Lungs & Pleura.pptx

Brief description of lungs and pleura anatomy

1. THE LUNG & PLEURA

2. Case of Billy Parker 9 year old child presents with acute shortness of breath to the emergency room. Billy was diagnosed with asthma at the age of 4 when he presented with a persistent nocturnal cough and mild shortness of breath. Billy lives with his family on a large sheep farm in New Zealand and his family also have a small number of cattle, several cats and 4 dogs. Billy’s father smokes 20 cigs per day. Billy’s symptoms were difficult to control despite appropriate use of medication and his family decided that due to repeated time off school and the concern that his environment seemed to provoke his symptoms, Billy should attend a residential school in Wellington, their closest city. Billy has just returned for the Easter vacation when he awoke this morning feeling tightness in his chest and feeling unable to breathe. He has tried taking his albuterol but he feels his symptoms are getting worse.

3. Any one knows what is wrong with Billy Parker?

4. Respiratory System

5. Thoracic Cavity Thoracic cavity has Two lateral pleural cavities Contains lungs A central compartment (mediastinum) Contains all other thoracic structure (Heart, Great Vessels, Trachea, Esophagus, Thymus)

6. Section I PLEURA

7. Pleura Each lung is surrounded by Visceral pleura Parietal pleura Both pleura are continuous at hilum of lung

8. Pleura Each lung is enclosed in a serous sac (pleura) Visceral Pleura invests the lungs Parietal Pleura lines thoracic wall ( adherent to thoracic wall, diaphragm & mediastinum ) Visceral and parietal pleura are continuous at hilum of lung Pleural space is a potential space between parietal and visceral pleura Contains pleural fluid Lubrication Cohesion

9. Parietal pleura Lines the thoracic wall, mediastinum , diaphragm Very sensitive to pain Intercostal and phrenic nerves [somatic nerves] Has 4 parts Costal pleura- Lining internal surface of thoracic wall Mediastinal pleura- Covering sides of mediastinum Diaphragmatic pleura- Covering superior surface of dome of each hemidiaphragm Cervical pleura- A dome of pleura extending superiorly into superior thoracic aperture IMP

10. Pleural Nomenclature Cervical pleura Mediasinal pleura Costal pleura Diaphragmatic pleura Visceral pleura

11. Cervical pleura Extends 2-3 cm above medial end of clavicle Strengthened by Sibson’s fascia

12. Hilum of lung Mediastinal pleura becomes continuous with the visceral pleura. Inferior to hilum mediastinal pleura passes inferiorly as a double layer → Pulmonary ligament

13. Visceral (pulmonary) pleura Covers the lungs Cannot be dissected from lung Insensitive to pain Does not have any somatic sensory innervation but may be supplied by autonomic nerves which also supply lung substance IMP

14. Pleural cavity Potential space between parietal and visceral pleura Contains a thin layer of serous pleural fluid Lubricates and allows pleurae to move smoothly over each other during respiration Surface tension keeps lung surface in contact with thoracic wall IMP

15. Lines of Pleural Reflection Lines of pleural reflection are lines along which parietal pleura changes directions from one wall to another Apex of lung at neck or 1 st rib Inferior margin of lung 6 th rib MCL 8 th rib MAL 10 th rib MSL Inferior pleural reflection 8 th rib MCL 10 th rib MAL Neck of 12 th rib on either side of the vertebral column IMP

16. Lines of Pleural Reflection

17. Lines of Pleural Reflection Costomediastinal recesses Costodiaphragmatic recesses

18. Lungs do not fully occupy pleural cavities during expiration Costodiaphragmatic recesses Areas where diaphragmatic and costal pleura come in contact Costomediastinal recesses Areas posterior to sternum where costal and mediastinal pleura come in contact with each other Larger on left, because of cardiac notch

19. Costodiaphragmatic Recess Ribs ( costo ) Lung Costodiaphragmatic recess Diaphragm liver

20. Costomediastinal Recess Right and left Costomediastinal recesses Pericardium in direct contact with chest wall

21. Pleural effusion Excess fluid that accumulates in pleural cavity Can impair breathing by limiting the expansion of lungs during inhalation Types Serous fluid (hydrothorax) Blood ( haemothorax ) Chyle ( chylothorax ) Pus ( pyothorax / empyema ) IMP

22. Pleural effusion Minimal pleural effusion = Fluid in Costodiaphragmatic recess IMP Symptoms include shortness of breath, chest pain, and cough. It can be treated by removing fluid by thoracocentesis .

