Respiratory system II. - Univerzita Karlovaanatomie.lf3.cuni.cz/centralni_prezentace/Dychani2_eng.pdfPulmo dexter, lobus superior Segmentum apicale [S I] Segmentum posterius [S II]

Respiratory system

II.

© David Kachlík 30.9.2015

Anatomical division

• upper respiratory tract

– nasal cavity

– paranasal cavities

– nasopharynx

• lower respiratory tract

– larynx

– trachea

– tracheobronchial tree

– respiratory compartment


Anatomical

division


– nasal cavity


– nasopharynx


– larynx

– trachea



Surgical division


– nasal cavity


– nasopharynx

– larynx


border: apertura thoracis sup.

– trachea




General structure of respiratory system wall

• tunica mucosa (mucosa)– epithelium

- ciliated pseudostratified columnar (respiratory epithelium)

- non-keratinized stratified squamous

- lamina basalis

– lamina propria

• glands (seromucinous tuboalveolar), lymph nodes (noduli lymphoidei)

• tunica fibromusculocartilaginea– collagenous and elastic tissue (and its ligaments – larynx, trachea)

– smooth muscles (trachea, bronchi, bronchioli)

– skeletal muscles (larynx)

• tunica serosa or tunica adventitia– tunica serosa (pleura) has three layers:

• mesothelium

– lamina basalis

• lamina propria

• tela subserosa © David Kachlík 30.9.2015


Trachea

• pars cervicalis (C6- C7)

• pars thoracica (T1-T4)

newborn at the level of C4, child C5

• bifurcatio tracheae (T4)

= 1st branching of tracheobronchial tree

• carina tracheae

• calibers: length 10-11 cm, width 25 mm

• syntopy: ventrally thyroid gland, dorsally

oesophagus © David Kachlík 30.9.2015

TRACHEA

Pars cervicalis

Pars thoracica

Cartilagines tracheales

M. trachealis

Ligg. anularia / trachealia

Paries membranaceus

Bifurcatio tracheae

Carina tracheae


Endoscopy view of trachea


Trachea – supply

• Arteries:– a. thyroidea inf. → rr. tracheales

– aorta thoracica → rr. bronchiales

– (a. thyroidea ima – 2 %)

– newborns and children – branches from thymus arteries

• Veins:– drain into oesophageal veins, into plexus thyroideus

impar and into v. brachiocephalica sin.

• Lymph:– nodi tracheobronchiales, nodi tracheales → truncus

bronchomediastinalis dx.+ sin.

• Nerves:– n. vagus → n. laryngeus recurrens

– truncus sympathicus© David Kachlík 30.9.2015


Coniotomy (coniopuncture)

emergency procedure in outdoor (rare)

transversal section between cartilago thyroidea et

cricoidea through lig. cricothyroideum medianum

Approach passes through following layers:

• skin + subcutaneous tissue

• lamina superficialis fasciae cervicalis

• lamina pretrachealis fasciae cervicalis

• lig. cricothyroideum medianum + mucosa

!Cave! – interconnection of rr. cricothyroidei a.

laryngeae superioris below cartilago thyroidea

– lobus pyramidalis glandulae thyroideae (40%)© David Kachlík 30.9.2015


Tracheotomysagittal section for canylation through several tracheal

cartilages (done in hospital)

• tracheostomia superior– above isthmus glandulae thyroideae (in the extent of cartilago

trachealis 2-4)

• tracheostomia inferior– below isthmus, above incisura jugularis

Approach passes through following layers:

• skin + subcutaneous tissue

• lamina superficialis fasciae cervicalis

• venous arcus venosus jugularis (only in lower tracheotomy)

• lamina pretrachealis fasciae cervicalis + cutting through midline fibrous connection of both mm. sternohyoidei

(only in lower tracheotomy)

• venous plexus thyroideus impar (only in lower tracheotomy)

• cartilagines tracheales + ligg. anularia + mucosa© David Kachlík 30.9.2015

• coniotomy

• upper

tracheotomy

• lower

tracheotomy


Tracheotomy – risks

bleeding from:

• plexus thyroideus impar

• a. thyroidea ima (2%)

• arcus venosus jugularis

• lobus pyramidalis glandulae thyroideae

(40%)


Trachea – wall structure

• epithelium of respiratory tract

• glandulae tracheales – seromucous glands

• cartilagines tracheales (15-20)

– C-shaped rings

• ligg. anularia / trachealia

• paries membranaceus – dorsal wall

• m. trachealis – smooth (horizontal as well as

longitudinal fibers)

• adventicia on the surface© David Kachlík 30.9.2015



Tracheobronchial tree (Arbor bronchialis)

23 divisions – dichotomic branching

• primary bronchi (bronchus pricipalis dx.+ sin.)

