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Respiratory

1. DEPARTMENT OF ANATOMY COLLEGE OF HEALTH SCIENCES UNIVERSITY OF ILORIN, ILORIN FACULTY OF BASIC MEDICAL SCIENCES B. U. Enaibe (PhD) ALWAYS REMEMBER THAT GOD KNOWS YOU AND YOUR THOUGHTS. RESPIRATORY ANATOMY LECTURE ONE INTRODUCTION & OUTLINE PROFESSOR OF ANATOMY

2. OUTLINE INTRODUCTION NASAL CAVITY PARANASAL AIR SINUSES THORACIC CAGE PHARYNX & LARYNX TRACHEA/BRONCHIAL TREE PLEURA & CAVITY LUNGS SURFACTANT/HYALINE MEMBRANE DISEASES EMBRYOLOGY/DISORDERS MEDIASTINUM THORACIC VERTEBRAE BREAST DIAPHRAGM HISTOLOGY RESPIRATORY MOVEMENTS SURFACE ANATOMY RADIOLOGICAL ANATOMY BLOOD SUPPLY LYMPHATIC DRAINAGE CLINICAL ANATOMY PROF. ENAIBE DR. IBIYEYE DR. IMAM

3. THERE IS GOD OOOO DO YOU KNOW HIM ?

4. Sometimes a person will describe a habit as being “as natural as breathing.” Indeed, what could be more natural? We rarely think about breathing, and it isn’t something we look forward to, as we might look forward to a good dinner. We just breathe, usually at the rate of 12 to 20 times per minute, and faster when necessary (such as during exercise). You may have heard of trained singers “learning how to breathe,” but they are really learning how to make their breathing more efficient. INTRODUCTION

5. Most of the respiratory system is concerned with what we think of as breathing: moving air into and out of the lungs. The lungs are the site of the exchanges of oxygen and carbon dioxide between the air and the blood. Both of these exchanges are important. All of our cells must obtain oxygen to carry out cell respiration to produce ATP. Just as crucial is the elimination of the CO2 produced as a waste product of cell respiration, and, as you already know, the proper functioning of the circulatory system is essential for the transport of these gases in the blood. INTRODUCTION

6. The respiratory system may be divided into the upper respiratory tract and the lower respiratory tract. The upper respiratory tract consists of the parts outside the chest cavity: the air passages of the nose, nasal cavities, pharynx, larynx, and upper trachea. The lower respiratory tract consists of the parts found within the chest cavity: the lower trachea and the lungs themselves, which include the bronchial tubes and alveoli. Also part of the respiratory system are the pleural membranes and the respiratory muscles that form the chest cavity: the diaphragm and intercostal muscles. INTRODUCTION

7. UPPER RESPIRATORY TRACT

8. UPPER RESPIRATORY TRACT

9. LOWER RESPIRATORY TRACT

10. FOLLOW PEACE WITH ALL MEN AND HOLINESS

11. NASAL CAVITY The nasal cavity is divided into right and left halves by a median nasal septum formed by the perpendicular plate of the ethmoid bone, the septal cartilage and the vomer . Each cavity extends from the nostril (or anterior nares ) in front to the posterior nasal aperture behind, communicating through the latter with the nasopharynx .

12. The lateral wall is very irregular, due to the projection of the three conchae (superior, middle and inferior) and the underly - ing meatuses . The superior meatus receives the opening of the posterior ethmoidal air cells. Opening into the middle meatus are ( antero-posteriorly ) the frontal and maxillary sinuses and the anterior and middle ethmoidal air cells. Only the nasolacri -mal duct opens, in solitary splendour, into the inferior meatus. NASAL CAVITY

13. The roof of the cavity is horizontal in its central portion, where it is formed by the cribriform plate of the ethmoid, but slopes downwards both anteriorly (the frontal and nasal bones) and posteriorly (the sphenoid). The floor corresponds to the roof of the mouth; it comprises the palatine process of the maxilla, the horizontal process of the palatine bone and the soft palate. NASAL CAVITY

14. PARANASAL SINUSES There are four paranasal air sinuses - the ethmoidal cells , and the sphenoidal , maxillary , and frontal sinuses . Each is named according to the bone in which it is found. The paranasal sinuses develop as outgrowths from the nasal cavities and erode into the surrounding bones. All are: lined by respiratory mucosa, which is ciliated and mucus secreting; open into the nasal cavities; innervated by branches of the trigeminal nerve [V].