23. Pleural Effusion Obliteration of costodiaphragmatic recess IMP

24. Left Pleural Effusion Lateral Chest Film

25. Pleuritis Pleurisy Inflammation of pleurae Makes the lung surfaces rough Plural rub is heard with a stethoscope Acute pleuritis S/S- sharp, stabbing pain, especially on exertion , such as climbing stairs, when rate and depth of respiration may be increased even slightly, it also increases on cough but is relieved by sleeping on the affected side. Treatments consist of relieving pain with analgesics, as necessary, and lidocaine for intercostal nerve block IMP

26. Pneumothorax Air in pleural cavity Hydropneumothorax : Both fluid & air in pleural cavity

27. Thoracocentesis ( Paracentesis thoracis ) To obtain a sample of pleural fluid or to remove blood or pus To avoid damage to intercostal nerve and vessels, needle is inserted superior to rib, high enough to avoid collateral branches It is performed at Mid- Axillary Line, one or two intercostal spaces below the fluid level but not below the ninth intercostal space. The ideal site is eighth or ninth intercostal space in midaxillary line, and this site avoids possible accidental puncture of the lung, liver, spleen, and diaphragm. IMP

28. Section II LUNGS

29. Lungs - Surface Anatomy R6 R4

30. Lung Lobes

31. Lungs, Fissures, and Lobes Picture the lungs and their fissures and lobes on the chest wall. Anteriorly, the apex of each lung rises about 2 cm to 4 cm above the inner third of the clavicle. The lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line. Posteriorly, the lower border of the lung lies at about the level of the T10 spinous process. On inspiration, it descends farther Each lung is divided roughly in half by an oblique (major) fissure. This fissure may be approximated by a string that runs from the T3 spinous process obliquely down and around the chest to the 6th rib at the midclavicular line. The right lung is further divided by the horizontal (minor) fissure. Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle , and lower lobes. The left lung has only two lobes, upper and lower

32. Posterior View

33. Lateral View - Rt R6 R4 R5

34. Lateral View - Lt R6

35. Anterior View 3 lobes on Right 2 lobes on Left

36. R4

37. Lungs Organs of respiration Light, soft and elastic Right is larger than left Right has 3 lobes Superior or upper Middle Inferior or lower Left has 2 lobes Superior or upper Inferior or lower

38. Fissures Divides the lungs into lobes Each lung has an oblique fissure Separates upper lobe from lower lobe on left and upper and middle lobes from lower lobe on right Right lung has a horizontal fissure , separating middle lobe from upper lobe Each lung has three surfaces Costal Mediastinal Diaphragmatic

39. Lingula Anterior margin of left lung has an indentation- cardiac notch Each lung is connected to mediastinum by root of lung

40. Lung root contains Main stem or lobar bronchi Pulmonary vessels and bronchi. Bronchial vessels, lymphatics, and autonomic nerves Lung root is surrounded by a pleural sleeve, from which extends pulmonary ligament ROOT OF LUNG IMP

41. IMP

42. IMP

43. Surface marking of lungs and pleura

44. TRACHEA

45. Anterior & lateral relations of Trachea

46. Posterior & lateral relations of Trachea

47. Tracheobronchial Tree Trachea Bronchi Right and left [primary] Lobar [secondary] [3 or 2] Segmental [Tertiary] [10] Large & Small Intra-segmental Bronchiole Terminal Respiratory Alveoli Alveolar duct Alveolar Sac Alveoli IMP

48. IMP

49. Bronchopulmonary Segments Trachea bifurcates → two main stem bronchi, right and left Carina- keel-like ridge between two openings of main stem bronchi Main stem bronchus divides into lobar bronchi 3 lobar bronchi on right: upper, middle, and lower 2 lobar bronchi on left: upper and lower Each lobar bronchus branches into segmental bronchi that supply a bronchopulmonary segment IMP

50. A bronchopulmonary segment Is a pyramidally shaped section of lung with its base covered by visceral pleura Is separated from adjacent segments by connective tissue septa Is aerated by segmental bronchus Has its own segmental bronchus and segmental branch of pulmonary artery and segmental branch of bronchial artery but not pulmonary vein Pulmonary veins are intersegmental IMP

51. THERE ARE 10 BRONCHOPULMONARY SEGMENTS ON EACH SIDE

52. BP segments of Right lung

53. BP segments of Left lung

54. Each segmental bronchus has its own pulmonary artery but shares pulmonary veins with adjoining segments Bronchopulmonary Segment

55. Bronchopulmonary Segment Has its own Bronchus Has its own Pulmonary artery ( Blue ) Drains to multiple pulmonary veins ( Red ) between segments So, each segment has its own bronchus and artery but not its own vein.