– right: shorter, wider, straighter foreign body enters in

75% into the right one

• secondary bronchi (bronchi lobares)

– 2 left and 3 right

• tertiary bronchi (bronchi segmentales)

– 8 on the left and 10 on the right

• left: 1+2 connected, 7+8 connected in 90%

• exception: 6th bronchus segmentalis of both sides

branches in trichotomic way!© David Kachlík 30.9.2015


Tracheobronchial tree (Arbor bronchialis)

• bronchi 4th order (bronchus subsegmentalis):

b = ventral, a = dorsal

• bronchi 5th order: ii = ventral, i = dorzal

• bronchi 6th order: β = ventral, α = dorzal

• terminal bronchioli (bronchiolus terminalis)

= 14th-16th order (originate by 14th division)

1 bronchiolus terminalis = 1 secondary pulmonary lobulus (visible on the lung surface)

alveolar tree (originate by 17th branching)© David Kachlík 30.9.2015

Bronchi (Bronchi)

tunica mucosa:

• epithelium of respiratory tract

pseudostratified columnar with cilia

• seromucous glands

tunica fibromusculocartilaginea:

• cartilages have irregular shape (more peripheralydisappear)

• smooth muscle – spiral (more peripheralyincreases)

• nodes of lymphoid tissue – at the branching© David Kachlík 30.9.2015


Bronchioli (Bronchioli)

• caliber < 1 mm

• epithelium changes into simple cuboidal

• exocrinocyti bronchiolares (Clara cells)

– produce constituents of surfactant, lysosomal

activity, mitotic activity

• no cartilage, glands and lymph nodes

• increase of elastic fibers

• 1 bronchiolus terminalis = 1 secondary

pulmonary lobule© David Kachlík 30.9.2015


Lungs (Pulmo)

description: basis, apex

• facies costalis (+ pars vertebralis)

• facies mediastinalis (+ impressio cardiaca)

• facies diaphragmatica

• (facies interlobaris)

• margo anterior (incisura cardiaca p.sin.)

• margo inferior

• hilum pulmonis, radix pulmonis

• fissura obliqua, fissura horizontalis p. dx.

• impressions© David Kachlík 30.9.2015

RIGHT LUNG LEFT LUNG


Lungs – division

• hilum (clinically hilus)

– structures: left „ABV“ - right „BAV“

• right lung – 3 lobes (sup., middle, inf.)

• left lung – 2 lobes (sup., inf.)

– lingula p. sin.

• segments (segmenta bronchopulmonalia)

– 10 on the right

– 10 on the left (sometimes 8)

• I+II fused, VII missing in 90%© David Kachlík 30.9.2015

HILUM PULMONISLeft lung Right lung

B

A

V

A

B

V


Lungs – impressions• sulcus arteriae subclaviae (facies mediastinalis)

• impressio costae primae (margo anterior)

• impressiones costarum (facies costalis)

• impressio cardiaca (facies mediastinalis)

Left lung: all on facies mediastinalis

• sulcus aorticus

• impressio oesophagea

• sulcus venae brachiocephalicae sinistrae

Right lung: all on facies mediastinalis

• sulcus venae cavae superioris

• sulcus venae azygos (!correctly s.v. azygoi !)

• sulcus oesophageus© David Kachlík 30.9.2015

Segments

right lung (apalmsmalp) left lung (apasismalp)

Abb. Segmentum No. of

segment

Lobe

AP apico-

posterious

I + II upper

A anterius III

S lingulare

superius

IV

I lingulare

inferius

V

S superius VI lower

M basale

mediale

VII

A basale

anterius

VIII

L basale

laterale

IX

P basale

posterius

X

Abb. Segmentum No. of

segment

Lobe

A apicale I upper

P posterius II

A anterius III

L laterale IV middle

M mediale V

S superius VI lower

M basale

mediale

VII

A basale

anterius

VIII

L basale

laterale

IX

P basale

posterius

X© David Kachlík 30.9.2015

Lung segments


Segmenta bronchopulmonalia

Pulmo dexter, lobus superior

Segmentum apicale [S I]