15. The frontal sinuses, one on each side, are variable in size and are the most superior of the sinuses. Each is triangular in shape and is in the part of the frontal bone under the forehead. The base of each triangular sinus is oriented vertically in the bone at the midline above the bridge of the nose and the apex is laterally approximately one-third of the way along the upper margin of the orbit. Each frontal sinus drains onto the lateral wall of the middle meatus via the frontonasal duct, which penetrates the ethmoidal labyrinth and continues as the ethmoidal infundibulum at the front end of the hiatus semilunaris . The frontal sinuses are innervated by branches of the supra-orbital nerve from the ophthalmic nerve [V 1 ]. Their blood supply is from branches of the anterior ethmoidal arteries. PARANASAL SINUSES

16. PARANASAL SINUSES The ethmoidal cells on each side fill the ethmoidal labyrinth. Each cluster of cells is separated from the orbit by the thin orbital plate of the ethmoidal labyrinth, and from the nasal cavity by the medial wall of the ethmoidal labyrinth.The ethmoidal cells are formed by a variable number of individual air chambers, which are divided into anterior, middle, and posterior ethmoidal cells based on the location of their apertures on the lateral wall of the nasal cavity: the anterior ethmoidal cells open into the ethmoidal infundibulum or the frontonasal duct; the middle ethmoidal cells open onto the ethmoidal bulla, or onto the lateral wall just above this structure;

17. PARANASAL SINUSES the posterior ethmoidal cells open onto the lateral wall of the superior nasal meatus. Because the ethmoidal cells often erode into bones beyond the boundaries of the ethmoidal labyrinth, their walls may be completed by the frontal, maxillary, lacrimal , sphenoid, and palatine bones. The ethmoidal cells are innervated by : the anterior and posterior ethmoidal branches of the nasociliary nerve from the ophthalmic nerve [V 1 ]; the maxillary nerve [V 2 ] via orbital branches from the pterygopalatine ganglion. The ethmoidal cells receive their blood supply through branches of the anterior and posterior ethmoidal arteries.

18. PARANASAL SINUSES Maxillary sinuses .The maxillary sinuses, one on each side, are the largest of the paranasal sinuses and completely fill the bodies of the maxillae. Each is pyramidal in shape with the apex directed laterally and the base deep to the lateral wall of the adjacent nasal cavity. The medial wall or base of the maxillary sinus is formed by the maxilla, and by parts of the inferior concha and palatine bone that overlie the maxillary hiatus. The opening of the maxillary sinus is near the top of the base, in the center of the hiatus semilunaris , which grooves the lateral wall of the middle nasal meatus.

19. PARANASAL SINUSES Relationships of the maxillary sinus are as follows: the superolateral surface (roof) is related above to the orbit; the anterolateral surface is related below to the roots of the upper molar and premolar teeth and in front to the face; the posterior wall is related behind to the infratemporal fossa. The maxillary sinuses are innervated by infra-orbital and alveolar branches of the maxillary nerve [V 2 ], and receive their blood through branches from the infra-orbital and superior alveolar branches of the maxillary arteries.