56. Each bronchopulmonary segment can be surgically resected, independent of adjacent segments Surgeons follow interlobar veins to pass between segments Bronchial and pulmonary disorders such as Tumors or abscesses (collections of pus) often localize in a bronchopulmonary segment, which may be surgically resected IMP CLINICAL IMPORTANCE OF BRONCHOPULMONARY SEGMENTS

57. Structure of Bronchioles and Alveoli

58. IMP Q – Which is the most dependent area/segment in both lungs?

59. Aspiration of Foreign Bodies More likely to enter in right bronchus Because right bronchus is wider and shorter and runs more vertically than left bronchus Encountered by dentists Aspiration of piece of tooth, filling material, or a small instrument

60. Location with Aspiration 1. Standing or Sitting Posterobasal segment of Rt. Lower Lobe 2. Lying Down on back Superior segment of Rt. Lower Lobe MC site of lung abscess 3. Lying on Right side Rt. Middle Lobe Posterior segment of Rt. Upper Lobe 4. Lying on Left side Lingular IMPORTANT

61. ANTERIOR VIEW MEDIAL VIEW Broncho – Pulmonary Segments IMP

62. Bronchogram

63. Bronchoscopy

64. Bronchoscopy Examining bronchi with an endoscope Carina- Cartilaginous projection of last tracheal ring Distorted, widened posteriorly, and immobile In case of tracheobronchial lymph nodes in angle between main bronchi are enlarged because of cancer (bronchogenic carcinoma) IMP

65. Posteroanterior bronchogram- right and left bronchial tree is shown

66. Vasculature of lungs Pulmonary artery Carries unoxygenated blood from heart to lungs Each artery gives lobar and segmental arteries Pulmonary veins Intrasegmental veins drain to intersegmental veins in pulmonary septa, which drain to two pulmonary veins for each lung Carry oxygenated blood from lungs to heart IMP 2 sets of Blood Supply 1.Pulmonary Vessels : for Gas Exchange 2. Bronchial Vessels: for blood supply to lung substance like any other organ

67. Pulmonary Angiogram

68. Bronchial arteries Basically supply lung substance From thoracic aorta Carry oxygenated blood to tissue of lungs, traveling along posterior surface of bronchi 2 Left bronchial arteries- arise from descending thoracic aorta 1 Right bronchial artery- arise from 3rd right posterior intercostal A. Bronchial veins drain to azygos and accessary hemiazygos veins IMP

69. IMP

70. IMP

71. Vagus & Phrenic Nerves nearby lungs Vagus nerve Phrenic nerve Left Recurrent laryngeal nerve Hilum of left lung IMP

72. Lymphatic drainage Lymph from lungs drains to Pulmonary lymph nodes (along lobar bronchi) Bronchopulmonary lymph nodes (along main stem bronchi) Superior and inferior tracheobronchial lymph nodes (superior and inferior to bifurcation of trachea) Deep Cervical Lymphnodes Costomediastinal Trunk Thoracic duct [left side] and Right lymphatic duct [right side] IMP

73. Lymphatic Drainage of Lung Inferior deep cervical (Scalene) lymph nodes Paratracheal nodes Aortic node Subcarinal nodes Hilar nodes intrapulmonary nodes Once cancer spreads beyond hilar nodes it cannot be removed surgically IMP

74. Lung cancer spreads to regional lymphnodes Once cancer spreads beyond hilar nodes it cannot be removed surgically Special case of Left Upper Lobe : cancer can spread to aortic lymph nodes, which can enlarge to compress the recurrent laryngeal nerve. Since this nerve supplies vocal cords, compression of the nerve can lead to paralysis of vocal cord and hoarseness. Interestingly left lower lobe cancer are likely to skip this aortic lymph node as lymphatics from LLL cross to opposite side & therefore can not cause hoarseness. Obviously right lung cancer do not cause hoarseness... IMP

75. Left Vocal Cord Paralysis Secondary metastatic involvement of the left recurrent laryngeal nerve near the ligamentum arteriosum by lung CA epiglottis aryepiglottic fold Vestibular fold Vocal fold Vocal Fold midline Paralyzed

