Thorax and Lungs Learning and Understanding Objectives


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Thorax and Lungs Learning and Understanding Objectives

  1. 1. Thorax and Lungs
  2. 2. Learning and Understanding Objectives • Understand: – Surface anatomy and the relationship of the heart and lungs in the thoracic cavity – Functions of the pleural cavities – Projected placement of the lungs, visceral and parietal pleura using anatomical landmarks – Functions & deformities of the thoracic cage and vertebrae – Relationship of nerves, arteries, and veins – Hierarchy of respiratory system in the thorax – Clinical correlations
  3. 3. C7 Spinous Process (Veterbra Prominens) Vertebral Border of Scapula 12th Rib Inferior Angle of Scapula Surface Anatomy of the Posterior Thoracic Wall Thieme Atlas 4.1A
  4. 4. Thieme Atlas 9.1A Surface Anatomy of the Anterior Thoracic Wall Jugular Notch (T2 Vertebral Level) Clavicle Sternal Angle (T4 Vertebral Level)
  5. 5. Vertebral Levels of Thoracic Landmarks (T2) (T4) (T9)
  6. 6. Visualize Internal Anatomy when Looking at a Patient Figure 21.13a, Marieb R L
  7. 7. The Thoracic Cage 1.) Protects organs and structures of the thorax 2.) Provides stable support for the upper extremity and head 3.) Flexible and can change dimensions during ventilation Thieme Atlas 5.1A T2 T4 T9
  8. 8. Thieme Atlas 5.3 False Ribs (8-10) Attach to the 7th costal cartilage ThreeTypes of Ribs True Ribs (1-7) Attach directly to the sternum Floating Ribs (11-12) No anterior attachment
  9. 9. Anatomy of a Typical Rib
  10. 10. The Sternum A blade-like bone with three parts: Manubrium Body Xiphoid process It articulates with the clavicle and ribs 1 -7 Has several important landmarks
  11. 11. Thoracic Vertebrae 1.) Protects organs and structures of the thorax 2.) Protects and houses spinal cord 3.)Support structure for the thorax and articulates with the ribs 4.) Flexible Thieme Atlas 5.1C
  12. 12. Thoracic Vertebrae [ We’ll study these in the lab]
  13. 13. Three Joints of Thoracic Cage
  14. 14. Joints of Thoracic Cage Marieb, Fig 7.20 a & b
  15. 15. Movements of the Ribs
  16. 16. Thorax Cage Articulates with the Shoulder Girdle Thieme, Fig 5.5A
  17. 17. Ratio of Anterior-Posterior Diameter : Transverse Diameter Post. Ant. Children (< 6yrs old) 1:1 Adults (> 6yrs old) Between 1:1.4 - 1:2
  18. 18. Physical Examination and Health Assessment, Table 18-3 Jarvis 2008 Normal Kyphosis* Scoliosis* Pectus Carinatum Pectus Excavatum Barrel Chest*
  19. 19. Thieme 5.26 Anterior Thoracic Wall Muscles
  20. 20. Pectoralis Major Look for this in Lab From A.D.A.M. Interactive Anatomy
  21. 21. Pectoralis Minor From A.D.A.M. Interactive Anatomy Look for this in Lab
  22. 22. From A.D.A.M. Interactive Anatomy Serratus Anterior
  23. 23. External Intercostals (Inspiration) Internal Intercostals (Forced Expiration) Muscles of Respiration
  24. 24. Depress ribs (Contract thoracic cavity) Elevate ribs (Expand thoracic cavity) Action of the Intercostal Muscles
  25. 25. R L Diaphragm Major Muscle of Inspiration -Innervated by the Phrenic Nerve C3, C4, C5 “C3, 4 & 5 keeps the diaphragm alive” Muscles of Respiration
  26. 26. Diaphragm: Inferior view Caval aperture Psoas major aortic aperture esophageal aperture right crus left crus Quadratus lumborum central tendon
  27. 27. Inspiration Marieb 21.16d Diaphragm flattens External intercostals contract to raises the ribs Volume of thoracic cavity increases Decreases internal gas pressure Deep inspiration also requires: Scalenes, pectoralis minor, sternocleidomastoid, and serratus posterior superior all help to elevate the ribs Erector spinae – extends the back
  28. 28. Expiration Marieb 21.16d Diaphragm and Ext. Intercostals relax Volume of thoracic cavity decreases Increase in internal gas pressure Normally Passive Little or no muscle contraction Little or no nerve stimulation of muscles Forced Expiration Internal intercostals m. contract to depress ribs
  29. 29. Respiration can be aided by the abdominal wall muscles
  30. 30. Thieme 6.4B Arteries of the Posterior Thoracic Wall Intercostal arteries Thoracic aorta
  31. 31. Thieme Fig 5.17 pg 56 Arteries of the Thoracic Wall Intercostal a. 2nd Intercostal a. Subclavian a. Internal thoracic a. Internal thoracic a.