20. PARANASAL SINUSES The sphenoidal sinuses , one on either side within the body of the sphenoid, open into the roof of the nasal cavity via apertures on the posterior wall of the spheno-ethmoidal recess. The apertures are high on the anterior walls of the sphenoid sinuses. The sphenoidal sinuses are related: superiorly to the cranial cavity, particularly to the pituitary gland and to the optic chiasm; laterally, to the cranial cavity, particularly to the cavernous sinuses; anteroinferiorly , to the nasal cavities. Because only thin shelves of bone separate the sphenoidal sinuses from the nasal cavities below and hypophyseal fossa superiorly,

21. PARANASAL SINUSES the pituitary gland can be surgically approached through the roof of the nasal cavities by passing first through the anteroinferior aspect of the sphenoid bone and into the sphenoidal sinuses and then through the top of the sphenoid bone into the hypophyseal fossa. Innervation of the sphenoidal sinuses is provided by: the posterior ethmoidal branch of the ophthalmic nerve [V 1 ]; the maxillary nerve [V 2 ] via orbital branches from the pterygopalatine ganglion. The sphenoidal sinuses are supplied by branches of the pharyngeal arteries from the maxillary arteries.

22. WHAT A FRIEND WE HAVE IN HIM

23. THE RIB CAGE BONY THORAX The thoracic cage, or rib cage protects the vital organs within the thorax and forms a semi-rigid chamber that can increase and decrease in volume during respiration. It consists of the thoracic vertebrae, the ribs with their associated costal (rib) cartilages, the sternum

24. THORACIC VERTEBRAE Possess long, thin spinous processes, which are directed inferiorly, and they have relatively long transverse processes. The first 10 thoracic vertebrae have articular facets on their transverse processes, where they articulate with the tubercles of the ribs.

25. THORACIC VERTEBRAE Additional articular facets are on the superior and inferior margins of the body where the heads of the ribs articulate. The head of most ribs articulates with the inferior articular facet of one vertebra and the superior articular facet for the rib head on the next vertebra below.

26. Spinous process Vertebral foramen Articular facet for rib tubercle Superior articular facet Superior articular facet for rib head Body Pedicle Superior articular process Transverse process Lamina Thoracic vertebra, superior view THORACIC VERTEBRAE

27. Articular facets for rib head Articular facet for rib tubercle Spinous process Intervertebral foramen T1 T2 T3 T4 T5 T6 T7 Transverse process Body intervertebral disk Space THORACIC VERTEBRAE

28. RIBS AND COSTAL CARTILAGES The 12 pairs of ribs are classified as either true or false ribs. The superior seven pairs are called true ribs, or vertebrosternal ribs , in that they articulate with the thoracic vertebrae and attach directly through their costal cartilages to the sternum. The inferior five pairs, or false ribs, articulate with the thoracic vertebrae but do not attach directly to the sternum. The false ribs consist of two groups. The 8 th ,9 th and 10 th ribs, the vertebrochondral are joined by a common cartilage to the costal cartilage of the seventh rib, which, in turn, is attached to the sternum.

29. 1 2 3 4 5 6 7 8 9 10 11 12 T 12 L 1 Clavicle T 1 Jugular notch Manubrium Body Xiphoid process True ribs 1-7 False ribs 8-12 Sternal angle ENTIRE THORACIC CAGE - ANTERIORLY VIEW. Floating ribs 11-12 RIBS AND COSTAL CARTILAGES

30. The 11 th and 12 th ribs are also called floating, or vertebral, ribs because they do not attach to the sternum. The costal cartilages are flexible and permit the thoracic cage to expand during respiration. Most ribs have two points of articulation with the thoracic vertebrae i.e. the head and the tubercle. The head articulates with the bodies of two adjacent vertebrae(the inferior articular facet of the superior vertebra and the superior articular facet of the inferior vertebra) and the intervertebral disk between them. The tubercle articulates with the transverse process of one vertebra RIBS AND COSTAL CARTILAGES

31. Articular facets for body of vertebrae Neck Articular facet for transverse process of vertebrae Angle Tubercle Head Sternal end Body THE RIBS

32. Head of rib set against the inferior articular facet of the superior vertebra and the superior articular facet of the inferior vertebra Tubercle of rib set against the articular facet on the transverse process of the inferior vertebra Angle of rib Body of the rib Photograph of two thoracic vertebrae and the proximal end of a rib, as seen from the left side, showing the relationship between the vertebra and the head and tubercle of the rib. THE RIBS