Segmentum posterius [S II]

Segmentum anterius [S III]

Pulmo dexter, lobus medius

Segmentum laterale [S IV]

Segmentum mediale [S V]

Pulmo dexter, lobus inferior

Segmentum superius [S VI]

Segmentum basale mediale;

Segmentum cardiacum [S VII]

Segmentum basale anterius [S VIII]

Segmentum basale laterale [S IX]

Segmentum basale posterius [S X]© David Kachlík 30.9.2015

Segmenta bronchopulmonalia

Pulmo sinister, lobus superior

Segmentum apicoposterius [S I+II]

Segmentum anterius [S III]

Segmentum lingulare superius [S IV]

Segmentum lingulare inferius [S V]

Pulmo sinister, lobus inferior

Segmentum superius [S VI]

Segmentum basale mediale;

Segmentum cardiacum [S VII]

Segmentum basale anterius [S VIII]

Segmentum basale laterale [S IX]

Segmentum basale posterius [S X]© David Kachlík 30.9.2015

Blood supply of lungs – functional circuit

• right heart ventricle (deoxygenated blood) → truncus pulmonalis → arteria pulmonalis dx.+ sin. →branching correspond to bronchi– left hyparterial bronchus, right eparterial bronchus

• elastic arteries– low-pressure vasculature 25/5 Torr

– smooth muscle cells in fetus, in adults since < 1 mm

→ capillaries (continuous) → oxygenated blood

→ venules independent on arteries in septa between lobules

→ 4 venae pulmonales (2 right and 2 left) → left heart atrium



http://www.biosbcc.net/doohan/sample/index.htm

http://www.biosbcc.net/doohan/sample/index.htm

Blood supply of lungs

functional circuit

• arterio-venous anastomoses

• arterio-arterial anastomoses

• veno-venous anastomoses

• during hypoxia fastly growing arterial

smooth muscle → hypertrophy of right

ventricle


Vascular supply of lungs – nutritive circuit

• aorta thoracica → rami bronchiales

– 1 right – usually from a. intercostalis tertia

– 2 left – directly from thoracic aorta

→ along bronchi as far as bronchioli respiratorii

– (rami bronchiales accessorii within lig. pulmonale)

• venae bronchiales

– deep system opening into vv. pulmonales

– superficial system drains blood from extrapulmonary

bronchi, pleura and hilar lymphnodes → vv.

pulmonales or v. azygos / hemiazygos accessoria© David Kachlík 30.9.2015

Lungs – lymph drainage

• superficial subpleural plexus

• deep plexus around bronchi and vessels

Lung alveoli have no lymph vessels in their walls

• nodi lymphoidei intrapulmonales → n.l. bronchopulmonales → n.l. tracheobronchiales inferiores (both lungs except of three left upper segments I+II, III) → n.l. tracheobronchiales sup. dx. → truncus bronchomediastinalis dx. →angulus venosus dx. → v. brachiocephalica dx.

I+II, III segments on the left – directly into n.l. tracheobronchiales sin. → truncus bronchomediastinalis sin. → ductus thoracicus →angulus venosus sin. → v. brachiocephalica sin.© David Kachlík 30.9.2015


Lungs – innervation

• nn. vagi both sides

viscerosensory + autonomic

parasympathetic stimuli

• truncus sympathicus

autonomic sympathetic stimuli


Tracheobronchial tree (Arbor alveolaris)

• dichotomic

branching

• from bronchioli

respiratorii

onwards

• 17th-23rd order

• functionally

respiratory

compartment© David Kachlík 30.9.2015

Tracheobronchial tree (Arbor alveolaris)• respiratory bronchioles (bronchioli respiratorii)

17th-19th order (originating by 17th branching) – pulmonary alveoli evaginate from their walls

– 19th order forms lobulus pulmonis primarius (8 primary lobuli together form one secondary)

• alveolar ducts (ductus alveolares)

20th-22nd order– pulmonary alveoli evaginate from their walls

– at the end of 3rd orderalveolar duct there is atrium(atrium), divided by last, 23rd branching into two:

• alveolar saccules (sacculi alveolares)

23rd order– evaginate only into:

• pulmonary alveoli (alveoli pulmonis)© David Kachlík 30.9.2015

Respiratory bronchioli

Bronchioli respiratorii

• diameter < 0,3 mm

• simple ciliated cuboidal epithelium

• branching of pulmonary alveoli

• continue into alveolar ducts



Lung alveoli

Alveoli pulmonis

• 200 μm size, polyedric, thin-walled

• alveolar mucosa = respiratory epithelium

• alveolar septum

• alveolar pores (Kohn)


Alveolar mucosa• pneumocytus typus I (pneumocyte type I,

type I alveolar cell; membranous p.)• 95% of mucosa

• flat, thin (25 nm)

• organels around nucleus

• pinocytic vesicles

• pneumocytus typus II (pneumocyte type II, type II alveolar cell; granular, spetal, great alveolar cells)

• ovoid shape with microvilli

• secretory structure (Mit, GER, GA)

• lamellar bodies (1,5 μm) = surfactant

• proliferate and differentiate (recovery of mucosa)© David Kachlík 30.9.2015


Interalveolar septum

Septum interalveolare

• cells• fibroblasts (collagen type I and III) – septum cells

• endothelial cells of capillaries

• alveolar macrophages (macrophaygocyti alveolares)

• reticular and elastic fibers

• alveolar pores (pori septales) – 10 μm



Blood – air barrier

(Claustrum aerosanguineum)

• alveolar component (alveolar cell layer, lamina

pneumocytica)

– pneumocytes type I

• basal lamina (lamina basalis)

• endothelial layer (lamina endotheliocytica)

– endothelial cells of capillaries

• Whole respiratory surface of lungs = 140 m2

(almost two volleyball grounds )


Surfactant (Surfactantum)

(alveolar „lining complex“)

• surface-active-agent

• lowers surface tension of pulmonary alveoli

• prevents from collapsing during expiration

• watery hypophasis and lipid epiphasis

(dipalmitoyl lecithin)

• resorption and recovery by alveolar cells

• enters into respiratory tract →

bronchoalveolar fluid © David Kachlík 30.9.2015

Defense mechanisms

• nasal apertures – mucus, nasal cartilages, hairs of veostibule of nose (vibrissae)

• ciliated epithelium (mucocilliary transport)

• alveolar macrophages (= dust cells)

• lymph nodes in the wall

• intra-epithelial dendritic cells

• T and B lymfocytes (IgA)

• antimicrobial substances in mucus (lysosym, defensins, surfactant protein A,D)


Lungs – clinical examination

• inspection, percussion, auscultation,

palpation

• X-ray, CT

• bronchoscopy (rigid, flexibile)

• bronchography

• spirometry (vital capacity of lungs)


A-P and lateral X-ray of lungs


CT

of

thorax


Bronchogra

m

Bronchogram© David Kachlík 30.9.2015

Lungs – clinical units

• atelectasis

• embolia

• bronchiectasis

• fibrosis

• lung oedema

• RDS (IRDS), ARDS

• emphysema

• tumors, inflammations (e.g. TBC)© David Kachlík 30.9.2015

Kartagener syndrome

• missing movement of cilia

• molecular defect in ciliar mobility

apparatus

• chronic pyogenic rhinitis and sinusitis

• bronchiectasis


Cystic fibrosis (mucoviscidosis)

• insufficient hydration of mucous layer →

increased viscosity

• decrease of periciliary layer of fluid →

missing free space for ciliar movement →

mucus rests directly on epithelium

• clogging of bronchi with mucus → chronic

inflammation + bronchiectasis →

respiratory insufficiency


Lung tumors

• squamous cell carcinoma

– effect of smoking

– arises from metaplasis of respiratory epithelium into non-keratinized stratified squamous

• small cell lung carcinoma

– very malign tumor

• neuroendocrine tumor (carcinoid)

– may be hormonally active


Small cell lung carcinoma


Pleura


Parietal + visceral pleura

Pleura parietalis et visceralis

• serous membrane

– mesothelium (simpler flat)

– tunica serosa

– tela subserosa

• pleura visceralis

• pleura parietalis

– pars costalis, diaphragmatica, mediastinalis


Pleura


Pleura

• cupula pleurae – reinforced by membrana suprapleuralis Sibsoni– lig. scalenopleurale, lig. vertebropleurale,

transversopleurale + m. scalenus minimus Sibsoni, lig. costopleurale

• recessus pleurales:– costodiaphragmaticus (puncture)

– costo-, phrenico- a vertebromediastinalis

• lig. pulmonale

• cavitas pleuralis

• liquor pleurae

• pneumothorax (external x internal)© David Kachlík 30.9.2015

Pleura


Left pneumothorax


Parietal pleura – supply

Arteries:

• a. subclavia → a. thoracica interna → a. musculophrenica + aa. intercostales ant.