  32. 32. Thieme 5.19A Veins of the Thoracic Wall Hemiazygos v.. 3rd Intercostal v. Accessory Hemiazygos v. Intercostal v.. Subclavian v. Internal thoracic vv. Azygos v.
  33. 33. - supply intercostal muscles, abdominal muscles, and skin of thorax & abdomen - major pathway for the sympathetic division of the autonomic nervous system - supply visceral organs. Nerves of the Posterior Thoracic Wall
  34. 34. Intercostal VAN (Vein, Artery, Nerve)
  35. 35. Thoracic Cavity
  36. 36. 3 Compartments of the Thorax (Heart) (Great Vessels)
  37. 37. Superior Thoracic Aperture (Thoracic Outlet ) The apex of the each lung extends above the first rib.
  38. 38. The diaphragm attaches at the inferior border of the ribs, sternum and the body of vertebra T12.. Inferior Thoracic Aperture
  39. 39. rib Visceral Pleura [on the surface of the lung itself] Pleural Membranes Secrete serous fluid – Allows for smooth breathing Pleural cavity Potential space between the visceral and parietal pleurae Surface Tension between parietal and visceral pleura keeps the lungs ‘stuck’ to the thoracic wall during respiration – Necessary for proper ventilation Parietal Pleura
  41. 41. Parietal Pleura: four parts cervical mediastinal diaphragmatic costal
  42. 42. • A Vacuum Seal Makes Ventilation Work
  43. 43. Anterior PosteriorLateral Midclavicular Midaxillary Paravertebral Lung 6th rib 8th rib 10th rib Pleura 8th rib 10th rib 12th rib Thieme Atlas, pg 102 At the edges of the thoracic cavity the pleura extend lower than the lungs to form the Pleural Gutter
  44. 44. Pneumothorax – Air in the pleural cavity Damage to visceral or parietal pleura can cause air to leak into the pleural cavity. Causes: a penetrating wound, infection, cancer, asthma, Treatment : treat wound, chest tube, thorascopic surgery
  45. 45. Pnemothorax can cause the affected lung to collapse leading to difficulty breathing, cyanosis, and possible shifting the placement of the heart.
  46. 46. Hemothorax - Blood in the pleural cavity • difficult ventilation • painful breathing, cyanosis, tachycardia • causes – trauma resulting in rupture of pleura • treatment — remove source of bleeding, drain blood, thrombolytic agents
  47. 47. • painful breathing, cough, fever, chills • causes: infection, heart surgery, autoimmune, cancer • treatment: drain fluid, anti- inflammatory, antibiotics, cancer treatment Pleurisy (Pleuritis) – Inflammation of the pleura
  48. 48. Thieme Cl. 5.200A Thoracentesis Procedure to remove excess fluid from the pleural space Most easily done from the back where the pleural gutter is deepest and the neurovascular bundle is closer to the inferior edge of the rib.
  49. 49. Thieme Cl. 5.200A Chest Tube Placement To remove air or large amounts of fluid from the pleural space. Common emergency procedure Most commonly done along the mid-axillary line between the 4th and 5th ribs
  50. 50. SUP MIDDLE INF SUP INF R L 3 Lobes 2 Lobes Figure 21.8 Marieb Lungs
  51. 51. Lobes Divided into 10 Bronchopulmonary Segments on each Side Don’t need to name them individually
  52. 52. Lungs Projections on chest Inferior is posterior Superior lobe is mostly anterior Middle is lateral
  53. 53. Thieme Atlas fig 8.4 R L Lungs in situ ( Heart removed)
  54. 54. Hilum—where air and blood enter and leave Arteries are up high. Bronchi are posterior and near the top. Veins tend to be more anterior and inferior.