33. The neck is between the head and tubercle The body, or shaft , is the main part of the rib. The angle of the rib is located just lateral to the tubercle and is the point of greatest curvature. Clinical correlates Separation of the tenth rib is the most common. The angle is the weakest part of the rib and may be fractured in a crushing accident, such as an automobile accident. The transverse processes of the seventh cervical vertebra may form separate bones called cervical ribs. THE RIBS

34. STERNUM The sternum, or breastbone, has been described as being swordshaped and has three parts; the manubrium , the body and the xiphoid process The superior margin of the manubrium has a jugular (neck) notch in the midline, which can be easily felt at the anterior base of the neck The first rib and the clavicle articulate with the manubrium.

35. The manubrium joins the body of the sternum at a point that can be felt as a prominence on the anterior thorax, called the sternal angle of Louis The cartilage of the 2 nd rib attaches to the sternum at the sternal angle, the 3 rd – 7 th ribs attach to the body of the sternum, and no ribs attach to the xiphoid process STERNUM

36. CLINICAL CORRELATES The sternal angle is important clinically because the 2 nd rib is found lateral to it and can be used as a starting point for counting the other ribs. (Counting ribs is important because they are landmarks used to locate structures in the thorax, such as areas of the heart). The sternum often is used as a site for taking red bone marrow samples because it is readily accessible. Because the xiphoid process of the sternum is attached only at its superior end, it may be broken during cardiopulmonary resuscitation (CPR) and then may lacerate the liver.

37. sternum Jugular notch clavicle Acromion process Surface Anatomy showing bones of the Upper Thorax

38. STERNAL ANGLE EVENTS ASSIGNMENT: MENTION THE EVENTS SUBMIT IN TWO WEEKS THANK YOU CLASS REP TAKE NOTE

39. The anterior median (midsternal) line (AML) indicates the intersection of the median plane with the anterior thoracic wall. • The midclavicular line (MCL) passes through the midpoint of the clavicle, parallel to the AML. THE THORACIC PLANES

40. The anterior axillary line (AAL) runs vertically along the anterior axillary fold that is formed by the inferolateral border of the pectoralis major as it spans from the thoracic cage to the humerus in the arm. • The midaxillary line (MAL) runs from the apex (deepest part) of the axillary fossa (armpit), parallel to the AAL. THE THORACIC PLANES

41. The posterior axillary line (PAL), also parallel to the AAL, is drawn vertically along the posterior axillary fold formed by the latissimus dorsi and teres major muscles as they span from the back to the humerus. THE THORACIC PLANES

42. The posterior median ( midvertebral ) line (PML) is a vertical line along the tips of the spinous processes of the vertebrae. • The scapular lines (SLs) are parallel to the posterior median line and intersect the inferior angles of the scapula. THE THORACIC PLANES

43. THE THORACIC PLANES

44. Breasts are the most prominent surface features of the anterior thoracic wall, especially in women. Except when there is an overabundance of subcutaneous tissue, the breasts in men are mostly an accentuation of the contour of the pectoralis major muscles, highlighted by the presence of the nipple in the 4th intercostal space, lateral to the MCL. In moderately athletic individuals, the contour of the pectoralis major muscles is apparent, separated in the midline by the intermammary cleft overlying the sternum, with the lateral border forming the anterior axillary fold . THE THORACIC PLANES

45. Inferolaterally , finger-like slips, or digitations of the serratus anterior, have a serrated (sawtooth) appearance as they attach to the ribs and interdigitate with the external oblique . The inferior ribs and costal margins are often apparent, especially when the abdominal muscles are contracted to “pull the belly in.” The intercostal musculature is not normally evident; however, in (rare) cases in which there is an absence or atrophy of the intercostal musculature, the intercostal spaces become apparent with respiration: during inspiration, they are concave; during expiration, they protrude. THE THORACIC PLANES

46. THORACIC WALL MUSCLES Some muscles attached to and/or covering the thoracic cage are primarily involved in serving other regions. Axio -appendicular muscles extend from the thoracic cage (axial skeleton) to bones of the upper limb (appendicular skeleton). Similarly, some muscles of the anterolateral abdominal wall, back, and neck muscles have attachments to the thoracic cage. The axio -appendicular muscles act primarily on the upper limbs. But several of them, including the pectoralis major and pectoralis minor and the inferior part of the serratus anterior, may also function as accessory muscles of respiration, helping elevate the ribs to expand the thoracic cavity when inspiration is deep and forceful (100m race).