• aorta thoracica → aa. intercostales post.

Veins: thoracic wall veins

Lymph: n.l. intercostales, parasternales, diaphragmatici, mediastinales posteriores

Nerves:

• nn. intercostales (pleura costalis + peripheral pleura diaphragmatica)

• n. phrenicus (pleura mediastinalis + central pleura diaphragmatica)


Pleura visceralis – supply

• corresponds to lung supply

arteries: rr. bronchiales

veins: vv. bronchiales

lymph: see lungs

nerves: only autonomic nerves around vessels,

around hilum from n. vagus

!!! Visceral pleura is not painfull !!!


Projection of pleura and lungs

• projection of lungs 1-2 intercostal space

higher lower compared to pleura

• 10 lines on thorax

• area interpleuralis superior (thymus)

• area interpleuralis inferior (heart)

puncture: 7.-8. intercostal space in posterior

axillary or scapular line by upper costal

margin© David Kachlík 30.9.2015

Projection of

lungs and

pleura


Respiratory muscles

• inspiratory

– main: diaphragm, mm. intercostales externi, (mm. scaleni,

mm. levatores costarum)

– auxiliary: m. pectoralis major + minor, m. latissimus dorsi, m.

serratus anterior + post. sup., m. sternocleidomastoideus, m.

subclavius, (m. sternothyroideus, m. sternohyoideus) –

orthopnoic posture

• expiratory

– main: mm. intercostales interni (+ intimi, m. subcostales)

– auxiliary: m. rectus abd., m. obliquus abd. ext. + int., m.

trasnversus abd., m. serratus post. inf., m. transversus

thoracis, (m. quadratus lumborum), m. levator ani


Mediastinum

• anatomical division:

– upper

– lower (anterior, middle, posterior)

• surgical division (many ): e.g.

– anterior

– posterior



Mediastinum superius

structures in 5 layers ventrodorsally:

1. thymus, insertions of mm.

sternothyroideus et sternohyoideus,

vasa thoraciaca int. + branches

2. layer of veins: vv.

brachiocephalicae (plexus thyroideus

impar, v. intercostalis sup. sin.) join ito

v. cava sup., ductus thoracicus, nn.

phrenici

3. layer of arteries: arcus aortae +

branches

4. organs: trachea + bifurcation (at

level of vertebra T4), bronchi

principales, oesophagus + nn. vagi, rr.

cardiaci, n. laryngeus reccurens sin.,

nodi lymphoidei tracheobronchiales,

nodi lymphoidei paratracheales,

membrana bronchopericardiaca

5. truncus sympathicus dx. et sin., nn.

cardiaci, nodi lymphoidei

juxtaesophageales, m. longus colli© David Kachlík 30.9.2015

Mediastinum inferius

Mediastinum inferius anterius

• ligg. sternopericardiaca

• nodi lymphoidei parasternales, prepericardiaci (= "n.l.

mediastinales posteriores")

• vasa thoracica int. + branches

• m. transversus thoracis

Mediastinum inferius medium

• heart in pericardium

• aorta ascendens + truncus pulmonalis

• v. cava sup., v. cava inf. (+ ostium of v. azygos)

• nn. phrenici, vasa pericardiacophrenica

• plexus cardiacus

• vv. pulmonales

• nodi lymphoidei pericardiaci laterales

Mediastinum inferius posterius

• oesophagus + plexus oesophageus

• truncus symphicus + nn. splanchnici (major, minor, imus)

• nodi lymphoidei prevertebrales, juxtaesophageales (= "n.l.

mediastinales posteriores")

• ductus thoracicus

• v. azygos, hemiazygos et hemiazygos accessoria (+

tributaries)

• aorta thoracica + branches


Mediastinum

posterius


Documents

Respiratory system II. - Univerzita Karlovaanatomie.lf3.cuni.cz/centralni_prezentace/Dychani2_eng.pdfPulmo dexter, lobus superior Segmentum apicale [S I] Segmentum posterius [S II]