  55. 55. Superficial lungs: lateral view apex lingula superior lobe horizontal fissure inferior lobe oblique fissure middle lobe right lung left lung
  56. 56. Medial Views of the Lungs groove for azygos vein right pulmonary arteries bronchii diaphragmatic recess right pulmonary veins cardiac impression groove for esophagus groove for aorta left pulmonary arteries left pulmonary veins
  57. 57. Oral Cavity Nasal Cavity Pharynx Larynx Trachea* Lungs* Respiratory System
  58. 58. Respiratory System—Two Zones • Conducting zone – Rigid conduits (pipes) for air to reach the sites of gas exchange – Includes the nose, nasal cavity, pharynx, trachea, and bronchi. • Respiratory zone – Site of gas exchange – Consists of terminal bronchioles, alveolar ducts, and alveoli
  59. 59. The Bronchial Tree One main trunk = Trachea Two Primary bronchi = One left, one right Secondary or lobar bronchi = 3 on right, 2 on left Tertiary to bronchopulmonary segments = 10 each
  60. 60. Trachea thyroid cartilage right main bronchus left main bronchus tracheal bifurcation Anterior View
  61. 61. Trachea membranous wall with tracheal glands carina mucosa cricoid cartilage tracheal cartilage Trachea bifurcates into two primary bronchi Carina at the bifurcation and is very sensitive to irritants – cough reflex Posterior view
  62. 62. Hyaline Cartilage Post. Ant. Psudostratified columnar Epithelium (ciliated) Figure 21.7, Marieb •Has 16-20 C-shaped rings of Hyaline Cartilage •Functions to protect airway •Prevent collapse of airway during breathing •Pseudostratified columnar epithelium •Ciliated to propel debris to the pharynx Trachea
  63. 63. Respiratory Segment Pulmonary Alveoli Thieme Atlas fig 8.12 Terminal Bronchioles
  64. 64. Where the gas exchange takes place between the outside world and the inside world -- blood Figure 21.8a Respiratory Zone 300 million Alveoli – external to your body A potential site of invasion—bacteria, smoke, particles, gases.
  65. 65. Respiratory Membrane Figure 21.9.c, d
  66. 66. Respiratory Centers in the Brainstem Pontine Respiratory Center Medullary Respiratory Centers
  67. 67. Autonomic Innervation of the Respiratory System • parasympathetic innervation is from the vagus (CN X) • sympathetic innervation is from sympathetic trunk ganglia
  68. 68. Clinical Correlation - Lungs
  69. 69. Lung Compliance = Stretchability • The ease with which the lungs can expand, (change in lung volume for a given change in pressure) • Determined by two main factors – Distensibility of the lung tissue and surrounding thoracic cage, disease can diminish compliance, but emphysema can increase compliance. – Surface tension at the air-water interface in the alveoli. Surfactant reduces the surface tension allowing the alveoli to expand more easily.
  70. 70. COPD (Chronic obstructive pulmonary disease) Hard to breath—Accessory muscles for forced inspiration and expiration. May involve emphysema—Need forced expiration Figure 21.28 Muscles work more: External Intercostals and diaphragm. Accessory muscles: Sternocleidomastoid, Scalenes, Serratus posterior superior Patient may lean on table to elevate chest (tripod posture).
  71. 71. Pneumonia • inflammation of aveoli causes build up of fluid in the lungs • causes – virus, fungi, bacteria • treatment — antibiotics, antivirals
  72. 72. Tuberculosis • infectious disease caused by the bacterium mycobacterium tuberculosis • symptoms include fever, night sweats, weight loss, a racking cough, and splitting headache • treatment — 12-month course of antibiotics
  73. 73. Emphysema • The walls of the alveoli begin to breakdown. Alveoli lose their elasticity – increase in lung compliance • shortness of breath - difficult to remove air from the lungs – Continual forced expiration • causes – typically smoking • treatment — irreversible, stop smoking, anticholinergics, lung volume reduction surgery, lung transplant
  74. 74. Lung Cancer • About 1/3 of all cancer deaths in the u.s. • 90% of all patients were smokers • Three most common types are: * squamous cell carcinoma (20-40% of cases) arises in bronchial epithelium * adenocarcinoma (25-35% of cases) originates in peripheral lung area * small cell carcinoma (20-25% of cases) lymphocyte-like cells that originate in the primary bronchi and subsequently metastasize • Treatment — chemotherapy, radiotherapy surgery (removal of sections of or whole lung
  75. 75. Asthma • characterized by dyspnea (trouble breathing), wheezing, and chest tightness • active inflammation of the airways precedes bronchospasms (mast cells, allergies) • airway inflammation is an immune response caused by release of products that stimulate IgE and recruit inflammatory cells • airways thickened with inflammatory exudates magnify the effect of bronchospasms • treatment – bronchodilators (inhalers, spacers), intubation, steroids, mechanical ventilation in cases of extreme attack
  76. 76. Respiratory Centers in the Brainstem Pontine Respiratory Center Medullary Respiratory Centers
  77. 77. Autonomic Innervation of the Respiratory System • parasympathetic innervation is from the vagus (CN X) • sympathetic innervation is from sympathetic trunk ganglia