47. THORACIC WALL MUSCLES The scalene muscles of the neck, which descend from vertebrae of the neck to the 1st and 2nd ribs, act primarily on the vertebral column. So, they also serve as accessory respiratory muscles by fixing these ribs and enabling the muscles connecting the ribs below to be more effective in elevating the lower ribs during forced inspiration.

48. THORACIC WALL MUSCLES

49. THORACIC WALL MUSCLES

50. THORACIC WALL MUSCLES The serratus posterior muscles have traditionally been described as inspiratory muscles, but this function is not supported by electromyography or other evidence. On the basis of its attachments and disposition, the serratus posterior superior was said to elevate the superior four ribs, thus increasing the AP diameter of the thorax and raising the sternum. On the basis of its attachments and disposition, the serratus posterior inferior was said to depress the inferior ribs, preventing them from being pulled superiorly by the diaphragm.

51. THORACIC WALL MUSCLES

52. THORACIC WALL MUSCLES However, recent studies suggest that these muscles, which span the superior and inferior thoracic apertures as well as the transitions from the relatively inflexible thoracic vertebral column to the much more flexible cervical and lumbar segments of the column, may not be primarily motor in function. Rather, they may have a proprioceptive function. These muscles, particularly the serratus posterior superior, have been implicated as a source of chronic pain in myofascial pain syndromes. The levatores costarum muscles (L. levator , a lifter) are 12 fan-shaped muscles that elevate the ribs, but their role, if any, in normal inspiration is uncertain. They may play a role in vertebral movement and/or proprioception.

53. THORACIC WALL MUSCLES The external intercostal muscles (11 pairs) occupy the intercostal spaces from the tubercles of the ribs posteriorly to the costochondral junctions anteriorly. Anteriorly, the muscle fibers are replaced by the external intercostal membranes . These muscles run infero -anteriorly from the rib above to the rib below. Each muscle attaches superiorly to the inferior border of the rib above and inferiorly to the superior border of the rib below. These muscles are continuous inferiorly with the external oblique muscles in the anterolateral abdominal wall. The external intercostals are most active during inspiration.

54. THORACIC WALL MUSCLES • The internal intercostal muscles (11 pairs) run deep to and at right angles to the external intercostals. Their fibers run inferoposteriorly from the floors of the costal grooves to the superior borders of the ribs inferior to them. The internal intercostals attach to the bodies of the ribs and their costal cartilages as far anteriorly as the sternum and as far posteriorly as the angles of the ribs. Between the ribs posteriorly, medial to the angles, the internal intercostals are replaced by the internal intercostal membranes. The inferior internal intercostal muscles are continuous with the internal oblique muscles in the anterolateral abdominal wall. The internal intercostals—weaker than the external intercostal muscles—are most active during expiration— especially their interosseous (vs. interchondral ) portions.

55. THORACIC WALL MUSCLES • The innermost intercostal muscles are similar to the internal intercostals and are essentially their deeper parts. The innermost intercostals are separated from the internal intercostals by intercostal nerves and vessels. These muscles pass between the internal surfaces of adjacent ribs and occupy the lateral-most parts of the intercostal spaces. It is likely (but undetermined) that their actions are the same as those of the internal intercostal muscles.