76. Innervation of lungs Via pulmonary plexuses Located anterior and posterior to lung roots Plexus contains both sympathetic and parasympathetic fibers [2 types of autonomic fibers] sympathetic fibers Innervate smooth muscle of bronchial tree, pulmonary vessels, and glands of bronchial tree Bronchodilators, vasoconstrictors, and inhibit glandular secretion IMP

77. Parasympathetic fibers Preganglionic parasympathetic fibers from vagus nerve Postganglionic parasympathetic nerves Innervate smooth muscle of bronchial tree, pulmonary vessels, and glands of bronchial tree Bronchoconstrictors, vasodilators, and secretomotor to glands Visceral afferent fibers carry information involved in cough reflexes, stretch reception, blood pressure, chemoreception, and nociception IMP

78. Normal Chest Xray {Lungs} Air filled lungs Normal Pulmonary Vascular Marking Hilum area Clear Costodiaphragmatic Recess IMP

79. Pneumonia A bacterial or viral infection of lung Can lead to widespread systemic infection and lung collapse Lobar pneumonia Confined to a single lobe of one lung Broncho pneumonia Patches in lung

80. IMP

81. Lobar Pneumonia: which lobe of lung? Right Upper Lobe Is this Right Lower Lobe pneumonia? No Actually in right middle lobe – look at the lateral view! IMP

82. Herpes Zoster Infection Shingles A viral disease of spinal ganglia Dermatomally distributed skin lesion Herpes virus invades a spinal ganglion and is transported along the axon to skin Sharp burning pain in dermatome supplied by involved nerve A few days later, skin of dermatome becomes red and vesicular eruptions appear IMP

83. Pulmonary Collapse If a sufficient amount of air enters pleural cavity [=pneumothorax], the surface tension adhering visceral to parietal pleura is broken, and lung collapses It can be partial or total One lung may be collapsed without collapsing other because pleural sacs are separate Other Causes- a growing tumor, an infection, or even an inhaled foreign object blocking a major airway IMP

84. Pneumothorax Entry of air into pleural cavity S/S- Chest pain, short breath Uncomplicated pneumothorax may heal on its own in a week or two IMP

85. Pneumothorax IMP

86. Which side has Pneumothorax? IMP

87. Pneumothorax Spontaneous Mild to moderate Leads to partial lung collapse Decreased breath sounds, trachea in midline or shifted [pulled] to same side, diaphragm normal or elevated on affected side Tension Quite severe/emergency Leads to partial or total lung collapse Decreased breath sounds, trachea shift/pushed to opposite side, diaphragm pushed down on affected side IMP

88. Pulmonary embolism Blockage of pulmonary artery (or one of its branches) Cause- DVT (Venous thrombus)- thromboembolism Fat (trauma), air (diving), clumped tumor cells, and amniotic fluid (affecting mothers during childbirth) S/S- Difficult breathing, pain in chest, collapse, circulatory instability and sudden death Treatment- Anticoagulant medication (heparin and warfarin ) with thrombolysis or surgery IMP

89. IMP

90. Thrombus in Deep vein >>> got dislodged >>> thrombo -embolism >>> IVC >>> Rt. Atrium >>> Tricuspid valve >>> right ventricle >>> Pulmonary Valve >>> Pulmonary trunk and Artery. Stopped the blood flow going to the lungs PATHWAY of travelling Thrombus IMP

91. An abnormal arteriogram of right lung. A pulmonary embolus (blood clot), which appears pale, is seen inside a large blood vessel (arrowheads) Pulmonary Angiogram

92. Abnormal Perfusion (Q) Scan Normal Ventilation (V) Scan Abnormal Perfusion (Q) Scan Ventilation Perfusion Scan for diagnosis of Pul Embolism

93. Pancoast’s Tumor Is a malignant neoplasm/ Cancer of the lung apex and causes Pancoast's syndrome , 1) Lower trunk brachial plexus compression - severe pain radiating toward the shoulder and the medial aspect of the arm, and atrophy of the muscles of the forearm and hand) 2) Lesion of cervical sympathetic chain ganglia with Horner's syndrome ( ptosis , enophthalmos , miosis , anhydrosis , and vasodilation ). The treatment is radiation therapy followed by surgical resection of tumor and thoracic wall when feasible. IMP

94. A MRI scan for Lungs