nerves: from the vagus nerves. They supply: 1) Motor to the smooth muscles of the bronchial tree. 2) Secretomotor to the glands of the bronchial tree. b. Sympathetic nerves: from T25. They are: 1) Inhibitory to the smooth muscles of the bronchial tree. 2) Vasomotor to the blood vessels. Lymphatic Drainage of the Lung The walls of the alveoli are devoid of lymph vessels. The lymphatics form: - A superficial lymphatic plexus beneath the pleura. - A deep lymphatic plexus along the bronchial tree and the pulmonary vessels. Both plexuses drain into: 1) Pulmonary lymph nodes, to 2) Bronchopulmonary lymph nodes, to 3) Tracheobronchial lymph nodes, to pretracheal lymph nodes, from them arise the right and left

bronchomediastinal lymph trunks, which open into the junction of the internal jugular and subclavian veins. 17