56. THORACIC WALL MUSCLES

57. THORACIC WALL MUSCLES

58. THORACIC WALL FASCIAE Each part of the deep fascia is named for the muscle it invests or structure(s) it is attached. Consequently, a large portion of the deep fascia overlying the anterior thoracic wall is called pectoral fascia for its association with the pectoralis major muscles. In turn, much of the pectoral fascia forms a major part of the bed of the breast (structures against which the posterior surface of the breast lies). Deep to the pectoralis major and its fascia is another layer of deep fascia suspended from the clavicle and investing the pectoralis minor muscle, the clavipectoral fascia. The thoracic cage is lined internally with endothoracic fascia. This thin fibro-areolar layer attaches the adjacent portion of the lining of the lung cavities (costal parietal pleura) to the thoracic wall. It becomes more fibrous over the apices of the lungs ( suprapleural membrane ).

59. THORACIC WALL FASCIAE

60. The 12 pairs of thoracic spinal nerves supply the thoracic wall. As soon as they leave the IV foramina in which they are formed, the mixed thoracic spinal nerves divide into anterior and posterior (primary) rami or branches. The anterior rami of nerves T1–T11 form the intercostal nerves that run along the extent of the intercostal spaces. The anterior ramus of nerve T12, coursing inferior to the 12th rib, is the subcostal nerve. The posterior rami of thoracic spinal nerves pass posteriorly, immediately lateral to the articular processes of the vertebrae, to supply the joints, deep back muscles, and skin of the back in the thoracic region. THORACIC WALL NERVES

61. TYPICAL INTERCOSTAL NERVES The 3rd–6th intercostal nerves enter the medial-most parts of the posterior intercostal spaces, running initially within the endothoracic fascia between the parietal pleura (serous lining of pulmonary cavity) and the internal intercostal membrane nearly in the middle of the intercostal spaces. Near the angles of the ribs, the nerves pass between the internal intercostal and the innermost intercostal muscles. At this point, the intercostal nerves pass to and then continue to course in or just inferior to the costal grooves, running inferior to the intercostal arteries (which, in turn, run inferior to the intercostal veins).

62. TYPICAL INTERCOSTAL NERVES The neurovascular bundles (especially the vessels) are thus sheltered by the inferior margins of the overlying ribs. Collateral branches of these nerves arise near the angles of the ribs and run along the superior border of the rib below. The nerves continue anteriorly between the internal and innermost intercostal muscles, supplying these and other muscles and giving rise to lateral cutaneous branches in approximately the midaxillary line (MAL). Anteriorly, the nerves appear on the internal surface of the internal intercostal muscle. Near the sternum, the nerves turn anteriorly, passing between the costal cartilages to become anterior cutaneous branches.

63. TYPICAL INTERCOSTAL NERVES Through its posterior ramus and the lateral and anterior cutaneous branches of its anterior ramus, most thoracic spinal nerves (T2–T12) supply a strip-like dermatome of the trunk extending from the posterior median line to the anterior median line. The group of muscles supplied by the posterior ramus and anterior ramus (intercostal nerve) of each pair of thoracic spinal nerves constitutes a myotome. The myotomes of most thoracic spinal nerves (T2–T11) include the intercostal, subcostal, transversus thoracis, levatores costarum , and serratus posterior muscles associated with the intercostal space that includes the anterior ramus (intercostal nerve) of the specific spinal nerve, & the overlying portion of the deep muscles of back.

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65. OUTLINE INTRODUCTION NASAL CAVITY PARANASAL AIR SINUSES THORACIC CAGE PHARYNX & LARYNX TRACHEA/BRONCHIAL TREE PLEURA & CAVITY LUNGS SURFACTANT/HYALINE MEMBRANE DISEASES EMBRYOLOGY/DISORDERS MEDIASTINUM THORACIC VERTEBRAE BREAST DIAPHRAGM HISTOLOGY RESPIRATORY MOVEMENTS SURFACE ANATOMY RADIOLOGICAL ANATOMY BLOOD SUPPLY LYMPHATIC DRAINAGE CLINICAL ANATOMY PROF. ENAIBE DR. IBIYEYE DR. IMAM

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